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HYPERTHYROIDISM

A Practical Approach to Dx. and Rx.


Dr. R.V.S.N.Sarma., M.D., M.Sc.,
(Canada)

Consultant Physician and Chest


Specialist
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Clinical Exam. of Thyroid

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Have patient seated on a stool / chair

Inspect neck before & after swallowing

Examine with neck in relaxed position

Palpate from behind the patient

Remember the rule of finger tips

Use the tips of fingers for palpation

Palpate firmly down to trachea

Pembertons sign for RSG

Where to look for Thyroid ?

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Clinical Anatomy of Thyroid

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Clinical Exam of Thyroid

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Clinical Exam of Thyroid

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Clinical Exam of Thyroid

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Thyromegaly

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Hyperthyroidism
A hyper metabolic biochemical state
It is a multi system disease with

Elevated levels of FT4 or FT3 or both

What is thyrotoxicosis ?
What is hyperthyroidism ?

What are the various causes ?


How to differentiate the causes ?

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What is the appropriate treatment ?

Causes of Hyperthyroidism
1.
2.
3.
4.
5.
6.

Graves Disease Diffuse Toxic Goiter


Plummers Disease Toxic MNG
Toxic phase of Sub Acute Thyroiditis - SAT
Toxic Single Adenoma STA
Pituitary Tumours excess TSH
Molar pregnancy & Choriocarcinoma ( HCG)

8.

Metastatic thyroid cancers (functioning)


Struma Ovarii (Dermoid and Ovarian tumours)

9.

Thyrotoxicosis Factitia ; INF, Amiodarone, SSRIs

7.

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Graves Disease

The most common cause of thyrotoxicosis (50-60%).


Organ specific auto-immune disease
The most important autoantibody is

Thyroid Stimulating Immunoglobulin (TSI) or TSA


TSI acts as proxy to TSH and stimulates T4 and T3
Anti thyro peroxidase (anti-TPO) antibodies
Anti thyro globulin (anti-TG) Anti Microsomal and other
Autoimmune diseases - Pernicious Anemia, T1DM
RA, Myasthenia Gravis, Vitiligo, Adrenal insufficiency.

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Graves Disease

I 123 or TC 99m Normal v/s Graves


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Graves Disease

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Toxic Multinodular Goiter


(TMG)

TMG is the next most common hyperthyroidism - 20%


More common in elderly individuals long standing goiter

Lumpy bumpy thyroid gland


Milder manifestations (apathetic hyperthyroidism)

Mild elevation of FT4 and FT3

Progresses slowly over time


Clinically multiple firm nodules (called Plummers disease)

Scintigraphy shows - hot and normal areas

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Toxic Multinodular Goiter


(TMG)

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Toxic Multinodular Goiter


(TMG)

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Sub Acute Thyroiditis (SAT)

SAT is the next most common hyperthyroidism 15%

T4 and T3 are extremely elevated in this condition

Immune destruction of thyroid due to viral infection

Destructive release of preformed thyroid hormone

Thyroid gland is painful and tender on palpation

Nuclear Scintigraphy scan - no RIU in the gland


Treatment is NSAIDs and Corticosteroids
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Toxic Single Adenoma (TSA)

TSA is a single hyper functioning follicular thyroid adenoma.

Benign monoclonal tumor that usually is larger than 2.5 cm

It is the cause in 5% of patients who are thyrotoxic

Nuclear Scintigraphy scan shows only a single hot nodule

TSH is suppressed by excess of thyroxines

So the rest of the thyroid gland is suppressed

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Toxic Single Adenoma (TSA)


Nucleotide
Scintigraphy

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Age and Sex

Age

Graves disease

20 to 40

Toxic MNG

> 50 yrs

Toxic Single Adenoma 35 to 50

Sub Acute Thyroiditis

Any age

Sex M : F ratio

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Graves Disease
Toxic MNG

1: 5 to 1:10
1: 2 to 1: 4

Nucleotide Scintigraphy

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Clinical Features
1.

Those that occur with any type of thyrotoxicosis

2.

Those that are specific to Graves disease

3.

Non specific changes of hyper metabolism

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Common Symptoms
1.
2.
3.
4.
5.
6.
7.
8.
9.

Nervousness
Anxiety
Increased perspiration
Heat intolerance
Tremor
Hyperactivity
Palpitations
Weight loss despite increased appetite
Reduction in menstrual flow or oligo-menorrhea

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Common Signs
1.
2.
3.
4.
5.
6.
7.
8.

Hyperactivity, Hyper kinesis


Sinus tachycardia or atrial arrhythmia, AF, CHF
Systolic hypertension, wide pulse pressure
Warm, moist, soft and smooth skin- warm handshake
Excessive perspiration, palmar erythema, Onycholysis
Lid lag and stare (sympathetic over activity)
Fine tremor of out stretched hands format's sign
Large muscle weakness, Diarrhea, Gynecomastia

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Specific to Graves Disease


2.

Diffuse painless and firm enlargement of thyroid gland


Thyroid bruit is audible with the bell of stethoscope

3.

Ophthalmopathy Eye manifestations 50% of cases

1.

Sand in eyes, periorbital edema, conjunctival edema


(chemosis), poor lid closure, extraocular muscle dysfunction,
diplopia, pain on eye movements and proptosis.

Dermoacropathy Skin/limb manifestations 20% of cases

4.

Deposition of glycosamino glycans in the dermis of the lower


leg non pitting edema, associated with erythema and
thickening of the skin, without pain or pruritus - called
(pre tibial myxedema)

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Clinical Presentations

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MNG and Graves

Huge Toxic MNG


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Diffuse Graves Thyroid

Higher grades of Goiter

Toxic MNG
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(Diffuse) Graves

Grade IV Toxic MNG

Huge Toxic MNG


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Huge Toxic MNG

Thyroid Ophthalmopathy
Proptosis

Lid lag

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Ophthalmopathy in Graves

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Periorbital edema and chemosis

Ophthalmopathy in Graves

Occular muscle palsy


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Laka Laka Laka

Severe Exophthalmia

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Thyroid Dermopathy

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Pink and skin coloured papules, plaques on the shin

Graves with Acropathy

Graves Goiter
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Acropathy

Thyroid Acropathy

Clubbing and
Osteoarthropathy
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Onycholysis

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Non specific changes


1.
2.
3.
4.

Hyperglycemia, Glycosuria
Osteoporosis and hypercalcemia
LDL and Total Cholesterols
Atrial fibrillation, LVH, LV EF

6.

Hyper dynamic circulatory state


High output heart failure

7.

H/o excess Iodine, amiodarone, contrast dyes

5.

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HIGH
NORMAL

PRIMARY
HYPERTHYROID

LOW

FREE THYROXINE or FT4

Nine Square Approach

LOW

NORMAL

HIGH

THYROID STIMULATING HORMONE - TSH


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HIGH
NORMAL

SUB CLINICAL
HYPERTHYROID

LOW

FREE THYROXINE or FT4

Nine Square Approach

LOW

NORMAL

HIGH

THYROID STIMULATING HORMONE - TSH


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Diagnosis
1.

Typical clinical presentation

2.

Markedly suppressed TSH (<0.05 IU/mL)

3.

Elevated FT4 and FT3 (Markedly in Graves)

4.

Thyroid antibodies by Elisa anti-TPO, TSI

5.

ECG to demonstrate cardiac manifestations

6.

Nuclear Scintigraphy to differentiate the causes

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Algorithm for Hyperthyroidism


Measure TSH and FT4
TSH, FT4 N

TSH, FT4
Primary (T4)
Thyrotoxicosis

Measure FT3

TSH, FT4

N TSH, FT4 N

Pituitary Adenoma

FNAC, N Scan

Features of Graves
Yes

No

Rx. Graves
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RAIU

Low RAIU

Single Adenoma, MNG

High

T3 Toxicosis

Normal

Sub-clinical Hyper
F/u in 6-12 wks

Sub Acute Thyroiditis, I2, Thyroxine

Treatment Options
1.

Symptom relief medications

2.

Anti Thyroid Drugs ATD

Methimazole, Carbimazole

Propylthiouracil (PTU)

3.

Radio Active Iodine treatment RAI Rx.

4.

Thyroidectomy Subtotal or Total

5.

NSAIDs and Corticosteroids for SAT

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Symptom Relief
Rehydration is the first step
blockers to decrease the sympathetic excess

1.
2.

3.

Propranalol, Atenelol, Metoprolol


Rate limiting CCBs if blockers contraindicated

5.

Treatment of CHF, Arrhythmias


Calcium supplementation

6.

SSKI or Lugol solution for vascularity of the gland

4.

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Anti Thyroid Drugs (ATD)


Imp. considerations

Methimazole

Propylthiouracil

Efficacy

Very potent

Potent

Duration of action

Long acting BID/OD

Short acting QID/TID

In pregnancy

Contraindicated

Safely can be given

Mechanism of action

Iodination, Coupling

Iodination, Coupling

Conversion of T4 to T3

No action

Inhibits conversion

Adverse reactions

Rashes, Neutropenia Rashes, Neutropenia

Dosage

20 to 40 mg/ OD PO

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100 to 150mg qid PO

How long to give ATD ?

Reduction of thyroid hormones takes 2-8 weeks

Check TSH and FT4 every 4 to 6 weeks

In Graves, many go into remission after 12-18 months

In such pts ATD may be discontinued and followed up

40% experience recurrence in 1 yr. Re treat for 3 yrs.

Treatment is not life long. Graves seldom needs surgery

MNG and Toxic Adenoma will not get cured by ATD.

For them ATD is not the best. Treat with RAI.

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Radio Active Iodine (RAI Rx.)

In women who are not pregnant

In cases of Toxic MNG and TSA

Graves disease not remitting with ATD

RAI Rx is the best treatment of hyperthyroidism in adults

The effect is less rapid than ATD or Thyroidectomy

It is effective, safe, and does not require hospitalization.

Given orally as a single dose in a capsule or liquid form.

Very few adverse effects as no other tissue absorbs RAI

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Radio Active Iodine (RAI Rx.)


I123 is used for Nuclear Scintigraphy (Dx.)
I131 is given for RAI Rx. (6 to 8 milliCuries)

Goal is to make the patient hypothyroid

No effects such as Thyroid Ca or other malignancies

Never given for children and pregnant/ lactating women

Not recommended with patients of severe Ophthalmopathy

Not advisable in chronic smokers

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Surgical Treatment
Subtotal Thyroidectomy, Total Thyroidectomy
Hemi Thyroidectomy with contra-lateral subtotal

ATD and RAI Rx are very efficacious and easy so


Surgical treatment is reserved for MNG with

1.
2.
3.
4.

Severe hyperthyroidism in children


Pregnant women who cant tolerate ATD
Large goiters with severe Ophthalmopathy
Large MNGs with pressure symptoms
Who require quick normalization of thyroid function

5.
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Preoperative Preparation

ATD to reduce hyper function before surgery

eta blockers to titrate pulse rate to 80/min

SSKI 1 to 2 drops bid for 14 days

This will reduce thyroid blood flow

And there by reduce per operative bleeding

Recurrent laryngeal nerve damage

Hypo parathyroidism are complications

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Dietary Advice

Avoid Iodized salt, Sea foods

Excess amounts of iodide in some

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Expectorants, x-ray contrast dyes,


Seaweed tablets, and health food
supplements
These should be avoided because
The iodide interferes with or complicates the
management of both ATD and RAI Rx.

Summary of
Hyperthyroidism
Hyperthyroidism

Age

Enlarged Pain

RAIU Treatment

Graves (TSI Ab
eye, dermo, bruit)

20 - 40

60% Diffuse

None

ATD 18 m

Toxic MNG

> 50

20% Lumpy

Pressure

RAI, Surgery

Single Adenoma

35 - 50

5%

None

RAI, ATD

Yes

NSAID, Ster.

Single

S Acute Thyroiditis Any age 15% None


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TSH is markedly low, FT4 is elevated

Thyrotoxicosis Factitia

Excessive intake of Thyroxine causing thyrotoxicosis

Patients usually deny it is willful ingestion

This primarily psychiatric disorder

May lead to wrong diagnosis and wrong treatment

They are clinically thyrotoxic without eye signs of Graves

High doses of Thyroxine lead to TSH suppression

This causes shrinkage of the thyroid

Stop Thyroxine and give symptom relief drugs

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Algorithm for Thyroid


Thyroid Nodule
Nodule
Low TSH

Normal TSH

TC 99 Nuclear Scan
Hot Nodule
RAI Ablation,
Surgery or
ATD

Cold Nodule
4%
Malignant

Surgery
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FNAC or US
guided biopsy

10%

69%

Suspicious or
follicular Ca

Benign

T4
suppression

Cyst

17%
Non diagnostic
repeat FNAC

Surgery or
Cytology

Case # 1
A patient complains of sandy sensation in his eyes,weight
loss, and a tremor. His extraocular muscles are inflammed.
His thyroid is diffusely enlarged and non tender.
The most likely diagnosis is
a. Iodine deficiency
b. Sub-acute thyroiditis
c. Multinodular goiter
d. Graves disease
e. Silent thyroiditis
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Case # 2
A 55 year old woman is anxious, irritable, frequent semi
solid stools and she reports weight loss of 5 kgs in the past
six months. She was having a lumpy bumpy painless
swelling in her neck for past 20 years.
The most likely diagnosis is
a. Iodine deficiency goiter
b. Sub-acute thyroiditis
c. Multinodular goiter
d. Graves disease
e. Solitary toxic adenoma
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Case # 3
A 60 year patient from a mountain region complains of
constipation. He has a heart rate of 60, dry thick skin,
and a tongue that has scalloped edges from teeth
indentation. He has a goiter.
The most likely diagnosis is
a. Iodine deficiency
b. Subacute thyroiditis
c. Graves disease
d. Silent thyroiditis
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Case # 4
A 25 year old woman is three months pregnant. She has
a large goiter. Her exam is otherwise normal. Her thyroid
tests are normal.
You recommend
a. Cassava five times weekly
b. Fish three times weekly
c. Formula milk for the baby when it is born
d. A very low salt diet
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Case # 5
A 72 year old man complains of tremor and inability to
concentrate. On exam, he has a heart rate of 100 beats
per minute. He has a large goiter with many nodules. He
has a fine tremor. His serum T4 is very high and TSH is
very low.
Treatments that are likely to improve his symptoms are
a. Iodine therapy
b. Ethanol injection of his thyroid (PEI)
c. 6 weeks of Methimazole
d. Radio Active Iodine therapy

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Case # 6
In Nuclear Scintigraphy Scan I123 uptake is very high in
the thyroid of patients with
a. Silent thyroiditis
b. Single functional adenoma
c. Sub-acute thyroiditis
d. Acute ingestion of animal thyroid extract
e. Graves disease
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