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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
##Hashimoto thyroiditis
**Single hyperfunctioning nodule
###Initially gland is overactive (hyperthyroidism state) followed by hypothyroidism
**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>
##Subacute painful thyroiditis (de Quervain thyroiditis)
 
##Subacute painless thyroiditis
 
##Radiation thyroiditis  
'''Secondary Hyperthyroidism'''
#Other causes
*Thyrotropin-secreting pituitary adenoma
##Metastatic thyroid cancer
*Thyroiditis
##Iodine-induced thyrotoxicosis
**Hashimoto thyroiditis
##Amiodarone (contains iodine)
***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]]
 
{{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]]
 
==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)
 
{{Palpitations DDX}}
 
==Evaluation==
===Workup===
*TSH (↓)
*Free T4 (↑)
*Free T3 (↑)
 
===Diagnosis===
[[File:thyroid studies.JPG|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==
==See Also==
[[Thyroid Storm]]
*[[Thyroid storm]]
[[Thyroid (General)]]
*[[Thyroid (Main)]]


==Source ==
==References==
Tintinalli
<references/>


[[Category:Endo]]
[[Category:Endocrinology]]

Latest revision as of 15:41, 1 November 2023

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

Palpitations

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.
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