Symptoms:
- General – fine tremor, anxiety, irritability, emotional lability, panic attacks, heat intolerance, sweating
- CV – palpitations
- GI – increased appetite, diarrhea, wt loss
- GU – menstrual dysfunction, infertility
- Graves’ – blurring of vision, photophobia, double vision, increased lacrimation
Signs
- General – hyperreflexia
- CV – tachycardia, atrial fibrillation
- Neuro – proximal muscle weakness
- Skin – fine hair, moist warm skin, vitiligo, soft nails
- MSK – bone mass, hypercalcemia, muscle wasting
- Graves’ – exophthalmos, lid retraction, lid lag, clubbing, acropachy, pretibial myxedema
Physical Exam
Etiology:
- Graves’ disease (80 – 90 %)
- Hashimoto’s thyroiditis
- Subacute thyroiditis
- Toxic multinodular goiter
- Toxic adenoma
- Iatrogenic and factitious
Differential Diagnosis:
- Anxiety disorder
- Pheochromocytoma
- Metastatic neoplasm
- Diabetes mellitus
- Premenopausal state
Investigations:
Bloodwork
- TSH (low), T4 & T3 (elevated)
- Thyroid antibodies – can use to differentiate Graves’ and toxic multinodular goiter
Imaging
- RAIU
- Increased uptake in overactive thyroid, decreased in thyroiditis and iatrogenic T4 ingestion
- Uptake is homogeneous in Graves’, heterogeneous in multinodular goiter, and single focus in a hot nodule
Management
ANTITHYROID DRUGS:
- Thionamides
- Propylthiouracil (PTU) and Methimazole (Tapazole
- Inhibit thyroid hormone synthesis (block thyroid peroxidase); inhibit peripheral conversion of T4 to T3
- Most useful in young, nonpregnant patients with small glands and mild disease
- Patients should be seen every 1 – 3 months until euthyroid, then q 3-4mo while remaining on medication
- Propylthiouracil (PTU) and Methimazole (Tapazole
- B-BLOCKERS – Propranolol for symptomatic control
MEDICAL ABLATION
- Radioactive iodine – used in Graves’ when PTU or MMI fail to produce remission
- Usually require lifelong thyroid hormone replacement
SURGICAL ABLATION:
- Subtotal thyroidectomy