Hyperthyroidism

1. ACD 10/20/14 YOGITA ROCHLANI

2. SIMULATED CASE CHIEF COMPLAINT 30 Y.O. WOMAN PRESENTS TO THE ER WITH INCREASING ANXIETY, PALPITATIONS, TREMORS, WEIGHT LOSS.

3. SIMULATED CASE HISTORY OF PRESENT ILLNESS • APPARENTLY HEALTHY UNTIL DELIVERY OF A BABY ABOUT 4 MONTHS AGO • PALPITATIONS AND TREMORS THAT ARE FELT THROUGHOUT THE DAY BUT DON'T HAMPER HER DAILY ACTIVITIES. • SIGNIFICANT WEIGHT LOSS • INTERMITTENT DIARRHEA WITH NO NAUSEA, VOMITING OR ABDOMINAL PAIN. • ALSO HAS A DRY COUGH FOR THE LAST MONTH BUT NO DIFFICULTY SWALLOWING OR BREATHING. • NO FEVERS, CHILLS, RECENT INFECTIONS, PAIN IN THE NECK AREA OR CHANGE IN APPETITE.

4. SIMULATED CASE PHYSICAL EXAM • VITAL SIGNS - TEMP: 98.6 °F , HEART RATE: 125, RESP: 22, BP: 135/70 • GEN: AAO X 3, NOT IN DISTRESS. • HEENT: PERRL, EOMI, NO PALLOR OR JAUNDICE, NORMAL HEARING, GOOD ORAL HYGIENE. EXOPHTHALMOS +, LID LAG + • NECK: SOFT NECK SWELLING THAT MOVES WITH SWALLOWING, NO NODULARITY, 3 X 3 CM IN SIZE WITH LOWER MARGINS NOT FELT, AUDIBLE BRUIT OVER THE THRYOID MASS. NO JVD, MIDLINE TRACHEA, NO LYMPHADENOPATHY. • CHEST: NORMAL BREATHING MOVEMENTS, NO VISIBLE SCARS. • RESP: CLEAR BILATERAL AIR ENTRY, NO WHEEZING OR CRACKLES. • CV:S1 S1 NORMAL, TACHYCARDIC, NO M/R/G, PULSES 2+ BILATERALLY. • GI: SOFT, NOT DISTENDED, NO TENDERNESS, NO ORGANOMEGALY, +BS X 4 • MSS: NO LOWER EXT. EDEMA OR SWELLING, NORMAL PASSIVE AND ACTIVE MOVEMENTS. • NEURO: CN II-XII INTACT, NO FOCAL DEFICITS NOTICED. TREMORS +

5. SIMULATED LABORATORY WORK UP CBC WBC count 7 K/uL Hb – 12 g/dL Platelet count – 150 K/uL BMP Na – 140 mmol/L K – 3.8 mmol/L Cl – 106 mmol/L Co2 – 24 mmol/L BUN – 6 mg/dl Creatinine - 0.3 mg/dl Calcium - 10 mg/dl Glucose - 120 mg/dl UA wnl Thyroid function tests TSH – 0.02 uIU/ml (Normal range 0.34-5.60 uIU/mL) Free T4- 6 (Normal range - 0.58-1.64 ng/dL) Free T3 – 30 (Normal range - 2.5-3.9 pg/mL) TSH receptor Ab – 40 ( Normal range - <=1.75 IU/L)

6. SO YOU DIAGNOSE GRAVES DISEASE • NOW WHAT?

7. HYPERTHYROIDISM

8. EPIDEMIOLOGY • MORE COMMON IN WOMEN THAN MEN (5:1). • INCREASES WITH AGE • MORE COMMON IN SMOKERS

9. HYPERTHYROIDISM - NORMAL OR HIGH RADIOIODINE UPTAKE • GRAVE’S DISEASE • HASHITOXICOSIS • TOXIC ADENOMA • TOXIC MULTI-NODULAR GOITER • IODINE INDUCED HYPERTHYROIDISM • TSH MEDIATED (PITUITARY ADENOMA) • HCG MEDIATED ( HYPEREMESIS GRAVIDARUM, TROPHOBLASTIC DISEASE)

10. HYPERTHYROIDISM -LOW OR ABSENT RADIOIODINE UPTAKE • THYROIDITIS 1. DRUG INDUCED (AMIODARONE) 2. SUB- ACUTE GRANULOMATOUS THYROIDITIS (DE QUVERVAIN’S – PAINFUL) 3. SUB- ACUTE LYMPHOCYTIC THYROIDITIS (POST PARTUM – PAINLESS) 4. RADIATION INDUCED 5. POST SURGICAL – PALPATION THYROIDITIS • ECTOPIC THYROID HORMONE PRODUCTION (STRUMA OVARII, FOLLICULAR THYROID CARCINOMA METS) • EXOGENOUS THYROID HORMONE USE (EXCESSIVE LEVOTHYROXINE USE)

11. CLINICAL FEATURES - HISTORY • ANXIETY, INSOMNIA, TREMORS • PALPITATIONS, NEW ONSET ATRIAL FIBRILLATION, PREMATURE ATRIAL COMPLEXES, DYSPNEA ON EXERTION • DIAPHORESIS • HYPERDEFECATION • WEIGHT LOSS WITH NORMAL OR INCREASED APPETITE • HEAT INTOLERANCE • URINARY FREQUENCY • AMENORRHEA OR OLIGOMENORRHOEA IN WOMEN, GYNECOMASTIA AND ERECTILE DYSFUNCTION IN MEN • MYOPATHY, OSTEOPOROSIS • WEAKNESS AND ASTHENIA ( APATHETIC THYROTOXICOSIS) • WORSENING GLYCEMIC CONTROL • CHF EXACERBATIONS

12. CLINICAL FEATURES – PHYSICAL EXAM • RESTLESSNESS, TREMOR, RAPID SPEECH • TACHYCARDIA – IRREGULAR IRREGULAR, SYSTOLIC HYPERTENSION • PROXIMAL MUSCLE WEAKNESS, HYPERREFLEXIA • MOIST WARM SKIN • THIN, FINE HAIR • EXOPHTHALMOS, CONJUCTIVAL EDEMA, STARE AND LID LAG ( GRAVE’S DISEASE). • PRETIBIAL MYXEDEMA (INFILTRATIVE DERMOPATHY) • THYROID ENLARGEMENT (NO ENLARGEMENT IN PAINLESS THYROIDITIS VS GENERALIZED ENLARGEMENT TMN OR GRAVE’S VS. SINGLE NODULE IN ADENOMA)

13. LABORATORY TESTS • TSH LOW AND SERUM FREE T4 AND/ OR SERUM T3 HIGH - SUBCLINICAL HYPERTHYROIDISM – TSH LOW, T4 AND T3 ARE NORMAL - T3 TOXICOSIS – T3>> FT4 ( GRAVE’S DISEASE, NODULAR GOITER) - T4 TOXICOSIS – HIGH FT4 AND NORMAL T3 DUE TO DECREASE IN THE PERIPHERAL T4 TO T3 CONVERSION (EG. AMIODARONE, CONCURRENT ILLNESS). • TESTING FOR ETIOLOGY - 24 HOUR RI UPTAKE SCAN - THYROTROPIN RECEPTOR ANTIBODIES • TSH HIGH AND FT4 AND/OR T3 HIGH - SCREEN FOR THYROTROPIN SECRETING PITUITARY ADENOMA WITH MRI AND SERUM ALPHA SUBUNIT - RESISTANCE TO FEEDBACK DUE TO GENETIC DEFECTS

14. MANAGEMENT • BETA BLOCKERS – ATENOLOL 25-50 MG /DAY • THIONAMIDES – FOR 3-8 WEEKS PRIOR TO ABLATION, CI IN ANC < 500 AND TRANSAMINASE ELEVATION – METHIMAZOLE - ONCE DAILY DOSING, RAPID EFFICACY, LOWER SIDE EFFECTS, 10-30 MG DIALY - PROPYLTHIOURACIL – PREFERRED IN THE 1ST TRIMESTER OF PREGNANCY • IODINE OR IODINATED CONTRAST AGENTS • RADIOIODINE ABLATION VS. SURGERY FOR PERMANENT REMISSION • OTHER AGENTS – STEROIDS, LITHIUM, CHOLESTYRAMINE, CARNITINE, RITUXIMAB