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Thyroid Disease. Prof T O’Brien. Thyroid Hormone Excess Clinical Features. General Heat intolerance, fatigue, tremor. Cardiovascular Tachycardia, heart failure. Gastrointestinal Weight loss, diarrhoea Ophthalmological Lid lag, ophthalmopathy. Thyroid Hormone Excess Clinical Features.

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Thyroid disease l.jpg

Thyroid Disease

Prof T O’Brien


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Thyroid Hormone ExcessClinical Features

  • General

    • Heat intolerance, fatigue, tremor.

  • Cardiovascular

    • Tachycardia, heart failure.

  • Gastrointestinal

    • Weight loss, diarrhoea

  • Ophthalmological

    • Lid lag, ophthalmopathy


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Thyroid Hormone ExcessClinical Features

  • Genitourinary

    • Amenorrhea, infertility.

  • Neuromuscular

    • Proximal muscle weakness, HPP, MG

  • Psychiatric

    • Irritability, agitation, anxiety, psychosis

  • Dermatological

    • Pruritus, hair thinning, onycholysis, vitiligo.


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Diagnosis

  • High Free T4, T3 and supressed

    sTSH

    If sTSH is high suspect pituitary tumour or rare cases of thyroid hormone resistance


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Causes of Thyroid Hormone Excess

  • Increased radioactive iodine uptake

    • Graves

    • TMG

    • Toxic solitary adenoma

    • Pituitary tumour


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Causes of Thyroid Hormone Excess

  • Reduced radioactive iodine uptake

    • Thyroiditis

    • Iodine induced (amiodarone)

    • Factitious

    • Struma ovarii

    • Thyroid carcinoma


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Graves Disease

  • Most common cause in Ireland

  • Diffuse Goitre

  • Hyperthyroidism

  • Ophthalmopathy

  • Dermopathy

  • Autoimmune. TSI.


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TMG

  • Older

  • Usually less severe hyperthyroidism

  • May have subclinical hyperthyroidism

  • May have long history of goitre


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Toxic Solitary Adenoma

  • Rare cause (< 2% of patients with hyperthyroidism)

  • Younger people 30’s and 40’s

  • Scan

  • Benign follicular adenomas


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Thyroiditis

  • Painful (subacute, de Quervain’s)

  • Painless (post partum)

  • Hyperthyroid, hypothyroid and euthyroid phases

  • Anti thyroid drug therapy does not work


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Treatment of hyperthyroidism

  • Antithyroid drugs

    • Carbimazole 10 mg tid

    • Reduce to maintenance after 4 weeks

    • Rash, GI, agranulocytosis

    • Graves – withdraw drugs after course of treatment


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Treatment of hyperthyroidism

  • Radio-iodine

    • Inflammatory response followed by fibrosis

    • May be used for Graves, TMG or TA

    • ? Need for drug treatment before and after

    • May need retreatment

    • Long term risk of hypothyroidism


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Treatment of Hyperthyroidism

  • Surgery

    • Rarely used nowadays

    • Need to be rendered euthyroid before surgery

    • Lugol’s iodine 0.1-0.3 mls tid for 10 days before surgery


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Treatment of Hyperthyroidism

  • Patient presents with hyperthryoidism

  • Make diagnosis, get RAI uptake.

  • Beta block (inderal 40-80 mg tid).

  • If RAI uptake is high – treat with RAI.

  • If RAI is low - symptomatic


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Thyroid Storm

  • Carbimazole (or PTU)

  • Inderal, 80mg qid

  • Iodine (Lugols 5 drops q6)

  • Dexamethasone 2mg q6

  • Other supportive measures


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Graves Eye Disease

  • Onset relative to hyperthyroidism is variable.

  • Pain, watering, photophobia, blurred vision, double vision

  • Usually mild – Tx, protective glasses, elevate head of bed, conjunctival lubricants


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Graves Eye Disease

  • High dose steroids

  • External radiotherapy

  • Orbital decompression


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Hypothyroidism

  • Hashimoto’s

  • Iatrogenic

  • Congenital

  • Hypopituitarism


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Treatment

  • Thyroxine 100-150ug daily.

  • Aim to normalize sTSH

  • In patients with CAD start with lower dose e.g. 25ug qd.


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Simple non-toxic goitre

  • Normal TFT’s

  • No treatment required

  • Surgery if obstructive symptoms


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Non-thyroidal illness

  • Ill patients may have low T3 and/or T4 usually with a normal sTSH

  • Psychotic patients may have elevated T3 and/or T4.


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Thyroid Nodule

  • FNA

  • Benign no further intervention

  • Malignant or suspicious– papillary or follicular.


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Papillary Cancer

  • Controversies

    • Extent of surgery (near total thyroidectomy). Follow up with sTSH, thyroglobulin exam and US.

    • Radioactive iodine ablation for high risk tumours. Follow up with RAI scans plus the above.


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Follicular cancer

  • Less common than papillary

  • Total thyroidectomy (or near total).

  • Routine remnant ablation with RAI due to increased risk of metastatic disease.


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