Graves' Disease Overview Quiz
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Questions and Answers

Which factor is NOT associated with the predisposition to Graves' disease?

  • Genetic susceptibility
  • Excessive physical activity (correct)
  • Smoking
  • Failure of immune tolerance

    • What is the most common manifestation of Graves' disease?

  • Dermopathy
  • Goitre
  • Hyperthyroidism (correct)
  • Thyroid eye disease

    • In which percentage of patients with Graves' disease does thyroid eye disease typically occur?

  • 10%
  • 50%
  • 25% (correct)
  • 75%

    • Which of the following is a possible precipitating factor for Graves' disease?

    <p>Iodine-containing drugs</p> Signup and view all the answers

    What role do TSH receptor antibodies (TRAb) play in the context of Graves' disease?

    <p>They have sensitivity and specificity over 90%.</p> Signup and view all the answers

    What is a characteristic feature of deQuervain’s thyroiditis?

    <p>Tender diffuse goitre</p> Signup and view all the answers

    Which of the following conditions is most likely to lead to hyperthyroidism with a predictable course of hyperthyroidism followed by hypothyroidism?

    <p>Viral thyroiditis</p> Signup and view all the answers

    What mechanism drives the hyperthyroidism seen in Graves' disease?

    <p>TSH receptor activation by antibodies</p> Signup and view all the answers

    Which symptom is least likely to be associated with hyperthyroidism?

    <p>Hypotension</p> Signup and view all the answers

    Which of the following statements regarding toxic adenoma is correct?

    <p>It is a solitary autonomous nodule.</p> Signup and view all the answers

    Which condition is associated with the presence of TSH receptor antibodies?

    <p>Graves' disease</p> Signup and view all the answers

    What is the recommended starting dose of Levothyroxine for treating primary hypothyroidism?

    <p>1.6 mcg/kg body weight per day</p> Signup and view all the answers

    Which thyroid function test is NOT typically included when assessing thyroid function?

    <p>Calcitonin</p> Signup and view all the answers

    In which situation is fine needle aspiration (FNA) of a thyroid nodule typically indicated?

    <p>When the nodule meets criteria for FNA</p> Signup and view all the answers

    What is the effect of taking Levothyroxine with calcium or ferrous sulfate?

    <p>It decreases the absorption of Levothyroxine</p> Signup and view all the answers

    What should be excluded or treated before starting levothyroxine in patients with suspected central hypothyroidism?

    <p>Adrenal insufficiency</p> Signup and view all the answers

    Which of the following is a thyroid hormone synthesis inhibitor used in the treatment of hyperthyroidism?

    <p>Carbimazole</p> Signup and view all the answers

    Which of the following treatments is indicated mainly in preparation for surgery or managing a thyroid storm?

    <p>Iodides</p> Signup and view all the answers

    What is a common side effect associated with the use of Propythiouracil (PTU) for hyperthyroidism treatment?

    <p>Agranulocytosis</p> Signup and view all the answers

    What is a potential complication of performing a total thyroidectomy?

    <p>Hypothyroidism</p> Signup and view all the answers

    What is the primary cause of primary hypothyroidism?

    <p>Thyroid gland failure despite adequate TSH stimulation</p> Signup and view all the answers

    Which of the following symptoms is NOT associated with hyperthyroidism?

    <p>Cold intolerance</p> Signup and view all the answers

    How does thyroid hormone affect the cardiovascular system?

    <p>Increases cardiac output and contractility</p> Signup and view all the answers

    Which autoimmune condition is the most common cause of hypothyroidism in iodine-sufficient countries?

    <p>Hashimoto's thyroiditis</p> Signup and view all the answers

    What distinguishes central or secondary hypothyroidism from primary hypothyroidism?

    <p>Low T4 with normal or low TSH levels</p> Signup and view all the answers

    Which of the following describes a potential cause of thyroid tissue destruction in primary hypothyroidism?

    <p>Autoimmune response</p> Signup and view all the answers

    What role does thyroid hormone play during childhood?

    <p>Stimulates bone growth in conjunction with growth hormone</p> Signup and view all the answers

    What is the impact of thyroid hormone on muscle tissue?

    <p>Increases expression of fast-twitch muscle fibers</p> Signup and view all the answers

    What is the characteristic pathologic hallmark of thyroiditis?

    <p>Follicular destruction</p> Signup and view all the answers

    Which condition exhibits persistently high TSH with normal T4 levels?

    <p>Subclinical hypothyroidism</p> Signup and view all the answers

    What factor may prompt treatment for subclinical hypothyroidism?

    <p>Infertility</p> Signup and view all the answers

    Which of the following is commonly associated with overt hyperthyroidism?

    <p>Low TSH, high T4</p> Signup and view all the answers

    What is a potential cause of hyperthyroidism related to autoimmune response?

    <p>Graves' disease</p> Signup and view all the answers

    Which statement regarding subclinical hypothyroidism is true?

    <p>Annual progression to overt hypothyroidism is 2-5%.</p> Signup and view all the answers

    Which of the following is not a cause of hyperthyroidism?

    <p>Cretinism</p> Signup and view all the answers

    Which lymphocytic condition is characterized by scar tissue formation and possible goiter?

    <p>Hashimoto's thyroiditis</p> Signup and view all the answers

    What characterizes viral thyroiditis, specifically deQuervain’s thyroiditis?

    <p>A tender diffuse goitre with a predictable progression from hyperthyroidism to euthyroidism</p> Signup and view all the answers

    Which of the following best explains the mechanism of hyperthyroidism in Graves' disease?

    <p>Inappropriate activation of thyroid cells by antibodies against TSH receptors</p> Signup and view all the answers

    What is a potential long-term outcome of deQuervain’s thyroiditis?

    <p>Hypothyroidism that may resolve with treatment</p> Signup and view all the answers

    Which symptom is primarily associated with increased sympathetic activity in hyperthyroidism?

    <p>Sweating and palpitations</p> Signup and view all the answers

    Which of the following conditions could lead to hyperthyroidism but is not autoimmune in nature?

    <p>Amiodarone-induced hyperthyroidism</p> Signup and view all the answers

    What does a high uptake of radioiodine or technetium indicate in a hyperthyroid patient?

    <p>Toxic multinodular goitre or Graves’ disease</p> Signup and view all the answers

    For Levothyroxine treatment of primary hypothyroidism, how should the dosage be titrated in elderly patients with unstable heart disease?

    <p>Start low and go slow</p> Signup and view all the answers

    Which antibody is specifically associated with Graves' disease?

    <p>TSH receptor antibodies (TRAb)</p> Signup and view all the answers

    What factor should be avoided when taking Levothyroxine to ensure optimal absorption?

    <p>Consuming calcium or ferrous sulfate</p> Signup and view all the answers

    In which scenario is Fine Needle Aspiration (FNA) most likely indicated?

    <p>If the thyroid nodule meets specific criteria</p> Signup and view all the answers

    What is the primary aim when treating patients with levothyroxine therapy in cases of suspected central hypothyroidism?

    <p>To keep T4 in the middle of the normal range</p> Signup and view all the answers

    Which of the following side effects is least likely to be associated with the use of Carbimazole for hyperthyroidism treatment?

    <p>Weight gain</p> Signup and view all the answers

    In which situation may beta-adrenergic blockers be primarily used in the context of hyperthyroidism treatment?

    <p>To manage symptoms during thyroid storm</p> Signup and view all the answers

    What is the most appropriate management for a patient with severe thyroiditis?

    <p>Corticosteroids</p> Signup and view all the answers

    Which procedure is most likely indicated as a treatment option for patients with refractory hyperthyroidism and compressive features?

    <p>Total thyroidectomy</p> Signup and view all the answers

    What is the typical yearly progression rate from subclinical hypothyroidism to overt hypothyroidism?

    <p>2-5% per year</p> Signup and view all the answers

    Which condition primarily leads to autoimmune hyperthyroidism?

    <p>Graves' disease</p> Signup and view all the answers

    Under which circumstances is treatment for subclinical hypothyroidism generally recommended?

    <p>If symptomatic with TSH &gt;10</p> Signup and view all the answers

    What laboratory finding typically characterizes overt hypothyroidism?

    <p>Normal T4, High TSH</p> Signup and view all the answers

    Which factor is least likely to indicate subclinical hypothyroidism treatment?

    <p>TSH levels between 4 and 10</p> Signup and view all the answers

    What is a potential cause of hyperthyroidism related to excessive hormone production?

    <p>Toxic adenoma</p> Signup and view all the answers

    What distinguishes subclinical hyperthyroidism from overt hyperthyroidism?

    <p>Normal T4 levels</p> Signup and view all the answers

    Which statement correctly describes secondary hyperthyroidism?

    <p>Elevated T4 levels with elevated TSH.</p> Signup and view all the answers

    What is the most common cause of hypothyroidism in iodine-sufficient countries?

    <p>Autoimmune thyroiditis.</p> Signup and view all the answers

    Which of the following systemic effects is NOT caused by thyroid hormones?

    <p>Decreased growth and development.</p> Signup and view all the answers

    What can cause goitre in the context of hypothyroidism?

    <p>Increased TSH from the pituitary.</p> Signup and view all the answers

    What characterizes the pathophysiology of Hashimoto's thyroiditis?

    <p>Autoimmune-mediated destruction of thyroid tissue.</p> Signup and view all the answers

    Which of the following symptoms is typically associated with hypothyroidism?

    <p>Cold intolerance.</p> Signup and view all the answers

    In the context of hypothyroidism, what does the term 'cretinism' refer to?

    <p>Short stature and intellectual disability in children.</p> Signup and view all the answers

    With regards to TSH actions on the thyroid gland, which of the following is NOT a consequence of TSH binding?

    <p>Inhibition of thyroid hormone production.</p> Signup and view all the answers

    Which condition is characterized by the accumulation of mucopolysaccharides in subcutaneous tissues?

    <p>Myxoedema</p> Signup and view all the answers

    What is one of the critical symptoms of thyroid storm?

    <p>Heat intolerance</p> Signup and view all the answers

    What treatment is recommended for moderate-severe thyroid eye disease?

    <p>Corticosteroids</p> Signup and view all the answers

    What muscle dysfunction is commonly seen in thyroid eye disease?

    <p>Impaired extraocular muscles</p> Signup and view all the answers

    Which of the following is NOT a complication of myxoedema?

    <p>Strabismus</p> Signup and view all the answers

    What is a possible consequence of untreated goitre?

    <p>Tracheal or esophageal compression</p> Signup and view all the answers

    What factor can exacerbate thyroid eye disease?

    <p>Smoking</p> Signup and view all the answers

    Which intervention is primarily used in the acute management of a thyroid storm?

    <p>Iodine solutions</p> Signup and view all the answers

    Study Notes

    Thyroid Function & Disease

    • RCSI Royal College of Surgeons in Ireland, Department of Medicine, focused on thyroid function and disease.
    • RCSI aims to develop healthcare leaders globally.

    Learning Outcomes

    • Students will define hypothyroidism and hyperthyroidism.
    • Students will explain the pathophysiology of both conditions.
    • Students will list cardinal symptoms and signs of both conditions.
    • Students will explain the cause of each symptom in both conditions.
    • Students will develop differential diagnoses for both conditions.
    • Students will understand investigative and management principles for thyroid disorders.

    Thyroid Hormone

    • Thyroid hormone significantly impacts all body organs, especially in response to stress.
    • It increases basal metabolic rate and thermogenesis.
    • Cardiovascular system: Increases beta-receptor expression leading to enhanced cardiac output and contractility.
    • Respiratory system: Increases oxygenation by stimulating respiratory centers and enhancing lung perfusion.
    • Skeletal muscle: Increases fast-twitch muscle fiber expression.
    • Metabolism: Enhances basal metabolic rate, carbohydrate metabolism, and protein anabolism.
    • Growth: Works synergistically with growth hormone to promote bone growth during childhood.
    • Central nervous system: Influences brain maturation prenatally, affecting mood, memory, and sleep in adults.
    • Reproductive system: Influences fertility, ovulation, and menstruation.

    Hypothyroidism

    • Definition: A pathological condition characterized by insufficient thyroid hormone synthesis and secretion.
    • Primary hypothyroidism (high TSH, low free T4): Thyroid gland failure. Despite pituitary stimulation (TSH), the thyroid gland cannot respond to produce T4.
    • Central/secondary hypothyroidism: Deficient TSH production commonly due to pituitary lesions (e.g., tumors). Low T4; normal or low TSH. No compensatory increase in TSH despite low T4 levels.
    • Differentials (primary hypothyroidism):
      • Congenital: Agenesis of the thyroid gland. Screened at birth.
      • Autoimmune: Hashimoto's thyroiditis (most common cause in iodine-sufficient areas; characterized by thyroid peroxidase antibodies (TPO))., Reidel's thyroiditis (T cell/IgG4-mediated inflammation leading to fibrosis extending beyond the thyroid capsule), Radiation (e.g., radioactive iodine treatment for hyperthyroidism), Post-thyroidectomy, and Infiltrative diseases (e.g., haemochromatosis).
      • Anti-thyroid drugs (e.g., lithium, iodine-containing drugs, radiographic contrast material, amiodarone, checkpoint inhibitors).

    Hyperthyroidism

    • Definition: A pathological disorder characterized by excessive thyroid hormone synthesis and secretion.
    • Hyperthyroidism is often associated with thyrotoxicosis.
    • Primary hyperthyroidism: Elevated free T4; suppressed/undetectable TSH (<0.1).
    • Secondary hyperthyroidism: Elevated T4; elevated TSH.

    Pathophysiology

    • Hypothalamic-Pituitary-Thyroid Axis: TRH released from the hypothalamus stimulates the anterior pituitary gland to release TSH. TSH then stimulates the thyroid gland to produce T3 and T4.
    • TSH binds to TSH receptors on thyroid cells, leading to T3 and T4 production and thyroid gland hyperplasia.
    • T3 and T4 impact various organs, enhancing metabolism, growth, development, and catecholamine effects.

    Hypothyroidism Causes

    • Primary gland insufficiency is most common.
    • Pituitary and hypothalamus (secondary & tertiary) less common.
    • Iodine deficiency is a widespread global cause.
    • Autoimmune (Hashimoto's thyroiditis) is common in developed and iodine-sufficient countries.

    Hypothyroidism Symptoms

    • Symptoms related to decreased metabolic rate include: Bradycardia, weight gain, cold intolerance, poor appetite, hair loss, cold dry skin, constipation, myopathy.
    • Children may exhibit cretinism (short stature, intellectual disability).

    Hypothyroidism Signs and Symptoms

    • Psychological: poor memory, poor concentration, poor hearing, hoarseness.
    • Heart: Slow pulse rate, pericardial effusion
    • Muscular: Delayed reflex relaxation
    • Extremities: Coldness, carpal tunnel syndrome
    • Other: fatigue, anorexia, dry skin (coarse), brittle nails.

    Hashimoto's Thyroiditis

    • Inflammation of thyroid tissue.
    • Most frequent cause of hypothyroidism in iodine sufficient regions.
    • Associated with autoimmune factors: Primarily T cell mediated response and circulating antibodies (TPO antibodies), leading to thyroid gland damage and progressive failure.

    Subclinical Hypothyroidism

    • High TSH, normal T4.
    • Usually treated if TSH exceeds 10, or during pregnancy/infertility, or in symptomatic patients especially in older age groups.
    • Progression to overt hypothyroidism is possible (2-5% per year).

    Hyperthyroidism Differentials

    • Graves' disease
    • Toxic multinodular goitre (MNG)
    • Toxic adenoma
    • Drug-induced (e.g., amiodarone)
    • factitious hyperthyroidism
    • Subacute viral thyroiditis
    • Thyrotoxicosis (or thyroid storm)

    Hyperthyroidism Causes

    • Graves' disease: Autoimmune.
    • Toxic multinodular goitre: Multiple nodules with autonomous hormone production. Often benign, but there is potential for malignancy.
    • Toxic adenoma: Solitary nodule with autonomous hormone production.
    • Viral thyroiditis (de Quervain's): Subacute granulomatous variant, often tender diffuse goitre.
    • Less common: pituitary adenoma, drug-induced (e.g., amiodarone), factitious hyperthyroidism (excessive exogenous use).

    Hyperthyroidism Symptoms

    • Hypermetabolism- Heat intolerance, weight loss, increased appetite, sweating.
    • Palpitations, tachycardia; sinus, atrial fibrillation, hypertension, heart failure.
    • Tremor, myopathy, restlessness, anxiety, depression.

    Hyperthyroidism Additional Symptoms

    • Nervousness/tremor
    • Mental disturbance; irritability; difficulty sleeping
    • Bulging eyes/unblinking stare; vision changes
    • Enlarged thyroid (goiter); menstrual irregularities; light periods
    • Frequent bowel movements; warm, moist palms
    • First-trimester miscarriage/ excessive vomiting

    Graves' Disease

    • Antibody-mediated autoimmune thyroid disease characterized by TSH receptor antibody (TRAb)-mediated stimulation of thyroid hormone synthesis, leading to hyperthyroidism.
    • Inappropriate activation of thyroid cells (TSH agonist).
    • Increased T4 and T3 production.
    • Hyperplasia and growth of the gland.
    • Increased TSH receptor activation.
    • Associated risk factors: Genetic susceptibility, immune tolerance failure, molecular mimicry, greater prevalence in females, smoking, and certain drugs. (e.g., iodine/iodide containing drugs, amiodarone, CT contrast media)
    • High incidence (4.6/1000 during observation)
    • Antibody: TRAb: (sensitivity and specificity over 90%)

    Thyroid Eye Disease

    • Autoimmune condition affecting orbital tissues.
    • Often seen in combination with Graves' disease; but may occur with less severe Hashimoto's thyroiditis.
    • Orbital inflammation, fibrous tissue, muscular dysfunction, and impaired venous drainage. Leading to periorbital swelling.
    • Symptoms: Proptosis (bulging eyes), conjunctival inflammation, periorbital edema, lid retraction, lagophthalmos, strabismus (eye misalignment), optic neuropathy from compression.
    • Risk factors: Smoking, Radioactive iodine therapy.
    • Treatment: Depends on severity, mild cases can be treated with selenium, or selenium therapy; moderate-severe cases benefit from steroids, immunosuppressants, or more novel treatments like teprotumumab.

    Myxoedema

    • Severe hypothyroidism that is life-threatening (rare).
    • Characterized by accumulation of mucopolysaccharides in subcutaneous tissues (thickening of the skin).
    • Associated with multiple low systems: Hyponatremia, hypoglycemia, hypotension, hypothermia, heart failure, confusion, and coma.
    • High mortality (severe cases)

    Thyroid Storm/Thyrotoxic Crisis

    • Life-threatening emergency (acute severe hyperthyroidism)
    • Often triggered by stress, infection, or surgery.
    • Rapid onset with multiple serious symptoms: Fever, agitation, seizures, coma, tachycardia or atrial fibrillation (AFib), heart failure.
    • Treatment: Use of beta-blockers (selective), high dose thionamides, iodine solutions, corticosteroids.

    Goitre

    • Enlargement of the thyroid gland (swelling in the anterior neck).
    • Multiple causes: Iodine deficiency, excess TSH stimulation, inflammation, scarring, masses.

    Thyroid Function Tests

    • Useful to investigate both hypo & hyperthyroidsim.
    • Elevated TSH (low T4): Hypothyroidism
    • Low TSH (high T4): Hyperthyroidism

    Investigations

    • Blood tests for thyroid function (TSH, T4, T3).
    • Antibodies, e.g., anti-TPO, TSH receptor antibodies (TRAbs)
    • Radioiodine or technetium uptake
    • Thyroid ultrasound (selected cases).

    Hypothyroidism Treatment

    • Levothyroxine (T4).
    • Dose is approximately 1.6 mcg/kg body weight daily.
    • Administered on an empty stomach with water, avoiding medications interfering with absorption (e.g., calcium, iron, soy).
    • "Start low and go slow" in elderly patients.
    • Exclude/treat concurrent adrenal insufficiency prior to Levothyroxine treatment.

    Subclinical Hypothyroidism Treatment

    • Treatment depends on multiple patient factors, including age, symptoms, concomitant conditions (e.g., coronary heart disease, heart failure), and thyroid peroxidase antibody status.
    • Options: Observation ("wait-and-see"), treatment might be considered at certain levels dependent on clinical assessment.

    Hyperthyroidism Treatment

    • Pharmacological: Thyroid hormone synthesis inhibitors (e.g., carbimazole, propylthiouracil), antithyroid drugs; beta-blockers; and iodine solution.
    • Procedures: Radioactive iodine ablation, Total thyroidectomy.
    • Treatment of associated symptoms is important; and management is based on the cause and severity of the condition.

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