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THYROTOXICOSIS AND HYPERTHYROIDISM

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THYROTOXICOSIS AND HYPERTHYROIDISM An overview DR PRAVEEN SHETTY DEPARTMENT OF INTERNAL MEDICINE Thyrotoxicosis Defined as the clinical,physiologic,and biochemical ... – PowerPoint PPT presentation

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Title: THYROTOXICOSIS AND HYPERTHYROIDISM


1
THYROTOXICOSIS ANDHYPERTHYROIDISM
  • An overview
  • DR PRAVEEN SHETTY
  • DEPARTMENT OF INTERNAL MEDICINE

2
Thyrotoxicosis
  • Defined as the clinical,physiologic,and
    biochemical findings that result when the tissues
    are exposed to,and respond to,excess thyroid
    hormone.
  • Rather than being a specific disease,thyrotoxicosi
    s can originate in a variety of ways.
  • RAIU is subnormal

3
Hyperthyroidism
  • Denotes only those conditions in which sustained
    hyperfunction of the thyroid gland leads to
    thyrotoxicosis.
  • Increased RAIU is the hallmark.

4
Varieties of Thyrotoxicosis
  • Associated with thyroid hyperfunction
  • Excess production of TSH(rare)
  • Abnormal thyroid stimulator-EgGraves disease
  • Intrinsic thyroid autonomy-EgHyperfunctioning
    adenoma, Toxic multinodular goitre
  • Not associated with thyroid hyperfunction
  • Disorders of hormone storage-EgSubacute
    thyroiditis, chronic thyroiditis
  • Extrathyroid source of hormone- Thyrotoxicosis
    factitia,ectopic thyroid tissue- struma ovarii,
    functioning follicular Ca.

5
HyperthyroidismGraves disease
  • Also known as Parrys or Basedows disease.
  • Graves disease is a disorder with three major
    manifestations
  • 1)Hyperthyroidism with diffuse goitre
  • 2)Ophthalmopathy and
  • 3)Dermopathy.
  • These three manifestations may not appear
    together.

6
Incidence and prevalence
  • Relatively common disease that can occur at any
    age
  • More common in the 3rd and 4th decade
  • Disease is more frequent in women(71)
  • Genetic factors play a important role
  • An overlap exsists with other autoimmune diseases
    suggesting Graves is also a autoimmune thyroid
    disease

7
Etiology and Pathogenesis
  • Cause of Graves is unknown
  • No single factor is responsible for the entire
    syndrome
  • With respect to hyperthyroidism,the central
    disorder is a disruption of homeostatic
    mechanisms that normally control hormone
    secretion.This disruption results from the
    presence in the plasma of thyroid stimulating
    immunoglobulins(TSIs) of IgG class and
    inhibition of the binding of TSH to its
    receptors(TBIIs).These factors represent TRAbs.

8
Pathology
  • Thyroid gland is diffusely enlarged,soft and
    vascular.
  • There is parenchymatous hyperplasia and
    hypertrophy with lymphocytic infilteration.
  • The ophthalmopathy is characterized by an
    inflammatory infilterate of the orbital
    contents,with lymphocytes,mast cells and plasma
    cells
  • The dermopathy of Graves disease is
    characterized by thickening of the dermis,which
    is infilterated by lymphocytes and
    mucopolysaccharides

9
Clinical features
  • The clinical manifestations include those that
    reflect the associated thyrotoxicosis and those
    specifically related to Graves disease

10
Clinical features of thyrotoxicosis
  • Neuromuscular
  • Nervousness,irritability,emotional
    liability,psychosis
  • Tremor
  • Hyperreflexia,ill sustained clonus
  • Muscle weakness,proximal myopathy,bulbar myopathy
  • ReproductiveAmenorrhoea,Oligomenorrhoea
  • Infertility,impotence

11
Thryotoxicosis..
  • Gastrointestinal
  • Weight loss despite increased appetite
  • Hyperdefecation
  • Diarrhoea and steatorrhoea
  • Vomiting
  • Cardiorespiratory
  • Palpitations,Sinus tachycardia,Atrial
    fibrillation
  • Increased pulse pressure
  • Dyspnea on exertion
  • Angina,cardiomyopathy and heart failure

12
Thyrotoxicosis..
  • Others
  • Heat intolerance
  • Increased sweating
  • Fatigue
  • Gynaecomastia
  • Palmar erythema, Onycholysis

13
Manifestations of Graves disease
  • The distinctive manifestations-diffuse
    hyperfunctioning goiter,ophthalmopathy,and
    dermopathy-appear in varying combinations,and in
    varying frequencies,goiter being the most common.
  • Premature greying of hair and patchy vitiligo are
    non specific features of Gravess

14
Goiter
  • Is diffuse and toxic and maybe asymetric and
    lobular.
  • There may be presence of bruit over the goiter

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Ophthalmopathy
  • Signs of Gravess ophthalmopathy are divided into
    two components
  • 1) Spastic Stare, lid lag and lid retraction
    which account for the frightened facies.
  • 2) Mechanical Proptosis of varying
    degrees,ophthalmoplegia,and congestive
    occulopathy characterized by chemosis,conjunctivit
    is,periorbital swelling and the potential
    complications of corneal ulceration,optic
    neiritis and optic atrophy.

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Dermopathy
  • Usually occurs over the dorsum of the legs or
    feet and is termed localized or pretibial
    myxedema.
  • It is usually a late phenomenon
  • The affected area is usually demarcated from the
    normal skin by being raised andthickened and
    having a peau d orange appearanceit may be
    pruritic and hyperpigmented.
  • The most common presentation is non pitting
    oedema,but lesions maybe plaque like,nodular or
    polypoid.
  • Clubbing of the fingers and toes accompanies and
    is termed thyroid acropachy

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Differential diagnosis
  • Anxiety
  • Pheochromocytoma
  • Hydatidiform mole
  • Ectopic thyroid tissue(struma ovarii)
  • Factitious thyrotoxicosis

28
Investigations
  • Thyroid function test
  • TSH- Undetectable
  • T4 - Raised
  • T3 - Raised
  • RAIU- Raised
  • TSH-receptor antibodies(TRAb)-elevated in
    Gravess disease
  • Isotope scanning- Increased uptake

29
Other non specific findings
  • Hepatic dysfunction- Raised AST,ALT
  • Mild hypercalcemia
  • Glycosuria- Associated diabetes mellitus

30
Treatment of Hyperthyroidism
31
Anti thyroid drugs
  • Chemically block hormone synthesis
  • Enhance evolution to remission
  • Best indicated for children,adolescents,young
    adults and pregnant women.
  • Propylthiouracil-100-150mg every 6or 8 hrs
  • Carbimazole- 40-60mg daily initially for 3
    weeks,then reduce to 20-40mg for another 8 weeks
    and maintain at 5-20mg daily for 18-24 months.
  • Methimazole-active metabolite of Carbimazole

32
Duration of treatment
  • 18-24 months
  • Side effects- Rash
  • Leukopenia
  • Agranulocytosis

33
Control of adrenergic symptoms
  • Adrenergic antagonists
  • Propranolol-40-120mg/day

34
Ablative therapy(Surgery Iodine)
  • Indications
  • Relapse or recurrance following drug therapy
  • A large goiter
  • Failure to follow medical regimen.
  • Radioactive iodine is simple,effective and
    economical

35
Complications of ablative therapy
  • Immediate complications of surgery
  • Bleeding,injury to recurrant laryngeal nerve and
    thyroid crises.
  • Other complications
  • Hypothyroidism
  • Radiation thyroiditis

36
Complications of thyrotoxicosis
  • 1)Cardiac- Heart failure
  • Atrial fibrillation
  • 2)Thyrotoxic crises or storm
  • Fulminating increase in signs and symptoms of
    thyrotoxicosis.
  • Occurs in medically untreated or inadequately
    treated patients.May be precipitated by surgery
    or sepsis
  • The syndrome is characterized by extreme
    irritability,delirium or coma,fever 41C or
    more,tachycardia,restlessness,hypotension,vomiting
    and diarrhea.

37
Treatment of thyroid crisis
  • Provide supportive care
  • Treat dehydration
  • Administer glucose and saline
  • Vitamin B complex and glucocorticoids
  • Digitalization is required in those with atrial
    fibrillation
  • Immediate and large doses of anti thyroid
    agents(Eg-propylthiouracil 100mg every 2h)
  • Iodine intravenously or by mouth
  • Propranolol 40-80mg every 6h
  • Dexamethasone(2mg every 6h) and to be tapered
    later.

38
Treatment of ophthalmopathy and Dermopathy
  • Methylcellulose eye drops
  • Tinted glasses
  • Persistant diplopia can be corrected by surgery
  • Papilloedema,loss of visual field or acuity
    requires urgent treatment with prednisolone 60 mg
    daily.
  • Majority of patients require no treatment other
    than reassurance.
  • Dermopathy of Graves rarely requires treatment

39
THANK YOU
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