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Endocrine Teaching

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Endocrine Teaching A thyroid miscellany: Wednesday, August 5, 2009 Dr. Merrill Edmonds – PowerPoint PPT presentation

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Title: Endocrine Teaching


1
Endocrine Teaching
  • A thyroid miscellany
  • Wednesday, August 5, 2009
  • Dr. Merrill Edmonds

2
Case 1
  • 55 y.o. female
  • mother of 3 (1976, 1978, 1983)
  • family history of thyroid disease
  • mother hypothyroid, cousin hyperthyroid
  • Referred for hyperthyroidism

3
Case 1
  • HPI
  • Hypothyroid 1985
  • TSH gt 50
  • Rx - l-thyroxine 0.15mg daily
  • - 0.125 mg in 1990
  • Hyperthyroid 2005
  • Wt. loss, heat intol., sweating, shaky, palps
  • HR 104/min, thyroid 3x rubbery
  • TSH lt0.001, free T4 65 (11-22)

4
Case 1
  • HPI
  • Hypothyroid 1985
  • Hyperthyroid 2005
  • dose reduced to 0.05mg and then stopped
  • TSH lt0.001, free T4 35 (11-22)
  • 131I uptake 37 Scan diffuse uptake

5
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6
Case 1
  • What has caused the change?
  • Hypothyroid 1985
  • Hyperthyroid 2005
  • dose reduced to 0.05mg and then stopped
  • TSH lt0.001, free T4 35 (11-22)
  • 131I uptake 37 Scan diffuse uptake

7
Pathogenesis
  • TSH receptor antibodies (TSHR-Ab)
  • Assays
  • TSH-binding inhibitory immunoglobulin (TBII)
  • measure displacement of bovine TSH off
    solubilized porcine TSH receptor
  • measure displacement of bovine TSH off
    immobilized solubilized human TSH receptor
  • measures thyroid stimulating (TSAb) or blocking
    (TBAb)
  • Functional assay
  • measure cAMP in chinese hamster ovary cells
    transfected with the human TSH receptor)
  • can differentiate between thyroid stimulating
    (TSAb) or blocking (TBAb)

8
Case 2
  • 50 y.o. female
  • PUD 1993
  • Breast CA (lumpectomy, radiation, chemo) 2006
  • no family history of thyroid disease
  • Referred for hyperthyroidism Dec 2006
  • asymptomatic doesnt know why TSH done
  • Sept/06 TSH lt.01 free T426.5 free T38.2
  • Euthyroid on exam 70 Kg 112/72 80/min
  • Thyroid slightly enlarged and firm
  • Repeat TSH28.675 free T48.6

9
Case 2
  • July 19, 2007
  • Asymptomatic, weight stable, HR 120/min
  • Euthyroid, thyroid slightly enlarged, pebbly
  • TSH0.17 free T414.4 free T38.6
  • Anti-TPO 1400 IU/ml (lt40)
  • anti-TG 75 IU/ml (lt40)
  • TBII 15.7 (lt1)
  • What is going on?

10
Case 3
  • 29 y/o female
  • Hyperthyroid Oct/2005
  • Tapazole 20mg daily (reduced from 30mg 2 mos ago)
  • TSH lt0.001, free T4 21 (11-22)
  • Exophthalmos
  • eyes gritty, periorbital edema, diplopia

11
Case 3
12
  • Ophthalmic phenomena reflecting thyrotoxicosis
    per se and apparently resulting from
    sympathetic overactivity
  • Wide palpebral aperture (stare) Dalrymple sign
  • Lid lag von Graefe sign
  • Lower lid lag on upward gaze Griffith sign
  • Infrequent blinking Stellwag sign
  • Absence of forehead wrinkling on upward gaze
    Joffroy sign
  • Tremor of closed eyelids Rosenbach sign
  • Spasmodic lid retraction during fixation Kocher
    sign
  • Nystagmoid jerks during abduction to
    adduction Wilder sign
  • Ophthalmic phenomena unique for Graves' disease
    caused by specific pathologic changes in the
    orbit and its contents
  • Inability to keep the eyeballs converged Mobius
    sign
  • Extrinsic muscle palsies Ballet sign
  • Increased pigmentation Jellinek sign
  • Edema of lower lid Enroth sign

13
Case 3
  • What else do you want to know
  • Smoking?
  • Eye symptoms worse in the morning?
  • What would you recommend now?

14
Case 4
  • 28 y/o female
  • Hyperthyroid 1996
  • Tapazole for 18 months but no remission
  • treated with 131I in 1998
  • Hypothyroid 1998
  • treated with thyroxine 0.1mg daily - TSH normal
  • Spontaneous abortion 2004 at 6 mos
  • baby small for dates

15
Case 4
  • 28 y/o female
  • Hyperthyroid 1996
  • Hypothyroid 1998 -on thyroxine 0.1mg daily - TSH
    normal
  • Spontaneous abortion 2004 at 6 mos
  • Pregnant - 3 mos
  • What to do?
  • TSH

16
Case 4
  • 28 y/o female
  • Hyperthyroid 1996
  • Hypothyroid 1998 -on thyroxine 0.1mg daily - TSH
    normal
  • Spontaneous abortion 2004 at 6 mos
  • Pregnant - 6 mos
  • Baby small for dates
  • Fetal tachy
  • Treatment?

17
Case 4
  • TSH receptor antibodies (TSHR-Ab)
  • Diagnostic value
  • Graves - 70-100
  • level grossly parallels the degree of
    hyperthyroidism
  • probably no better than degree of hyperthyroidism
    and size of goitre in predicting remission
  • not helpful in deciding the form of treatment
  • Fetal hyperthyroidism (2-10 of women with
    Graves)
  • Should measure TBII in
  • previous Graves Rx with Sx or I131
  • concurrent hyper and pregnancy (early 3rd
    trimester)
  • previous neonatal hyperthyroidism (early in 1st
    trim)

18
Case 5
  • 19 y/o female
  • Pregnant - 6 weeks
  • hyperemesis
  • palpitations, shakiness
  • TSH lt0.001, free T4 35 (11-22)
  • What to do?

19
Case 5
20
Case 6
  • Hyperthyroid Feb/2006
  • 5 months postpartem - breast feeding
  • weight loss (6 lbs) despite ravenous appetite
  • palpitations, insomnia
  • Lab
  • TSH lt 0.01 (0.3-5.5)
  • free T4 33 (11-22)
  • What to do next?

21
Case 7
  • 67-year-old woman
  • Fatigue, weight gain
  • Thyroid palpable, firm, slightly increased in
    size
  • Lab
  • TSH 8.4 (0.3-5.5), free T4 12 (11-22)
  • What to do next??

22
Case 7
23
Case 8
  • 34-year-old woman
  • Hypothyroid 1998
  • on l-thyroxine 0.10 mg daily
  • TSH 1.3 (0.3-5.5), free T4 15 (11-22)
  • Fatigue 1998
  • Still feels tired all the time
  • Friend taking T3 and feels a lot better
  • What would you do?

24
Subclinical Thyroid Dysfunction
25
Subclinical Thyroid Dysfunction
26
Subclinical Thyroid Dysfunction
27
T4 T3
28
T4 T3
  • Does T3 provide any additional benefit?
  • No effect on bodily pain
  • No effect on quality of life
  • No effect on depression
  • No effect on fatigue
  • No effect on cholesterol

29
T4 T3
  • Does T3 cause any harm?
  • T3 normally present but doses used in some
    studies made patients hyperthyroid which may give
    you more energy but this can be harmful in the
    long term
  • T3 does not last as long and if given once a day
    the levels can vary a lot whereas they are
    normally very steady
  • Amounts of T4 and T3 vary in thyroid extracts
  • More expensive

30
T3 and Depression
  • T3 does appear to enhance the benefit of
    antidepressant medications
  • Augmentation of improvement in depression
  • Acceleration of improvement in depression

31
Case 9
  • Judy
  • 24 y/o white, female
  • 2 cm nodule of right thyroid lobe
  • No family history
  • No history of radiation
  • What to do next?
  • TSH
  • ?

32
Thyroid Nodules
Nuclear Scan (Sens 100 / Spec 30) FNA (Sens
95 / Spec 90)
33
Thyroid Nodule Work-up
34
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