Download - Thyroid Disease
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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.