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Thyroid Disease

APIRADEE SRIWIJITKAMOL
DIVISION OF ENDOCRINOLOGY AND METABOLISM
FACULTY OF MEDICINE SIRIRAJ HOSPITAL

OUTLINE

Examination of Thyroid gland Thyroid function test Thyrotoxicosis /Hyperthyroidism Hypothyroidism Thyroid nodule

Thyroid Disease
EXAMINATION OF THYROID GLAND

Thyroid Disease

THYROID FUNCTION TEST

THYROID FUNCTION TEST

Total T3 Total T4 Free T3 Free T4 TSH


Total T3 = free T3 + TBGT3 Total T4 = free T4 + TBGT4

FACTORS AFFECTED TBG

Increased TBG

Drug Estrogens Tamoxifen Heroin Methadone Mitotane Fluorouracil

Others Pregnancy Hepatitis

T3 , T4

Decreased TBG

Drug Androgens Anabolic steroids SR nicotinic acid Glucocorticoids

Others Nephrotic Cirrhosis Illness

syndrome

T3 , T4

Thyroid Disease

THYROTOXICOSIS

APPROACH TO THYROTOXICOSIS

Symptoms and signs of thyrotoxicosis

With hyperthyroidism

Without hyperthyroidism

APPROACH TO THYROTOXICOSIS

Symptoms and signs of thyrotoxicosis

THYROTOXICOSIS SYMPTOMS AND SIGNS


HISTORY

Weight loss Increased appetite Hand tremor Palpitation Agitation Heat intolerance Frequent bowel movement Abnormal menstruation Apathetic thyrotoxicosis Family History

Tachycardia Atrial fibrillation Lid lag, lid retraction Moist skin Hand tremor Onycholysis Goiter Thyroid bruit Ophthalmopathy Dermopathy Acropachy

PHYSICAL EXAMINATION

Specific for Graves' disease

EYE SIGNS IN THYROTOXICOSIS

Exophthalmos

Lid retraction

Lid lag

SKIN AND NAILS IN THYROTOXICOSIS

Acropachy

Pretibial myxedema
Bilateral, firm, shiny pink to purple-brown nonpitting plaques or nodules. Peau d'orange texture.

Onycholysis

APPROACH TO THYROTOXICOSIS

Symptoms and signs of thyrotoxicosis

With hyperthyroidism

Without hyperthyroidism

THYROTOXICOSIS VS. HYPERTHYROIDISM


THYROTOXICOSIS HYPERTHYROIDISM

Pathophysiological
condition resulting from excess T3 or T4

Thyrotoxicosis Overactive thyroid gland

Thyrotoxicosis
Hyperthyroidism

APPROACH TO THYROTOXICOSIS
Symptoms and signs of thyrotoxicosis

With hyperthyroidism

Without hyperthyroidism

Graves disease Toxic multinodular goiter (toxic MNG) Toxic adenoma TSHoma

Thyroiditis Thyroxine ingestion

THYROTOXICOSIS WITH HYPERTHYROIDISM


GRAVES DISEASE
Thyroid gland Diffusely enlarged

TMNG

TOXIC ADENOMA
Single thyroid nodule size>3cm with unable to palpate other part of thyroid gland

Multiple nodules varying in size

Other signs

Ophthalmopathy, dermopathy, acropachy

Thyroid scan

Diffuse uptake

Hot and cold nodules

Solitary hot nodule

THYROTOXICOSIS WITHOUT HYPERTHYROIDISM


GRAVES DISEASE
Symptoms thyrotoxicosis

THYROIDITIS
thyrotoxicosis +pain, postpartum period
<3 months Thyroid gland firm and enlarged T3/T4 < 20 ESR Low

Duration of thyrotoxicosis Signs

> 3 months Thyroid bruit, dermopathy, ophthalmopathy T3/T4 > 20

Laboratory

Thyroid uptake

High

APPROACH TO THYROTOXICOSIS
Symptoms and signs of thyrotoxicosis

With hyperthyroidism

Without hyperthyroidism

Graves disease Toxic multinodular goiter (toxic MNG) Toxic adenoma TSHoma

Thyroiditis Thyroxine ingestion

THYROID FUNCTION TEST

THYROTOXICOSIS THYROID FUNCTION TEST


T3, freeT3 Normal T4, freeT4 TSH

Thyrotoxicosis
T3 toxicosis T4 toxicosis TSHoma, RTH

TSHoma = TSH producing pituitary adenoma RTH = Resistant to thyroid hormone

APPROACH TO THYROTOXICOSIS

Symptoms and signs of thyrotoxicosis TSH T3, free T4 TSH

With hyperthyroidism

Without hyperthyroidism

TSHoma, RTH

Graves disease Toxic multinodular goiter (toxic MNG) Toxic adenoma

Thyroiditis Thyroxine ingestion

MANAGEMENT

Thyrotoxicosis with hyperthyroidism

Graves disease

Toxic adenoma, toxic MNG

Antithyroid drugs

Surgery/ 131I

MANAGEMENT
Graves disease
MMI 15-30 mg OD OR PTU 100-150 mg tid (PTU cannot use OD)

ANTITHYROID DRUGS
Methimazole (MMI; 5 mg/tab) Administration Clinical response Agranulocytosis Transplacental passage Concentrations in breast milk Effect on 131I outcome Once daily Faster Dose related High High No effect Propylthiouracil (PTU; 50 mg/tab) 2-3 times/day Slower Idiosyncracy Low Low Decrease effect

MANAGEMENT
Check CBC and LFT before starting antithyroid drugs (ATD) Monitor BW, HR, goiter size, T3 and FT4 at 1st month (TSH is unnecessary)
Lab investigation indicated in: 1.In doubt in hyperthyroid or hypothyroid 2.Pregnancy 3.Before discontinue ATD

Graves disease
MMI 15-30 mg OD OR PTU 100-150 mg tid (PTU cannot use OD)

When achieving euthyroid decrease the dose of ATD 30-50%


Check TFT at appropriate interval or as indicated Discontinue ATD after 18-24 months (T3, free T4 and TSH must be normal) Monitor clinical and TSH every 2-3 months in first 6 months then less frequently

MANAGEMENT
THYROTOXICOSIS PAIN (SUBACUTE THYROIDITIS)

Beta blocker:
Atenolol OD Propranolol bid-tid If contraindicate to beta blocker use Verapamil or diltiazem

NSAID Prednisolone

Thyroid Disease

HYPOTHYROIDISM

HYPOTHYROIDISM SYMPTOMS AND SIGNS


HISTORY

Weight gain Cold intolerance Constipation Impaired memory Cramping Abnormal menstruation History of thyroid surgery or radiation Family history

PHYSICAL EXAMINATION

Bradycardia Loss of lateral one-third of eyebrows Dry skin Hoarseness Goiter Surgical scar at neck Slow relaxation of deep tendon reflex Myoedema

HYPOTHYROIDISM THYROID FUNCTION TEST

T3, freeT3
Normal Primary hypothyroid Secondary or central hypothyroid

T4, freeT4

TSH

CAUSES OF PRIMARY HYPOTHYROIDISM

Hashimotos thyroiditis Iatrogenic: thyroidectomy, 131I treatment, external


irradiation of neck

Iodine deficiency/excess Congenital hypothyroidism Infiltrative disorders: amyloidosis, hemochromatosis

HYPOTHYROIDISM THYROID FUNCTION TEST

T3, freeT3
Normal Primary hypothyroid Secondary or central hypothyroid

T4, freeT4

TSH

Anti Thyroperoxidase (TPO or anti-microsomal) Anti-thyroglobulin

MANAGEMENT

Thyroxine (L-T )
4

The only medication to treat hypothyroidism


Long half life of thyroxine ~ 7days Duration to get steady state of drug ~4-6 weeks Average requirement dose is 1.6-1.8 mcg/kg/day The initial dose is 12.5-25 mcg/day Slowly increase the dose every 4-6weeks

In the elderly or coronary artery disease

MONITORING

Primary hypothyroidism:
Central hypothyroidism:
reference range TSH levels cannot be used to monitor therapy

TSH ideally in the lower half of the reference range


maintain freeT4 levels in the upper half of the

INTERFERENCE OF THYROXINE ABSORPTION

Always prescribe thyroxine before breakfast or bedtime Drugs interfere absorption of thyroxine:
Cholestyramine Ferrous Calcium Aluminium hydroxide

Thyroid Disease

THYROID NODULE

APPROACH TO THYROID NODULE


Thyroid nodule
Hx and PE TSH

THYROID NODULE HISTORY TAKING

MALIGNANCY
Sex and age: male, extreme age (high-risk) Characteristics of nodule(s): size, growth rate Pressure effects Hoarseness of voice Dysphonia Dysphagia Previous neck radiation Family history of thyroid cancer, multiple endocrine neoplasia type 2 (MEN)

Hyperthyroid symptoms Hypothyroid symptoms

FUNCTIONING

THYROID NODULE PHYSICAL EXAMINATION


MALIGNANCY FUNCTIONING

Characteristics of nodule(s): site, size, consistency Cervical lymphadenopathy

Signs of hyperthyroidism
and hypothyroidism

THYROID NODULE LABORATORY TESTING


MALIGNANCY FUNCTIONING

Fine needle aspiration

Serum TSH Thyroid scan (if TSH


suppress)

APPROACH TO THYROID NODULE


Thyroid nodule
TSH Hx and PE TSH

Thyroid scan

THYROID SCAN

APPROACH TO THYROID NODULE


Thyroid nodule
TSH Hx and PE TSH Cold nodule or TSH

Thyroid scan

US thyroid Nodule 0.5-1 cm.

Hot nodule -Hypoechogenictiy -Hypervasculazied Treat-Irregular border -Microcalcification thyrotoxicosis Follow up

Nodule >1 cm.

History and US finding suggest malignancy

FNA

FINE NEEDLE ASPIRATION

FINE NEEDLE ASPIRATION

THYROID NODULE MANAGEMENT


THYROXINE SUPPRESION

Not recommended Contraindicated in functioning nodule, suspicious (for malignancy) nodule Increased risk of bone loss and arrhythmia Malignant Suspicious for neoplasm Neoplasm, either follicular or Hurthle cell neoplasm

SURGERY

FOLLOW UP

Thyroid Disease

DIVISION OF ENDOCRINOLOGY AND METABOLISM FACULTY OF MEDICINE SIRIRAJ HOSPITAL