Hypertyroidism
Hypertyroidism
Hypertyroidism
Dharma Lindarto
Div. Endokrin-Metabolisme dan Diabetes. Dep Ilmu
Penyakit Dalam FK USU / RSUP HAM Medan
Tiroid Disease
Aspect
function
eutiroid,
hypotiroid
morphology
hypertiroid,
normal, atrophic, nodule,
diffus
Hypothyroidism
Hyperthyroidism
Subclinical Hypothyroidsm
Subclinical Hyperthyroidsm
TSH
T4
T3
High
Low
High
Low
Low
High
normal
normal
Low
High
normal
normal
Hyperthyroidism
Sustained increases in thyroid hormone
biosynthesis and secretion by the thyroid gland
Prevalence of Thyrotoxicosis
In a cross-sectional study of urban and
rural adults, the prevalence of
thyrotoxicosis ranged from
1.9% to 2.7% in women
0.16% to 0.23% in men
Hyperthyroidism Etiology
Graves disease
Multinodular goiter
Autonomous nodule
Exogenous thyroid hormone
Transientsubacute thyroiditis,
postpartum thyroiditis
Drugsamiodarone
Causes of Thyrotoxicosis
Divided by Degree of Radioiodine Uptake
High I123 Uptake
Graves disease
I
Toxic nodular goiter
TSH-mediated thyrotoxicosis
Pituitary tumor
Pituitary resistance to
thyroid hormone
HCG-mediated thyrotoxicosis
Hydatidiform mole
Choriocarcinoma
Other HCG-secreting tumors
Thyroid carcinoma (very rare)
123
I123
Signs
Nervousness
Fatigue
Weakness
Increased perspiration
Heat intolerance
Tremor
Hyperactivity
Palpitations
Appetite/weight changes
Menstrual disturbances
Hyperactivity
Tachycardia
Systolic hypertension
Warm, moist, or smooth skin
Stare and eyelid retraction
Tremor
Hyperreflexia
Muscle weakness
SYSTEMIC EFFECTS
RESPIRATORY
Dyspnea, panting, hyperventalation
respiratory muscle weakness
increased tissue carbon dioxide levels
+/- congestive heart failure
SYSTEMIC EFFECTS
CARDIOVASCULAR
Thyrotoxic cardiomyopathy
Hypermetabolic state
Systemic hypertension
Direct T3 and T4 action on heart
muscle
LV hypertrophy, IVS hypertrophy, RA
and aortic dilation, enhanced
contractility
Graves Disease
Autoimmune disorder
Production of TSH receptor autoantibodies
Stimulate thyroid hormone overproduction
Graves' Disease
Goiter
Hyperthyroidism
Exophthalmos
Localized myxedema
Thyroid acropachy
Thyroid stimulating immunoglobulins
Margins sharply
demarcated
Nodularity
Thickened skin
Margins sharply
demarcated
Graves Ophthalmopathy
DIAGNOSTICS
Endocrine Testing
Total T4: 5-10% will be normal
Total T3: 30% will be normal
Free T4: false negative with NTI and
shipping
fT4d better
T3 supression
TRH stimulation and TSH response
DIAGNOSTICS
RADIONUCLIDE IMAGING
Pertechnetate imaging
extent of involvement
detect metastasis to other gland
no palpable enlargement (within thorax)
Carcinoma metastasis
3. Toxic Adenoma
Autonomously functioning thyroid
nodule hypersecreting T3 and T4
resulting in thyrotoxicosis (Plummers
disease)
Almost never malignant
Manage with antithyroid drugs followed
by either I-131 or surgery
Free T4:
direct measure of thyroxine activity
May be transiently suppressed in severe acute illness
Free T3: suspect hyperthyroid but normal FT4
Scans/Ultrasound
Treatment of Hyperthyroidism
1. Antithyroid drugs
2. Surgical resection
3. Radioactive iodine therapy
Propylthiouracil (PTU)
Methimazole [generic] or Tapazole
B. Methimazole [generic]:
Inhibits thyroid hormone synthesis and
release from thyroid gland
C. Beta-blocker therapy:
Ameliorates tachycardia, sweating, tremor,
nervousness
Propanolol: starting dose 20-40 mg PO
q6h
Caution in patients with CHF or
bronchospasm
2. Subtotal Thyroidectomy
Surgical complications:
Vocal cord paralysis (1%)
Hypothyroidism (up to 43% after 10 years)
Hypoparathyroidism
Recurrence of hyperthyroidism (10-15%)
Thyroid Storm
A life-threatening crisis .
Estimated mortality : 20-30% .
the result of thyroid surgery .
Caused more often by antecedent
Graves disease .
Surgery .
Radioiodine therapy .
Iodinated contrast dyes .
Thyroid hormone ingestion .
Diabetic Ketoacidosis .
Cerebrovascular accident .
Pulmonary embolism and CHF .
Pathophysiology of Thyroid
Storm
1) An acute decrease in thyroxinebinding globulin => high levels of free
hormone .
2) Thyroid hormone increases the
density of beta-adrenergic receptors &
alters responsiveness to
catecholamines at a postreceptor level .
Laboratory Diagnosis of
Thyroid Storm
A combination of low TSH and elevated
free T4 => makes the diagnosis .
If TSH is lower than normal and free T4
is normal => free T3 testing is
recommended .
ED measurement of thyroglobulin or
thyroid antibodies : No indication .
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