Thyrotoxicosis
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Thyrotoxicosis

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Thyrotoxicosis Thyrotoxicosis Presentation Transcript

  •   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.
  •  Not all manifestations are related to elevated thyroid hormones.
  •     Primary thyrotoxicosis – Grave’s Disease Secondary Thyrotoxicosis – Plummer’s Disease Toxic nodule Rare causes for hyperthyroidism
  •     Diffuse vascular goitre. Symptom appears with goitre Younger women with eye signs TSH-R Abs – hypertrophy and hyperplasia of the thyroid tissue.
  •     Long standing nodular goitre Middle aged women infrequently associated with eye signs Internodular tissue is the active region Rarely , autonomous nodules.
  •    Overactive nodule part of generalised nodularity or true toxic adenoma. Not related to TSH-R Abs. Normal thyroid tissue is suppressed and inactive.
  • SCALLOPED PATTERN
  • THYROXINE IS THE KEY FOR ADRENALINE TO ACT ON THE CELL
  • 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
  •  Secondary thyrotoxicosis  Multiple extrasystoles  Paroxysmal atrial fibrillations  Paroxysmal atrial tachycardia  Paroxysmal atrial fibrillations.
  •         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
  •  Malignant exophthtalmus – eyes may be destroyed.
  •  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.
  •  Hyaluranic acid – dermis and subcutaneous tissue.  Rx – topical steroids
  •    Clinical features Biochemical investigation Thyroid antibodies T3 T4 TSH HYPERTHYROIDSM INCREASED INCREASED SUPPRESSED T3 TOXICOSIS INCREASED NORMAL SUPPRESSED
  •  Thyroid scan  Toxic nodular goitre
  •  Anti thyroid durgs  Carbimazole and propylthiouracil,  Beta blockers – propranolol and nadolol  Iodides – reduce vascularity, preoperative scenario  Cannot cure toxic nodule
  •  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
  •  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.
  •     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.
  • 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
  •  Factors influencing  Type of thyrotoxicosis  Age of the patient  Co existing medical illness  Post treatment care  Follow up  Compliance and  Patient wishes.
  • Age >45 Age<45 Radio Iodine Large goitre – surgery Small goitre – antithyroid drugs or radio iodine
  •  Enlarges with antithyroid drugs.  Responds poorly with drugs and radio iodine  Surgical removal is the treatment.
  •  Surgery vs Radio Iodine.  Pros and cons to be considered.
  • 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
  •  Thyrotoxicosis factitia  Jod-Basedow Thyrotoxicosis  Large doses of iodine in endemic goitre  deQuervain’s thyroiditis  Carcinoma
  •  Extent of resection  Biochemically euthyroid  Antithyroid drugs  Block and replacement regimen  Lugol’s iodine  Beta blockers
  • 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
  •  Thyroid storm  Acute exacerbation  Etiology  Inadequately preapred  Infection / stress  Clinical features  Dehydration  Hyperpyrexia  Tacycardia  Diaphoresis
  •  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
  •  Hypocalcemia  Thyroid function test  Replacement of thyroxine