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Case study:
Tyrotoxicosis
Patient's history:
37 yr-old woman
P/C : unintentional weight loss
HoPC :
- over past 3 months - lost appx 15 lb w/o changing her diet / activity level
- feels great
- excellent appetite
- no GI complaints - except occasional loose stool
- good energy level
- no fatigue
- no heat / cold intolerance
O/E :
- HR 108 bpm
- BP 142/82 mmHg
- afebrile
- stare-looking, protuberant eye
- large, smooth, non-tender thyroid gland
- 2/6 systolic ejection murmur
- skin warm and dry
- no tremor
1)most likely diagnosis:
- Thyrotoxicosis / Graves Disease
2) how to confirm?
- TSH - serum low
- free T4 - increased
- clinical presentation
- OTHER TESTS : thyroid-stimulating immunoglobulin / diffusely elevated uptake of radioactive iodine on thyroid scan
3)tx options
- anti-thyroid drugs
- radioactive iodine ablation
- surgical ablation of thyroid
Clinical approach
Cardiac : long standing thyrotoxicosis can cause cardiomegaly
GI : hyperdefecation - increased GI motility
Eyes : retraction of upper eyelid - increased of sympathetic tone
Skin : warm, moist, velvety. sweating - vasodilation and heat dissipation
reproduction : oligomenorrhea (infrequent menstruation), impotence, gynaecomastia
metabolism: weight loss, preference for cold temperature
Etiology: Graves disease
- most common cause of hyperthyroidism
- women
- 30-50 yr old
- autoimmune disease
- autoantibodies that activate TSH receptor of thyroid follicular cells
- autoantibodies - cross placenta and can cause neonatal thyrotoxicosis
other causes of thyrotoxicosis:
- toxic multinodular goiter
- autonomous hyperfunctioning adenoma (hot nodule)
- increased uptake (hot)
- thyroiditis
- medications : exogenous thyroid hormones
clinical:
- goiter (enlarged thyroid gland)
- thyroid bruit
- hyperthyroidism
- ophthalmopathy
- inflammation of extraocular muscle, orbital fat, and connective tissue - proptosis. periorbital edema
- dermopathy
- raised hyperpigmented orange peel texture papules
- common site : shin - pretibial myxedema
Tx:
- meds
- beta-blockers (for symptoms relief)
- antithyroid drugs (methimazole , propylthiouracil)
- decreasing production of thyroid hormone
- short term, prior to radioactive treatment
- long term treatment
- SE : rash, allergic reactions, arthritis, hepatitis, agranulocytosis
- radioactive iodine (treatment of choice)
- C/I pregnancy, women of child-bearing age
- graves ophthalmopathy exacerbated by radioactive, may use glucocorticoid
- Surgery
- reserved for large goiter (if obstructive symptoms)
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