Silent Thyroiditis Case

Question 1

What are some physical exam maneuvers you should do when evaluating the thyroid?1

Answer 1

1. palpation of neck for mass, nodularity, thyromegaly or thrill
2. Listen to the neck for a thyroid bruit
3. Reflexes
4. Vitals - bradycardia with hypotension or tachycardia with hypertension?
5. Weight - increase or decrease?
6. body temp - low?
7. Facial appearance - loss of hair? puffiness?
8. Eyes - exopthalmos? lid lag?
9. Hair growth patterns
10. Skin - palmar erythema? diaphoresis? dry or pale? myxedema?
11. Hands and nails - onycholysis? swollen fingers?
12. Tremor? shaky hands? hyperkinetic?
13. facial expression - dull? slow movement? slow speech? hoarseness?
14. Listen to heart - arrhytmias?

Question 2

When would you hear a thyroid bruit?

Answer 2

typically with graves disease or anythign that causes a big thyroid (the extra blood flow can be heard - very hypervascular)

Question 3

When would you see hyperreflexia? hyporeflexia?

Answer 3

hyper in hyperthyroid

hypo in hypothyroid

Question 4

What would the vitals look like in hypothyroid?

Answer 4

bradycardic with hypotension

also might see low temperature

Question 5

In which would you expect to see puffy eyelids?

Answer 5

hypoT

Question 6

In which would you expect to see exopthalmos and lid lag?

Answer 6

lid lag in hyperT

exopthalmos is specific to graves

Question 7

In which would you see hair loss?

Answer 7

both

just thinning in hyperT
coarse, brittle, strawlike with diffuse alopecia and lateral eyebrow loss in hypoT

Question 8

What skin findings would you expect in hyperT?

Answer 8

palmar erythema and diaphoresis

Question 9

What skin findings would you expect to see in hypoT?

Answer 9

dry wtih slight palor

pretibial myxedema

Question 10

What would you espect on the hand and nail exam in hyperT?

Answer 10

onycholysis and swollen fingers (acropachy)

Question 11

Which would you expect to see tremor in?

Answer 11

hyperthyroid

Question 12

Which one would you expect to see hoarseness in?

Answer 12

hypoT - because of myxedema in the throat

Question 13

What’s the most common thyroid blood test?

Answer 13

the TSH

Question 14

If the TSH is elevated, it’s ____

Answer 14

hypothyroidism (over 3)

Question 15

If the TSH is low, it’s___

Answer 15

hyperthyroidism (under 0.3)

Question 16

What does free T4 measure?

Answer 16

it measure the free T4 that’s floating around in the blood

it will be elevated in hyperthyroidism and low in hypothyroidism (usually)

Question 17

Which gives you a better sense of actual T4 - the free T4 or total T4?

Answer 17

you would think it would be total, but it’s actually free

this is because the free T4 is what’s available for uptake and use by the cells. Bound levels may not be immediately available and is more affected by other drugs, illness and physical changes like pregnancy.

Question 18

So what does total T4 actually give you a sense of?

Answer 18

how much binding protein a patient is making (since 99% of the hormone is bound)

Question 19

Simiarly, which do we care more about - gree T3 or total T3

Answer 19

free

Question 20

What does the free thyroxine index tell us?

Answer 20

it tells us how much T4 is free compared to bound.

this can help tell if abnormal amounts of T4 are present because of abnormal amounts of thyroxine-binding globulin

Question 21

Thyroglobulin levels can be low or normal with normal thyroid function, but when can it be elevated?

Answer 21

thyroiditis, Graves disease, or thyroid cancer

Question 22

When do we most commonly monitor the thyroglobulin level?

Answer 22

when we’re evaluating the effectiveness of treatment for thyroid cancer and to monitor for thyroid cancer recurrence

Question 23

When are thyroid peroxidase antibodies most often present?

Answer 23

in hashimotos disease and less commonly in other forms of thyroiditis

Question 24

THyroglobulin antibodies are present in ___% of hashimoto patients and __%of graves patients

Answer 24

60% of hashimotos

30% of graves

Question 25

If you have already been diagnosed with graves, a high level of anti-thyroglobulin antibodies are indicative of what?

Answer 25

more likely to eventually become hypothyroid

Question 26

Anti-TSH receptor antibodies are seen in what?

Answer 26

graves disease (rarely hashimotos)

Question 27

In Graves disease, the radioactive iodine uptake is ____

Answer 27

high (because it's hyperthyroid)

Question 28

In Hashimoto's thyroiditis, the radioactive iodine uptake is ____

Answer 28

generally low with patchy hot spots in the gland

Question 29

How do we tell is a nodule is hot or cold?

Answer 29

hot will have increased radioactive iodine uptake while cold will have low

Question 30

A ___ nodule is rarely cancerous

Answer 30

hot

Question 31

What percentage of cold nodules are cancerous?

Answer 31

only 10-20%

Question 32

What is thyroid US used for?

Answer 32

evaluation of nodules, lumps and enlargement

Question 33

Can a US determine if a nodule is malignant?

Answer 33

nope - can only tell you if it's fluid filled or solid tissue

Question 34

What would be some US findings suspicious for cancer?

Answer 34

size over 10 mm, micro-calcifications, hypoechoic, hypervascular, irregular margins, height greater than width?

Question 35

If the US is concerning, what is the next step?

Answer 35

Do a fine need aspiration of the nodule

Question 36

If you have high TSH and low FT4, what's the diagnosi?

Answer 36

primary hypothyroidism

Question 37

High TSH, High T4?

Answer 37

secondary hyperthyroidism

Question 38

High TSH and normal T4?

Answer 38

subclinical hypothyroidism

Question 39

If TSH is low and T4 is low, what's the diagnosis?

Answer 39

secondary hypothyroidism (rare)

Question 40

If TSH is low and T4 is high?

Answer 40

hyperthyroidism or thyrotoxicosis

Question 41

If TSH is low but T4 is normal?

Answer 41

sublinical hyperthyroidism

Question 42

What kind of thyroiditis occurs in the postpartum window?

Answer 42

silent thyroiditis

Question 43

Does silent thyroiditis cause a thyrotoxicosis or hypothyroidism?

Answer 43

can do either - usually thyrotoxicosis first and then hypothyroidism later

Question 44

What is the cause of silent thyroiditis?

Answer 44

not sure - probably autoimmune since you can find anti-thyroid peroxidase and anti-thyroglobulin antibodies

Question 45

How common is silent thyroiditis in the US?

Answer 45

higher than you think - 5-10%

Question 46

Who is at increased risk for developing postpartum thyroiditis?

Answer 46

``` any women with: autoimmune disorders those with positive anti-thyroid antibodies hx of previous thyroid dysfunction Hx of previous postpartum thyroiditis family hx of thyroid dysfunction ```

Question 47

What percentage of women will have a recurrence of silent thyroidis with subsequent pregnancies?

Answer 47

20%

Question 48

What is the typical timeline for silent thyroiditis?

Answer 48

THe thyrotoxic phase occurs 1-4 months after delivery and lasts for about 1-3 months the hypothyroid phase typically occurs 4-8 months after the delivery and can last up to 9-12 months most women return to their normal thyroid function within 12-18 months after the onset of symptoms, but approximately 20% that go into the hypothyroid phase will remain hypothyroid

Question 49

In which phase do women usually present? Why?

Answer 49

Usually present in the hypothyroid phase this is because the hyperthyroid symptoms (anxiety, insomnia, palpitations, fatigue, weight loss and irritability) are attributed to being post-partum with the stress of having a new baby

Question 50

Describe the treatment plan for silent thyroidits?

Answer 50

depends on the stage for the thyrotoxicosis - use beta blockers (if not nursing) for symptoms, but don't use thyroid suppressants for the hypothyroid - try hormoen replacement and continue for about 6-12 months. then taper to see if they can stop taking it. only 20% will need to go back on.

Question 51

When does postpartum depression usually start?

Answer 51

1-3 weeks after delivery requires treatment!

Question 52

What are the postpartum baby blues?

Answer 52

mother feels upset,d epressed and anxious 2-3 days after birth go away without treatment!

Question 53

What is postpartum psychosis?

Answer 53

a much more severe verions of postpartum depression - often in women who have bipolar disorders or schizophrenia