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Thyroid disorders

Case 1. . 30 yr femalePuffiness around eyes, hair loss, 15kg weight gain, cold intolerance, dry skin, nausea, giddiness, vomitingFree T4 0.2 pmol/lTSH 129 mIU/l. . Examination. Puffy around eyesSlow-relaxing reflexesCool dry skinSmall goitre - diffuseDark skin (father ? Polynesian ancestry

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Thyroid disorders

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    1. Thyroid disorders Visiting Endocrinologist, John James Memorial Hospital, The Canberra Hospital, Cootamundra Hospital Visiting Fellow, John Curtin School of Medical Research

    2. Case 1

    3. 30 yr female Puffiness around eyes, hair loss, 15kg weight gain, cold intolerance, dry skin, nausea, giddiness, vomiting Free T4 0.2 pmol/l TSH 129 mIU/l

    4. Examination Puffy around eyes Slow-relaxing reflexes Cool dry skin Small goitre - diffuse Dark skin (father ? Polynesian ancestry) Pigment in palmar creases, striae BP 112/80 lying, 94/70 standing

    5. Investigations Synacthen test: (rise > 200, peak > 500) ACTH 1095 P renin 3282 H fm/L/s (130-2350) Adrenal Ab: positive Thyroid Ab: positive

    6. Diagnosis Hashimoto’s hypothyroidism Addison’s disease

    7. Case 2

    8. 50 year-old lady Weight gain, tiredness Saw GP because of unrelated problem TFTs: Examination: overweight; normal otherwise Thyroid antibodies: negative

    9. Hypothyroidism

    10. Earliest change: ?FT4 leads to ?TSH FT4 may be normal (compensated hypothyroidism) Incidence: autoimmune 3.5/1000 women/year High risk: high antibodies, high TSH (even 2-5 mIU/l) Usually permanent

    11. Chronic autoimmune thyroiditis Thyroid usually not palpable Goitrous variety less common Frequently euthyroid May initially be thyrotoxic (Hashitoxicosis) Thyroid peroxidase antibodies: hallmark 5% spontaneous recovery

    12. Treatment Elderly, cardiac disease: initially low dose thyroxine (50 ?g daily/alt daily) TFT monitoring: 6 weeks after dose change Before morning dose Half-life 7 days Aim for normal TSH Interfering factors: high-fibre diet, ferrous sulphate, bile acid sequestering agents

    13. Treatment (contd) Pregnancy - higher dose requirements early (4 weeks) Poor compliance commonest reason for high dose requirements T3 therapy Myxoedema coma Preparation for whole body scan With T4: improved psych. function and mood

    14. Subclinical hypothyroidism High TSH, normal FT3 & FT4 Prevalence: F: 75/1,000, M: 28/1,000 Return to normal TSH: 5% Progression to hypothyroidism: 5%/year Progression common with antibodies None - mild symptoms

    15. Treatment Controversial Effects: symptomatic improvement in 1/3 in trials ? cholesterol symptoms may improve “Wait and see” - treat early (eg. TSH > 8)

    16. Case 3

    17. 61 yr male, farmer Referred to oncologist Tiredness, upper respiratory symptoms, dyspnoea No heat intolerance, tremor palpitations,sweating, weight loss

    18. Examination Appeared well BP 158/70, p 90 bpm regular Thyroid slightly enlarged, firm Fine tremor, minimal lid lag Reflexes, skin temp normal CT chest, abdomen, pelvis normal

    19. Investigations ESR 59 mm/r, Hb 121 g/l ANA positive, speckled, titre 40 CRP 20 mg/l FT4 33.3 pmol/l TSH <0.008 mU/l FT3 5.0 pmol/l (normal) Anti TPO 29.0 IU/ml (normal)

    20. Nuclear scan thyroid No uptake within thyroid D/W radiologist: had iodine-containing contrast during CT scan. Had poor uptake of contrast in thyroid gland during CT scan.

    21. Diagnosis Painless thyroiditis: Thyrotoxic TFTs (mild) High ESR, CRP Anaemia of chronic disease Firm thyroid gland No uptake of tracer on scan

    22. Progress 2 months later: TSH 52.3 mU/l FT4 7.4 pmol/l FT3 2.5 pmol/l Hb 124 g/l ESR, CRP normal

    23. Graves’ disease

    24. Features Stimulation of TSH receptor by antibody Features Thyrotoxicosis Symmetrical diffuse goitre Ophthalmopathy (not always concurrent) Pretibial myxoedema May have T3 toxicosis TPO, TSH receptor antibodies Radionucleotide scan Diff diag: thyroiditis, toxic nodule, factitious

    25. Treatment Thionamides: Carbimazole, Propylthiouracil ? blockers (not if asthmatic) TFT > 6wk after dose change Remission usually occurs Relapse rate 50-60% 1 year SEs: agranulocytosis, rash, hepatitis Definitive treatment Radioactive iodine Surgery Drugs

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