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Thyroid Disease

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

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  1. Thyroid Disease Prof T O’Brien

  2. Thyroid Hormone ExcessClinical Features • General • Heat intolerance, fatigue, tremor. • Cardiovascular • Tachycardia, heart failure. • Gastrointestinal • Weight loss, diarrhoea • Ophthalmological • Lid lag, ophthalmopathy

  3. Thyroid Hormone ExcessClinical Features • Genitourinary • Amenorrhea, infertility. • Neuromuscular • Proximal muscle weakness, HPP, MG • Psychiatric • Irritability, agitation, anxiety, psychosis • Dermatological • Pruritus, hair thinning, onycholysis, vitiligo.

  4. Diagnosis • High Free T4, T3 and supressed sTSH If sTSH is high suspect pituitary tumour or rare cases of thyroid hormone resistance

  5. Causes of Thyroid Hormone Excess • Increased radioactive iodine uptake • Graves • TMG • Toxic solitary adenoma • Pituitary tumour

  6. Causes of Thyroid Hormone Excess • Reduced radioactive iodine uptake • Thyroiditis • Iodine induced (amiodarone) • Factitious • Struma ovarii • Thyroid carcinoma

  7. Graves Disease • Most common cause in Ireland • Diffuse Goitre • Hyperthyroidism • Ophthalmopathy • Dermopathy • Autoimmune. TSI.

  8. TMG • Older • Usually less severe hyperthyroidism • May have subclinical hyperthyroidism • May have long history of goitre

  9. Toxic Solitary Adenoma • Rare cause (< 2% of patients with hyperthyroidism) • Younger people 30’s and 40’s • Scan • Benign follicular adenomas

  10. Thyroiditis • Painful (subacute, de Quervain’s) • Painless (post partum) • Hyperthyroid, hypothyroid and euthyroid phases • Anti thyroid drug therapy does not work

  11. 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

  12. 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

  13. 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

  14. 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

  15. Thyroid Storm • Carbimazole (or PTU) • Inderal, 80mg qid • Iodine (Lugols 5 drops q6) • Dexamethasone 2mg q6 • Other supportive measures

  16. 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

  17. Graves Eye Disease • High dose steroids • External radiotherapy • Orbital decompression

  18. Hypothyroidism • Hashimoto’s • Iatrogenic • Congenital • Hypopituitarism

  19. Treatment • Thyroxine 100-150ug daily. • Aim to normalize sTSH • In patients with CAD start with lower dose e.g. 25ug qd.

  20. Simple non-toxic goitre • Normal TFT’s • No treatment required • Surgery if obstructive symptoms

  21. 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.

  22. Thyroid Nodule • FNA • Benign no further intervention • Malignant or suspicious– papillary or follicular.

  23. 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.

  24. 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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