Hypothyroidism
Thyroid Disease
Definition
Clinical syndrome caused by cellular responses to insufficient thyroid
hormone production.
Etiology
Primary increased TSH, decreased T4
1. Goitrous
a. Hashimoto’s Thyroiditis common in women 20-60,
autoimmune destruction of the thyroid, ass with autoimmune
disorders
b. Iodine Deficiency rural areas, less common = iodine
supplementation in food and salt
c. Post-Viral Thyroiditis (De Quervain’s) less common, 6 weeks
after viral prodrome, tender goiter, labs reveal
hypo/hyper/euthyroid. Self limiting
2. Non-Goitrous
a. Surgical, radioactive iodine/radiation, drugs Amiodarone
Secondary decreased TSH, decreased T4
1. Hypothalamic or pituitary failure very rare
Clinical Features
General Fatigue, cold intolerance, slowing of mental and physical
performance, hoarseness, macroglossia
Neurological Paresthesia, slow speech, muscle cramps, delay in relaxation phase of
deep tendon reflexes, carpal tunnel syndrome, asymptomatic increase
in CK, seizures
CVS Pericardial effusion, bradycardia, hypotension, worsening CHF and
angina, hypercholesterolemia, hyperhomocysteinemia, myxedema
heart
Respiratory Decreased exercise capacity, hypoventilation secondary to weak
muscles, decreased pulmonary responses to hypoxia, sleep apnea due
to macroglossia
GI Weight gain despite poor appetite, constipation
GU Menorrhagia, amenorrhea, impotence
Dermatological Puffiness of face, periorbital oedema, cool and pale, dry and rough
skin, hair dry and coarse, thinned eyebrows, discolouration
Hematological Anemia usually pernicious
Examination
General
1. Signs of obvious mental and physical
slowness, evidence of myxedema
madness
2. Hypothyroidism speech slow, nasal
and deep pitch
Hands
1. Peripheral cyanosis reduced cardiac
output
2. Swelling of the skin cool and dry
3. Palmar crease pallor Anemia due to:
a. Chronic disease
b. Folate deficiency secondary to
bacterial overgrowth OR Vit B12 deficiency due to pernicious
anemia
c. Iron deficiency due to menorrhagia
4. Pulse small volume and slow
5. Carpal tunnel
Arms
1. Proximal myopathy and hung-up bicep or Achilles tendon reflex
Face
1. Hypercarotenaemia Skin yellow but sclera isn’t
2. Thickened skin
3. Alopecia
4. Vitiligo associated autoimmune disease
5. Eyes periorbital oedema, thinning of eyebrow
6. Xanthelasmata
7. Palpate for coolness and dryness if the skin and hair
8. Tongue swelling, coarse, croaking, slow speech
9. Bilateral nerve deafness
Thyroid
1. Goiter +/-
Chest
1. Pericardial effusion and lungs for pleural effusion
Legs
1. +/- non pitting oedema
2. Signs of peripheral neuropathy
Investigations/Diagnosis/ Criteria
Diagnosis
1. TSH, free T4
2. Anti-thyroid peroxidase and anti-thyroglobulin antibodies (Hashimoto’s)
Treatment
1. Thyroid replacement with levothyroxine, start 50-150mcg od
(1.5ug/kg/day), retest TSH 6 weeks later and titrate until TSH <5. Lower
starting dose if patient at risk for Ischaemic heart disease.
2. Iodine deficiency Schiller’s Iodine (1:30 dilute) 2 drops od x6months
3. Secondary monitor via measurement of free T4
Myxedema Coma Medical Emergency
Definition
Severe hypothyroidism complicated by (made worse with) trauma, sepsis,
cold, MI, inadvertent administration of hypnotics or narcotics, and other
stressful events
Clinical Features
Hallmark decreased mental status, hyponatremia, hypotension,
hypoglycemia, bradycardia, hypoventilation, generalized oedema
Investigations
1. Decreased T4
2. Increased TSH
3. Decreased glucose
4. Check ACTH and cortisol adrenal insufficiency
Treatment aggressive
1. ABC’s ICU
2. Corticosteroids (risk of concomitant adrenal insufficiency)
hydrocortisone
3. L-thyroxine 0.2-0.5mg IV loading dose, 0.1mg IV od until oral therapy
tolerated
4. Supportive measures mechanical ventilation, fluids, vasopressors,
passive rewarming, IV dextrose
5. Monitor for arrhythmia
Hyperthyroidism
Thyroid Disease
Definition
Clinical, physiological and biochemical findings in response to elevated thyroid
hormone.
Etiology
Primary Hyperthyroidism decreased TSH, increased T4
1. Goitrous (enlarged thyroid)
a. Toxic Multi-nodular Goiter common, thyroid has multiple
nodules
b. Graves Disease common in women 20-40, genetic
predisposition leads to antibodies to TSH receptors
i. Unique symptoms diffuse, nontender, proptosis,
diplopia, pretibial myxedema
ii. Diagnosis TSH antibodies
c. Thyroiditis
d. Toxic Adenomas nodule producing T3/T4
2. Non-Goitrous
a. Iodine-induced, struma ovarii (T3/T4 producing ovarian tumour)
Secondary Hyperthyroidism increased TSH, increased T4
1. TSH-secreting pituitary tumour
Clinical Features (“sympathetic overactivity”)
General Fatigue, heat intolerance, irritability, fine tremor
Neurological Proximal muscle weakness, hypokalemic periodic paralysis
CVS Tachycardia, atrial fibrillation, palpitations
GI Weight loss with increased appetite, thirst, increased
frequency of bowel movements
GU Oligomenorrhea, amenorrhea decreased fertility
Dermatological Fine hair, skin moist and warm, vitiligo, soft nails with
onycholysis, palmer erythema, pruritis
Graves: clubbing, pretibial myxedema
Hematological Graves disease: leukopenia, lymphocytosis, splenomegaly,
lymphadenopathy
Eye Graves: lid lag, retraction, proptosis diplopia, decreased
acuity, puffiness, conjunctival injection
MSK Decreased bone mass, proximal muscle weakness
Examination
General
1. Weight loss
2. Anxiety
3. Frightened facies of thyrotoxicosis
Hands
1. Look for a fine tremor
2. Nails onycholysis (separation of nail from its bed)
3. Clubbing
4. Palmar erythema, and feel the palms for warmth and sweatiness
5. Pulse sinus tachycardia, or AF, collapsing character due to high
cardiac output
Arms
1. Proximal myopathy lift hands above head
2. Arm reflexes for abnormal briskness
Eyes
1. Exophthalmos protrusion of the eyeball
from the orbit, look from behind over the
patients forehead
2. Complications of proptosis
a. Chemosis oedema of the conjunctiva
and injection of the sclera
b. Conjunctivitis
c. Corneal ulceration due to inability
to close eyelids
d. Optic atrophy
e. Opthalmoplegia convergence is weakened
3. Thyroid ophthalmopathy
4. Thyroid stare frightened expression and lid retraction (Dalrymples
sign)
5. Lid lag (Graefes sign) ask patient to follow your finger as it descends
at a moderate rate from the upper to lower part of visual fields
6. Ptosis rule out myasthenia gravis
Neck
1. Thyroid enlargement esp in Grave’s disease
2. Thyroidectomy scar
Chest
1. Gynaecomastia
2. Heart systolic flow murmurs, signs of CCF
Legs
1. Pretibial myxedema bilateral firm, elevated dermal nodules and
plaques, which can be pink, brown, skin coloured. Only in Graves
2. Proximal myopathy and hyperreflexia in the legs
Diagnosis/ Investigations
Diagnosis
1. Increased free T4/ free T3, decreased TSH (except tumours)
2. Thyroid ultrasound assess for nodules
3. Radioactive iodine uptake scan
a. Homogenous uptake Graves
b. Heterogeneous increase Multinodular goiter
c. Single “hot nodule” toxic adenoma
d. No uptake thyroiditis, iodine load, struma ovarii
Treatment
1. Beta-Blockers (Propranolol) control tachycardia and decrease
T4T3 conversion
2. Graves/ Thyroiditis: anti-thyroid medication or radiation
a. Carbimazole (thionamides) (inhibit T3/T4 synthesis)
b. Radioactive iodine
3. Nodular Hyperthyroidism surgery or anti-thyroid medication or
radiation
Graves’ Disease
Definition
Autoimmune disorder characterized by antibodies to the TSH receptor that
leads to hyperthyroidism.
Clinical Features
1. Signs and symptoms of thyrotoxicosis
2. Diffuse goiter +/- thyroid bruit secondary to
increased blood flow
3. Ophthalmopathy Proptosis, diplopia,
conjunctival injection, corneal abrasions,
periorbital puffiness, lid lag (Graefes),
decreased visual acuity
4. Dermopathy pretibial myxedema
5. Clubbing
Investigations
1. Low TSH
2. Increased free T4 (+/- increased T3)
3. Positive TSI (thyroid-stimulating immunoglobulin)
4. Increased radio active iodine uptake
5. Homogenous uptake on thyroid scan
Treatment
1. Thionamides PTU (anti-thyroid chemo drugs)
2. Beta-Blocker symptomatic
3. Thyroid ablation
4. Subtotal/ total thyroidectomy
5. Ophthalmopathy smoking cessation, prevent drying, high dose
prednisone, surgical decompression
Thyroid Storm/ Thyrotoxic Crisis Medical Emergency
Definition
Acute exacerbation of thyrotoxicosis presenting in a life-threatening state
secondary to uncontrolled hyperthyroidism
Etiology
Often precipitated by infection, trauma, hyperthermia, drug overdose,
neuroleptic malignant syndrome
Clinical Features
1. Hyperthyroidism
2. Extreme hyperthermia, tachycardia, vomiting, diarrhea, vascular
collapse, hepatic failure with jaundice, and confusion
3. Tachyarrhythmia, CHF, shock
4. Mental status changes ranging from delirium to coma
Laboratory Investigations
1. Increased free T3 and T4, undetectable TSH
2. +/- Anemia, leukocytosis, hyperglycemia, hypercalcaemia, elevated
LFTs
General Measures
1. Fluids, electrolytes, and vasopressor agents
2. Cooling blanker and acetaminophen pyrexia
3. Propranolol beta-adrenergic blockade and decreased peripheral
conversion of T4 T3
Specific Measures
1. PTU high dose
2. Iodine acutely inhibits release of thyroid hormone, 1 hour after first
dose of PTU
a. Sodium iodine 1 gm IV drip over 12h q12h OR
b. Lugols solutions 2-3 drops q8h OR
c. Potassium iodide (SSKI) 5 drops q8h
3. Dexamethasone (steroid) 2-4mg `iv q6h for the first 24-28 hours
