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THYROTOXICOSIS

By PROFESSOR : MOHAMED A. EL GHARBAWI e - mail: elgharma2@yahoo.com Web Site: www.dr-elgharbawi.com. THYROTOXICOSIS. ILOS, BY END OF THIS LECTURE YOU WILL KNOW. Thyrotoxicosis Etiology , Pathology & types Clinical picture & diagnosis Investigations

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THYROTOXICOSIS

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  1. ByPROFESSOR : MOHAMED A. EL GHARBAWIe-mail: elgharma2@yahoo.comWeb Site: www.dr-elgharbawi.com THYROTOXICOSIS

  2. ILOS, BY END OF THIS LECTUREYOU WILL KNOW • Thyrotoxicosis • Etiology , Pathology & types • Clinical picture & diagnosis • Investigations • Treatment Medical Radioactive iodine Surgery

  3. TOXIC GOITERTHYROTOXICOSIS TYPES 1.PRIMARY TOXIC GOITER (Grave’sDisease) 2. SECONDARY TOXIC GOITER(Plummer’s Disease) 14%

  4. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Etiology:Unknown, but may be due to hypothalamic pituitary thyroid disturbances (may follow psychic trauma or certain fevers)Now, considered as autoimmune disease with antibodies binding to TSH receptors leading to release of excess thyroxin

  5. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Pathology: A. Macroscopically Moderately enlarged thyroid gland, Sometimes, no enlargement is detectedBrick red in color with opaque meaty look Highly Vascular Consistency : Fleshy

  6. MACROSCOPY OF PATHOLOGICAL SPECIMEN (THYROTXICOSIS)

  7. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Pathology: B. Microscopically Marked hyperplasia (several layers of cells)Lumen of acini: marked diminutionNo colloid in the lumen Marked lymphocytic infiltration • Incidence: Females > Males. More in certain familiesGrave’s disease is common in young adult females

  8. MICROSCOPY OF THYROTOXICOSIS

  9. أد. محمد عبد اللطيف و أد. حسن العوضى أثناء مناقشة رسالتى للدكتوراه1984

  10. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture:Onset: Gradual or Acute with Insomnia, irritability, weight lossCourse: ProgressiveThyrotoxicosis affects all systems of the body Excitation &ends with failure or depression

  11. TOXIC GOITER

  12. Examine for Water hummer pulse by Raising & holding the middle of forearm

  13. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture:B .Nervous system: Insomnia, Irritability, Anxiety, Hyper- reflexia Tremors (in Outstretched hands, Protruding unsupported tongue, Upper eye lids) Psychological changes & Mania with severe cases

  14. Testing tremors in out stretched hands

  15. Testing tremors in outstretching hands using a sheet of paper

  16. Testing tremors in protruding unsupported tongue

  17. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture:C .Metabolic EffectsWeight loss is due to increased metabolic rate in spite of a good appetite. Palms of hands aresweaty,warm & may be palmar erythema Intolerance to heat & tolerance to cold weather D. GIT symptoms Polyphagia (increased appetite) then loss of appetite Abdominal pains & diarrhea

  18. PALMARERYTHEMA

  19. MANIFESTATION OF DISTURBED THYROID FUNCTION

  20. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture: E. Sexual symptoms: Females: menorrhagia, dysmenorrhea or amenorrhea Males: Increased libido, then impotence F. Musculo-skeletal system: Bone aches due to osteoporosis Muscle weakness (Thyrotoxic myasthenia)G. Urinary system : Polyuria & glycosuria H. Skin: Flushing, Pigmentations, Coarse hair, hair fall

  21. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture:Local Examination:Moderately enlarged thyroid. Sometimes, the gland is small with no enlargement ( Masked thyrotoxicosis). This happens in old age where it presents weight loss and myasthenia. Heart is mainly affected, which may pass into failure with evident cause.

  22. MODERATE, SYMETRICAL SMOOTH THYROID SWELLING

  23. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture:Local Examination (Cont.)Symmetricalswelling + Smooth surfaceConsistency: Firm or rubbery Increased Vascularity: Dilated vessels in the skin over the thyroid.Bruit may be feltHot sensation (felt by dorsum of hand) Auscultation : Murmur may be heard

  24. MODERATE, SYMETRICAL SMOOTH THYROID SWELLING + EXOPHTHALMOS

  25. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture:Eye Manifestations: A. Exophthalmos (Proptosis): 1. True Exophthalmos:Actual protrusion of the eye ball Due to retrobulbar deposition of edematousfibro fatty tissueAuto-immune disease Exophthalmos producing substance ( E.P.S) or Long acting thyroid stimulator (L.A.T.S.) may be responsible It is progressive. Rarely regress & may be sever (Malignant Exophthalmos)

  26. TRUE EXOPHTHALMOS, ACTUAL PROTRUSION

  27. SEVERE PROTRUSION OF THE EYE EXOPHTHALMOS

  28. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture:Eye Manifestations: A. Exophthalmos (Proptosis): 1. True Exophthalmos (Cont.): May be aggravated By thyroid ablation ( post Surgery or Radio-active iodine)Conjunctiva is more exposed, it becomesedematous & congested. Severe exophthalmos may lead to cornealulceration & even, loss of vision

  29. EXOPHTHALMOS

  30. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture:Eye Manifestations: A. Exophthalmos (Proptosis): 2. False Exophthalmos : Upper eye lid is retracted (no actual protrusion) Due to spasm Levator palpebri superioris (Muller’s muscle) Sympatheticoveractivity It usually improves if thyrotoxicosis is treated B. Stellwag’s sign:Staring look with infrequent blinking

  31. Stellwag’s sign(Starring look) &Dalrymple’s sign(Rim of sclera)

  32. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture:Eye Manifestations: C. Von Graef’s sign: Lagging of upper eye lid behind the eye ball while the patient looks downwards without moving the headD. Dalrymple’s sign:A rim of white sclera is seen between the upper eye lid and upper edge of cornea ( protrusion of eye ball + retraction of upper eye lid as a result of levator pulpebrae superioris sympathetic overtone

  33. TOXIC GOITER PRIMARY TOXIC GOITER (Grave’s Disease) • Clinical picture:Eye Manifestations: E. Goffroy’s sign: Lack of wrinkling of forehead skin on looking upwards without moving the head . It is due to increased field of vision (protruded eye ball)F. Mobius sign:No convergence of eyes on looking at a near object Due to paresis of medial recti muscles

  34. الصوت والضوء تحت سفح الهرم

  35. TOXIC GOITER SECONDARY TOXIC GOITER (Plummer’s Disease) Different from Grave’s disease in the following: 1. Incidence: 14% of toxic goiter cases Older age group than with Grave’s. Middle age orelderly females 2. Nodular Thyroid before or at time of thyrotoxicity (Smooth surface with Grave’s disease) 3. Exophthalmos (Proptosis) is usually absent 4. More Cardio-vascular manifestations & Less nervous manifestations than with Grave’s5. Medical treatment is less effective. If given, it should be for long time to be effective, So it is better to be treated surgically.

  36. SECONDARY THYROTOXICOSISPlummer’s Disease

  37. TOXIC GOITER SECONDARY TOXIC GOITER (Plummer’s Disease) Different from Grave’s disease in the following:6. Recurrence of symptoms after old subtotal thyroidectomyis rare (1%), while it is 10-20% with Grave’s disease7. As it occurs in older age group. So Surgery is better because it removes other pathology (Malignancy)8 . Post-operative myxedema is extremely rare ( Morefrequent in Grave’s disease)9 . Surgery improves Cardiac symptoms

  38. TOXIC GOITER Differential Diagnosis:1. Anxiety2. Psychoneurosis: It is accompanied with Anorexia (polyphagia with thyrotoxicosis) Normal sleeping pulse (High with thyrotoxicosis) Cold hands (Hot with thyrotoxicosis) Sweating & tremors in both Normal Thyroid function test with psychoneurosis 3. Heart diseases 4. Myasthenia 5. T.B.6. Pheochromocytoma 7. Menopausal syndrome8. Other causes of exophthalmos

  39. TOXIC GOITER INVESTIGATIONS OF THYROTOXICOSIS 1. Thyroid Function Tests (TFTs):TSH decreasesT3 & T4 Increase2. Radioactive Iodine uptake:Technique: a. No drugs containing iodine are allowed for 3 weeks before the test( e.g.Lugol’s iodine, expectorants, radio-opaque dye studies).

  40. TOXIC GOITER INVESTIGATIONS OF THYROTOXICOSISb. 25 micrograms of radioactive iodine (I123)are given by mouth in a small amount ofwater or milk c. After 24 hours the thyroid uptake is measured using Geiger Muller Counter Interpretation: a .Normal Thyroid uptake: 15 – 50 % of the given dose, rest is excreted in urine (48 H)b. Thyrotoxicosis: Uptake > 50%c. Hypothyroidism : Uptake < 10%

  41. TOXIC GOITER INVESTIGATIONS OF THYROTOXICOSIS 3. Sleeping Pulse: To grade Severitya. Mild case: 80 - 90 / min. b. Moderate case: 90 – 110 /minc. Sever case: > 110/min4. Thyroid Isotope (scintillation) ScanningTechnique:a. A tracer dose of Iodine123 or 125 isotope is givenorallyb. Gamma Camera (Scintillation Scan) is used to scan the thyroidc. shows size, shape & retrosternal extension

  42. IODINE 123 SCAN FOR GRAVE’S DISEASE

  43. IODINE 123 ISOTOPE SCANCOMPARATIVE

  44. TOXIC GOITER INVESTIGATIONS OF THYROTOXICOSISInterpretation of thyroid isotope scan:a. Hot nodule: It takes the isotope > the surrounding thyroid tissue. It indicateshyper function (Thyrotoxicosis)b. Warm nodule: It takes the isotope = to surrounding thyroid tissuec. Cold nodule: Doesn't take the isotope It is suspicious of malignancy

  45. BIG HOT SOLITARY TOXIC THYROID NODULE SCAN

  46. TOXIC GOITER TREATMENT OFTHYROTOXICOSIS 1. Medical treatment 2. Radioactive Iodine 3. Surgery after good medical preparation

  47. TOXIC GOITER I. MEDICAL TREATMENT OF THYROTOXICOSISIndications: 1.Primary thyrotoxicosis especially, the mild cases occurring during periods of stress e.g. Puberty, pregnancy or lactation2. Children & young patients (high recurrence post surgery 3. Bad general condition &unfit patients: Heart failure4. Recurrence after surgery: Re operation is difficult due to adhesions. Injury of recurrent laryngeal nerve is high. Choice is between medical treatment or radioactive iodine

  48. TOXIC GOITER I. MEDICAL TREATMENT OF THYROTOXICOSIS Indications ( Cont.) 5. Pre operative preparation: To control symptoms Precautions: During pregnancy:a. Anti thyroid drugs should be given with caution, better on under dose side. b. To be stopped one month before delivery and substituted with Lugol’s iodine c. These drugs are secreted in milk. So, nobreastfeeding

  49. TOXIC GOITER I. MEDICAL TREATMENT OF THYROTOXICOSIS Contra-indications:1. Toxic nodular goiter 2. Retrosternal goiterDrugs in use: 1. Neomercazol (Carbimazol) Action: It blocks binding iodine to tyrosineSafest , less toxic & less goitergenic drug Dose: 5 – 15 mg tds

  50. TOXIC GOITER I. MEDICAL TREATMENT OF THYROTOXICOSISDrugs in use (Cont.):2. Thiouracil Action: Blocks iodine binding to tyrosine & inhibitsconversion of T4 to T3 Dose: Methyl- thiouracil 300 – 600 mg/day Propyl- thiouracil 200 – 300 mg /day 3. Potassium perchlorate: Action: Inhibits iodine uptake Dose: 200 – 800 mg /day

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