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1.Hyperthyroidism 2 2.Grave's Disease 4 3.Thyroid Storm 7 4

1.Hyperthyroidism 2 2.Grave's Disease 4 3.Thyroid Storm 7 4

1. 2 2.Grave's Disease 4 3. Storm 7 4. 9 5.Hashimoto's 12 6. 14 7.Subacute Lymphocytic Thyroiditis 16 8.Subacute Granulomatous (De Quervain's) Thyroiditis 18 9.Thyroid-Associated Ophthalmopathy 20 10.Fibrous (Riedel) Thyroiditis 22 11.Generalized Resistance to Thyroid Hormone 23 12.Papillary Thyroid 24 13.Follicular Thyroid Cancer 26 14.Anaplastic Thyroid Cancer 28 16.Grave's Ophthalmopathy 30 17.Factitious Thyrotoxicosis 31 18. 32 19.Toxic Multinodular Goiter 34 20.Toxic adenoma 36 Hyperthyroidism Typical 22-year-old woman presenting for presentation evaluation of nervousness, irritability,

Insomnia, weight loss, diarrhea, sweating,

and palpitations for several

Pathophysiology Excessive

Risk factors Grave's disease

Toxic multinodular goiter

Plummer's disease

Hashimoto's thyroiditis

Toxic adenoma Signs/symptoms Enlarged thyroid gland, tachycardia, systolic

hypertension, widened pulse pressure,

atrial fibrillation/flutter

Nervousness, irritability, insomnia, weight

loss, diarrhea, heat intolerance, sweating,

tremors, palpitations, proximal muscle

weakness and myopathy, bone loss and

osteoporosis

Treatment Beta blockers, antithyroid drugs

(methimazole and propylthiouracil),

radioactive iodine ablation, surgical excision

Complications

Grave's Disease Typical 32-year-old woman presenting with presentation nervousness, Sweating, Palpitations, Heat

intolerance, Weight loss, Diarrhea, and

Physical exam reveals a diffusely enlarged

mass in the neck and large, bulging eyes

Epidemiology Women > men, 40-60 years of age

Pathophysiology Thyroid-stimulating immunoglobulins target

the thyrotropin (TSH) receptor leading to

overstimulation and over-secretion of T3

and T4

Risk factors Family history of Signs/symptoms Goiter with thrill and bruit, proptosis,

Pretibial myxedema

Symptoms of hyperthyroidism

Radioactive Diffuse uptake of radioactive iodine iodine uptake

Thyroid ↓ TSH, ↑ Free T4 and T3 function tests

Treatment Radioactive iodine ablation is best, other

treatments include beta blockers for

symptomatic relief, methimazole and

propylthiouracil, and surgical excision Complications Treatment with radioactive iodine ablation

can worsen ophthalmopathy

Patients are more likely to develop

hypothyroidism after radioactive iodine

ablation

Thyroid Storm Typical presentation 29-year-old woman presents with fever,

palpitations, Irritability, Nausea,

Vomiting, and Diarrhea following an

upper respiratory illness

Pathophysiology Acute exacerbation of hyperthyroidism

symptoms

Risk factors Recent illness

Diabetic ketoacidosis (DKA)

Stress

Signs/symptoms Extreme symptoms of hyperthyroidism

(High fever, Palpitations, Nausea,

vomiting, diarrhea) Treatment IV fluids, supportive care, glucose,

propylthiouracil and iodine, beta-

blockers, and dexamethasone

Complications Death in up to 20% of patients

Hypothyroidism Typical presentation 42-year-old woman presenting with

symptoms of difficulty concentrating,

fatigue, weakness, weight gain,

constipation, and

Pathophysiology Primary - failure of the thyroid to

produce hormone,

Secondary problem in the pituitary

leading to ↓ TSH,

Tertiary - problem in the

leading to ↓ TRH

Risk factors Hashimoto's disease

Radiation Thyroidectomy

Thyroiditis

Drugs (, )

Signs/symptoms Dry skin and coarse hair, Hoarseness,

non-pitting edema, slowed deep

tendon reflexes, , goiter

Fatigue and weakness, weight gain,

constipation, menorrhagia, cold

Intolerance, difficultly concentrating,

depression, myalgias, muscle

hypertrophy, myopathy and

rhabdomyolysis ↑ TSH

Treatment

Complications

Hyperlipidemia, ,

elevations in creatine kinase, and

transaminitis

Hashimoto's Thyroiditis Typical presentation 36-year-old woman presenting for

evaluation of an enlarging non-tender

thyroid gland, fatigue, weight gain,

constipation, and menorrhagia

Pathophysiology Anti-thyroid peroxidase (anti-TPO)

and anti- antibodies lead

to autoimmune destruction of the

thyroid gland

Risk factors , , ↑ iodine intake,

Radiation exposure

Signs/symptoms Goiter, symptoms of hypothyroidism Thyroid ↑ TSH, ↑ anti-microsomal antibodies function tests

Treatment Levothyroxine

Complications Risk of developing thyroid lymphoma

characterized by rapid enlargement

and compressive symptoms

Myxedema Coma Typical presentation 25-year-old Caucasian female brought

into the emergency room by her

parents with reduced consciousness,

reduced respiratory rate, and low body

temperature

Risk factors Years of untreated hypothyroidism

Trauma, , cold, Narcotics

Signs/symptoms Depressed consciousness, altered

mental status, , and

reduced respiratory rate

Treatment Supportive care, IV thyroxine and

hydrocortisone Complications High mortality rate even with

treatment

Subacute Lymphocytic Thyroiditis Typical presentation 30-year-old Caucasian female

presenting with weight loss,

Heat intolerance, Diarrhea and

a painless swelling of the thyroid and

Labs show ↓ TSH, ↑ free T4, and

diffusely ↓ radioactive iodine uptake

Epidemiology Women > men

Risk factors Postpartum period

Signs/symptoms Painless enlargement of thyroid gland

Radioactive iodine Radioactive iodine uptake is ↓ uptake diffusely Thyroid function ↓ TSH, ↑ Free T4 and T3 tests

Treatment Symptomatic Beta-blockers during

hyperthyroid state

Subacute Granulomatous (De Quervain's) Thyroiditis Typical presentation 31-year-old woman presenting with

an extremely painful thyroid gland

following an upper respiratory

infection

Epidemiology Women > men

Pathophysiology Inflammation of the thyroid gland

leads to leakage of hormones

followed by depletion of hormonal

stores

Risk factors Viral illness, HLA-B35 Signs/symptoms Intense pain, Tenderness, and

swelling of the thyroid

Radioactive iodine Radioactive iodine uptake is uptake ↓ diffusely

Thyroid function ↓ TSH, ↑ Free T4 and T3 tests

Labs ↑ Erythrocyte sedimentation rate

(ESR)

Treatment NSAIDs and Aspirin, oral

corticosteroids may be used in more

severe cases

Thyroid-Associated Ophthalmopathy Typical presentation 38-year-old woman with a history of

hypothyroidism presenting with

bulging eyes, tearing and edema,

and inability to close her eyelids fully

Pathophysiology Autoantibodies targeted toward

periorbital connective tissue and

muscle

Signs/symptoms Lid retraction, Inability to close eyes

completely, proptosis, and diplopia

Treatment Usually self limited, or oral

corticosteroids may be useful Complications Most patients without thyroid

dysfunction will go on to develop

thyroid dysfunction within 2 years

Fibrous (Riedel) Thyroiditis Typical presentation 44-year-old asymptomatic woman

presenting with an extremely hard, firm

thyroid

Epidemiology Women > men

Pathophysiology Fibrous tissue replaces normal thyroid

tissue

Signs/symptoms Most patients are euthyroid, but may

present with hypo-or hyperthyroidism

Treatment Surgery if compressive symptoms such

as hoarseness, difficulty breathing, or

difficulty swallowing are present

Generalized Resistance to Thyroid Hormone Typical presentation 28-year-old man presenting with growth

retardation, mental retardation, fatigue,

depression, weight gain, constipation and

cold Palpation of thyroid gland is TSH ↑

T3 and

Pathophysiology Resistance to thyroid hormones due to

defects in thyroid hormone receptors on

peripheral tissues

Signs/symptoms Growth and mental retardation,

symptoms of hypothyroidism

Thyroid function tests Normal or ↑ TSH, ↑ Free T4 and T3

Treatment Levothyroxine

Papillary Thyroid Cancer Typical presentation 41-year-old woman with a history of

Hodgkin's lymphoma status post

radiation therapy presenting for

evaluation of a new asymptomatic

bump on the

Epidemiology Most common type of thyroid cancer

(>70%), more common in women

Risk factors History of radiation exposure

Family history

Gardner's and Cowden's syndrome Signs/symptoms Firm nodule on thyroid, ipsilateral

cervical lymphadenopathy, hoarseness

and compressive symptoms

Radioactive iodine ↑ Iodine uptake in uptake

Thyroid function tests Thyroid hormone levels normal

Labs Psammoma bodies and large cells with

ground glass cytoplasm and pale nuclei

Treatment Lobectomy, total thyroidecomy

Complications Metastasize to local lymph nodes

Follicular Thyroid Cancer Typical presentation 58-year-old man with a history of

presenting for

evaluation of a new asymptomatic

lump on the thyroid

Epidemiology About 15% of thyroid ,

average 40-60 years of age

Risk factors Iodine deficiency

Signs/symptoms Firm nodule on thyroid, rarely

associated with lymphadenopathy

Thyroid function Thyroid hormone levels normal tests Labs Invasion of the capsue and blood

vessels with follicular appearing cells;

uniform microfollicular architecture

Treatment Total thyroidecomy with

postoperative iodine ablation

Complications Metastasizes hematogenously to lung,

brain, and bone

Anaplastic Thyroid Cancer Typical presentation 65-year-old woman with a history of

papillary thyroid cancer presents

with a thyroid mass, anorexia, weight

loss, fatigue, and pulmonary

symptoms

Epidemiology About 5% of thyroid cancers, more

common in women, older age of

presentation

Risk factors History of papillary or follicular

thyroid cancer

History of multinodular goiter Signs/symptoms Firm mass on thyroid, neck pain,

compressive symptoms, chest pain,

bone pain, constitutional symptoms

Thyroid function tests Thyroid hormone levels normal

Treatment Surgical excision, radiotherapy,

chemotherapy, supportive care

Complications Metastasis is very common,

Mortality is high

Grave's Ophthalmopathy Typical 31-year-old woman with a history of Grave's presentation disease presenting for evaluation of large,

bulging eyes with a gritty feeling

Epidemiology Most common cause of exophthalmos in

adults

Pathophysiology Anti-thyrotropin receptor antibodies leads to

retro-orbital lymphocytic infiltration and ↑

connective and adipose tissue

Risk factors Can worsen with radioactive iodine ablation

treatment

Treatment Oral steroids can be helpful

Factitious Thyrotoxicosis Typical presentation 24-year-old using herbal weight loss pills

presents with heat intolerance,

irritability, weight loss, sweating, and

Labs demonstrate ↓ TSH, ↑ free

Radioactive iodine uptake is diffusely ↓

Pathophysiology Exogenous ingestion of thyroid hormone

Radioactive iodine Diffusely ↓ radioactive iodine uptake uptake

Thyroid function ↓ TSH, ↑ free T4, ↓ serum tests thyroglobulin

Treatment Treat underlying cause

Euthyroid Sick Syndrome Typical presentation 58-year-old man hospitalized for

diverticulitis and septic

presenting with ↓ T3, normal T4, and

Normal TSH.

Physical exam is unremarkable.

Pathophysiology Reduced conversion of T4 to T3 by

5'-deiodination due to caloric

deprivation, ↑ and ↑

inflammatory markers following acute

illnesses

Risk factors Severe acute illness Signs/symptoms No signs or symptoms of

hyperthyroidism or hypothyroidism

Thyroid function ↓ T3, Normal T4 and TSH tests

Treatment None

Toxic Multinodular Goiter Typical presentation 56-year-old man presenting with a

bumpy thyroid gland and symptoms of

nervousness, sweating, palpitations,

heat intolerance, weight loss, diarrhea,

and insomnia.

Pathophysiology Multiple independently

Hyper functioning thyroid nodules

within the thyroid gland

Risk factors ↑ Age, Iodine deficiency

Signs/symptoms Enlarged thyroid gland with multiple

firm nodules, symptoms of

hyperthyroidism Thyroid function ↓ TSH, ↑ Free T4 and T3 tests

Treatment Beta blockers, antithyroid drugs

(methimazole and propylthiouracil),

radioactive iodine ablation, surgical

excision

Toxic adenoma Typical presentation 44-year-old man presenting with a firm

mass on the thyroid gland and

symptoms of nervousness, sweating,

palpitations, heat intolerance, weight

loss, diarrhea, and

Pathophysiology Solitary independently

Hyper functioning thyroid nodule

within the thyroid gland

Signs/symptoms Solitary, firm thyroid nodule, symptoms

of hyperthyroidism

Thyroid function ↓ TSH, ↑ Free T4 and T3 tests Treatment Beta blockers, antithyroid drugs

(methimazole and propylthiouracil),

radioactive iodine ablation, surgical

excision

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