Difference between revisions of "Hyperthyroidism"

(Clinical Features)
(Clinical Features)
 
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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
 +
**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 multinodular goitre
 
**2nd most common cause
 
**2nd most common cause
*Toxic nodular (adenoma) goiter
+
**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>
**Enlarged thyroid gland w/ small nodules that overproduce thyroid hormone
+
**Milder, more gradual disease than Graves' hyperthyroidism
 +
*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'''  
 
'''Secondary Hyperthyroidism'''  
 
*Thyrotropin-secreting pituitary adenoma
 
*Thyrotropin-secreting pituitary adenoma
 
*Thyroiditis
 
*Thyroiditis
*Hashimoto thyroiditis
+
**Hashimoto thyroiditis
**Initially gland is overactive (hyperthyroidism state) followed by hypothyroidism
+
***Autoimmune disorder
*Subacute painful thyroiditis (de Quervain thyroiditis)
+
***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>
*Subacute painless thyroiditis
+
***Painless goitre
*Radiation thyroiditis  
+
***Initially gland is overactive (hyperthyroidism state) followed by hypothyroidism
 +
**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>
 +
***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  
 
'''Other causes:'''
 
'''Other causes:'''
*[[Apathetic thyrotoxicosis]] (elderly, masking comorbidities)
+
*Apathetic thyrotoxicosis (elderly, masking comorbidities)
 
*Metastatic thyroid cancer
 
*Metastatic thyroid cancer
 
*Iodine-induced thyrotoxicosis
 
*Iodine-induced thyrotoxicosis
*Amiodarone (contains iodine)
+
*[[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]]
 
*[[Molar pregnancy]]
 +
 +
{{Thyroid gen background}}
  
 
==Clinical Features==
 
==Clinical Features==
'''Constitutional signs:''
+
[[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.]]
 +
[[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.]]
 +
'''Constitutional signs:'''
 +
*[[Lethargy]]
 
*Diaphoresis
 
*Diaphoresis
*Weakness
+
*[[Weakness]]
*Fever
+
*[[Fever]]
 
*Heat intolerance
 
*Heat intolerance
 
*Weight loss
 
*Weight loss
'''Neuropsychiatric:''
+
'''Neuropsychiatric:'''
 
*Emotional lability
 
*Emotional lability
*Fine tremor
+
*Fine [[tremor]]
*Anxiety
+
*[[Anxiety]]
 
*Muscle wasting
 
*Muscle wasting
*Confusion
+
*[[Confusion]]
 
*Hyperreflexia
 
*Hyperreflexia
*Coma
+
*[[Coma]]
*Periodic paralysis
+
*[[Thyrotoxic periodic paralysis|Periodic paralysis]]
 
*Psychosis  
 
*Psychosis  
 
'''Ophthalmologic:'''
 
'''Ophthalmologic:'''
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*Neck fullness/tenderness (thyroid gland)
 
*Neck fullness/tenderness (thyroid gland)
 
'''Cardiorespiratory:'''
 
'''Cardiorespiratory:'''
*Dyspnea
+
*[[Dyspnea]]
 
*Widened pulse pressure
 
*Widened pulse pressure
*Palpitations
+
*[[Palpitations]]
*Systolic hypertension
+
*Systolic [[hypertension]]
*Chest pain
+
*[[Chest pain]]
*Sinus tachycardia
+
*[[Sinus tachycardia]]
*A-fib/flutter
+
*[[Atrial fibrillation]]
*CHF
+
**Occurs in 10-20% of patients and can revert to sinus rhythm when hyperthyroidism treated
 +
*[[Atrial flutter]]
 +
*[[CHF]]
 
'''GI:'''
 
'''GI:'''
*Diarrhea
+
*[[Diarrhea]]
 
*Hyperactive bowel sounds
 
*Hyperactive bowel sounds
 
'''Reproductive:'''
 
'''Reproductive:'''
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*Sparse pubic hair
 
*Sparse pubic hair
 
'''Hematologic:'''
 
'''Hematologic:'''
*Anemia
+
*[[Anemia]]
*Leukocytosis
+
*[[Leukocytosis]]
 
'''Dermatologic:'''
 
'''Dermatologic:'''
*Hair loss
+
*[[alopecia|Hair loss]]
 
*Pretibial myxedema
 
*Pretibial myxedema
 
*Warm, moist skin
 
*Warm, moist skin
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*Onycholysis
 
*Onycholysis
 
'''Apathetic hyperthyroidism:''' (elderly patients)<ref>Rehman SU et al. Thyroid Disorders in Elderly Patients. South Med J. 2005;98(5):543-549.</ref>
 
'''Apathetic hyperthyroidism:''' (elderly patients)<ref>Rehman SU et al. Thyroid Disorders in Elderly Patients. South Med J. 2005;98(5):543-549.</ref>
*Placid apaethetic facies
+
*Placid apathetic facies
 
*Depression
 
*Depression
 
*Lethargy
 
*Lethargy
 
*Muscular weakness and wasting
 
*Muscular weakness and wasting
 
*Excessive weight loss
 
*Excessive weight loss
*Cardiac dysrrhythmias
+
*Cardiac [[dysrhythmias]]
 
*Absent or small goiter
 
*Absent or small goiter
 
*Absence of ocular symptoms
 
*Absence of ocular symptoms
*Agitation and confusion
+
*[[Agitation]] and [[confusion]]
  
 
==Differential Diagnosis (Tachycardia)==
 
==Differential Diagnosis (Tachycardia)==
*Anemia
+
*[[Anemia]]
*Dehydration
+
*[[Dehydration]]
 
*[[Fever]]
 
*[[Fever]]
*Drug intoxication
+
*[[Infection]], [[Sepsis]]
*Drug withdrawal
+
*[[Anion gap acidosis]]
*Pain
 
*Infection
 
*Anion gap acidosis
 
*[[Sepsis]]
 
 
*[[Hyperthyroid]]
 
*[[Hyperthyroid]]
*Psych (anger, fear)
 
 
*[[Arrhythmia]]
 
*[[Arrhythmia]]
 
*[[PE]]
 
*[[PE]]
 
*[[CHF]]
 
*[[CHF]]
 +
*[[MI]]
 
*[[Tamponade]]
 
*[[Tamponade]]
 
*[[Myocardial contusion]]
 
*[[Myocardial contusion]]
*Cardiac valvular disease
+
*Cardiac [[valvular emergencies|valvular disease]]
 
*Hyper/[[hypoglycemia]]
 
*Hyper/[[hypoglycemia]]
*AMI
+
*[[drug overdose|Drug intoxication]]
 +
*Drug withdrawal
 
*Toxicity
 
*Toxicity
**ASA
+
**[[salicylate toxicity|ASA]]
**TCA
+
**[[TCA toxicity|TCA]]
**Anticholinergic
+
**[[Anticholinergic toxicity|Anticholinergic]]
**Theophylline
+
**[[Theophylline toxicity|Theophylline]]
 +
*Pain
 +
*Psych (anger, fear)
  
==Diagnosis==
+
==Evaluation==
 
===Workup===
 
===Workup===
 
*TSH (↓)
 
*TSH (↓)
 
*Free T4 (↑)
 
*Free T4 (↑)
 
*Free T3 (↑)
 
*Free T3 (↑)
 +
 +
===Diagnosis===
 +
[[File:thyroid studies.JPG|px200]]
  
 
==Management==
 
==Management==

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.