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Thyroid Part 1Overview • Hyperthyroidism • Hypothyroidism • Thyroid cancers • Thyroid emergencies (Myxoedema coma vs Thyroid storm) SBA 1 48 year old female who has a history of Hashimoto’s thyroiditis presents to GP with ongoing fatigue and tiredness. She currently takes levothyroxine for her condition. She has recently bought some thyroxine medication online and plans to take this with her current thyroid medication to relieve her symptoms. Her recent thyroid function tests performed 1 month later shows: Thyroid stimulating Hormone (TSH) 0.04 (0.5-5.5) Free Thyroxine (T4) 26 (9.0-18) What does this put her at an increased risk for? A. Acropachy B. Exophthalmos C. Menorrhagia D. Osteoporosis E. Ventricular fibrillation SBA 1 48 year old female who has a history of Hashimoto’s thyroiditis presents to GP with ongoing fatigue and tiredness. She currently takes levothyroxine for her condition. She has recently bought some thyroxine medication online and plans to take this with her current thyroid medication to relieve her symptoms. Her recent TFTs performed 1 month later shows: Thyroid stimulating Hormone (TSH) 0.04mU/L (0.5-5.5) Free Thyroxine (T4) 26mU/L (9.0-18) What does this put her at an increased risk for? A. Acropachy – symptom/sign of Graves disease B. Exophthalmos – symptom/sign of Graves disease C. Menorrhagia- symptom of hyperthyroidism doesn’t mention this in question stem D. Osteoporosis – Side effect of too much thyroxine E. Ventricular fibrillation SBA 2 th You’re a 5 Year medical student currently on their elective in Cambodia where a 7 year old child presents to the hospital where you are. He has a goitre, on neck palpation you feel that he has few nodules on his goitre. You perform some thyroid function tests which show: Thyroid Stimulation Hormone (TSH) 4.0nmol/L (0.5-5.5) Free Thyroxine (T4) 9.1pmol/L (9.0-18) Total Thyroxine (T4) 72nmol/L 70-140 Your report your findings to the consultant in which he has asks… Given the likely diagnosis, what is the most appropriate treatment? A. Levothyroxine B. Iodine supplements C. Thyroidectomy D. Radioactive iodine E. Liothyronine SBA 2 th You’re a 5 Year medical student currently on their elective in Cambodia where a 7 year old child presents to the hospital where you are. He has a goitre, on neck palpation you feel that he has few nodules on his goitre. You perform some thyroid function tests which show: Thyroid Stimulation Hormone (TSH) 4.0nmol/L (0.5-5.5) Free Thyroxine (T4) 9.1pmol/L (9.0-18) Total Thyroxine (T4) 72nmol/L 70-140 Your report your findings to the consultant in which he has asks… Given the likely diagnosis, what is the most appropriate treatment? A. Levothyroxine B. Iodine supplements – since TFTs are normal and given that iodine deficiency is most common cause of hypothyroidism in developing countries. C. Thyroidectomy D. Radioactive iodine E. Liothyronine SBA 3 A 45 year old male patient is referred to secondary care presenting with temporal visual field loss and headache. He says that for the past 2 months he has been feeling fatigue and has noticed his hair has gotten thinner and has gained 5kg in weight. Thyroid function tests were performed which shows: Thyroid Stimulating Hormone (TSH) 0.02 (0.5-5.5) Free thyroxine (T4) 7.5 (9.0-18) What is the likely diagnosis? A. Transient Thyroiditis B. Subclinical hypothyroidism C. Hashimoto’s thyroiditis D. Secondary thyroiditis E. Sick Euthyroid syndrome SBA 3 A 45 year old male patient is referred to secondary care presenting with temporal visual field loss and headache. He says that for the past 2 months he has been feeling fatigue and has noticed his hair has gotten thinner and has gained 5kg in weight. Thyroid function tests were performed which shows: Thyroid Stimulating Hormone (TSH) 0.02 (0.5-5.5) Free thyroxine (T4) 7.5 (9.0-18) What is the likely diagnosis? A. Transient Thyroiditis – no sings of post-infective or post partum in question stem is very unlikely B. Subclinical hypothyroidism – TSH would be mildly elevated and T4 normal C. Hashimoto’s thyroiditis TSH would be either normal or raised and T4 low, also would see serum TPO Ab’s D. Secondary hypothyroidism – temporal visual field loss and hypothyroid symptoms suggests pituitary problem e.g. pituitary tumour hypopituitarism E. Sick Euthyroid syndrome – generally wouldn’t have symptoms of thyroid diseaseHypothalamic-Pituitary- Thyroid axis Source: https://en.wikipedia.org/wiki/Hypothalamic%E2%80%93pituitary%E2%80%93thyroid_axisHypothyroidismCauses Signs & Symptoms • Autoimmune- Hashimoto’s thyroiditis Common: Less Common: General: General: • Drugs- Carbimazole, methimazole, propylthiouracil, Amiodarone, Weight gain, fatigue Depression Lithium Cold intolerance Infertility • Iodine deficiency (due to poor diet, common in developing countries) Anaemia, tiredness Skin: Constipation • Iatrogenic- thyroidectomy, radioactive iodine ablation Dry skin & hair (thin hair too!) Non-pitting oedema (hands and Signs • Transient thyroiditis- Postpartum thyroiditis, subacute (de face) Goitre, Hoarse voice Quervain’s) thyroiditis Loss of lateral eyebrows Bradycardia Erythema ab igne • Secondary causes due to hypothalamic or pituitary disorders (TSH Neurological: deficiency) Gynaecological: Slow relaxation of reflexes • Menorrhagia Carpal tunnel syndrome Investigations Management st Levothyroxine (1 line) • TFTs to look at thyroid status • If >50yrs, IHD or severe hypothyroidism Lower initial dose e.g. 25mcg OD then slowly titrated up • Anti-TPO antibodies (ab) high prevalence in • Dose is adjusted to maintain TSH levels within the reference range. Hashimoto’s thyroiditis Side effects of levothyroxine: Due to TSH suppression • Osteoporosis (reduced bone mineral density) • Hyperthyroidism and atrial fibrillation • Worsen angina Interactions: • Iron & Calcium carbonate reduces levothyroxine absorption thus give at least 4hrs apartSBA 4 A 32 year old female presents to GP clinic after giving birth 4 months ago. She tells the GP that she has been getting tremors in her hands, ongoing palpitations, loose bowel motions and has lot around 4.5kg since the delivery. However, she reports that baby is bottle feeding and is doing well. Thyroid function tests are performed and they show: Thyroid Stimulating Hormone (TSH) 3.0mU/L (0.5-5.5) (9.0-18) Free Thyroxine (T4) 21mU/L What is the most appropriate treatment, given the likely diagnosis? A. Carbimazole B. Radioactive iodine C. Iodine supplements D. Aspirin E. PropranololSBA 4 A 32 year old female presents to GP clinic after giving birth 4 months ago. She tells the GP that she has been getting tremors in her hands, ongoing palpitations, loose bowel motions and has lot around 4.5kg since the delivery. However, she reports that baby is bottle feeding and is doing well. Thyroid function tests are performed and they show: Thyroid Stimulating Hormone (TSH) 3.0mU/L (0.5-5.5) Free Thyroxine (T4) 21mU/L (9.0-18) What is the most appropriate treatment, given the likely diagnosis? A. Carbimazole – not initial treatment for post-partum thyroiditis. ATDs are avoided as thyroid isn’t overactive B. Radioactive iodine C. Iodine supplements D. Aspirin E. Propranolol – Given in acute/GP setting to help relieve adrenergic symptomsSBA 5 A 42 year old female is referred to endocrinologyas for the past few weeks she has been feeling symptoms of palpitations,irritability, anxiety and has raised purplish plaques on her shins. Some blood tests are performed which found her free thyroxine(T4) levelto be elevatedand to be positive for TSH receptorantibodies. Some other investigations are performed and she is diagnosed with Graves’ disease. She is started on anti-thyroid medication. Given the likely medication prescribed, which of these is a side effect of this medication? A. Agranulocytosis B. Atrial fibrillation C. Long QT syndrome D. Bradycardia E. Black hairy tongueSBA 5 A 42 year old female is referred to endocrinologyas for the past few weeks she has been feeling symptoms of palpitations,irritability, anxiety and has raised purplish plaques on her shins. Some blood tests are performed which found her free thyroxine(T4) levelto be elevatedand to be positive for TSH receptorantibodies. Some other investigations are performed and she is diagnosed with Graves’ disease. She is started on anti-thyroid medication. Given the likely medication prescribed, which of these is a side effect of this medication? A. Agranulocytosis- given patient is not pregnant this is most likely side effect B. Atrial fibrillation C. Long QT syndrome – side effect of macrolides,haloperidol,SSRIs, amiodarone D. Bradycardia E. Black hairy tongue – side effect of tetracyclinesSBA 6 32 year old woman is 5 weeks pregnant presents to GP surgery with concerns over her levothyroxine medication she takes for her hypothyroidism. She is currently well and is asymptomatic. She currently takes 100mg of levothyroxine OD. What is the most appropriate advice the GP should give regarding her levothyroxine? A. Decrease dose by 50% B. Continue current dose C. Stop levothyroxine and avoid all other anti-thyroid drugs D. Increase dose by 50% E. Replace it with propylthiouracilSBA 6 32 year old woman is 5 weeks pregnant presents to GP surgery with concerns over her levothyroxine medication she takes for her hypothyroidism. She is currently well and is asymptomatic. She currently takes 100mg of levothyroxine OD. What is the most appropriate advice the GP should give regarding her levothyroxine? A. Decrease dose by 50% B. Continue current dose C. Stop levothyroxine and avoid all other anti-thyroid drugs – if hypothyroidism isn’t corrected this could cause problems in fetal cognitive development D. Increase dose by 50%- thyroxine is safe in pregnancy and breastfeeding and should be increased for it be effective in pregnancy E. Replace it with propylthiouracil – this is prescribed for hyperthyroidism and could worsen their hypothyroid state.HyperthyroidismCauses Signs & Symptoms Autoimmune Grave’s disease Common Symptoms Other symptoms: Toxic multinodular goitre • Weight loss • Loose bowel motions Solitary thyroid adenoma • Normal/increased appetite • Oligomenorrhoea/amenor rhoea Iodide-induced CT contrast media, Iodine • Heat intolerance supplements, • Irritability, anxiety • Pretibial myxoedema Drugs: Amiodarone, Levothyroxine (T4), liothyronine • Goitre/Bruit Common signs: • Grave’s ophthalmopathy (T3) • Palpitations, tachycardia • Systolic hypertension Transientthyroiditis e.g.Subacute and post-partum • Palmar erythema, acropachy Secondary causes TSHsecreting pituitary adenoma • Lid lag/Lid retraction (excess TSH) Investigations Management • TFTs look at thyroid status Acute/GP setting: Technetium scintigraphy scan (for thyroid enlargement) • Beta blockers e.g. Propanolol relieve adrenergic • Distinguishes between Grave’s disease and other causes of thyrotoxicosis e.g. toxic multinodular goitre, toxic adenoma or symptoms thyroiditis Secondary care: • Fine-needle biopsy with cytology looks at thyroid nodules or st if you are concerned about malignancy that cannot be • Anti-thyroid drugs (ATD) e.g. Carbimazole (1 line) determined radiologically etc. • Ultrasound for goitre or nodules • TSH receptor antibodies (TRab) Specific for Graves • ECG as thyrotoxicosis can cause AFib Grave’s Disease Autoimmune (due to TSH receptor ab) cause of hyperthyroidism and most common cause in countries with sufficient iodine intake. Usually seen in females aged 30-50 years old. Features: • Typical features of thyrotoxicosis Investigations: Same as mentioned in slide above. • Anti-TSH receptor ab has high prevalence in Specific Features: Grave’s disease. Skin: Pretibial Myxoedema, Acropachy • Technetium scan to distinguish between Thyroid: Bruit (due to increased vasc. of gland) other forms of thyrotoxicosis Eyes: • Exophthalmos (eyes bulging out) • Periorbital/Conjunctival oedema Management: Same as above slide • Ophthalmoplegia (diplopia on upward and However, consider Radioiodine Tx if… lateral gaze) • Relapse with or treatment resistant to ATD NB: Lid lag/retraction occur in all forms of therapy thyrotoxicosis • CI in pregnancy, age<16yrs, thyroid eye disease (may worsen it)Sources: https://geekymedics.com/thyroid-status-examination/ TFT s TSH T4 (non-active) T3 (active) Most likely Dx Low Raised Raised Primary Thyrotoxicosis e.g. Grave’s, Toxic multinodular Elevated Raised Raised Secondary Thyrotoxicosis Elevated Low Low Primary Hypothyroidism Mildly elevated/low Low Low Secondary hypothyroidism Normal/Low Low Really low Sick Euthyroid syndrome Thyroid cancers Type Age at presentation Information Prevalence (years) Papillary Carcinoma 20-40 • Best prognosis 70% - • Young females Commonest Follicular Adenoma (aka Toxic 40-60 • Solitary thyroid nodule 20% adenoma) • Malignancy excluded using histological assessment e.g. biopsy • Encapsulated lesion (macro- + micro-scopically) Follicular Carcinoma • Metastasises via blood (although rare) -> bone, lungs and brain Medullary Carcinoma >40 • Cancer of parafollicular cells, secretecalcitonin (raised 5% blood) • Associated with MEN-2 Anaplastic Carcinoma Usually >60 • Worst prognosis 1% • Common in elderly females • Local invasion common • Rapid growing thyroid • Hard goitre, tracheal compression (stridor) and hoarseness Lymphoma >60 • Similar to anaplastic RARE • Associated with Hashimoto’s thyroiditis • Mostly due to Non-Hodgkin’s lymphoma Thyroid emergencies Myxoedema Coma (Hypothyroidism) Thyroid crisis/Thyrotoxic Storm (Hyperthyroidism) Signs & Symptoms: Symptoms: • Low level of conciousness/coma/confusion and looks • Fever (>38.5º C), confusion, agitation, N+V, myxoedematous hypertension • Usually in elderly, pt with poor medication compliance • Tachycardia/atrial fibrillation or undiagnosed hypothyroidism) triggered by onset of other conditions e.g. heart failure, sepsis or stroke. Mx: • Hypothermia (low as 25ºC), convulsions, coma and • Symptomatic Tx e.g. paracetamol • Beta blockers -> IV propranolol (prevents adrenergic raised CSF pressure and protein content, bradycardia symptoms e.g. tachycardia, tremor, anxiety etc. • Mortality rate is 50% thus early recognition and Tx • Anti-thyroid drugs e.g. methimazole or propylthiouracil Mx: • IV Dexamethasone (prevents conversion of T4 to T3 • Thyroid hormone replacement (IV levothyroxine or IV peripherally) e.g. 4mg IV qds Liothyronine) • Lugol’s iodine -> restores T3 to normal within 2-3days • Correct hypothermia, provide ventilatory and circulatory support if needed • Treating underlying trigger of event such as trauma, infection, acute iodine load e.g. CT contrast, • Glucocorticoid e.g. hydrocortisone if 2º hypothyroidism suspected thyroid/non-thyroidal surgery due to ill-preparation of patient prior to surgery. Subclinical Hyper-/Hypothyroidism Both present with asymptomatic patients with abnormal thyroid functions tests Subclinical Hypothyroidism: Subclinical Hyperthyroidism: • Serum TSH raised • Serum TSHis below normal (e.g. <0.1mU/L) • T3 & T4 are at lower end of reference ranges. • T3&4are at upper end of reference range. • Risk of progression to overt hypothyroidism • Potential to cause Afib and osteoporosis (especially if Anti-TPO Ab’s or TSH>10mlU/L Causes: • Older population with multinodular goitre Mx: (particular females) TSH=4-10mU/L & T4 is normal: • Excessive thyroxine due to meds • <65yrs with symptoms of hypothyroidism give levothyroxine • No improvement? Stop levothyroxine Mx: • Trial of low dose ATDs ofr 6mths to induce remission • Asymptomatic? repeat TFT in 6mths and observe • Annual review and surveillance with TFTs TSH>10mU/L & T4 is normal: • Start levothyroxine if ≤70yrs (even if no symptoms) >80yrs or elderly Watch + wait strategyThank you for attending! Fill in the feedback form to get access to the slides! Upcoming Events: • Monday 17th October - Diabetes Part 1 • Wednesday 19th October - Diabetes Part 2 • Monday 24th October - Thyroid Part 1 • Wednesday 26th October - Thyroid Part 2 • Wednesday 2 ndNovember - Endocrine SBA Quiz
