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Medicine > Case 7 - Thyroid Disease - Progress Test > Flashcards

Case 7 - Thyroid Disease - Progress Test Flashcards

1
Q

What causes thyroid hormones to be released?

A
  • Hypothalamus secretes thyrotropin-releasing hormone (TRH)
  • This stimulates the anterior pituitary to secrete thyroid-stimulating hormone (TSH)
  • This stimulates the thyroid to release T3 (triiodothyronine) and T4 (thyroxine)
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2
Q

What do thyroid hormones do in the body?

A

They act on a variety of tissues to:

  • help regulate the use of energy sources
  • help regulate protein synthesis
  • control the body’s sensitivity to other hormones
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3
Q

What is primary hypothyroidism caused by?

A

A problem with the thyroid gland

eg. an autoimmune condition

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4
Q

What is secondary hypothyroidism caused by?

A

A problem with the pituitary gland
(eg. pituitary apoplexy)

or a lesion compressing the pituitary gland

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5
Q

What is congenital hypothyroidism?

A

A problem with thyroid dysgenesis

or thyroid dyshormonogenesis

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6
Q

What is the main type of hyperthyroidism?

A

Primary hyperthyroidism

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7
Q

What is the most common pathology assoicatied with hypothyroidism?

A

Hashimoto’s thyroiditis

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8
Q

What is Hashimoto’s thyroiditis and what other conditions is it associated with?

A

An autoimmune disease

Associated with:

  • type 1 DM
  • Addison’s
  • Pernicious anaemia
  • Vitiligo

Hashimoto’s is assoicated with development of MALT lymphoma

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9
Q

What are the other causes of hypothyroidism?

A
  • Subacute thyroiditis (de Quervain’s)
    (causes a painful goitre and a raised ESR)
  • Riedel thyroiditis
    (causes a painless goitre. The normal tissue is replaced by fibrous tissue)
  • Post-partum thyroiditis
  • Drugs: lithium, amiodarone
  • Iodine deficinecy
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10
Q

What is the most common pathology associated with hyperthyroidism?

A

Grave’s disease

thyroid eye disease may also be seen

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11
Q

What are the other causes of hyperthyroidism?

A

Toxic multinodular goitre
(treatment of choice = radioiodine)

Drugs: amiodarone

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12
Q

What are the symptoms of hypothyroidism?

A
  • Weight gain
  • Lethargy
  • Cold intolerance
  • Dry, cold, yellowish skin
  • Dry, coarse scalp hair
  • Loss of the lateral aspect of the eyebrows
  • Constipation
  • Menorrhagia
  • Decreased deep tendon reflexes
  • Carpal tunnel syndrome
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13
Q

What are the symptoms of thyrotoxicosis?

A
  • Weight loss
  • Manic restlessness
  • Heat intolerance
  • Palpitations (may provoke arrhythmias)
  • Pre-tibial myxoedema
  • Thyroid acropachy (clubbin)
  • Diarrhoea
  • Oligomenorrhea
  • Anxiety
  • Tremor
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14
Q

What would investigations for primary hypothyroidism show?

A

High TSH

Low free T4

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15
Q

What would investigations for secondary hypothyroidism show?

A

Low TSH

Low free T4

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16
Q

What would investigations for sick euthyroid syndrome show?

A

Low TSH

Low free T4

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17
Q

What would investigations for subclincial hypothyroidism show?

A

High TSH

Normal free T4

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18
Q

Would would investigation in patients with poor complicance to thyroxine show?

A

High TSH

Normal free T4

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19
Q

Would would investigations for primary hyperthyroidism show?

A

Low TSH

High free T4

20
Q

What antibodies are seen in Graves’ disease?

A

TSH receptor antibodies

21
Q

What antibodies are seen in Hashimoto’s thyroiditis?

A

anti-TPO antibodies

anti-thyroglobulin (Tg) antibodies may also be seen

22
Q

What investigation would be used to diagnose toxic multinodular goitre?

A

Nuclear scintigraphy

Toxic multinodular goitre reveals patchy uptake

23
Q

How is hypothyroidism managed?

A

Thyroxine

24
Q

How is hyperthyroidism managed?

A

Propanolol for symptomatic relief

Carbimazole

Radioiodine treatment

25
Q

What is the pharacology of carbimazole?

A

Carbimazole blocks thyroid peroxidase from coupling and iodinating the thyrosine residues on thyroglobulin - reducing thyroid hormone production

26
Q

What is an important side effect of carbimazole?

A

Agranulocytosis (dangerously low WBC count)

27
Q

How is carbimazole taken?

A

Taken OD for 6-9 months

Then withdrawn to see if in remission

Thyroixine is added once the patient is euthyroid

28
Q

How long should you avoid contact with children and pregnant women after radioiodine treatment?

A

3 weeks

29
Q

What complication of hyperthyroidism can be worsened by radioiodine treatment?

A

Thyroid eye disease

30
Q

How is thyroid eye disease prevented from worsening after radioiodine treatment?

A

Prednisolone

31
Q

How are thyroid cancers investigated?

A

Thyroid US

Fine needle aspiration

32
Q

What are some side effects of levothyroxine?

A

Hyperthyroidism (due to over treatment)

Osteoporosis (reduced bone mineral density)

Worsening angina

AF

33
Q

What does of levothyroxine should be given initially?

A

50-100mcg.

25 mcg should be given in patients over 50 and those with cardiac disese or severe hypothyroidism, and then slowly titrated up.

34
Q

When should thyroid levels be checked after starting levothyroxine?

A

8-12 weeks

35
Q

What TSH range is levothyroixine hoping to achieve?

A

0.5-2.5

36
Q

How should a levothyroxine dose be adjusted in pregnancy?

A

Increase dose by at least 25-50 mcg of levothyroxine.

37
Q

What medications interact with levothyroxine?

A

Iron

Calcium carbonate

38
Q

What is subacute thyroiditis?

A

Thyroiditis thought to occur following a viral infection

39
Q

What are the phases of subacute thyroiditis?

A

Phase 1 (3-6 weeks) : hyperthyroidism, painful goitre, raised ESR

Phase 2 (1-3 weeks) : euthyroid

Phase 3 (weeks to months) : hypothyroidism

Phase 4 : thyroid structure and function returns to normal

40
Q

How is subacute thyroiditis investigated?

A

thyroid scintigraphy

Shows globally reduced uptake of iodine-131

41
Q

How is subactue thyroiditis managed?

A

Usually self-limiting and doesn’t require treatment

Thyroid pain may respond to aspirin or NSAIDs

In more severe cases, or if hypothyroidism develops, then steroids are used

42
Q

What is post-partum thyroiditis and how is it managed?

A

Thyrotoxicosis, followed by hypothyroidism, followed by normal thyroid function.

anti-TPO is found in 90% of cases.

Management:

  • Propanolol in the thyrotoxic phase
  • Thyroxine in the hypothyroid phase
43
Q

What can trigger a thyroid storm?

A
  • Surgery
  • Trauma
  • Infection
  • Acute iodine load eg. CT contrast media
44
Q

What are the clinical features of a thyroid storm?

A 
Fever > 38.5 
Tachycardia 
Confusion and agitation 
Nausea and vomiting 
Hypertension 
Heart failure 
Abnormal liver function tests (may be jaundiced)
45
Q

How is a thyroid storm managed?

A

Symptomatic treatment:

  • Paracetamol
  • beta blockers eg. propanolol IV

Treat underlying cause

Anti-thyroid drugs:

  • methimazole or
  • propylthiouracil

Lugol’s iodine

Dexamathasone - 4mg IV qds
(blocks conversion of T4 to T3)

Medicine (15 decks)

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