Difference between revisions of "Hyperthyroidism"

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(Clinical Features)
 
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==Background==
 
==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 <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref>
 +
**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
 +
**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>
 +
**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>
  
Precipitants:
 
  
-infc
+
'''Secondary Hyperthyroidism'''
 +
*Thyrotropin-secreting pituitary adenoma
 +
*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
 +
**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:'''
 +
*Apathetic thyrotoxicosis (elderly, masking comorbidities)
 +
*Metastatic thyroid cancer
 +
*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]]
  
-surg
+
{{Thyroid gen background}}
  
-trauma
+
==Clinical Features==
 +
[[File:PMC5384127 TJO-47-94-g6.png|thumb|Bilateral infiltrative thyroid-associated exophthalmos]]
 +
[[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
 +
*[[Weakness]]
 +
*[[Fever]]
 +
*Heat intolerance
 +
*Weight loss
 +
'''Neuropsychiatric:'''
 +
*Emotional lability
 +
*Fine [[tremor]]
 +
*[[Anxiety]]
 +
*Muscle wasting
 +
*[[Confusion]]
 +
*Hyperreflexia
 +
*[[Coma]]
 +
*[[Thyrotoxic periodic paralysis|Periodic paralysis]]
 +
*Psychosis
 +
'''Ophthalmologic:'''
 +
*[[Diplopia]]
 +
*Lid lag
 +
*Eye irritation
 +
*Exophthalmos
 +
*Ophthalmoplegia
 +
'''Endocrine:'''
 +
*Neck fullness/tenderness (thyroid gland)
 +
'''Cardiorespiratory:'''
 +
*[[Dyspnea]]
 +
*Widened pulse pressure
 +
*[[Palpitations]]
 +
*Systolic [[hypertension]]
 +
*[[Chest pain]]
 +
*[[Sinus tachycardia]]
 +
*[[Atrial fibrillation]]
 +
**Occurs in 10-20% of patients and can revert to sinus rhythm when hyperthyroidism treated
 +
*[[Atrial flutter]]
 +
*[[CHF]]
 +
'''GI:'''
 +
*[[Diarrhea]]
 +
*Hyperactive bowel sounds
 +
'''Reproductive:'''
 +
*Oligomenorrhea
 +
*Gynecomastia
 +
*Telangiectasia
 +
'''Gynecologic:'''
 +
*Menorrhagia
 +
*Sparse pubic hair
 +
'''Hematologic:'''
 +
*[[Anemia]]
 +
*[[Leukocytosis]]
 +
'''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]]
  
-dka
+
==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)
  
-hypoglycemia
+
==Evaluation==
 +
===Workup===
 +
*TSH (↓)
 +
*Free T4 (↑)
 +
*Free T3 (↑)
  
-palpation of gland
+
===Diagnosis===
 +
[[File:thyroid studies.JPG|px200]]
  
-withdrawal of meds
+
==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.
==DDX==
+
*Admit for significant symptoms or thyroid storm.
 
 
 
 
Grave's Disease
 
 
 
- exophthalmos, increased metabolism, pretib myxedema
 
 
 
- ab stim tsh receptor
 
 
 
- decreased tsh conc
 
 
 
- increased radioactive iodine uptake RAI
 
 
 
- tx first with propylthiouracil or methimazole, then either albation, surg or more meds. Meds I organfication of I2
 
 
 
 
 
 
==Treatment==
 
 
 
 
 
1) If no CHF, hydrate with D5NS
 
 
 
2) Prograffin 3 gms qd (stops conversion and release)
 
 
 
3) Propranolol 1-2 mg IV up to 0.1 mg/kg q 1- 2 h. or 40- 80 mg q6h. for conv & betablock. not if chf or brochospasm
 
 
 
4) Iodide 30 ggts KI/d in divided doses or 0.5- 1.0 gm KaI in 1L ns q 12h. or sski 5 ggts q 6h. (stops release from gland)
 
 
 
5) Dexamethasone 2mg q6 or hydrocortisone 100mg iv qh (stops conversion)
 
 
 
6) Dopamine if hypotensive
 
 
 
 
  
 
==See Also==
 
==See Also==
 +
*[[Thyroid storm]]
 +
*[[Thyroid (Main)]]
  
 +
==References==
 +
<references/>
  
Endo: Thyroid Storm
+
[[Category:Endocrinology]]
 
 
Endo: Thyroid (General)
 
 
 
 
 
 
==Source ==
 
 
 
 
 
6/06 MISTRY
 
 
 
 
 
 
 
 
 
[[Category:Endo]]
 

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.