Phys · endocrine
Thyroid Disorders
Also known as hyperthyroidism · thyrotoxicosis · Graves disease · toxic multinodular goitre · toxic adenoma · Plummer disease · subacute thyroiditis · de Quervain thyroiditis · postpartum thyroiditis · amiodarone-induced thyrotoxicosis · hypothyroidism · Hashimoto thyroiditis · myxoedema · myxoedema coma · thyroid storm · thyroid nodule · papillary thyroid carcinoma · follicular thyroid carcinoma · medullary thyroid carcinoma · anaplastic thyroid carcinoma · levothyroxine · carbimazole · propylthiouracil · radioiodine
Consultant-physician-depth guide to thyroid disorders — hyperthyroidism (Graves disease, toxic multinodular goitre, toxic adenoma, thyroiditis, amiodarone), thyroid storm, hypothyroidism (Hashimoto thyroiditis, post-treatment, iodine, drugs), myxoedema coma, thyroid nodules (Bethesda classification) and thyroid cancer (papillary, follicular, medullary, anaplastic) — structured for FRACP DWE and DCE preparation.
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Red flags
- Thyroid storm — hyperpyrexia, tachyarrhythmia, altered mental state, heart failure precipitated by infection, surgery or iodine load
- Myxoedema coma — hypothermia, hypoventilation, hyponatraemia, obtundation in neglected hypothyroidism
- Sight-threatening Graves orbitopathy — optic nerve compression (visual loss, colour desaturation) or corneal breakdown
- New atrial fibrillation with thyrotoxicosis — high thromboembolic risk, anticoagulate
- Rapidly enlarging thyroid mass in an older patient — anaplastic carcinoma or lymphoma until proven otherwise
- Recurrent laryngeal nerve palsy with a thyroid nodule — invasive malignancy until proven otherwise
- Agranulocytosis on carbimazole — fever or sore throat in the first three months mandates an urgent full blood count
Thyroid Disorders
Meet the patient
A 28-year-old woman arrives with palpitations, heat intolerance and a 4 kg weight loss despite a ravenous appetite. Her pulse is 110 and irregularly irregular, her palms are warm and tremulous, and a smooth diffuse goitre carries an audible bruit. Proptosis and lid lag greet you at the end of the bed.[1]
The registrar reaches for carbimazole — half right, but the move that decides everything has not yet been made. In every thyrotoxic patient the single question that sets the whole pathway is: is the gland overproducing hormone, or leaking stored hormone? Hold that question and every treatment below slots into place.[1]
References9ShowHide
- [1]Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis Thyroid, 2016.PMID 27521067
- [2]Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement Thyroid, 2014.PMID 25266247
- [3]Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer Thyroid, 2016.PMID 26462967
- [4]Bartalena L, Baldeschi L, Boboridis K, et al. The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy Eur Thyroid J, 2016.PMID 27099835
- [5]Fatourechi V, Aniszewski JP, Fatourechi GZ, Atkinson EJ, Jacobsen SJ Clinical features and outcome of subacute thyroiditis in an incidence cohort: Olmsted County, Minnesota, study J Clin Endocrinol Metab, 2003.PMID 12727961
- [6]Bartalena L, Bogazzi F, Chiovato L, Hubalewska-Dydejczyk A, Links TP, Vanderpump M 2018 European Thyroid Association (ETA) Guidelines for the Management of Amiodarone-Associated Thyroid Dysfunction Eur Thyroid J, 2018.PMID 29594056
- [7]Wells SA Jr, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma Thyroid, 2015.PMID 25810047
- [8]Cibas ES, Ali SZ The 2017 Bethesda System for Reporting Thyroid Cytopathology Thyroid, 2017.PMID 29091573
- [9]Caturegli P, De Remigis A, Rose NR Hashimoto thyroiditis: clinical and diagnostic criteria Autoimmun Rev, 2014.PMID 24434360