HYPERTHYROIDISM
Nervous system:
13.Over enthusiastic therapy
HEAD TO FOOT EXAMINATION IN HYPERTHYROIDISM
scalp-Alopacia
Eyes- Exophthalmos
lidlag,-Stellwags sign
lid retraction,-Von graffes sign
failure of convergence mobius sign
Neck:
thyroid enlargement with bruit
(diffuse,uninodular or multinodular)
Genito urinary system
Impotence,infertility, oligo menrrhea
Lower limbs
proximal muscle weakness
periodic hypokalemic paralysis
Mysthenia gravis
Legs
Pretibial myxedema
(peu 'd orange raised plaque)
Fingers
fine tremors
clubbing-periosteal bone thickening of distal phalanx
onycholysis
Palmar erythema
Digital pulsation
Pulse
tachycardia
increase in sleeping pulse rate
atrial fibillation
BP
High systolic BP
Skin:
smooth velvety ,moist sweating, warm
onycholysis-retraction of nail from nail bed
Normal level of Thyroid hormones
Note:From lab to lab reference range vary
T4- 4-12 µ.gms/100 ml
T3- 80 -200 nano gm/100ml
TSH- 0.5 -5µU/litre
Hyper thyroidism is a condition
resulting from excessive production of thyroid hormone by the thyroid gland.
Thyrotoxicosis is acondtion due to
excessive production of thyroid hormone from any cause .
Thyrotoxicosis
and hyperthyroidism are terms often used
interchangeably
systemic examination in Hyperthyroidism
Nervous system:
Nervousness,feeling of internal tension
Depression
tremors
brisk reflexes
emotional instability
inability to get along with others
poor at school and work
Depression
tremors
brisk reflexes
emotional instability
inability to get along with others
poor at school and work
Cardio vascular system
High blood pressure
Tacchy cardia,/
supraventricular tachycardia-on account of direct action upon the conduction system
atrial fibrillation can be superimposed on underlying heart disease
long standing hyperthyroidism can cause cardiomegaly and cardiac failure
this is due to hyperdynamic state
flow murmur-systolic
Pleuro pericardial rub in Graves disease
Means-lermans scratch-mid systolic scratching sound-at upper part of sternum-at end expiration(rare)
dyspnea on effort
angina on effort
High blood pressure
Tacchy cardia,/
supraventricular tachycardia-on account of direct action upon the conduction system
atrial fibrillation can be superimposed on underlying heart disease
long standing hyperthyroidism can cause cardiomegaly and cardiac failure
this is due to hyperdynamic state
flow murmur-systolic
Pleuro pericardial rub in Graves disease
Means-lermans scratch-mid systolic scratching sound-at upper part of sternum-at end expiration(rare)
dyspnea on effort
angina on effort
EYES:Ophthalmopathy:
can precede,accompany or follow Graves disease
i.e.ophthalmopathy runs a course independent of Graves Disease.cause is auto immune mechanism
Sympathetic overtone causes retraction of upper eyelid and so wide palpebral fissure
Von Grafes sign:
infiltration of inflammatory cells occurs over external ocular muscles producing swelling of the muscles and fibrosis causing restriction of ocular motility and diplopia
Mobius sign:in ability to converge the eyes
Lid lag-Stellwags sign-ask the patient to look up and then downwards-eye ball rotates down first upper lid lags behind.
Exophthalmoses/proptosis:Protrusion of eye ball from the orbit,exposing sclera below and above cornea Made out by asking the patient to look straight ahead and watching from the side. Retrobulbar deposition of immune complexes and inflammatory cells produces exophthalmos
Exposed cornea can go for keratitis
Pressure on optic nerve or keratitis can cause blindness. Proptosis also causes edema or chemosis of conjunctiva.
Rarely ophthalmopathy can can occur in Euthyroid patient(called Euthyroid Graves disease) or Hashimatos ophthalmopathy is one of the 3 components of Graves disease.
components of Graves Disease :
hyperthyroidism
Ophthalmopathy
Pretibial myxedema
ophthalmopathy may not correlate with severity of hyperthyroidism.
i.e.ophthalmopathy runs a course independent of Graves Disease.cause is auto immune mechanism
Sympathetic overtone causes retraction of upper eyelid and so wide palpebral fissure
Von Grafes sign:
infiltration of inflammatory cells occurs over external ocular muscles producing swelling of the muscles and fibrosis causing restriction of ocular motility and diplopia
Mobius sign:in ability to converge the eyes
Lid lag-Stellwags sign-ask the patient to look up and then downwards-eye ball rotates down first upper lid lags behind.
Exophthalmoses/proptosis:Protrusion of eye ball from the orbit,exposing sclera below and above cornea Made out by asking the patient to look straight ahead and watching from the side. Retrobulbar deposition of immune complexes and inflammatory cells produces exophthalmos
Exposed cornea can go for keratitis
Pressure on optic nerve or keratitis can cause blindness. Proptosis also causes edema or chemosis of conjunctiva.
Rarely ophthalmopathy can can occur in Euthyroid patient(called Euthyroid Graves disease) or Hashimatos ophthalmopathy is one of the 3 components of Graves disease.
components of Graves Disease :
hyperthyroidism
Ophthalmopathy
Pretibial myxedema
ophthalmopathy may not correlate with severity of hyperthyroidism.
Increased appetite but weight loss
Hyper defecation because of rapid motility
diarrhea uncommon
In advance hyperthyroidism malnutrition can cause abnormal Liver function
Reproductive System
In female infertility/oligomenorrheaIn
males-reduced sperm count and impotence and Gynecomatia because of increased peripheral conversion of androgen to estrogen inspite of hige testosterone level
Thryoid hormone increase sex hormone binding globulinSo inceased level of total testosterone and estrogen level
But serum LH(leutinising hormone) and FSH may be normal or increased
Musculo skeletal system
Excessive muscle catabolism causes atrophy and weakness of muscles
sssProximal muscle weakness,Hypokalemic periodic paralysis may occur
Myesthenia gravis
bone resorption is more than bone formation causing-hyper calcemia and hyper calciuria
Longstanding cases-osteopenia
Metabolic system
weight loss common especially in elderly with anorexia
Teenagers and young adults can loose control over appetite and gain weight
Increased heat production is dissipated by increased sweating and mild polydipsia
aversion for heat and preference for cold temperature
Insulin requirement in DM increases.
Skin
Skin is warm ,moist,velvety
palms are warm and sweating
Onycholysis of the nails -(retraction of nails from nail bed) occursa nd indicates long standing disease.
Pretibial myxedema
Peu d' orange appearance of the skin over pretibial area(appearance of dimpled texture of an orange peel.
Other areas involved are -dorsum of the foot,great toe/deltoid region
lesions are erythematous or violacoius in colour
May follow hyperthyroidism after treatment
It is due to mucoid swelling of the dermis and subcutaneous tissue.
Thyroid gland
usually enlarged
can be diffuse enlargement or multi nodular or uninodular
Causes of hyperthyroidism
1.Auto antibody induced -Graves disease
2.Toxic nodular goitre
3.Neo natalAutonomous tumor
4.Toxic adenoma
5.well differentiated thyroid carcinoma
6.Leakage of iodoprotein from damaged follicles
7.diffuse lymphocytic thyroiditis
8.Dequervains disease-subacute thyroiditis
9.Thyroiditis-Transient hyperthyroidism can occur in -
10.thyroiditis (by viral or bacterial infection or rarely in TB
11.Excessive TSH secretion-
12.ADMINISTRATION OF THYROID HORMONE Intensional(factitious)
13.Over enthusiastic therapy
14. Iodide induced -certain iodine containing medicines if used long periods can cause hyperthyroidism
15.Jod basedow syndromeIodide induced -
certain iodine containing medicines if used long periods can cause hyperthyroidism
Radiographic contrast media
HEAD TO FOOT EXAMINATION IN HYPERTHYROIDISM
scalp-Alopacia
Eyes- Exophthalmos
lidlag,-Stellwags sign
lid retraction,-Von graffes sign
failure of convergence mobius sign
Neck:
thyroid enlargement with bruit
(diffuse,uninodular or multinodular)
Chest:
gynecomatia
spidernevi
cardiomegaly
early sytolis murmur in pulmonary area
Means-lermans scratch-mid systolic scratching sound-at upper part of sternum-at end expiration(rare)
Pleuro pericardial rub
Abdomen
hyperphagia,
hyper defecation
splenomegaly
Genito urinary system
Lower limbs
proximal muscle weakness
periodic hypokalemic paralysis
Mysthenia gravis
Legs
Pretibial myxedema
(peu 'd orange raised plaque)
Fingers
fine tremors
clubbing-periosteal bone thickening of distal phalanx
onycholysis
Palmar erythema
Digital pulsation
Pulse
tachycardia
increase in sleeping pulse rate
atrial fibillation
BP
High systolic BP
Skin:
smooth velvety ,moist sweating, warm
onycholysis-retraction of nail from nail bed
THYROID STROM:
An uncommon complication
of hyperthyroidism
Precipitated by
conditions like infection,anesthesia
Suddenly symptoms
worsen causing
high temperature, confusion
and can result in death.
INVESTIGATIONS
assess levels of
·
TSH-In hyperthyroidism
TSH levels fall
·
T3
·
T4
sometimes T4 may be normal T3 can be high
False high levels may occur in pregnancy or due
to oral contraceptives
Low T4 levels occur in-corticosteroid therapy,severe illness-in
these,T4 binding proteins level go down.
·
Thyroid antibodies-to diagnose auto immune cause/graves
disease
Normal level of Thyroid hormones
Note:From lab to lab reference range vary
T4- 4-12 µ.gms/100 ml
T3- 80 -200 nano gm/100ml
TSH- 0.5 -5µU/litre
·
IMAGING
TESTS
1.Ultra sound of thyroid to look for thyroid nodules
2.Thyroid scan using radioactive iodine-to ascertain
size,shape and position of thyroid gland.
3.Radioactive iodine uptake test-to check thyroid function
and cause of hyperthyroidism
4.Fine needle aspiration biopsy of nodule to check or rule out malignancy.
Treatment of hyperthyroidism
Options
1.Medical treatment
2.Radioactive Iodine
3.Thyroid surgery
No single treatment works for every one.
Factors
influencing treatment:
1.age
2.possible allergies
3.Side effects of medicines
4.conditions like pregnancy,heart disease
Medical
therapy
1.Beta
blockers:
Usefull for symptomatic treatment:
tremors,tachycardia,nervousness until other treatments take effect
2.Antithyroid
medicines
Methimazole
Methimazole can harm the fetus
In pregnancy first 3 months- useful drug is propyl
thiouracil
Antithyroid medicines do not provide permanent cure:take
weeks or months to take effect-
They are not useful in thyroditis
Side
effects of antithyroid medicines
Allergy,-skin rash,itching
neutropenia manifest with sorethraot,fever
liver failure(rare)-causes jaundice
Methimazole is contra indicated in agranulocytosis,allergy and liver diseases.
3.Radiactive
iodine therapy
Common and effective mode of treatment
Radioactive iodine 131 orally as capsule or liquid-
Destroys the hyperactive
cells of thyroid gland
But do not affect other body tissues
Undesirable later
sequlae –hypothyroidism
Contraindicated
in pregnancy and during breast feeding
Thyroid
surgery
Least used mode of therapy
Removal of part of or most of thyroid .
Indications :
1.Large goiters
2.pregnancy
Pregnant women where radioactive and antithyroid medicines are contra
indicated
Preparatory to surgery antithyroid medicines are given to
bring thyroid level to normalcy-this to prevent
possible thyroid strom which can be
precipitated by general anesthesia.
Post surgically hypothyroidism may develop-to be treated
with thyroid hormone.
Diet prescription in hyper thyroidism
Avoid food containing
large amount of iodine likeseaweed
Avoid iodine suppliments
Avoid also cough syrups and multi vitamins containing
iodine.
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