A 45 year old male reports in OPD Mayo Hospital Lahore.
He has lost 12 kg of his weight over past 6 months. He
feels embarrassed because of his always shaky hands and
sweaty palms. His wife reports him being feverish all the
time. He is anxious, insomniac, restless and can’t sit idle
for few minutes. He always feels hungry and gets agitated
over petty matters. He sleeps without a quilt or blanket in
winter. He passes three to four stools in a day which are
He smokes 20 cigarettes in a day.
• Weight 45 kg
• Pulse 104/min, regular and bounding
• BP 150/90 mmHg
• Temperature 99 F
• Warm and moist hands
• Fine tremors of out stretched hands
• A faint grade 2 systolic murmur heard all over
• A firm nodule in right lobe of thyroid, non
tender, mobile with deglutition, skin
overlying it was not fixed to it.
• No lymph node enlargement.
• No audible bruit over thyroid or carotids.
How Will You Investigate?
• Ultrasound Neck (Soft Tissues & Thyroid)
• Thyroid Hormonal Assay(T3, T4, TSH)
• Thyroid Scan
• I131 Uptake
• A toxic nodular goiter (TNG) is a thyroid gland that
contains autonomously functioning thyroid nodules, with
• The most common cause of hyperthyroidism in elderly
and in areas of endemic iodine deficiency.
• Autonomously functioning nodules may become toxic in
10% of patients. Hyperthyroidism predominantly occurs
when single nodules are larger than 2.5 cm in diameter.
• TNG accounts for approximately 58% of cases of
• Majority presents with heat intolerance, palpitations,
tremor, weight loss, hunger, and frequent bowel
• In elderly symptoms are atypical:
– Weight loss is the most common complaint
– Anorexia and constipation as contrast to diarrhea in
– Dyspnea or palpitations more common
– Tremor may be confused with essential senile tremor.
– CVS complications like atrial fibrillation, congestive
heart failure, or angina are more common.
• Lahey first described apathetic
hyperthyroidism in 1931; this is
characterized by blunted affect, lack of
hyperkinetic motor activity, and slowed
mentation in a patient who is thyrotoxic.
• A large sub-sternal goiter may cause dysphagia,
dyspnea, or frank stridor. Rarely, this goitre
results in a surgical emergency.
• Involvement of the recurrent or superior
laryngeal nerve may result in complaints of
hoarseness or voice change.
• Many patients incidentally be found to have
hyperthyroidism during routine screening.
• The most common laboratory finding is a
suppressed TSH with normal free thyroxin (T4)
• Iodine deficiency--------low levels of T4
• Compensatory thyroid cell hyperplasia from raised TSH
• Increased thyroid cell replication predisposes single cells to somatic
mutations of the TSH receptor.
• Somatic mutations of the TSH receptors and G α protein confer
constitutive activation (cAMP) cascade of the inositol phosphate
• These mutations may be responsible for functional autonomy of the
thyroid in 20-80% of cases.
How to investigate?
• Serum T3, T4 and TSH
• Thyroid Scan
• Ultrasonography of neck
• CT scan neck & thorax
• CBC and ESR
• Blood sugar level
• Antithyroid drugs and beta blockers are used for
short courses in the treatment of TNG
• To render patients euthyroid in preparation for
radioiodine or surgery
• To treating hyperthyroidism while awaiting full
clinical response to radioiodine
Radio- Iodine Therapy
• Radio- Iodine: Na131 I treatment - In US and Europe,
radioactive iodine is considered the treatment of choice
• Except for pregnancy, there are no absolute
contraindications to radioiodine therapy.
• A single dose of radioiodine therapy has a success rate
of 85-100% in patients with TNG.
• Radioiodine therapy may reduce the size of the goiter
by up to 40%.
Complications of Radio-Iodine
Hypothyroidism occurs in 10-20% of patients
Mild thyrotoxic symptoms after radioiodine occur in
about one-third of patients
About 4% of patients develop radiation-induced
Elderly patients may have exacerbation CCF and A-
fibrillation. Pretreat elderly patients with antithyroid
Thyroid storm is a rare complication.
• Reserved for
• Young individuals
• Having 1 or more large nodules or with obstructive
• Patients with dominant nonfunctioning or suspicious
• In whom radioiodine therapy has failed
• Those requiring a rapid resolution of the thyrotoxic state.
An extreme hyperthyroid state usually seen as a
complication of toxic goiter surgery during
intraoperative and postoperative stage or as a
result of intercurrent illness in hyperthyroid patient.
A fulminating state and can be is fatal if untreated.
Mortality is 20-30%
Uncomplicated Thyrotoxicosis Thyroid Storm
1. Heat intolerance, diaphoresis 1. Hyperpyrexia, temperature in excess
of 106o C, dehydration
2. Sinus tachycardia, heart rate 100-
2. Heart rate faster than 140 beats/min,
hypotension, atrial dysrhythmias,
congestive heart failure
3. Diarrhea, increased appetite with
loss of weight
3. Nausea, vomiting, severe diarrhea,
abdominal pain, hepatocellular
4. Anxiety, restlessness 4. Confusion, agitation, delirium, frank
psychosis, seizures, stupor or coma
Raised T4, T3,
Elevated 24 hour radioiodine uptake
Increased BUN and Creatinine kinase
Electrolyte imbalance from dehydration
Anemia, thrombocytopenia, and leukocytosis
Elevated ALT, AST LDH ,ALP & bilirubin
Elevated calcium levels
Thyroid Storm: Treatment
• Admit for close clinical monitoring and
• Specific treatment-antithyroid medication
• Treatment of precipitating cause
• Treatment of underlying cause
Thyroid Storm: Treatment
– Propylthiouracil: (PTU)
• 200-400mg q6-q8hr
– Iodine: Prevents release of hormone
to be given 1hr after PTU
• Sodium Iodide iv 1-2g/day
• SSKI 5drops q6hr
– Beta blockers: Propranalol 1-5mg iv/20-40mg q4hr
– Glucocorticoids: Hydrocortisone 100mg q6hr
– Supportive care( IV fluids, Antipyretics, Digoxin for heart rate
Schiller was a German poet,
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