Hyperthyroidism in Adults: Variable Clinical Presentations and Approaches to Diagnosis
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Management of Graves Disease:€€A Review
Clinical Review & Education Review Management of Graves Disease A Review Henry B. Burch, MD; David S. Cooper, MD Author Audio Interview at IMPORTANCE Graves disease is the most common cause of persistent hyperthyroidism in adults. jama.com Approximately 3% of women and 0.5% of men will develop Graves disease during their lifetime. Supplemental content at jama.com OBSERVATIONS We searched PubMed and the Cochrane database for English-language studies CME Quiz at published from June 2000 through October 5, 2015. Thirteen randomized clinical trials, 5 sys- jamanetworkcme.com and tematic reviews and meta-analyses, and 52 observational studies were included in this review. CME Questions page 2559 Patients with Graves disease may be treated with antithyroid drugs, radioactive iodine (RAI), or surgery (near-total thyroidectomy). The optimal approach depends on patient preference, geog- raphy, and clinical factors. A 12- to 18-month course of antithyroid drugs may lead to a remission in approximately 50% of patients but can cause potentially significant (albeit rare) adverse reac- tions, including agranulocytosis and hepatotoxicity. Adverse reactions typically occur within the first 90 days of therapy. Treating Graves disease with RAI and surgery result in gland destruction or removal, necessitating life-long levothyroxine replacement. Use of RAI has also been associ- ated with the development or worsening of thyroid eye disease in approximately 15% to 20% of patients. Surgery is favored in patients with concomitant suspicious or malignant thyroid nodules, coexisting hyperparathyroidism, and in patients with large goiters or moderate to severe thyroid Author Affiliations: Endocrinology eye disease who cannot be treated using antithyroid drugs. -
Treating Thyroid Disease: a Natural Approach to Healing Hashimoto's
Treating Thyroid Disease: A Natural Approach to Healing Hashimoto’s Melissa Lea-Foster Rietz, FNP-BC, BC-ADM, RYT-200 Presbyterian Medical Services Farmington, NM [email protected] Professional Disclosures I have no personal or professional affiliation with any of the resources listed in this presentation, and will receive no monetary gain or professional advancement from this lecture. Talk Objectives • Define hypothyroidism and Hashimoto’s. • Discuss various tests used to identify thyroid disease and when to treat based on patient symptoms • Discuss potential causes and identify environmental factors that contribute to disease • Describe how the gut (food sensitivities) and the adrenals (chronic stress) are connected to Hashimoto’s and how we as practitioners can work to educate patients on prevention before the need for treatment • How the use of adaptogens can enhance the treatment of Hashimoto’s and identify herbs that are showing promise in the research. • How to use food, exercise, and relaxation to improve patient outcomes. Named for Hakuro Hashimoto, a physician working in Europe in the early 1900’s. Hashimoto’s was the first autoimmune disease to be recognized in the scientific literature. It is estimated that one in five people suffer from an autoimmune disease and the numbers continue to rise. Women are more likely than men to develop an autoimmune disease, and it is believed that 75% of individuals with an autoimmune disease are female. Thyroid autoimmune disease is the most common form, and affects 7-8% of the population in the United States. Case Study Ms. R is a 30-year-old female, mother of three, who states that after the birth of her last child two years ago she has felt the following: • Loss of energy • Difficulty losing weight despite habitual eating pattern • Hair loss • Irregular menses • Joints that ache throughout the day • A general sense of sadness • Cold Intolerance • Joint and Muscle Pain • Constipation • Irregular menstruation • Slowed Heart Rate What tests would you run on Ms. -
The Thyroid Nodule Information for Patients
The Thyroid Nodule Information for Patients What is a thyroid nodule? operations, since fewer than 10% of the removed nodules proved to be cancer. Most removed The thyroid gland is located in the lower front nodules could have simply been observed or of the neck, below the larynx (“Adam’s apple”) treated medically. and above the collarbones. A thyroid nodule is a lump in or on the thyroid gland. Thyroid nodules It is not usually possible for a physician to are common and occur in about 4% of women determine whether a thyroid nodule is cancerous and 1% of men; they are less common in on the basis of a physical examination or younger patients and increase in frequency with blood tests. Endocrin ologists rely heavily on age. Sometimes several nodules will develop in 3 specialized tests for help in deciding which the same person. Any time a lump is discovered nodules should be treated surgically: in thyroid tissue, the possibility of malignancy (cancer) must be considered. Fortunately, the tThyroid fine needle biopsy vast majority of thyroid nodules are benign (not tThyroid scan cancerous). tThyroid ultrasonography Many patients with thyroid nodules have no symptoms whatsoever, and are found by What is a thyroid needle biopsy? chance to have a lump in the thyroid gland on a routine physical exam or an imaging study of A thyroid fine needle biopsy is a simple the neck done for unrelated reasons (CT or MRI pro ce dure that can be performed in the scan of spine or chest, carotid ultrasound, etc). physician’s office. -
Feline Hyperthyroidism
Feline Hyperthyroidism Sponsored by Feline Hyperthyroidism Feline hyperthyroidism is the most common endocrine disorder in middle-aged to left) are advanced. Blood testing and older cats. It occurs in about 10 percent of feline patients over 10 years of age. can reveal elevation of thyroid Hyperthyroidism is a disease caused by an overactive thyroid gland that secretes hormones to establish a diagnosis excess thyroid hormone. Cats typically have two thyroid glands, one gland on of hyperthyroidism. Occasionally, each side of the neck. One or both glands may be affected. The excess thyroid additional diagnostics may be hormone causes an overactive metabolism that stresses the heart, digestive tract, required to confirm the diagnosis. and many other organ systems. Because hyperthyroidism can occur along with other medical conditions, If your veterinarian diagnoses your cat with hyperthyroidism, your cat should and it affects other organs, a receive some form of treatment to control the clinical signs. Many cats that are comprehensive screening of your diagnosed early can be treated successfully. When hyperthyroidism goes untreated, Cat years prior to developing the disease Same cat with hyperthyroidism cat’s heart, kidneys, and other clinical signs will progress leading to marked weight loss and serious complications organ systems is imperative. due to damage to the cat’s heart, kidneys, and other organ systems. MANAGEMENT AND TREATMENT OPTIONS CLINICAL SIGNS If your veterinarian diagnoses your cat with hyperthyroidism, he or she will discuss If you observe any of the following behaviors or problems in your cat, contact and recommend treatment options for your cat. Four common treatments for feline your veterinarian because the information may alert them to the possibility that hyperthyroidism are available and each has advantages and disadvantages. -
Thyroid Nodules Update in Diagnosis and Management Shrikant Tamhane1* and Hossein Gharib2,3
Tamhane and Gharib Clinical Diabetes and Endocrinology (2015) 1:11 DOI 10.1186/s40842-015-0011-7 REVIEW ARTICLE Open Access Thyroid nodules update in diagnosis and management Shrikant Tamhane1* and Hossein Gharib2,3 Abstract Thyroid nodules are very common. With widespread use of sensitive imaging in clinical practice, incidental thyroid nodules are being discovered with increasing frequency. Their clinical importance is primarily related to the need to exclude malignancy (4.0 to 6.5 percent of all thyroid nodules), assess for their functional status and any pressure symptoms caused by them. New Molecular tests are marketed for the assessment of thyroid nodules for the presence of cancer. The high prevalence of thyroid nodules requires evidence-based rational strategies for their differential diagnosis, risk stratification, treatment, and follow-up. This review addresses advances and controversies in thyroid nodule evaluation, including the new molecular tests, and their management considering the current guidelines and supporting evidence. Keywords: Thyroid, Thyroid Nodules, Molecular markers, Benign, Malignant, FNA, Management, Ultrasonography Introduction disorders, benign and malignant can cause thyroid nod- Thyroid nodule is a discrete lesion within the thyroid ules (Table 1) [1, 5]. gland that is radiologically distinct from the surrounding Fine needle aspiration (FNA) biopsy is the most accur- thyroid parenchyma. Thyroid nodules are common. ate method for evaluating thyroid nodules and helps to They are discovered as an accidental finding by a pa- identify patients who require surgical resection [6]. If a tient, or as an incidental finding during a routine phys- serum TSH is normal or elevated, and the nodule meets ical examination in 3 to 7 % [1] or by a radiologic criteria for sampling, the next step in the evaluation of a procedure: 67 % with ultrasonography (US) imaging, thyroid nodule is a FNA biopsy. -
Heterogenous Morphologic Forms of Goiter in Autoimmune Thyroid Disease
WJOES Heterogenous Morphologic Forms of Goiter in Autoimmune Thyroid Disease: An Insight based10.5005/jp-journals-10002-1140 on a Prospective Surgical Series ORIGINAL ARTICLE Heterogenous Morphologic Forms of Goiter in Autoimmune Thyroid Disease: An Insight based on a Prospective Surgical Series of 88 Cases PRK Bhargav ABSTRACT Usually, both GD and HT have diffuse goiter due to bilateral Two commonest forms of autoimmune thyroid disease (AITD) symmetrical involvement of thyroid gland by the disease are Graves’ disease (GD) and Hashimoto’s thyroiditis (HT) with process.7 But, in 20 to 30% of cases, they may be associated a diffuse goiter. The nature of goiter apart from clinical presenta- with nodules or assymetrical enlargement.8-11 The variability tion is crucial in the management of AITD. But, the goiter is not always diffuse, leading to diagnostic confusion. In this context, in proportion of nodularity depends upon clinical or sono- we conducted a prospective study on the goiter morphology in graphic methods of evaluation. In a classical case of AITD AITD. This is a prospective study conducted in Endocrine Surgery department of a teritiary care teaching hospital in South India (i.e. with usual clinical presentation, cardinal signs and over a period of 1 year. The cohort is a surgical series of 88 cases diffuse goiter), the standard diagnostic protocol with imaging of AITD (GD = 53; HT = 35). Morpho logy of all the ex vivo speci- and serology suffices, but appears to be insufficient in AITD mens were studied, documented and correlated with clinical and radiological forms of goiter. Sex ratio was M:F = 74:14. -
Thyroid Nodules MARY JO WELKER, M.D., and DIANE ORLOV, M.S., C.N.P
PRACTICAL THERAPEUTICS Thyroid Nodules MARY JO WELKER, M.D., and DIANE ORLOV, M.S., C.N.P. Ohio State University College of Medicine and Public Health, Columbus, Ohio Palpable thyroid nodules occur in 4 to 7 percent of the population, but nodules found incidentally on ultrasonography suggest a prevalence of 19 to 67 percent. The major- O A patient informa- ity of thyroid nodules are asymptomatic. Because about 5 percent of all palpable nod- tion handout on thy- roid nodules, written ules are found to be malignant, the main objective of evaluating thyroid nodules is to by the authors of this exclude malignancy. Laboratory evaluation, including a thyroid-stimulating hormone article, is provided on test, can help differentiate a thyrotoxic nodule from an euthyroid nodule. In euthyroid page 573. patients with a nodule, fine-needle aspiration should be performed, and radionuclide scanning should be reserved for patients with indeterminate cytology or thyrotoxico- sis. Insufficient specimens from fine-needle aspiration decrease when ultrasound guidance is used. Surgery is the primary treatment for malignant lesions, and the extent of surgery depends on the extent and type of disease. Ablation by postopera- tive radioactive iodine is done for high-risk patients—identified as those with metasta- tic or residual disease. While suppressive therapy with thyroxine is frequently used postoperatively for malignant lesions, its use for management of benign solitary thy- roid nodules remains controversial. (Am Fam Physician 2003;67:559-66,573-4. Copy- right© 2003 American Academy of Family Physicians.) Members of various thyroid nodule is a palpable jects 19 to 50 years of age had an incidental family practice depart- swelling in a thyroid gland with nodule on ultrasonography. -
Thyroid Disease
Thyroid Disease Thyroid disease occurs when the thyroid (a small, butterfly-shaped gland in the front of your neck) does not produce the right amount of thyroid hormone. These hormones control how your body uses energy. If you are feeling fatigued, notice skin or hair changes, or have hoarseness or pain, your doctor may conduct a physical exam and order blood tests. If these tests indicate a problem, your doctor may order thyroid scan and uptake, thyroid biopsy, or imaging tests to help diagnose and evaluate a thyroid condition. Treatment will depend on the specific nature of your thyroid condition and its underlying cause. What is thyroid disease? The thyroid is a small, butterfly-shaped gland in the front of your neck that wraps around your windpipe (trachea). The two halves of the thyroid gland are connected in the middle by a thin layer of tissue known as the isthmus. The thyroid gland uses iodine (mostly absorbed from food) to produce hormones that control how your body uses energy. Nearly every organ in the body is affected by the function of the thyroid gland. The pituitary gland and hypothalamus, an area at the base of the brain, control the rate at which the thyroid produces and releases these hormones. The main function of the thyroid gland is to release a hormone called thyroxine or T4, which is converted into a hormone called T3. Both of these hormones circulate in the bloodstream and help regulate your metabolism. The amount of T4 produced by the thyroid gland is determined by a hormone produced by the pituitary gland called TSH or thyroid-stimulating hormone. -
Endocrine Emergencies
Endocrine Emergencies • Neuroendocrine response to Critical illness • Thyroid storm/Myxedema Coma • Adrenal Crisis/Sepsis • Hyper/Hypocalcemia • Hypoglycemia • Hyper and Hyponatremia • Pheochromocytoma crises CASE 76 year old man presents with urosepsis and is Admitted to MICU. He has chronic renal insufficiency. During his hospital course, he is intubated and treated With dopamine. Thyroid studies are performed for Inability to wean from ventilator. What labs do you want? Assessment of Thyroid Function • Hormone Levels: Total T4, Total T3 • Binding proteins: TBG, (T3*) Resin uptake • Free Hormone Levels: TSH, F T4, F T3, Free Thyroid Index, F T4 by Eq Dialysis • Radioactive Iodine uptake (RAIU); primarily for DDx of hyperthyroidism • Thyroid antibodies; TPO, Anti-Thyroglobulin, Thyroid stimulating immunoglobulins, Th receptor antibodies Labs: T4 2.4 ug/dl (5-12) T3U 40% (25-35) FTI 1.0 (1.2-4.2) FT4 0.6 (0.8-1.8) TSH 0.2 uU/ml (.4-5.0) Non-thyroidal illness • Hypothesis: NTI vs 2° Hypothyroidism –RT3 ↑ in NTI and ↓ in Hypothyroidism • Hypothesis: NTI vs Hyperthyroidism – TT3 ↓ in NTI and in ↑ Hyperthyroidism • 75 year old woman with history of hypothyroidism is found unresponsive in her home during a cold spell in houston. No heat in the home. • Exam: T° 95, BP 100/60, P 50, RR 8 • Periorbital edema, neck scar, no rub or gallop, distant heart sounds, crackles at bases, peripheral edema • ECG: Decreased voltage, runs of Torsade de pointes • Labs? Imaging? • CXR: cardiomegaly • Glucose 50 • Na+ 120, K+ 4, Cl 80, HCO3¯ 30 • BUN 30 Creat 1.4 • ABG: pH 7.25, PCO2 75, PO2 80 • CK 600 • Thyroid studies pending • Management: Manifestations of Myxedema Coma • Precipitated by infection, iatrogenic (surgery, sedation, diuretics) • Low thyroid studies • Hypothermia • Altered mental status • Hyponatremia • ↑pCO2 • ↑CK • ↑Catecholamines with ↑vascular resistance • Cardiac: low voltage, Pericardial effusion, impaired relaxation with ↓C.O. -
Hyperthyroidism: a Guide for Families
Pediatric Endocrinology Fact Sheet Hyperthyroidism: A Guide for Families What is hyperthyroidism? roidism, free T4 and T3 are very elevated, and the TSH level Hyperthyroidism refers to a disease in which there is ex- is extremely low. cessive amount of thyroid hormone in the blood. This is gen- erally caused by overproduction or release of thyroid hormone What is the treatment of hyperthyroidism? by the thyroid gland. Hyperthyroidism is more common in Antithyroid medications the adolescent age group, and is more frequent in girls than The most common method of treatment of hyperthy- boys. However, it can also be found in younger children of roidism is administration of antithyroid medication, which both sexes. stops the thyroid gland from making and releasing thyroid hormone. The drug of choice is methimazole. Another an- What causes hyperthyroidism? tithyroid medication, propylthiouracil (PTU), is not used The most common cause of hyperthyroidism is Graves’ often in children, because it is associated with more frequent disease, or autoimmune hyperthyroidism. In this situation, serious side effects. Methimazole can be associated with side a person’s immune system makes antibodies that stimulate effects including an itchy skin rash (hives), and rarely joint the thyroid gland to become overactive. Over time, this leads and muscle pains and aches, jaundice (skin and eye yellowing to enlargement of the thyroid gland, which produces excessive from a liver problem), and a low white blood cell count, which amounts of thyroid hormone. Often, Graves’ disease, like might make it hard to fight infection. If one of these side other autoimmune thyroid disease, runs in families. -
Toxic Nodule and Toxic Multinodular Goiter
AMERICAN THYROID ASSOCIATION® www.thyroid.org Toxic Nodule and Toxic Multinodular Goiter WHAT IS THE THYROID GLAND? HOW IS IT DIAGNOSED? The thyroid gland is a butterfly-shaped endocrine gland The diagnosis of hyperthyroidism is made on the basis that is normally located in the lower front of the neck. of symptoms and physical exam findings, and it is The thyroid’s job is to make thyroid hormones, which are confirmed by laboratory tests showing excess thyroid secreted into the blood and then carried to every tissue hormones (see the Hyperthyroidism brochure). In in the body. Thyroid hormones help the body use energy, hyperthyroidism, there is a high level of thyroid hormone stay warm and keep the brain, heart, muscles, and other in the blood plus a low level of TSH. Once the diagnosis organs working as they should. of hyperthyroidism is made, a thyroid scan can be performed. This test uses radioactive iodine to show WHAT IS A TOXIC NODULE OR TOXIC where the thyroid is functioning. A toxic nodule appears a single area of overactivity and a toxic multinodular MULTINODULAR GOITER? goiter has multiple areas. A thyroid ultrasound can Toxic nodule or toxic multinodular goiter refers to also be used to better evaluate the presence of thyroid one or more nodules (typically benign growths) in nodules. the thyroid gland that make thyroid hormone without responding to the signal to keep thyroid hormone HOW ARE TOXIC NODULE AND TOXIC balanced. The end result is that too much thyroid MULTINODULAR GOITER TREATED? hormone can be produced and released into the bloodstream, resulting in hyperthyroidism. -
Is It Possible to Predict the Onset of Graves' Disease?
EDITORIAL www.nature.com/clinicalpractice/endmet Is it possible to predict the onset of Graves’ disease? Nobuyuki Amino Ideally, medicine enables us to prevent disease; It might be microsomes. Of the 71 of these antibody- failing that, it should allow us to detect and possible to positive women examined after preg- diagnose diseases at an early stage, and to nancy, 5 developed Graves’ disease. Hidaka stop them from progressing to a severe state. predict the et al. confirmed that all the women with post- Endocrine diseases are no exception to postpartum partum Graves’ disease had TRAb in early preg- these ideals. Autoimmune thyroid disease is onset of nancy that were detectable by highly sensitive a frequently observed illness (predominantly Graves’ bioassay. It might be possible, therefore, to affecting females), and hyperthyroid or hypo- disease, if predict the postpartum onset of Graves’ disease, thyroid conditions markedly disturb the quality if a sensitive enough assay for TRAb is used in of life. It is well established that hyperthyroidism a sensitive early pregnancy; however, cost-effectiveness of in Graves’ disease is induced by antibodies enough assay this approach should be considered. against the TSH receptor (TRAb) that stimulate is used in early Predicted cases of postpartum Graves’ the thyroid gland. Sensitive assay techniques pregnancy disease could, moreover, be prevented by for the detection of TRAb have been developed, short-term corticosteroid therapy initiated and these show a positive reaction in 99% of immediately after delivery, similar to the patients with Graves’ disease. In other auto- prevention of postpartum development of hypo- immune diseases, detection of the appropriate thyroidism (Tada H et al.