Endocrinology: Hyperthyroidism

Endocrinology: Hyperthyroidism 2018-01-30T16:36:27+00:00

Clinical manifestations

  • Symptoms
    • Anxiety
    • Tremor
    • Palpitations
    • Heat intolerance
    • Increased sweating
    • Weight loss
    • Diarrhoea
    • Menorrhagia
    • Dyspnoea
  • Signs
    • Flushed
    • Tremor
    • Pulse – tachycardia, may be in atrial fibrillation
    • Lid retraction
    • Lid lag
    • Graves’ ophthalmopathy
      • Exophthalmos
      • Periorbital, conjunctival oedema
      • Complex ophthalmoplegia
    • Goitre
      • Tender / non-tender
      • Multi-nodular goitre
      • Single toxic adenoma
    • Proximal myopathy
    • Thyrocardiac disease
      • Displaced apex beat
      • Pulmonary oedema
    • Pretibial myxoedema (Graves’ disease only)

Differential diagnosis

  • Inflammatory
    • Graves’ disease
    • Hashimoto’s thyroiditis (initial phase – Hashitoxicosis)
    • de Quervain’s thyroiditis (associated with coxsackie virus infection)
    • Riedel’s thyroiditis
    • Post-partum thyroiditis
  • Neoplastic
    • Toxic adenoma
    • Multinodular goitre
    • Thyroid carcinoma
    • TSH-secreting adenoma
  • Drugs
    • Iodine-induced hyperthyroidism (amiodarone)
    • Over-replacement of levothyroxine
    • Lithium
    • Interferon-α

Investigations

  • Thyroid screen: thyroid stimulating hormone (low), free T4 (high), free T3 (high)
  • Thyroid-stimulating hormone (TSH) receptor antibodies (TRAb)
  • Radioactive iodine uptake scan
    • Multiple areas of increased uptake (MNG)
    • Single area of increased uptake (toxic adenoma)
    • Diffuse increased uptake (Graves’)
    • Cold nodule (thyroid carcinoma)

Management

  • Multidisciplinary team approach
  • Patient education
  • Smoking cessation (worsens Graves’ ophthalmopathy)
  • β blockade for tachycardia and palpitations (propranolol)
  • Thionamides
    • Carbimazole (first-line
    • Propylthiouracil (preferred during pregnancy)
    • Risk of agranulocytosis
    • Monitor TFTs every 4-6 weeks
    • Suppressed TSH after 18 months predicts long-term treatment failure
  • Radioiodine ablation
    • Oral solition of Na131I, which is rapidly concentrated in thyroid disuse
    • Causes gland destruction and ablation over 6 – 18 weeks
    • Can cause worsening of Graves’ ophthalmopathy
    • Patients must avoid contact with children and pregnant women for two weeks
  • Surgery
    • Thyroidectomy with subsequent levothyroxine replacement

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