Thyroid Disease
Dr Mastura Hj Ismail FMS KK Seremban 2
Thyroid Hormone Excess Clinical Features
General
Heat intolerance, fatigue, tremor, sweating Tachycardia, heart failure. Weight loss, diarrhoea Lid lag, ophthalmopathy
Cardiovascular
Gastrointestinal
Ophthalmological
Thyroid Hormone Excess Clinical Features
Genitourinary
Amenorrhea, infertility. Proximal muscle weakness Irritability, agitation, anxiety, psychosis Pruritus, hair thinning, onycholysis, vitiligo.
Neuromuscular
Psychiatric
Dermatological
Diagnosis
High Free T4, T3 and supressed sTSH
If sTSH is high suspect pituitary tumour or rare cases of thyroid hormone resistance
There may be mild normochromic anemia, mild leucopaenia, Raised ESR, Se Calcium and LFT Thyroid antibodies
Causes of Thyroid Hormone Excess
Increased radioactive iodine uptake
Graves TMG Toxic solitary adenoma Pituitary tumour
Causes of Thyroid Hormone Excess
Reduced radioactive iodine uptake
Thyroiditis Iodine induced (amiodarone) Lithium (hypothyroid is commoner) Factitious: thyroxine intoxication Struma ovarii: ovarian teratoma containing thyroid tissue Metastatic follicular thyroid carcinoma
Isotope scan
If cause is unclear, to detect nodular disease or subacute thyroiditis
Isotope scan
Graves Disease
Common between 30-50 years Diffuse Goitre Hyperthyroidism Ophthalmopathy Dermopathy Autoimmune. TSI.
Grave Disease only
Eye disease: exopthalmos, ophthalmoplegia Pre-tibial myxoedema oedematous swelling above lateral malleleolai Thyroid acropachy-extreme manisfestation with clubbing, painful fingers, toes swelling and periosteal reaction in limbs bones
TMG
Older Nodules that secrete thyroid hormones Usually less severe hyperthyroidism May have subclinical hyperthyroidism May have long history of goitre
Toxic Solitary Adenoma
Rare cause (< 2% of patients with hyperthyroidism) Younger people 30s and 40s Scan solitary hot nodule Benign follicular adenomas
Thyroiditis
Self-limiting viral infection Painful goitre(subacute, de Quervains), fever, raised ESR Painless (post partum) Hyperthyroid, hypothyroid and euthyroid phases Anti thyroid drug therapy does not work Tx: NSAIDs
Treatment of hyperthyroidism
Antithyroid drugs
Carbimazole 20-45 mg/24 hours Reduce to maintenance after 4 -8weeks according TFT Maintenance :minimum for 18 months Side effect: Rash, GI, agranulocytosis (can lead to life threatening sepsis). Warn to stop and do urgent FBC if sign of infection Alternative: PTU Graves maintain for 12-18 months then withdraw drugs after course of treatment. 50% will relapse, requiring RAI or surgery
Treatment of hyperthyroidism
Block Replacement Regime: Give carbimazole and thyroxine simultaneously (less risk of iatrogenic hypothyroidism)
Rapid symptom control
Beta blocker: e.g propranolol
Treatment of hyperthyroidism
Radio-iodine
Inflammatory response followed by fibrosis May be used for Graves, TMG or TA ? Need for drug treatment before and after May need retreatment CI: pregnancy. Lactation Caution in active thyroidism can cause thyroid storm Long term risk of hypothyroidism
Treatment of Hyperthyroidism
Surgery
Rarely used nowadays Need to be rendered euthyroid before surgery Lugols iodine 0.1-0.3 mls tid for 10 days before surgery Risk damage to recurrent laryngeal nerve and hypoparathyroidism
Treatment of Hyperthyroidism
In pregnancy and infancy: get expert help
Treatment of Hyperthyroidism
Patient presents with hyperthryoidism Make diagnosis, get RAI uptake. Beta block (propranolol 40-80 mg tid). If RAI uptake is high treat with RAI. If RAI is low - symptomatic
Thyroid Storm
Carbimazole (or PTU) Propranolol, 80mg qid Iodine (Lugols 5 drops q6) Dexamethasone 2mg q6 Other supportive measures
Graves Eye Disease
Occur in 25-50% pts May not be correlate with the severity Main known risk factor is smoking Onset relative to hyperthyroidism is variable. Pain, watering, photophobia, blurred vision, double vision Usually mild Tx, protective glasses, elevate head of bed, conjunctival lubricants
Graves Eye Disease
High dose steroids External radiotherapy Orbital decompression
Complications
Heart failure (thyrotoxic cardiomyopathy esp in elderly) Angina, AF Osteoporosis Opthalmopathy Gynecomastia Thyroid storm
Causes Hypothyroidism
Autoimmune: i)Hashimotos ii) Primary atrophic hypothyroidism: no goitre Iodine deficiency: poor intake Drug induced: antithyroid drugs, amiodarone, lithium, iodine Congenital Hypopituitarism
Symptom hypothyroidism
Tiredness, lethargy, depression, dislike of cold, weight gain, constipation, menorrhagia, hoarse voice, poor cognition/dementia, myalgia
Signs
Bradycardia Dry skin and hair Non-pitting oedema (eye lids, hands, feet) Cerebellar ataxia Slow relaxing reflexes, perip neuropathy, toad-like face There may be goitre
Diagnosis
Raised TSH, Low T4
Treatment
Thyroxine 100-150ug daily. Adjust 6 weekly with clinical state and TFT Aim to normalize sTSH Once normal check TFT yearly In patients with CAD start with lower dose e.g. 25ug perday. Increase dose slowly
Subclinical hypothyroidism
Suspec t if TSH high but normal T4 and T3, no obvious symptoms Common, 10% of those above 55 years old Risk progression to frank hypothyroidism is about 2% and increase as TSH higher
Mx subclinical hypothyroidism
Confirm that raised TSH is persistent (recheck in 2-4 months) Recheck the history for any non-specific features e.g depression Discuss benefit of tx with patients One approach is to treat (thyroxine) if TSH > 10, positive thyroid autoantibodies present, previously treated Grave disease
Subclinical hyperthyroidism
Low TSH, normal T4 and T3 Confirm that raised T4 is persistent (recheck in 2-4 months) Recheck for non-thyroidal causes:illness, pregnancy, pituitary insufficiency Discuss benefit of tx with patients If TSH <0.1, treat on individual basis e.e with sx of hyperthyroidism, AF, weight loss, osteoporosis, goitre If no symptom, recheck 6 monthly
Simple non-toxic goitre
Normal TFTs No treatment required Surgery if obstructive symptoms
Non-thyroidal illness
Ill patients may have low T3 and/or T4 usually with a normal sTSH Psychotic patients may have elevated T3 and/or T4.
Thyroid Nodule
FNA Benign no further intervention Malignant or suspicious papillary or follicular.
Papillary Cancer
Controversies
Extent of surgery (near total thyroidectomy). Follow up with sTSH, thyroglobulin exam and US. Radioactive iodine ablation for high risk tumours. Follow up with RAI scans plus the above.
Follicular cancer
Less common than papillary Total thyroidectomy (or near total). Routine remnant ablation with RAI due to increased risk of metastatic disease.
