Thyrotoxicosis

Question 1

Define it

Answer 1

Symptoms caused by the excessive circulation of thyroid hormones

Question 2

What’s it caused by?

Answer 2

Conditions that lead to hyperthyroidism

• Graves’ disease - risk factor is Smoking
• Toxic multinodular goitre
• Toxic adenoma
• Amiodarone induced

Question 3

What groups does it happen more commonly in?

Answer 3

• F>M
• Graves’ disease present at 20-30 years old

Question 4

What is thyroid storm?

Answer 4

acute exacerbation of hyperthyroidism that results in alife-threateninghypermetabolic state

triggered by surgery, trauma, infection

Question 5

CF of thyrotoxicosis

Answer 5

• Hyperpyrexia
• hypertension
• tachycardia
• jaundice
• confusion and agitation/syncope
• severe N&V

Question 6

Management of thyroid storm

Answer 6

• IV propranolol - if contraindicated e.g. asthma/low BP give IV digoxin
• Propylthiouracil (followed by Lugol’s iodine 6 hours later)
• Prednisolone/hydrocortisone → reduces peripheral conversion of T4 to T3

Question 7

General CF

Answer 7

• Weight loss
• Restlessness
• Heat intolerance

Question 8

Cardiac CF

Answer 8

• Palpitations
• Tachycardia

Question 9

Skin CF

Answer 9

• Increased sweating
• Pretibial myxoedema (specific to Graves)
• Onycholysis (nail separates from nail bed)

Question 10

other CF

Answer 10

• Diarrhoea
• Anxiety
• Tremor
• Oligo/Amenorrhoea

Question 11

What Graves’ specific features are there?

Answer 11

• exophthalmos
• pretibial myxoedema
• thyroid acropachy (clubbing of fingernails)

Question 12

What are the main investigations we’d do?

Answer 12

TFTs: - High T3/T4 and Low TSH
Anti-TSH receptor antibody to detect graves
Thyroid ultrasound
Fine needle aspiration for neck lumps
Radioactive iodine uptake

Question 13

what results can you get with radioactive iodine uptake

Answer 13

Diffuse uptake throughout enlarged gland: Grave’s disease

Multinodular Gland with single hot nodule, patchy uptake Toxic Multinodular Goitre

Diffuse Uptake with single cold nodule: Thyroid Cancer

No uptake: De Quervain’s (viral) thyroiditis

Question 14

treatment of toxic multinodular goitre

Answer 14

Radioiodine therapy

Question 15

De Quervain’s thyroiditis presentation and management

Answer 15

Initially are hyperthyroid and have painful tender goitre after a viral (flu-like) illness. Then become hypothyroid after.

Self limiting and can be managed conservatively i.e. with NSAIDs

Question 16

How do we control the symptoms?

Answer 16

Propranolol

Question 17

What different definitive management is there?

Answer 17

Anti-thyroid drugs: Carbimazole for 12-18 months to inhibit TPO. 1st line for Graves’

Propylthiouracil: used for first trimester of pregnancy and thyroid storm

Potassium iodine

Radioactive iodine ablation: Destruction of thyroid tissue via radioactive iodine

Thyroid surgery (total thyroidectomy)

Question 18

What patients is carbimazole contraindicated in and what are the SE?

Answer 18

do not in Early pregnancy

SE: agranulocytosis. Seek urgent medical attention if infection developed so FBC can be measured

Question 19

When do you do radioactive iodine ablation

Answer 19

If resistant to antithyroid drugs

definitive treatment for graves’ disease and toxic multinodular goitre

Question 20

Complications

Answer 20

High output cardiac failure