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

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1.Hyperthyroidism 2 2.Grave's Disease 4 3.Thyroid Storm 7 4.Hypothyroidism 9 5.Hashimoto's Thyroiditis 12 6.Myxedema Coma 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 Cancer 24 13.Follicular Thyroid Cancer 26 14.Anaplastic Thyroid Cancer 28 16.Grave's Ophthalmopathy 30 17.Factitious Thyrotoxicosis 31 18.Euthyroid Sick Syndrome 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 thyroid hormones 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 Thyroid storm 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 autoimmune disease 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 hypothalamus leading to ↓ TRH Risk factors Hashimoto's disease Radiation Thyroidectomy Thyroiditis Drugs (Amiodarone, lithium) Signs/symptoms Dry skin and coarse hair, Hoarseness, non-pitting edema, slowed deep tendon reflexes, bradycardia, goiter Fatigue and weakness, weight gain, constipation, menorrhagia, cold Intolerance, difficultly concentrating, depression, myalgias, muscle hypertrophy, myopathy and rhabdomyolysis Thyroid function tests ↑ TSH Treatment Levothyroxine Complications Myxedema coma Hyperlipidemia, Hyponatremia, 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-thyroglobulin antibodies lead to autoimmune destruction of the thyroid gland Risk factors Infections, stress, ↑ 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, infection, cold, Narcotics Signs/symptoms Depressed consciousness, altered mental status, hypothermia, 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, surgery 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 thyroid nodule 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 iodine deficiency presenting for evaluation of a new asymptomatic lump on the thyroid Epidemiology About 15% of thyroid cancers, 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
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