Hyperthyroidism: Difference between revisions
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===Causes=== | ===Causes=== | ||
'''Primary Hyperthyroidism''' | '''Primary Hyperthyroidism''' | ||
*Graves disease (toxic diffuse | *Graves disease (toxic diffuse goitre) | ||
**Most common cause (85% of cases) | **Most common cause of hyperthyroidism (85% of cases) | ||
**Associated with diffuse | **Autoantibodies bind to TSH receptor and stimulate thyroid hormone production and release <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref> | ||
*Toxic multinodular | **Associated with diffuse goitre, ophthalmopathy, local dermopathy | ||
**Strong genetic relationship, often found with other autoimmune disorders <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref> | |||
*Toxic multinodular goitre | |||
**2nd most common cause | **2nd most common cause | ||
*Toxic nodular (adenoma) | **Multiple autonomously functioning nodules <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref> | ||
** | **Milder, more gradual disease than Graves' hyperthyroidism | ||
*Toxic nodular (adenoma) goitre | |||
**Single hyperfunctioning nodule | |||
**Similar presentation to multinodular goitre, but less common <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref> | |||
'''Secondary Hyperthyroidism''' | '''Secondary Hyperthyroidism''' | ||
*Thyrotropin-secreting pituitary adenoma | *Thyrotropin-secreting pituitary adenoma | ||
*Thyroiditis | *Thyroiditis | ||
*Hashimoto thyroiditis | **Hashimoto thyroiditis | ||
**Initially gland is overactive (hyperthyroidism state) followed by hypothyroidism | ***Autoimmune disorder | ||
*Subacute painful thyroiditis (de Quervain thyroiditis) | ***Thyroid antibodies and lymphocytic infiltration <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref> | ||
*Subacute painless thyroiditis | ***Painless goitre | ||
*Radiation thyroiditis | ***Initially gland is overactive (hyperthyroidism state) followed by hypothyroidism | ||
**Subacute painful thyroiditis (de Quervain thyroiditis)<ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref> | |||
***May be caused by viral infection | |||
***Viral prodrome followed by anterior neck pain | |||
***Tender thyroid (palpation, head movement, swallowing) | |||
***50% have symptoms of hyperthyroid lasting 3 - 6 weeks | |||
***1/3 have hypothyroidism for up to 6 months | |||
**Subacute painless thyroiditis <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref> | |||
***Small, non-tender goitre | |||
***Mild symptoms | |||
***Autoimmune | |||
**Postpartum thyroiditis <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref> | |||
***3 phases: | |||
****Thyrotoxic phase 2 -6 months postpartum (20-30% have only this phase) | |||
****Hypothyroid phase lasting 2 -3 months (but may be permanent) (40% have this phase only) | |||
****Euthyroid phase within first postpartum year | |||
***Some women develop permanent hypothyroidism | |||
***70% recurrence in subsequent pregnancies | |||
**Suppurative thyroiditis <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref> | |||
***Rare | |||
***Life-threatening | |||
***Infection usually bacterial, but can be parasitic, mycobacterial, or fungal | |||
***Usually have pre-existing thyroid disorder and immune compromise | |||
**Radiation thyroiditis | |||
'''Other causes:''' | '''Other causes:''' | ||
*[[Apathetic thyrotoxicosis]] (elderly, masking comorbidities) | *[[Apathetic thyrotoxicosis]] (elderly, masking comorbidities) | ||
*Metastatic thyroid cancer | *Metastatic thyroid cancer | ||
*Iodine-induced thyrotoxicosis | *Iodine-induced thyrotoxicosis | ||
*Amiodarone (contains iodine) | *Amiodarone-induced thyroiditis <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders </ref> | ||
**Possible mechanisms: | |||
***Drug-induced destructive thyroiditis | |||
***Hyperthyroidism caused by iodine load (amiodarone contains a large amount of iodine) | |||
**Drug-induced thyroiditis may also occur with interleukin-2, interferon alpha, lithium, tyrosine kinase inhibitors, HAART | |||
*[[Molar pregnancy]] | *[[Molar pregnancy]] | ||
Revision as of 00:41, 19 March 2019
Background
- Hyperthyroidism: Excess circulating hormone resulting from thyroid gland hyperfunction
- Thyrotoxicosis: Excess circulating thyroid hormone originating from any cause
Causes
Primary Hyperthyroidism
- Graves disease (toxic diffuse goitre)
- Toxic multinodular goitre
- 2nd most common cause
- Multiple autonomously functioning nodules [3]
- Milder, more gradual disease than Graves' hyperthyroidism
- Toxic nodular (adenoma) goitre
- Single hyperfunctioning nodule
- Similar presentation to multinodular goitre, but less common [4]
Secondary Hyperthyroidism
- Thyrotropin-secreting pituitary adenoma
- Thyroiditis
- Hashimoto thyroiditis
- Autoimmune disorder
- Thyroid antibodies and lymphocytic infiltration [5]
- Painless goitre
- Initially gland is overactive (hyperthyroidism state) followed by hypothyroidism
- Subacute painful thyroiditis (de Quervain thyroiditis)[6]
- May be caused by viral infection
- Viral prodrome followed by anterior neck pain
- Tender thyroid (palpation, head movement, swallowing)
- 50% have symptoms of hyperthyroid lasting 3 - 6 weeks
- 1/3 have hypothyroidism for up to 6 months
- Subacute painless thyroiditis [7]
- Small, non-tender goitre
- Mild symptoms
- Autoimmune
- Postpartum thyroiditis [8]
- 3 phases:
- Thyrotoxic phase 2 -6 months postpartum (20-30% have only this phase)
- Hypothyroid phase lasting 2 -3 months (but may be permanent) (40% have this phase only)
- Euthyroid phase within first postpartum year
- Some women develop permanent hypothyroidism
- 70% recurrence in subsequent pregnancies
- 3 phases:
- Suppurative thyroiditis [9]
- Rare
- Life-threatening
- Infection usually bacterial, but can be parasitic, mycobacterial, or fungal
- Usually have pre-existing thyroid disorder and immune compromise
- Radiation thyroiditis
- Hashimoto thyroiditis
Other causes:
- Apathetic thyrotoxicosis (elderly, masking comorbidities)
- Metastatic thyroid cancer
- Iodine-induced thyrotoxicosis
- Amiodarone-induced thyroiditis [10]
- Possible mechanisms:
- Drug-induced destructive thyroiditis
- Hyperthyroidism caused by iodine load (amiodarone contains a large amount of iodine)
- Drug-induced thyroiditis may also occur with interleukin-2, interferon alpha, lithium, tyrosine kinase inhibitors, HAART
- Possible mechanisms:
- Molar pregnancy
Clinical Features
Constitutional signs:
- Lethargy
- Diaphoresis
- Weakness
- Fever
- Heat intolerance
- Weight loss
Neuropsychiatric:
- Emotional lability
- Fine tremor
- Anxiety
- Muscle wasting
- Confusion
- Hyperreflexia
- Coma
- Periodic paralysis
- Psychosis
Ophthalmologic:
- Diplopia
- Lid lag
- Eye irritation
- Exophthalmos
- Ophthalmoplegia
Endocrine:
- Neck fullness/tenderness (thyroid gland)
Cardiorespiratory:
- Dyspnea
- Widened pulse pressure
- Palpitations
- Systolic hypertension
- Chest pain
- Sinus tachycardia
- Atrial fibrillation
- Occurs in 10-20% of patients and can revert to sinus rhythm when hyperthyroidism treated
- Atrial flutter
- CHF
GI:
- Diarrhea
- Hyperactive bowel sounds
Reproductive:
- Oligomenorrhea
- Gynecomastia
- Telangiectasia
Gynecologic:
- Menorrhagia
- Sparse pubic hair
Hematologic:
- Anemia
- Leukocytosis
Dermatologic:
- Hair loss
- Pretibial myxedema
- Warm, moist skin
- Palmar erythema
- Onycholysis
Apathetic hyperthyroidism: (elderly patients)[11]
- Placid apaethetic facies
- Depression
- Lethargy
- Muscular weakness and wasting
- Excessive weight loss
- Cardiac dysrrhythmias
- Absent or small goiter
- Absence of ocular symptoms
- Agitation and confusion
Differential Diagnosis (Tachycardia)
- Anemia
- Dehydration
- Fever
- Drug intoxication
- Drug withdrawal
- Pain
- Infection
- Anion gap acidosis
- Sepsis
- Hyperthyroid
- Psych (anger, fear)
- Arrhythmia
- PE
- CHF
- Tamponade
- Myocardial contusion
- Cardiac valvular disease
- Hyper/hypoglycemia
- AMI
- Toxicity
- ASA
- TCA
- Anticholinergic
- Theophylline
Evaluation
Workup
- TSH (↓)
- Free T4 (↑)
- Free T3 (↑)
Management
- If asymptomatic or mild symptoms, no treatment required in ED
- If symptomatic, consider Thyroid storm
Disposition
- If asymptomatic or no thyroid storm, discharge with outpatient follow-up.
- Admit for significant symptoms or thyroid storm.
See Also
References
- ↑ Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
- ↑ Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
- ↑ Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
- ↑ Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
- ↑ Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
- ↑ Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
- ↑ Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
- ↑ Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
- ↑ Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
- ↑ Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders
- ↑ Rehman SU et al. Thyroid Disorders in Elderly Patients. South Med J. 2005;98(5):543-549.