Difference between revisions of "Hyperthyroidism"

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==Background==
 
==Background==
 
*Hyperthyroidism: Excess circulating hormone resulting from thyroid gland hyperfunction
 
*Hyperthyroidism: Excess circulating hormone resulting from thyroid gland hyperfunction
*Thyrotoxicosis: Excess circulating thyroid hormone originating from any cause
+
*[[Thyrotoxicosis]]: Excess circulating thyroid hormone originating from any cause
  
 
===Causes===
 
===Causes===
*Primary Hyperthyroidism  
+
'''Primary Hyperthyroidism'''
**Graves disease (toxic diffuse goiter)
+
*Graves disease (toxic diffuse goitre)
***Most common cause (85% of cases)
+
**Most common cause of hyperthyroidism (85% of cases)
***Associated with diffuse goiter, ophthalmopathy, local dermopathy
+
**Autoantibodies bind to TSH receptor and stimulate thyroid hormone production and release <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
**Toxic multinodular goiter
+
**Associated with diffuse goitre, ophthalmopathy, local dermopathy
***2nd most common cause
+
**Strong genetic relationship, often found with other autoimmune disorders <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
**Toxic nodular (adenoma) goiter
+
*Toxic multinodular goitre
***Enlarged thyroid gland w/ small nodules that overproduce thyroid hormone
+
**2nd most common cause
*Secondary Hyperthyroidism  
+
**Multiple autonomously functioning nodules <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
**Thyrotropin-secreting pituitary adenoma
+
**Milder, more gradual disease than Graves' hyperthyroidism
**Thyroiditis
+
*Toxic nodular (adenoma) goitre
 +
**Single hyperfunctioning nodule
 +
**Similar presentation to multinodular goitre, but less common <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
 +
 
 +
 
 +
'''Secondary Hyperthyroidism'''
 +
*Thyrotropin-secreting pituitary adenoma
 +
*Thyroiditis
 
**Hashimoto thyroiditis
 
**Hashimoto thyroiditis
 +
***Autoimmune disorder
 +
***Thyroid antibodies and lymphocytic infiltration <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
 +
***Painless goitre
 
***Initially gland is overactive (hyperthyroidism state) followed by hypothyroidism
 
***Initially gland is overactive (hyperthyroidism state) followed by hypothyroidism
**Subacute painful thyroiditis (de Quervain thyroiditis)
+
**Subacute painful thyroiditis (de Quervain thyroiditis)<ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
**Subacute painless thyroiditis
+
***May be caused by viral infection
 +
***Viral prodrome followed by anterior neck pain
 +
***Tender thyroid (palpation, head movement, swallowing)
 +
***50% have symptoms of hyperthyroid lasting 3 - 6 weeks
 +
***1/3 have hypothyroidism for up to 6 months
 +
**Subacute painless thyroiditis <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
 +
***Small, non-tender goitre
 +
***Mild symptoms
 +
***Autoimmune
 +
**Postpartum thyroiditis <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
 +
***3 phases:
 +
****Thyrotoxic phase 2 -6 months postpartum (20-30% have only this phase)
 +
****Hypothyroid phase lasting 2 -3 months (but may be permanent) (40% have this phase only)
 +
****Euthyroid phase within first postpartum year
 +
***Some women develop permanent hypothyroidism
 +
***70% recurrence in subsequent pregnancies
 +
**Suppurative thyroiditis <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
 +
***Rare
 +
***Life-threatening
 +
***Infection usually bacterial, but can be parasitic, mycobacterial, or fungal
 +
***Usually have pre-existing thyroid disorder and immune compromise
 
**Radiation thyroiditis  
 
**Radiation thyroiditis  
*Other causes
+
'''Other causes:'''
**Metastatic thyroid cancer
+
*Apathetic thyrotoxicosis (elderly, masking comorbidities)
**Iodine-induced thyrotoxicosis
+
*Metastatic thyroid cancer
**Amiodarone (contains iodine)
+
*Iodine-induced thyrotoxicosis
 +
*[[Amiodarone]]-induced thyroiditis <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
 +
**Possible mechanisms:
 +
***Drug-induced destructive thyroiditis
 +
***Hyperthyroidism caused by iodine load (amiodarone contains a large amount of iodine)
 +
**Drug-induced thyroiditis may also occur with interleukin-2, [[Interferon-α]], [[lithium]], tyrosine kinase inhibitors, HAART
 +
*[[Molar pregnancy]]
 +
 
 +
{{Thyroid gen background}}
  
 
==Clinical Features==
 
==Clinical Features==
*Constitutional
+
[[File:PMC5384127 TJO-47-94-g6.png|thumb|Bilateral infiltrative thyroid-associated exophthalmos]]
**Lethargy
+
[[File:PMC3742527 OL-06-01-0144-g00.png|thumb|Enlarged and homogeneous thyroid.]]
**Diaphoresis
+
[[File:PMC3371544 IJD-57-247-g002.png|thumb|"Plummer's nail" demonstrating onycholysis (separation of the nail from the nail bed). Abnormal nail findings occurs in about 5% of hyperthyroid patients.]]
**Weakness
+
'''Constitutional signs:'''
**Fever
+
*[[Lethargy]]
**Heat intolerance
+
*Diaphoresis
**Weight loss
+
*[[Weakness]]
*Neuropsychiatric
+
*[[Fever]]
**Emotional lability
+
*Heat intolerance
**Fine tremor
+
*Weight loss
**Anxiety
+
'''Neuropsychiatric:'''
**Muscle wasting
+
*Emotional lability
**Confusion
+
*Fine [[tremor]]
**Hyperreflexia
+
*[[Anxiety]]
**Coma
+
*Muscle wasting
**Periodic paralysis
+
*[[Confusion]]
**Psychosis  
+
*Hyperreflexia
*Ophthalmologic
+
*[[Coma]]
**[[Diplopia]]
+
*[[Thyrotoxic periodic paralysis|Periodic paralysis]]
**Lid lag
+
*Psychosis  
**Eye irritation
+
'''Ophthalmologic:'''
**Exophthalmos
+
*[[Diplopia]]
**Ophthalmoplegia
+
*Lid lag
*Endocrine
+
*Eye irritation
**Neck fullness/tenderness (thyroid gland)
+
*Exophthalmos
*Cardiorespiratory
+
*Ophthalmoplegia
**Dyspnea
+
'''Endocrine:'''
**Widened pulse pressure
+
*Neck fullness/tenderness (thyroid gland)
**Palpitations
+
'''Cardiorespiratory:'''
**Systolic hypertension
+
*[[Dyspnea]]
**Chest pain
+
*Widened pulse pressure
**Sinus tachycardia
+
*[[Palpitations]]
**A-fib/flutter
+
*Systolic [[hypertension]]
**CHF
+
*[[Chest pain]]
*GI
+
*[[Sinus tachycardia]]
**Diarrhea
+
*[[Atrial fibrillation]]
**Hyperactive bowel sounds
+
**Occurs in 10-20% of patients and can revert to sinus rhythm when hyperthyroidism treated
*Reproductive
+
*[[Atrial flutter]]
**Oligomenorrhea
+
*[[CHF]]
**Gynecomastia
+
'''GI:'''
**Telangiectasia
+
*[[Diarrhea]]
*Gynecologic
+
*Hyperactive bowel sounds
**Menorrhagia
+
'''Reproductive:'''
**Sparse pubic hair
+
*Oligomenorrhea
*Hematologic
+
*Gynecomastia
**Anemia
+
*Telangiectasia
**Leukocytosis
+
'''Gynecologic:'''
*Dermatologic
+
*Menorrhagia
**Hair loss
+
*Sparse pubic hair
**Pretibial myxedema
+
'''Hematologic:'''
**Warm, moist skin
+
*[[Anemia]]
**Palmar erythema
+
*[[Leukocytosis]]
**Onycholysis
+
'''Dermatologic:'''
 +
*[[alopecia|Hair loss]]
 +
*Pretibial myxedema
 +
*Warm, moist skin
 +
*Palmar erythema
 +
*Onycholysis
 +
'''Apathetic hyperthyroidism:''' (elderly patients)<ref>Rehman SU et al. Thyroid Disorders in Elderly Patients. South Med J. 2005;98(5):543-549.</ref>
 +
*Placid apathetic facies
 +
*Depression
 +
*Lethargy
 +
*Muscular weakness and wasting
 +
*Excessive weight loss
 +
*Cardiac [[dysrhythmias]]
 +
*Absent or small goiter
 +
*Absence of ocular symptoms
 +
*[[Agitation]] and [[confusion]]
  
==Diagnosis==
+
==Differential Diagnosis (Tachycardia)==
 +
*[[Anemia]]
 +
*[[Dehydration]]
 +
*[[Fever]]
 +
*[[Infection]], [[Sepsis]]
 +
*[[Anion gap acidosis]]
 +
*[[Hyperthyroid]]
 +
*[[Arrhythmia]]
 +
*[[PE]]
 +
*[[CHF]]
 +
*[[MI]]
 +
*[[Tamponade]]
 +
*[[Myocardial contusion]]
 +
*Cardiac [[valvular emergencies|valvular disease]]
 +
*Hyper/[[hypoglycemia]]
 +
*[[drug overdose|Drug intoxication]]
 +
*Drug withdrawal
 +
*Toxicity
 +
**[[salicylate toxicity|ASA]]
 +
**[[TCA toxicity|TCA]]
 +
**[[Anticholinergic toxicity|Anticholinergic]]
 +
**[[Theophylline toxicity|Theophylline]]
 +
*Pain
 +
*Psych (anger, fear)
 +
 
 +
==Evaluation==
 
===Workup===
 
===Workup===
*Decreased TSH
+
*TSH (↓)
*Increased free T4
+
*Free T4 (↑)
*Increased free T3
+
*Free T3 (↑)
 +
 
 +
===Diagnosis===
 +
[[File:thyroid studies.JPG|px200]]
  
==Treatment==
+
==Management==
*Beta-antagonists
+
*If asymptomatic or mild symptoms, no treatment required in ED
*Methimazole
+
*If symptomatic, consider [[Thyroid storm]]
*Propylthiouracil
 
*Radioactive iodine
 
*Surgery
 
  
===In Pregnancy===
+
==Disposition==
*Propylthiouracil - 1st Trimester<ref>http://www.womenshealth.gov/publications/our-publications/fact-sheet/graves-disease.html*f</ref>
+
*If asymptomatic or no thyroid storm, discharge with outpatient follow-up.
*Methimazole - 2nd Trimester and on<ref>http://www.womenshealth.gov/publications/our-publications/fact-sheet/graves-disease.html*f</ref>
+
*Admit for significant symptoms or thyroid storm.
  
 
==See Also==
 
==See Also==
*[[Thyroid Storm]]
+
*[[Thyroid storm]]
*[[Thyroid (General)]]
+
*[[Thyroid (Main)]]
  
==Source ==
+
==References==
*Tintinalli
+
<references/>
*http://www.womenshealth.gov/publications/our-publications/fact-sheet/graves-disease.html*f
 
<references/>  
 
  
[[Category:Endo]]
+
[[Category:Endocrinology]]

Latest revision as of 23:23, 17 December 2019

Background

  • Hyperthyroidism: Excess circulating hormone resulting from thyroid gland hyperfunction
  • Thyrotoxicosis: Excess circulating thyroid hormone originating from any cause

Causes

Primary Hyperthyroidism

  • Graves disease (toxic diffuse goitre)
    • Most common cause of hyperthyroidism (85% of cases)
    • Autoantibodies bind to TSH receptor and stimulate thyroid hormone production and release [1]
    • Associated with diffuse goitre, ophthalmopathy, local dermopathy
    • Strong genetic relationship, often found with other autoimmune disorders [2]
  • Toxic multinodular goitre
    • 2nd most common cause
    • Multiple autonomously functioning nodules [3]
    • Milder, more gradual disease than Graves' hyperthyroidism
  • Toxic nodular (adenoma) goitre
    • Single hyperfunctioning nodule
    • Similar presentation to multinodular goitre, but less common [4]


Secondary Hyperthyroidism

  • Thyrotropin-secreting pituitary adenoma
  • Thyroiditis
    • Hashimoto thyroiditis
      • Autoimmune disorder
      • Thyroid antibodies and lymphocytic infiltration [5]
      • Painless goitre
      • Initially gland is overactive (hyperthyroidism state) followed by hypothyroidism
    • Subacute painful thyroiditis (de Quervain thyroiditis)[6]
      • May be caused by viral infection
      • Viral prodrome followed by anterior neck pain
      • Tender thyroid (palpation, head movement, swallowing)
      • 50% have symptoms of hyperthyroid lasting 3 - 6 weeks
      • 1/3 have hypothyroidism for up to 6 months
    • Subacute painless thyroiditis [7]
      • Small, non-tender goitre
      • Mild symptoms
      • Autoimmune
    • Postpartum thyroiditis [8]
      • 3 phases:
        • Thyrotoxic phase 2 -6 months postpartum (20-30% have only this phase)
        • Hypothyroid phase lasting 2 -3 months (but may be permanent) (40% have this phase only)
        • Euthyroid phase within first postpartum year
      • Some women develop permanent hypothyroidism
      • 70% recurrence in subsequent pregnancies
    • Suppurative thyroiditis [9]
      • Rare
      • Life-threatening
      • Infection usually bacterial, but can be parasitic, mycobacterial, or fungal
      • Usually have pre-existing thyroid disorder and immune compromise
    • Radiation thyroiditis

Other causes:

  • Apathetic thyrotoxicosis (elderly, masking comorbidities)
  • Metastatic thyroid cancer
  • Iodine-induced thyrotoxicosis
  • Amiodarone-induced thyroiditis [10]
    • Possible mechanisms:
      • Drug-induced destructive thyroiditis
      • Hyperthyroidism caused by iodine load (amiodarone contains a large amount of iodine)
    • Drug-induced thyroiditis may also occur with interleukin-2, Interferon-α, lithium, tyrosine kinase inhibitors, HAART
  • Molar pregnancy

Spectrum of Thyroid Disease

Thyroid physiology

Clinical Features

Bilateral infiltrative thyroid-associated exophthalmos
Enlarged and homogeneous thyroid.
"Plummer's nail" demonstrating onycholysis (separation of the nail from the nail bed). Abnormal nail findings occurs in about 5% of hyperthyroid patients.

Constitutional signs:

Neuropsychiatric:

Ophthalmologic:

  • Diplopia
  • Lid lag
  • Eye irritation
  • Exophthalmos
  • Ophthalmoplegia

Endocrine:

  • Neck fullness/tenderness (thyroid gland)

Cardiorespiratory:

GI:

Reproductive:

  • Oligomenorrhea
  • Gynecomastia
  • Telangiectasia

Gynecologic:

  • Menorrhagia
  • Sparse pubic hair

Hematologic:

Dermatologic:

  • Hair loss
  • Pretibial myxedema
  • Warm, moist skin
  • Palmar erythema
  • Onycholysis

Apathetic hyperthyroidism: (elderly patients)[11]

  • Placid apathetic facies
  • Depression
  • Lethargy
  • Muscular weakness and wasting
  • Excessive weight loss
  • Cardiac dysrhythmias
  • Absent or small goiter
  • Absence of ocular symptoms
  • Agitation and confusion

Differential Diagnosis (Tachycardia)

Evaluation

Workup

  • TSH (↓)
  • Free T4 (↑)
  • Free T3 (↑)

Diagnosis

px200

Management

  • If asymptomatic or mild symptoms, no treatment required in ED
  • If symptomatic, consider Thyroid storm

Disposition

  • If asymptomatic or no thyroid storm, discharge with outpatient follow-up.
  • Admit for significant symptoms or thyroid storm.

See Also

References

  1. Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
  2. Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
  3. Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
  4. Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
  5. Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
  6. Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
  7. Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
  8. Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
  9. Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
  10. Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
  11. Rehman SU et al. Thyroid Disorders in Elderly Patients. South Med J. 2005;98(5):543-549.