Thyrotoxicosis

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Thyrotoxicosis

  1. 1.   This disease result from an excess of circulating thyroid hormone. Its very important to distinguish disorders:  1.Cause excess production of hormone - characterized by increasing in radioactive iodine uptake.  2.An other condition which release stored hormone such as thyroiditis.
  2. 2.  Not all manifestations are related to elevated thyroid hormones.
  3. 3.     Primary thyrotoxicosis – Grave’s Disease Secondary Thyrotoxicosis – Plummer’s Disease Toxic nodule Rare causes for hyperthyroidism
  4. 4.     Diffuse vascular goitre. Symptom appears with goitre Younger women with eye signs TSH-R Abs – hypertrophy and hyperplasia of the thyroid tissue.
  5. 5.     Long standing nodular goitre Middle aged women infrequently associated with eye signs Internodular tissue is the active region Rarely , autonomous nodules.
  6. 6.    Overactive nodule part of generalised nodularity or true toxic adenoma. Not related to TSH-R Abs. Normal thyroid tissue is suppressed and inactive.
  7. 7. SCALLOPED PATTERN
  8. 8. THYROXINE IS THE KEY FOR ADRENALINE TO ACT ON THE CELL
  9. 9. Features Goitre Hyperthyroidism CVS Ophthalmic Features Primary Thyrotoxicosis Secondary Thyrotoxicosis Firm , diffuse and vascular / Bruit Nodular Severe Not severe Rare Most severe More common Lid lag and spasm
  10. 10.  Secondary thyrotoxicosis  Multiple extrasystoles  Paroxysmal atrial fibrillations  Paroxysmal atrial tachycardia  Paroxysmal atrial fibrillations.
  11. 11.         Primary thyroosicosis Lid spasm – sympathetic overactivity Exophthalmus Joffrey’s and VonGraffe’s sign Mobieus Sign Auto immune etiology – glycosamino glycans deposition Weakness of extraoccular muscle Pappilloedema and corneal ulcers
  12. 12.  Malignant exophthtalmus – eyes may be destroyed.
  13. 13.  Rx       Control of hyperthyroidism Sleeping propped up position Lateral tarsoraphy Prednisone Intraorbital steroid are to be avoided. Thryoid ablation with radio iodine worsens the malignant exophthalmus  Orbital decompression.
  14. 14.  Hyaluranic acid – dermis and subcutaneous tissue.  Rx – topical steroids
  15. 15.    Clinical features Biochemical investigation Thyroid antibodies T3 T4 TSH HYPERTHYROIDSM INCREASED INCREASED SUPPRESSED T3 TOXICOSIS INCREASED NORMAL SUPPRESSED
  16. 16.  Thyroid scan  Toxic nodular goitre
  17. 17.  Anti thyroid durgs  Carbimazole and propylthiouracil,  Beta blockers – propranolol and nadolol  Iodides – reduce vascularity, preoperative scenario  Cannot cure toxic nodule
  18. 18.  Dosage – 10 mg of carbimazole tds can be increased up to 120mg per day.  Levels of TSH R Ab fall and permanent cure in 50%  BLOCK AND REPLACEMENT REGIMEN  Inhibit all T3 and T4 with high dose of carbimazole and replace with thyroxine 0.1-0.15mg
  19. 19.  Helps in reducing the mass of overactive tissue.  Reduction of TSH R Abs or only limited stimulation.  Toxic nodule – suppressed tissue acts normal after the surgery.
  20. 20.     Destroys thyroid cells. Functioning tissue reduced beyond critical level. Accurate dosage is difficult and may require further dose after 12 weeks. No evidence proven – therapeutic dosage is carcinogenic.
  21. 21. Anti- thyroid drugs Surgery Radioiodine • No surgery and radio iodine effects • Goitre is removed • Cure is rapid • High cure rate • No prolonged drug therapy • prolonged • 50% failure rate • difficult to predict response. • agranulocytosis or aplastic anemia • Permanent thyroid failure • Hypoparathyroidi sm • Recurrence <5% • indefinite follow up • slow response • Accurate dosage - difficult
  22. 22.  Factors influencing  Type of thyrotoxicosis  Age of the patient  Co existing medical illness  Post treatment care  Follow up  Compliance and  Patient wishes.
  23. 23. Age >45 Age<45 Radio Iodine Large goitre – surgery Small goitre – antithyroid drugs or radio iodine
  24. 24.  Enlarges with antithyroid drugs.  Responds poorly with drugs and radio iodine  Surgical removal is the treatment.
  25. 25.  Surgery vs Radio Iodine.  Pros and cons to be considered.
  26. 26. Pregnancy Radio iodine – absolute C/I Surgery – abortion Drugs – hypothyroidism both mother abd baby Surgery in second trimester or careful administration of drugs Children Radio iodine – C/I Surgery recurrence Drugs till adoloscents Surgery later. Thyrocardiac Severe cardiac damage Radio iodine with anti thyroid drugs
  27. 27.  Thyrotoxicosis factitia  Jod-Basedow Thyrotoxicosis  Large doses of iodine in endemic goitre  deQuervain’s thyroiditis  Carcinoma
  28. 28.  Extent of resection  Biochemically euthyroid  Antithyroid drugs  Block and replacement regimen  Lugol’s iodine  Beta blockers
  29. 29. Surgical options Features Total Thyroidectomy Subtotal thyroidectomy Control of toxicity Immediate Immediate Return to euthyroid state Immediate Variable Recurrence None 5% Thyroid failure 100% 25% Hypoparathyroidism 5% 1% Followup Minimal lifelong
  30. 30.  Thyroid storm  Acute exacerbation  Etiology  Inadequately preapred  Infection / stress  Clinical features  Dehydration  Hyperpyrexia  Tacycardia  Diaphoresis
  31. 31.  Rx  Intravenous fluids / rehydration  Cooling the patient with ice packs  Diuretics  Manage cardiac failure with digoxin  Hydrocortisone  Specific Rx  Carbiamzole – 10-20mg q6hrly  Lugol’s iodine 10drops q8hrly  Sodium iodide 1g i.v  Propranolol 1-2 mg i.v
  32. 32.  Hypocalcemia  Thyroid function test  Replacement of thyroxine

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