Hyperthyroidism PDF

IN THE NAME OF ALLAH THE MOST MERCIFUL HYPERTHYROIDISM ENDOCRINOLOGY ICM-1 ONLY JUZVA SLIDES NOT AVAILABLE ...

IN THE NAME OF ALLAH THE MOST MERCIFUL HYPERTHYROIDISM ENDOCRINOLOGY ICM-1 ONLY JUZVA SLIDES NOT AVAILABLE  HYPERTHYROIDISM Thyrotoxicosis: The clinical syndrome is the result of the rise of thyroid hormones, and any reason that increases the level of thyroid hormones in the body creates thyrotoxicosis. For example, as a result of taking too much medicine (levothyroxine) or the release of thyroid follicle reserves due to inflammation. Note: In thyroiditis, the thyroid has lost its function and is not active, but the amount of thyroid hormones increases. Increased activity and overwork of the thyroid gland is one of the causes of thyrotoxicosis. Symptoms of thyrotoxicosis There are two general categories: Symptoms resulting from the direct effect of thyroid hormones Symptoms resulting from increased sensitivity to catecholamines The amount of catecholamines does not increase, but the thyroid hormones in the body provide a platform for catecholamines to be more active. T4, T3 increase beta receptors and decrease alpha. Tremor, staring, (delay in blinking ) or lid lag and sweating due to Increased sensitivity to catecholamines. The picture below shows the lag lid. If we hold our hand in front of the patient's eyes and slowly move down, the eyeballs move, but the eyelids are delayed in their movement. The chart below on top of page number 2 summarizes the symptoms and signs of the patient. Notes in the following table: The patient is losing weight despite the increase in appetite, although in few cases the weight may be constant or slightly increased. In the case of oligomenorrhoea women, irregular menses and even amenorrhea can be the main complaint, AF is seen especially in elderly people, increase in systolic blood pressure and decrease in diastolic pressure, and as a result Wide Pulse Pressure is seen, and Chemosis and hyperthyroidism may be present in Grave's disease.. Other hyperthyroid symptoms include irritable mood, thinning and hair loss, ophthalmopathy, gynecomastia, increased bowel movement, and diarrhea. Other hyperthyroid symptoms: In very severe cases, the patient goes into psychosis; thyroid enlargement; gynecomastia; decreased muscle strength; soft and moist skin; clubbing ;especially in graves; fast talking and fast movements. Thyrotoxic crisis or Thyroid storm It is one of the life-threatening complications of hyperthyroidism and is considered one of the most important emergencies in endocrinology. Predisposing factors including surgery, iodine radiotherapy and severe stress (such as MI, uncontrolled diabetes or acute infection) can be seen. Visible symptoms include: Fever, flushing, sweating, significant tachycardia, atrial fibrillation, cardiac failure Significant agitation: Restlessness, delirium, and coma Gastrointestinal : N/V/D or Nausea , Vomiting, Diarrhea , An increase in body temperature that is disproportionate to clinical findings is considered a hallmark of thyroid storm. If not treated, the patient can progress to coma or death. Note: False thyrotoxicosis can be caused by taking weight loss pills. Causes of thyrotoxicosis : Increased hormone secretion : Graves’ disease, toxic adenoma, multinodular goiter, thyroiditis In Thyroiditis we don't have hyperthyroid, hormones are released into the blood and the symptoms of thyrotoxicosis are caused. Increased use of hormones (for example, excessive use of levothyroxine) Misplaced secretion: example in stroma ovarii, which is from ovarian teratomas and may have thyroid tissue. In the table below, the causes are categorized according to frequency: The most common cause of hyperthyroidism and thyrotoxicosis is Graves' disease. Metastatic thyroid carcinoma and hydatidiform mole are other causes of thyrotoxicosis. Graves’ disease The most common cause of thyrotoxicosis An autoimmune disease More common in women A peak incidence between 20 and 40 years of age Pathogenesis : It is due to the excessive production of antibodies that bind to the TSH receptor (TSH Receptor Antibody), which acts like TSH and increases the growth of thyroid cells and, as a result, increases the production of thyroid hormones, hyperthyroidism and thyrotoxicosis. Ophthalmopathy is caused by inflammatory infiltration of lymphocytes and deposition of mucopolysaccharides in extraocular muscles. These inflammatory reactions can be due to sensitization of lymphocytes to common antigens of eye muscles and thyroid. Demonstrations: Goitre or thyroid enlargement Thyrotoxicosis in the form of hyperthyroidism Eye disease, from a single tear to Proptosis (eye protrusion), extraocular muscle paralysis, involving the optic nerve and amblyopia Thyroid dermopathy, a strong increase in the thickness of the skin in the pretibial area ( Peritibial Myxedema ), which is a non-invasive edema in the front of the tibia. young people: Young patients often present with common manifestations of thyrotoxicosis and may also show a diffuse goiter or specific eye symptoms of Grave's disease. Elderly people: Often, they do not show clear symptoms of thyrotoxicosis (Apathetic hyperthyroidism). These patients may present with the following: Flat mood Emotional lability Weight loss Muscle weakness Congestive heart failure AF resistant to standard therapy Eye symptoms: There are two categories, specific and nonspecific. The nonspecific category is also seen in other types of thyrotoxicosis and is caused by increased sensitivity to catecholamines (such as Staring: in the neutral state, the upper sclera of the iris is not seen, but in the thyrotoxic state, it is the same due to stretching Eyelid to the top of this part It can be seen that this state is called Dazzle. Lid retraction and lid lag are other nonspecific symptoms. The specific symptoms are due to the inflammatory reaction and are specific to Graves' disease, which include: Periorbital edema Conjunctival congestion and swelling Proptosis Extraocular muscle weakness Optic nerve damage with visual impairment Redness of the corner of the eye can be seen in graves and any type of thyrotoxicosis, but edema around the eyes is only specific to graves. Skin symptoms: in 2 to 3% of patients, thickening of the skin of the lower tibia is seen as non-tumorous edema, which is called pretibial myxedema. For this reason, Antibody Receptor TSH binds to skin surface fibroblasts and increases the production of glycosaminoglycans in the pretibial area. In the picture below, you can see the types of thyroid dermopathy. Do not pay attention to its different types. Onycholysis: 1) Separation of the nail from its bed, which can be seen in Graves' disease. (as in image below ) 2) Clubbing and onycolysis are very rare in Graves' disease and can be seen in severe chronic cases. Thyroid Acropachy Or Clubbing : The clubbing of the fingers shown in this above picture Diagnosis: An increase in the level of T3 and T4 hormones (total or free) along with the suppressed TSH hormone indicates thyrotoxicosis in a person. If a person came to us and had Graves' eye symptoms, but thyrotoxicosis had not yet been established, we can use the measurement of immunoglobulin stimulating thyroid ( Thyroid Stimulating Immunoglobulin) to confirm the diagnosis of Graves' ophthalmopathy. In some cases, Graves' ophthalmopathy occurs before thyrotoxicosis. Thyroid scanning is a method by which the decrease or increase of thyroid function can be measured. After the radioactive material such as iodine 123 or technetium 99 is given to the patient, the thyroid scan is done. Technetium 99 is not organified, that is, it is not placed on the thyroglobulin molecule and it is excreted quickly, and if we take a gamma scan in the first 10-15 minutes, it will show thyroid activity. For example, As you can see in the figure: 1. In Graves' disease, an increase in the absorption of a radioactive substance is observed uniformly throughout the thyroid. 2. In a single toxic adenoma, the increase in the uptake of radioactive material is observed in a regional manner, and the rest of the thyroid parts are functionally suppressed. (It can be due to TSH receptor activation mutation) 3. In Toxic moultinodular Goitre , increased absorption is seen in multiple spots. 4. In subacute thyroiditis, due to inflammation, there is destruction of thyroid follicles, and as a result, the absorption of radioactive iodine in the thyroid scan decreases. (background view) The increased uptake of iodine 123 in Graves' disease is used to differentiate it from the early stages of subacute thyroiditis (where uptake is low). MRI or Ultrasonography of the eye can also be used to detect enlargement of the muscles (orbital muscle enlargement) in the presence or absence of clinical signs of ophthalmopathy. In Graves, the ratio of T3 to T4 increases, but in thyroiditis, T4 increases more than T3. (In 3% of Graves' cases, we have T3 thyrotoxicity). solitary Toxic Adenoma One of the differential diagnosis of thyrotoxicosis is a toxic solitary adenoma, which is usually benign and is more common in the elderly. The clinical symptoms and manifestations that we see in the patient are the same symptoms of thyrotoxicosis, and during the examination of the patient, we touch a single nodule in the patient's thyroid. In laboratory tests, TSH is knocked down and T3 has increased a lot, and often an increase in T4 is also observed. In the thyroid scan, a hot nodule is observed, which is characterized by an increased uptake in one of the thyroid lobes. As it is clear in the whole picture, the non-diseased lobe is suppressed in the scan. Toxic moultinodular Goitter ; It usually occurs in elderly patients who have had multinodular goiter for a long time. These people usually live in iodine-deficient areas, and when they are exposed to a diet rich in iodine and radiocontrast materials that contain iodine, their nodules become more active, of course, this process can also happen spontaneously. Clinical manifestations: It often includes tachycardia, heart failure, and arrhythmia, and these manifestations can be more common in the elderly. Physical examination: Thyroid enlargement with numerous nodules is palpable. Laboratory diagnosis: Elevated T3,T4 and Supressed TSH In the thyroid scan, as you can see in picture, many points of increased uptake can be seen. Based on the level of activity, nodules are divided into three categories: hot, intermediate or warm (absorption almost similar to normal tissue) and cold (no absorption). Subclinical hyperthyroidism : In this disease, T3T4 level ( BOUND OR TOTAL ) normal, but TSH is suppressed. The reason for this disease can be all types of overactive thyroid in the early stages. Such as Graves' disease or toxic adenoma or toxic multinodular goiter whose early stages can be subclinical hyperthyroidism. Sometimes, this condition, especially in the elderly, can cause arrhythmia or decrease in bone density, in which cases we have to treat these people. Thyroiditis : Thyroiditis can be divided into three groups: acute, subacute and chronic: Accute Suppurative thyroiditis : Acute purulent thyroiditis is a rare disorder caused by an infection (usually bacterial). Its symptoms include infection, high fever, redness of the skin on the thyroid, and tenderness and sensitivity when touching the gland. Sometimes this disorder can be associated with thyroiditis. If the result of blood culture is negative, the organism can be identified by fine needle aspiration (FNA). In this case, strong antibiotic treatment should be prescribed for the person or even drain the pus by cutting and draining. Subacute thyroiditis or De Quervain's thyroiditis or granulomatous thyroiditis: It is an inflammatory disorder that is probably caused by a viral infection and usually recovers completely in ninety percent of cases. Patients usually complain of fever and pain in the front of the neck, but they may also have symptoms of hyperthyroidism when they come to us. The classic feature found in the physical examination of these people is the extreme sensitivity or tenderness of the thyroid gland when touched. (The virus does not attack the thyroid directly, but the body reacts to the respiratory infection of thyroid inflammation) Laboratory findings change based on the course of the disease: In the early stages of the disease, when patients present with symptoms of thyrotoxicosis, due to the destruction of follicles due to inflammation of the gland, the amount of serum T4 increases and TSH decreases. Also, we will have a decrease in RAIU (active radio iodine uptake). After that, due to the gradual decrease in the thyroid gland reserves, the thyroid gland hypofunction occurs for the person, and when the thyroid follicles are regenerated, it will automatically return to the thyroid iodine state. This state of increased uptake of radioactive iodine can be seen in the thyroid scan, which indicates the improvement of the thyroid gland and lasts about 6 to 8 weeks. Postpartum thyroiditis : In terms of the clinical course, it is similar to subacute thyroiditis. This disease usually develops within the first six months after childbirth and has three phases: 1. Hyperthyroidism 2. Hypothyroidism 3. Euthyroidism or return to normal state. In some cases, it may only manifest itself with thyroid dysfunction. Some patients who face this complication may have underlying chronic thyroiditis Chronic Thyroiditis, Hashimoto's Thyroiditis or Lymphocytic Thyroiditis: Due to the destruction of the normal structure of the thyroid, it is caused by the infiltration of lymphocytes, and then hypothyroidism and goiter appear. Hashimoto's thyroiditis is more common in women than men, and it is the most common cause of goiter and hypothyroidism in areas that do not have iodine deficiency. Sometimes, in Hashimoto's thyroiditis, patients temporarily experience symptoms of thyroid hyperactivity, at which time the absorption of radioactive iodine decreases, which is due to the release of T3T4 into the bloodstream. The difference between chronic thyroiditis and subacute thyroiditis in this case is that in Hashimoto's thyroiditis, the thyroid is not tender and the titer of anti-thyroid antibodies, including TPO anti, is higher. Riedel's struma : It is probably a variant of Hashimoto's disease and it is caused by extensive fibrosis in the thyroid tissue, and the thyroid gland becomes like Rock-Hard thyroid mass. The condition is called Riedel's struma. Thyrotoxicosis Factita or false thyrotoxicosis occurs when a person deliberately consumes large amounts of levothyroxine, often for weight loss. Clinically, its characteristics are similar to other thyrotoxicoses, and from the laboratory point of view, the concentration of T3T4 increases and TSH and Thyroglobulin are suppressed. (Differential diagnosis of False thyrotoxicosis and chronic thyroiditis: in the first case, the serum thyroglobulin concentration decreases, but in the second case, the serum thyroglobulin concentration increases due to the destruction of the thyroid tissue. On the other hand, the absorption of radioactive iodine decreases, because large amounts of hormones are introduced from outside the body and the production of hormones in the thyroid gland decreases. Sometimes we have to use psychiatric counseling for these people. By measuring thyroglobulin and ESR, it is possible to distinguish thyroiditis from a fake state. Rare causes of thyrotoxicosis: One of the rare causes of thyrocysticosis is ovarii stroma, which occurs due to the presence of teratoma in the ovarian tissue, which contains thyroid tissue and secretes thyroid hormone. The way to diagnose it is a body scan, through which he notices the removal of radioiodine and CT in the pelvis and confirms this disorder. Another rare cause of thyrotoxicosis is Hydatidiform mole, which occurs due to the proliferation of trophoblast tissue in pregnancy with excessive production of placental gonadotropin. As you know, this hormone acts similar to the TSH hormone and can affect its receptors and cause the release of thyroid hormones. In this case, hyperthyroidism is cured by surgery and drug treatment of molar pregnancy. Algorithm for differential diagnosis of hyperthyroidism: If a person comes to us with suspected symptoms of an overactive thyroid, the first step is to prescribe thyroid function tests for the person. If the TSH hormone is normal, but the individual's thyroid hormones, including free T4, are elevated, what should be done is to take an MRI to rule out TSH-secreting tumors in the pituitary region. Due to the fact that these tumors spontaneously secrete TSH hormone, despite the increase in thyroid hormones, the concentration of TSH is normal or even increased. (T3 and T4 hormones have not been able to suppress the TSH level). But if the concentration of T4T3 is also normal along with the concentration of TSH, hyperthyroidism is ruled out. If TSH is low and thyroid hormones are increased, then hyperthyroidism is proven, and in order to find out the type of thyrotoxicosis, we need to absorb radioactive iodine and perform a thyroid scan. If the uptake of radioactive iodine is increased, differential diagnosis such as Graves', toxic single adenoma, or toxic multinodular goiter, or other causes of thyrotoxicosis, which is accompanied by hyperthyroidism and increased thyroid activity, should be considered. If iodine absorption is reduced, an important differential diagnosis that should be considered is pseudothyroiditis or False. If TSH is low and hormones are within the normal range, subclinical hyperthyroiditis should be considered as a differential diagnosis. In these cases, we must observe the patient and, if necessary, perform the necessary treatments for this patient. Allahumma Salle al Fatima wa abeeha wa baleha wa baneeha wa sirril mustaudaeh fiha beadada maa ahaata behi ilmu