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Thyroid Disease
Dr Mastura Hj Ismail
FMSKK Seremban 2
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Thyroid Hormone Excess
Clinical Features General
Heat intolerance, fatigue, tremor, sweating
Cardiovascular Tachycardia, heart failure.
Gastrointestinal
Weight loss, diarrhoea Ophthalmological
Lid lag, ophthalmopathy
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Thyroid Hormone Excess
Clinical Features Genitourinary
Amenorrhea, infertility.
Neuromuscular Proximal muscle weakness
Psychiatric
Irritability, agitation, anxiety, psychosis Dermatological
Pruritus, hair thinning, onycholysis, vitiligo.
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Diagnosis High Free T4, T3 and supressed
sTSH
If sTSH is high suspect pituitary tumouror rare cases of thyroid hormoneresistance
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There may be mild normochromicanemia, mild leucopaenia,
Raised ESR, Se Calcium and LFT
Thyroid antibodies
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Causes of Thyroid Hormone
Excess Increased radioactive iodine uptake
Graves
TMG
Toxic solitary adenoma
Pituitary tumour
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Causes of Thyroid Hormone
Excess Reduced radioactive iodine uptake
Thyroiditis
Iodine induced (amiodarone)
Lithium (hypothyroid is commoner)
Factitious: thyroxine intoxication
Struma ovarii: ovarian teratoma containingthyroid tissue
Metastatic follicular thyroid carcinoma
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Isotope scan If cause is unclear, to detect nodular
disease or subacute thyroiditis
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Isotope scan
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Graves Disease Common between 30-50 years
Diffuse Goitre
Hyperthyroidism
Ophthalmopathy
Dermopathy Autoimmune. TSI.
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Grave Disease only Eye disease: exopthalmos,
ophthalmoplegia
Pre-tibial myxoedema oedematousswelling above lateral malleleolai
Thyroid acropachy-extreme
manisfestation with clubbing, painfulfingers, toes swelling and periostealreaction in limbs bones
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TMG Older
Nodules that secrete thyroid hormones
Usually less severe hyperthyroidism
May have subclinical hyperthyroidism
May have long history of goitre
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Toxic Solitary Adenoma Rare cause (< 2% of patients with
hyperthyroidism)
Younger people 30s and 40s
Scansolitary hot nodule
Benign follicular adenomas
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Thyroiditis Self-limiting viral infection
Painful goitre(subacute, de Quervains),
fever, raised ESR
Painless (post partum)
Hyperthyroid, hypothyroid andeuthyroid phases
Anti thyroid drug therapy does not work
Tx: NSAIDs
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Treatment of hyperthyroidism
Antithyroid drugs Carbimazole 20-45 mg/24 hours
Reduce to maintenance after 4 -8weeks accordingTFT
Maintenance :minimum for 18 months Side effect: Rash, GI, agranulocytosis (can lead to
life threatening sepsis). Warn to stop and dourgent 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
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Treatment of hyperthyroidism Block Replacement Regime: Give
carbimazole and thyroxine
simultaneously (less risk of iatrogenichypothyroidism)
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Rapid symptom control Beta blocker: e.g propranolol
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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
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Treatment of Hyperthyroidism Surgery
Rarely used nowadays
Need to be rendered euthyroid beforesurgery
Lugols iodine 0.1-0.3 mls tid for 10 days
before surgery Risk damage to recurrent laryngeal nerve
and hypoparathyroidism
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Treatment of Hyperthyroidism In pregnancy and infancy: get expert
help
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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
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Thyroid Storm Carbimazole (or PTU)
Propranolol, 80mg qid
Iodine (Lugols 5 drops q6)
Dexamethasone 2mg q6
Other supportive measures
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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, elevatehead of bed, conjunctival lubricants
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Graves Eye Disease High dose steroids
External radiotherapy
Orbital decompression
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Complications Heart failure (thyrotoxic
cardiomyopathy esp in elderly)
Angina, AF
Osteoporosis
Opthalmopathy
Gynecomastia
Thyroid storm
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Causes Hypothyroidism Autoimmune:
i)Hashimotos
ii) Primary atrophic hypothyroidism: no goitre Iodine deficiency: poor intake
Drug induced: antithyroid drugs, amiodarone,
lithium, iodine Congenital
Hypopituitarism
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Symptom hypothyroidism Tiredness, lethargy, depression, dislike
of cold, weight gain, constipation,
menorrhagia, hoarse voice, poorcognition/dementia, myalgia
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Signs Bradycardia
Dry skin and hair
Non-pitting oedema (eye lids, hands,feet)
Cerebellar ataxia
Slow relaxing reflexes, peripneuropathy, toad-like face
There may be goitre
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Diagnosis Raised TSH, Low T4
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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 lowerdose e.g. 25ug perday. Increase doseslowly
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Subclinical hypothyroidism Suspec t if TSH high but normal T4 and
T3, no obvious symptoms
Common, 10% of those above 55 yearsold
Risk progression to frank
hypothyroidism is about 2% andincrease as TSH higher
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Mx subclinical hypothyroidism Confirm that raised TSH is persistent (recheck
in 2-4 months)
Recheck the history for any non-specificfeatures 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
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Subclinical hyperthyroidism Low TSH, normal T4 and T3
Confirm that raised T4 is persistent (recheck in 2-4months)
Recheck for non-thyroidal causes:illness, pregnancy,pituitary insufficiency
Discuss benefit of tx with patients
If TSH
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Simple non-toxic goitre Normal TFTs
No treatment required
Surgery if obstructive symptoms
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Non-thyroidal illness Ill patients may have low T3 and/or T4
usually with a normal sTSH
Psychotic patients may have elevatedT3 and/or T4.
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Thyroid Nodule FNA
Benign no further intervention
Malignant or suspicious papillary orfollicular.
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Papillary Cancer Controversies
Extent of surgery (near total
thyroidectomy). Follow up with sTSH,thyroglobulin exam and US.
Radioactive iodine ablation for high risktumours. Follow up with RAI scans plusthe above.
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Follicular cancer Less common than papillary
Total thyroidectomy (or near total).
Routine remnant ablation with RAI dueto increased risk of metastatic disease.
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