Thyroid Disease

Jennifer Cheng D.O.

Assistant Professor of Medicine
Section of Endocrinology
1/24/2017
Objectives
Understand the function of the thyroid
Understand how to perform thyroid exam
Identify etiologies of thyroid disease
Recognize signs and symptoms of hypothyroidism
Recognize signs and symptoms of hyperthyroidism
Diagnosis and evaluate different causes of thyroid
disease
Know labs tests and clinical significance
Thyroid Hormone
Synthesis
Hypothalamic
Pituitary
Thyroid

Follicular cell
Secretes 90% T4 and 10%T3
TBG binds 75% of t4
 Thyroid Exam
Anterior
Midline
Neck
Structure
Below
Thyroid
Cartilage
Observe
Observe neck
Note any pulsation,
asymmetry, or scars
Skin changes
erythema, edema
Observe
Observe deglutition
(swallowing)
Thyroid will move up
and down due to
action of inferior
pharyngeal constrictor
muscles
Useful to evaluate
nodules/masses from
lipoma
Ausculation
Ausculation bruit
Palpation
Palpate both lobes and
isthmus
Note texture, shape,
density of
nodules/masses,
tenderness
Mobility palpate
movement with
deglutition
 Thyroid Exam
Palpate carotid pulse
Tracheal Deviation
Palpate for thrill/ bruit
Multiple nodules vs
single vs goiter
 Eye
Exam
Lid
retraction
Exopthalm
os
 Observe for tremor,
palmar hyperhidrosis
or erythema
Observe nail beds for
clubbing, onycholysis

Pembertons sign
https://
www.youtube.com/wat
ch?v=r1dkasbE7v8
 Hyperthyroidism will
have tachycardia
Thyroid Disease
Hypothyroidism (too little thyroid hormone)
Hyperthyroidism (too much thyroid hormone)
Thyroid nodule/thyroid cancer
Hypothyroidism
Hypothyroidism
In US, 0.3% overt have hypothyroidism and
4.3% subclinical hypothyroidism
More common in women with age over 60
years
Signs and Symptoms of
Hypothyroidism
 Signs and Symptoms of
Hypothyroidism
Slowing of metabolic causes
Symptoms:
Fatigue and weakness, Cold intolerance,
Weight gain, Cognitive dysfunction,
Constipation
Signs: slower movement/ speech,
delayed relaxation of tendon reflexes,
bradycardia
 Signs and Symptoms of
Hypothyroidism
Accumulation of Matrix Substances
Symptoms: Dry skin, hoarseness, edema
Signs: coarse skin, puff facies, loss of
eyebrows, periorbial edema, tongue
enlargement
 Signs and Symptoms of
Hypothyroidism
Other
Symptom: decreased hearing, myalgia,
depression, menorrhagia, arthralgia,
puberty delay
Signs: diastolic hypertension, Plural and
pericardial effusions, ascites,
galactorrhea
 Causes of Hypothyroidism
Primary (defect at end organ, thyroid),
99%
Secondary (defect at pituitary, TSH),
Tertiary (defect at Hypothalamus, TRH)
Central Hypothyroidism
Peripheral (extrathyroidal)
Reduced action of thyroid hormone
Consumptive hypothyroidism
 Causes of Hypothyroidism
Iodine deficiency (worldwide most
common)
Autoimmune Thyroid Disease
Hashimotos thyroiditis (most common in
US)
Autoimmune Disease
Medications
lithium, interferon alpha, amiodarone, or excessive iodine
ingestion (Kelp), tyrosine kinase inhibitors (Sunitinib)
Post RAI therapy, thyroid nodular disease, external
beam radiation for neck/head cancer
Central Hypothyroidism from pituitary or
 Hashimotos Thyroiditis
5-10x more common in females than males
Diagnosed via elevated anti-thyroid antibodies:
TPO Ab
Elevated TPO Ab titers help predict progression
to overt hypothyroidism
 Autoimmune disease
Autoimmune disease such as type 1 diabetes and
Addisons disease associated with hypothyroidism
Type I Polyglandular autoimmune syndrome
Hypoparathyroidism, Addisons disease,
mucocutaneous candidasis caused by defective AIRE
gene; autoimmune thyroid disease in 15%
Type II Polyglandular Autoimmune syndrome
(Schmidts Syndrome)
Addisons disease, autoimmune thyroid disease,
and DM1
 Central Hypothyroidism
(secondary & tertiary)
May be congenital or acquired insufficient
production of TSH
Causes include
pituitary or hypothalamic tumors
Caused by
Inflammatory (lymphocytic or granulomatous
hypophysitis)
Infiltrative disease
Hemorrhagic necrosis (Sheehan s syndrome)
Surgery or treatment of pituitary or
hypothalamic disease
 Diagnostic Tests
TSH is best diagnostic test then check free t4
anti TPO antibodies
Total cholesterol, LDL

Also palpable the thyroid to determine size. May

consider ultrasound if significant enlargement or if
nodules are palpable
 Treatment
Treatment Best with synthetic L thyroxine
(t4) sodium preparations (levothyroxine); no
natural thyroid/ T3 formulations
Recommend use of consistent levothyroxine
preparation for individuals to minimize
variability from refill to refill
Hyperthyroidism
Hyperthyroidism
Epidemiology
Hyperthyroidism more common in women
than men (5:1 ratio)

NHANES III
Iodine Sufficient population
1.3% or 2.6 million people had thyrotoxicosis
4-5% of older women
 Signs and
Symptoms
of
Hyperthyroidism
 Signs and Symptoms
Classic Symptoms:
Nervousness, fatigue, weakness, Heat
intolerance/excessive sweating, Palpitations,
Anxiety, increased bowel frequency,
Shortness of breath, poor concentration,
oligomenorrhea
Signs:
Weight loss, hair loss, tachycardia, proximal
myopathy, moist skin, stare/lid
lag/exophthalmos, emotional lability,
hyperactive reflexes, thyroid enlargement,
Thyroid Gland
Large thyroid = goiter
Graves eye disease
Signs: Exophthalmos, lid retraction, stare, lid lag,
and conjunctiva injected

Symptoms: blurring of vision, photophobia,

increased lacrimation, double vision, and deep
orbital pressure.
Graves Eyes
Skin manifestations
Clubbing of fingers associated with periosteal
new bone formation in other skeletal areas
(Graves acropachy) and pretibial myxedema

Chronic pretibial
Pretibial myxedema
Hyperthyroid
manifestations
Cardiac: Heart rate increased, Systolic
hypertension, and Atrial fibrillation
Metabolic : Hyperglycemia, amenorrhea,
hypercalcemia
Gastrointestinal : weight loss, increased gut
motility, malabsorption, dysphagia
Bone: thinning of bone, increased calcium in
blood
Neuropsychiatric: insomnia, anxiety, poor
concentration, confusion
 Causes of
Thyrotoxicosis
Thyrotoxicosis Etiologies
with normal to elevated
uptakes
Autoimmune Thyroid Disease
Graves Disease (most common)
Hashitoxicosis
Autonomous Thyroid Tissue
Toxic Adenoma
Toxic Multinodular Goiter
TSH Mediated Hyperthyroidism
TSH secreting pituitary adenoma
HCG Mediated Hyperthyroidism
Hyperemesis gravidarum
Trophoblastic disease
Thyrotoxicosis with low
uptake
Thyroiditis
Painless/Silent/Post partum thyroiditis
Subacute Thyroiditis
Amiodarone induced
Radiation thyroiditis
Exogenous thyroid intake
Too much exogenous thyroid hormone
Too much suppressive ATD
Factious hyperthyroidism
Ectopic Hyperthyroidism
Struma ovarii
Metastatic follicular cancer
 Work up for
Thyrotoxicosis
Tests to order
TSH
Free T4
Free or total T3
TSI,TSH receptor antibody
ESR if pain present
Tg if suspecting exogenous intake
 So you have low TSH with
elevated T3/T4
Do not order RAI if patient is pregnant or nursing!
(I 123 used not I 131)

Radioactive iodine uptake (RAIU)

Percentage of the RAI given that is taken up at
certain period of time usually 6 hours, 24 hours.
Normal RAIU is approximately 5-20%
Radioactive iodine scan
Picture showing location or locations of increased or
decreased activity
RAI scan
RAI scan
RAI scan
 Thyroid ultrasound

May be able to detect increased blood flow in

Graves disease
May be able to detect nodules in the goiter
and better characterize sizes of goiters
Diagnosis and
Treatments
 Thyrotoxicosis
caused by
increased thyroid
gland metabolism
Graves Disease
Autoimmune disorder in which autoantibodies
bind and stimulate the TSH receptor
Most common cause of hyperthyroidism in US
Specific features of Graves disease include:
pretibial myxedema, Graves eye disease,
increased pigmentation/vitiligo
Graves eye disease present in 50% of patients
and smoking is risk factor
Positive TSI, increased uptake on scan,
elevated uptake
Treatment : Radioactive iodine ablation,
Medications (Methimazole 5mg every 8 hours or
PTU 100 mg every 8 hours), Thyroidectomy
 Autonomous Thyroid
Tissue
Toxic Adenoma
Rarely resolve spontaneously
RAI ablation or surgical resection
Toxic Multinodular Goiters
Risks include women, smoking, and enlarged
thyroid
May have symptoms of compression-
dysphagia, dyspnea, neck pressure and
Pembertons sign
Rarely resolve spontaneously
RAI ablation or surgery
 TSH secreting pituitary
adenoma
Rare <2% of pituitary tumors
TSHoma has increased levels of thyroid
hormones
Tx: surgical resection, beta blockers and ATD
 Thyrotoxicosis
caused by
decreased thyroid
gland metabolism
Silent or Painless Thyroiditis
Painless thyroiditis- Lymphocytic thyroiditis
Focal or diffuse infiltrate of lymphocytes
Silent thyroiditis is autoimmune disease with
positive anti TPO antibodies
Lasts 2-9 weeks of thyrotoxic phase then 4-16
weeks of hypothyroidism then 80% normalize to
euthyroid.

Tx: beta blocker, continued screening in future

 Postpartum Thyroiditis
Autoimmune disease that develops during
period of immunologic rebound that can occur
up to one year after delivery
Transient hyperthyroidism, hypothyroidism.
Most women recover to euthyroid
Tx: beta blocker, treat symptoms
 Subacute thyroiditis
De Quervain thyroiditis or granulomatous
thyroiditis
Self-limited inflammatory disorder
Associated with thyroid tenderness (PAIN)
Usually follows upper respiratory infection
associated with adenovirus, Coxsackie, EBV,
influenza etc.
Increased ESR, negative antibodies
Febrile with palpable goiter
Initially hyperthyroidism for weeks then
hypothyroid but typically resolves
Tx NSAID for pain relief, corticosteroids
 Thyrotoxicosis Factitia
Exogenous administration of thyroid hormone
Iatrogenic
Abuse for weight loss and energy
enhancement
Diagnosis: Check Thyroglobulin

Hamburger Thyrotoxicosis
An unusual form of exogenous thyrotoxicosis
occurred in the midwestern portion of the
United States in 1984 and 1985. The source
was the inclusion of large quantities of bovine
thyroid in ground beef preparations
Treatment
Considerations
Surgery: Risks of infections, parathyroid injury,
vocal cord injury, lifelong levothyroxine
therapy

RAI: Dry mouth, metallic taste, sore neck,

nausea/vomiting, lifelong levothyroxine
therapy, NOT in pregnancy
Treatment
Considerations
Medication: Inhibits the synthesis of thyroid hormones by blocking the
oxidation of iodine in the thyroid gland; blocks synthesis of thyroxine and
triiodothyronine (T3); does not inactivate circulating T4 and T3
Tapazole (Methimazole): rare anca vasculitis,
headaches, agranulocytosis, myalgias, rare
hepatic necrosis, jaundice, hepatitis
Treatment of choice in 2/3rd trimester of
pregnancy
Congenital anomalies include: esophageal atresia, choanal atresia, aplasia cutis,
and dysmorphic facies
PTU: Hepatotoxicity (severe life injury/acute
liver failure), bone marrow suppression
(agranulocytosis), aplastic anemia, dermatitis,
Thyroid nodules/ Thyroid
Cancer
Thyroid nodules: Thyroid cancer
Ultrasound best Papillary, Follicular,
test to assess thyroid Medullary, Anaplastic
nodules types
Do FNA (fine needle Prognosis
aspiration) if thyroid Treatment
nodule suspicious
Suspicious features-
multiple speckled
calcification,
irregular borders,
Points to remember
Hypothyroidism Hyperthyroidism
Signs and Signs and
Symptoms Symptoms
Most common cause Most common
is Hashimotos Cause:
thyroiditis in US Graves disease
Check TSH RAI uptake and scan
Treat with Treatment depends
levothyroxine (other on etiology
supplements are not
recommended)
References
Melmed: Williams Textbook of Endocrinology, 12th ed.
McPherson: Henry's Clinical Diagnosis and Management by Laboratory Methods,
22nd ed.
MKSAP 15
Hollowell J.G., Staehling N.W., Flanders W.D., et al: Serum TSH, T(4), and thyroid
antibodies in the United States population (1988 to 1994): National Health and
Nutrition Examination Survey (NHANES III). JClinEndocrinolMetab 87. (2):
489-499.2002
SouleJ,MayfieldR.Gravesdiseaseafter131Itherapyfortoxicnodule.Thyroid.
2001;11:91-92.
Thyrotoxicosis Medical Clinics of North America - Volume 96, Issue 2 W. B.
Saunders Company (March 2012).
Diagnostic Criteria for Thyroid Storm BurchHB,WartofskyL.Life-threatening
thyrotoxicosis:thyroidstorm.EndocrinolMetabClinNorthAm.1993;22:263-277.
Thank you for listening!