Hyperthyroidism

How does toxic multinodular goiter (Plummer's disease) present clinically?

Clinical hyperthyroidism -Diffuse, enlarged thyroid -No skin/eye changes Palpable nodule(s)

How does toxic adenoma present clinically?

Clinical hyperthyroidism -Diffuse, enlarged thyroid -No skin/eye changes Palpable nodule(s) Compressive symptoms: dyspnea, dysphagia, stridor, hoarseness (laryngeal compression)

How is Grave's disease diagnosed?

(+) thyroid-stimulating immunoglobulins (Ab) are the most specific. TFTs will show increased T3/T4 and decreased TSH. RAIU will show diffuse uptake.

What is Grave's disease?

Autoimmune condition most common in women 20-40 years of age. Circulating TSH receptor antibodies cause increased thyroid hormone synthesis, release and thyroid gland growth that is worse with stress (ex: pregnancy, illness). Grave's disease is the most common cause of hyperthyroidism (90%).

What is a TSH-secreting pituitary adenoma?

Autonomous TSH secretion by pituitary adenoma.

What is toxic multinodular goiter (Plummer's disease)?

Autonomous functioning nodules, most common in the elderly.

How does a TSH-secreting pituitary adenoma present clinically?

Clinical hyperthyroidism -Diffuse, enlarged thyroid -Bitemporal hemianopsia -Mental disturbances

How does Grave's disease present clinically?

Diffuse, enlarged thyroid. -Thyroid bruits. Ophthalmopathy: lid lag, exophthalmos/proptosis (exclusive to Grave). -Smoking and iodine may make ophthalmopathy worse. Hyaluronic acid deposition. -Treat with steroids. Pretibial myxedema -Nonpitting, edematous, pink to brown plaques/nodules on shin (exclusive to Grave's disease).

What is toxic adenoma?

One autonomous functioning nodule.

How does thyroid storm present clinically?

Palpitations, tachycardia, atrial fibrillation, high fever, nausea, vomiting, psychosis, tremors (which later may progress to coma and hypotension).

What is thyroid storm (thyrotoxicosis crisis)?

Potentially fatal complication of untreated (or partially treated) thyrotoxicosis usually after a precipitating event (ex: surgery, trauma, infection, illness, pregnancy). Rare (only occurs in 1-2% of patients with hyperthyroidism). High mortality rate (75%).

How is thyroid storm diagnosed?

Primary hyperthyroid TFT profile: -Increased T3/T4 -Decreased TSH

How is Grave's disease managed?

Radioactive iodine is the most common therapy used. -Destroys thyroid gland. -Will need hormone replacement. Methimazole or propylthiouracil. -Block organification of iodine and formation of thyroid hormone. -PTU prevents peripheral conversion of T4 to T3 by deiodinase. Beta blockers for symptomatic relief (tremors, tachycardia, diaphoresis, anxiety, palpitations, etc). Thyroidectomy -If compressive symptoms, no response to medications or if RAI is contraindicated (ex: pregnancy)

How is toxic adenoma treated?

Radioactive iodine is the most common therapy. Surgery (subtotal thyroidectomy) if compressive symptoms are present. Methimazole or PTU -Inhibit hormone synthesis -Methimazole preferred (less side effects) -Both cause agranulocytosis (so monitor WBC) and hepatitis -PTU is preferred in pregnancy, especially first trimester Beta blockers for symptoms of thyrotoxicosis

How is toxic multinodular goiter (Plummer's disease) treated?

Radioactive iodine is the most common therapy. Surgery (subtotal thyroidectomy) if compressive symptoms are present. Methimazole or PTU -Inhibit hormone synthesis -Methimazole preferred (less side effects) -Both cause agranulocytosis (so monitor WBC) and hepatitis -PTU is preferred in pregnancy, especially first trimester Beta blockers for symptoms of thyrotoxicosis

How is a TSH-secreting pituitary adenoma diagnosed?

TFTS will show: -Increased T3/T4 -Increased TSH (inappropriate TSH elevation in the setting of elevated T3/T4) RAIU will show diffuse uptake. Pituitary MRI will show the presence of the adenoma.

How is toxic multinodular goiter (Plummer's disease) diagnosed?

TFTs will show: elevated T3/T4 and decreased TSH RAIU: patchy areas of both increased and decreased uptake.

How is toxic adenoma diagnosed?

TFTs will show: increased T3/T4, decreased TSH RAIU: increased local uptake (hot nodule)

How is a TSH-secreting pituitary adenoma treated?

Transsphenoidal surgery to remove the pituitary adenoma.