THYROID DISORDERS:2Toxic Adenoma Thyroid

Prof. Tariq Waseem

Dr. Hina Latif

Frankfurt 2012

Case Scenario

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 well formed.

He smokes 20 cigarettes in a day.

....Case Scenario

Examination• 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

precordium

Eyes and Face

Examination

• Proptosis+• Lid retraction ++• Lid lag +++• Exposure Keratitis• Mobiv’s sign +

Neck

• 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.

• Diagnosis??

Toxic Adenoma Thyroid

How Will You Investigate?

• Ultrasound Neck (Soft Tissues & Thyroid)• Thyroid Hormonal Assay(T3, T4, TSH)• Thyroid Scan• I131 Uptake

Plummer's disease• A toxic nodular goiter (TNG) is a thyroid gland that

contains autonomously functioning thyroid nodules, with resulting hyperthyroidism.

• 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 hyperthyroidism.

Signs & Symptoms

• Thyrotoxic Symptoms• Apathetic hyperthyroid• Obstructive Symptoms• Asymptomatic

Thyrotoxic Symptoms• Majority presents with heat intolerance, palpitations,

tremor, weight loss, hunger, and frequent bowel movements.

• In elderly symptoms are atypical:– Weight loss is the most common complaint – Anorexia and constipation as contrast to diarrhea in

young– 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.

Apathetic hyperthyroid

• 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.

Obstructive Symptoms

• 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.

Asymptomatic

• 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) levels.

Causes/ Mechanism

• 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 pathways.

• 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• FNAC• ECG• CBC and ESR• Blood sugar level

Treatment

• Pharmacotherapy• Radio-Iodine• Surgery

Pharmacotherapy

• 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

Pharmacotherapy

• Propyl thiouracil 100- 400 mg/day

• Carbimazole: 10- 40 mg/day

• Propranolol 40- 160 mg/day

Radio- Iodine Therapy• Radio- Iodine: Na131 I treatment - In US and Europe,

radioactive iodine is considered the treatment of choice for TNG.

• 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-IodineHypothyroidism 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 thyroiditis.

Elderly patients may have exacerbation CCF and A- fibrillation. Pretreat elderly patients with antithyroid drugs.

Thyroid storm is a rare complication.

Surgery

• Reserved for• Young individuals• Having 1 or more large nodules or with obstructive

symptoms• Patients with dominant nonfunctioning or suspicious

nodules• Pregnant • In whom radioiodine therapy has failed• Those requiring a rapid resolution of the thyrotoxic state.

Thyroid Storm

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%

Thyroid Storm Clinical Presentation

Uncomplicated Thyrotoxicosis Thyroid Storm

1. Heat intolerance, diaphoresis 1. Hyperpyrexia, temperature in excess of 106o C, dehydration

2. Sinus tachycardia, heart rate 100-140

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 dysfunction-jaundice

4. Anxiety, restlessness 4. Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma

Burch and Wartofsky criteria

• Hyperpyrexia (99->104) 5-30points• Altered mental state (mild-severe) 10-30 • Cardiac dysfunction

– tachycardia (90->140) 5-25 points– CHF (mild-severe) 5-15 points– A-fib 10 points

Precipitating event 10 points

>45 points –thyroid storm

DIAGNOSIS

Low TSH

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

Hyperglycemia

Thyroid Storm: Treatment

• Admit for close clinical monitoring and supportive measures

• 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

– Plamapheresis

– Supportive care( IV fluids, Antipyretics, Digoxin for heart rate control).

Schiller was a German poet, philosopher, historian, and

playwright.

Frankfurt 2012