EXAM #1: HYPERTHYROID

Question 1

What are the cardiac sequelae of hyperthyroidism?

Answer 1

1) A-fib

2) High-output failure

Question 2

What is Graves’ dermopathy?

Answer 2

Thickening of the skin in the setting of hyperthyroidism

Question 3

What changes in the eyes are specific to Graves’ disease?

Answer 3

1) Proptosis
2) Ophthalmoplegia*
3) Periorbital edema

*Can’t look in certain directions, can lead to diplopia

Question 4

What are the three major pathophysiologic mechanisms of hyperthyroidism?

Answer 4

1) Increased thyroid hormone synthesis
- Primary (thyroid)
- Secondary (TSH)
2) Inappropriate LEAK of T4

Question 5

What are the major etiologies of hyperthyroidism?

Answer 5

1) Graves’ Disease
2) Autonomous nodules
3) Subacute thyroiditis
4) Iodine-induced
5) TSH-producing adenoma
6) HCG-mediated (pregnancy)

Question 6

What are the TSH and FT4 levels in hyperthyroidism?

Answer 6

• Low TSH

- High FT4 (normal is subclinical)

Question 7

What antibody test is used in the diagnosis of hyperthyroidism?

Answer 7

TSI

Question 8

What is the most common cause of hyperthyroidism?

Answer 8

Graves’ Disease

Question 9

What causes Graves’ Disease?

Answer 9

Autoimmune antibodies to TSH receptors

• TRAb
• TSIg

Question 10

What are the “extra” manifestations of Graves’ disease compared to hyperthyroidism?

Answer 10

1) Graves’ Ophthalmopathy
- Inflammation
- GAG
- Edema
- Adipogenesis
- Extraocular muscle hypertrophy
2) Dermopathy

Question 11

What is the direct cause of Graves’ Ophthalmopathy?

Answer 11

Antibodies

Question 12

What is the main test used to diagnose Graves’ Disease? What is the expected outcome?

Answer 12

Radionuclear uptake and scan

• Uptake will be normal/high
• Homogenous scan

Question 13

What is the treatment for Graves’ Disease?

Answer 13

1) Symptomatic: beta-blockers, steroids

2) Specific

Question 14

What is the MOA of the antithyroid drugs?

Answer 14

Inhibits organification and coupling

Question 15

What drugs are “antithyroid?”

Answer 15

PTU

Methimazole

Question 16

What adverse is associated with the antithyroids, especially PTU?

Answer 16

Hepatitis

Question 17

How long are the antithyroid medications typically given?

Answer 17

2 years

Question 18

What is used for a radioactive ablation in Graves’ Disease?

Answer 18

I131 (different from what is used for the diagnostic test)

*Permanent but can take 4 weeks to 6 months

Question 19

What do you do when a patient becomes hypothyroid s/p radioactive thyroid ablation?

Answer 19

Levothyroxine

Question 20

Why would you treat a patient with iodine for a week prior to surgery?

Answer 20

Decreased T4 and vascularity

*Utilizes the Wolff Chiakoff Phenomenon

Question 21

What is an autonomously functioning thyroid nodule?

Answer 21

Hot nodule with hyperplasia of follicular cells

*There is overproduction of T4 INDEPENDENT of TSH

Question 22

How will the uptake and scan appear in autonomously functioning thyroid nodule?

Answer 22

• Normal to high uptake

- Focal hyperactivity i.e. NOT homogenous

Question 23

What is the preferred treatment for autonomously functioning thyroid nodule?

Answer 23

Radioactive ablation

*Only the focal hot-spots will uptake the radioactive material

Question 24

How does the outcome of radioablation for autonomously functioning thyroid nodule differ from Graves’ Disease?

Answer 24

Much less likely to cause hypothyroid

Question 25

What is the underlying pathology in thyroiditis?

Answer 25

Inflammation of thyroid tissue leading to leakage of preformed hormone

Question 26

What will a radionuclear scan appear in thyroiditis?

Answer 26

Low uptake

Question 27

What is the treatment for thyroiditis?

Answer 27

Supportive care

Question 28

What should you be sure to check after a patient with thyroiditis transitions to euthyroid?

Answer 28

TSH/T4 to ensure they don't develop hypothyroid

Question 29

When is iodine-induced hyperthyroidism commonly seen?

Answer 29

Amiodarone* *Utilizes the Jod Basedow effect

Question 30

What are the types of amiodarone induced hyperthyroid?

Answer 30

Type 1 AIH= increased synthesis Type 2 AIH= thyroiditis

Question 31

How can you diagnose Type 1 vs 2 AIH?

Answer 31

Ultrasound will show increased muscularity in Type 1

Question 32

How can AIH be treated?

Answer 32

1) Glucocorticoids i.e. prednisone | 2) Surgery

Question 33

What labs are seen in a TSH-producing pituitary adenoma? What name is given to this condition?

Answer 33

- Increased T4 - Increased TSH This is SECONDARY hyperthyroidism

Question 34

What clinical features are associated with TSH-producing pituitary adenomas?

Answer 34

1) Hyperthyroidism 2) Goiter 3) Visual field defects

Question 35

What is the treatment for a TSH-producing pituitary adenoma?

Answer 35

1) Octreotide | 2) Transphenodial resection

Question 36

Why is hyperthyroid seen in pregnancy?

Answer 36

HCG stimulates thyroid

Question 37

What is the treatment for HCG-mediated hyperthyroidism in pregnancy, IF T4 is high?

Answer 37

First trimester= PTU 2nd-3rd= Methimazole *Note if T4 is normal, no treatment necessary

Question 38

What typically triggers Thyroid Storm?

Answer 38

1) Omission of anti-thyroid drug 2) Surgery, MI, CVA *In patient with underlying hyperthyroidism

Question 39

What is the specific treatment algorithm for Thyroid Storm?

Answer 39

1) Beta-blocker 2) Glucocorticoids 3) Antithyroids 4) Iodine

Question 40

What is euthyroid sick syndrome?

Answer 40

Low serum levels of thyroid hormones in clinically euthyroid patients with nonthyroidal systemic illness *TSH is also low

Question 41

What is the treatment for euthyroid sick syndrome?

Answer 41

None--treatment is not necessary