Hyperthyroidism
• 60% due to Grave’s Disease
• 40% due to miscellaneous causes:
– Thyroiditis, toxic adenomas, TSH-secreting
pituitary tumors, struma ocarii, & hCG-secreting
tumors
• Diagnosis
– Increased T3 and T4
– Decreased TSH
• Except in TSH-secreting tumors
Hypothryoidism Causes
Etiology Clinical Manifestations
Grave’s Disease •TSI binds TSH receptor on •Diffuse nontender goiter
thyroid gland; leads to ↑ T3/T4 with bruit
(diffuse uptake on thyroid scan) •Infiltrative ophthalmopathy
•Associated w/ other (proptosis, extraocular
autoimmune disorders muscle dysfunction)
•Pretibial myxedema
Plummer’s Disease (toxic •Hyperfunctioning areas that •Less severe than Grave’s
multinodular goiter) make ↑ T3/T4 (patchy uptake •Associated w/ life-
on thyroid scan) threatening arrhythmias &
•More common in elderly CHF
Subacute Thyroiditis (de •Inflammation of thyroid •Thyroid gland firm, painful,
Quervain’s thyroiditis) glandspilling of thyroid tender
hormonetransient •Fever
hyperthyroidism •Increased ESR
•Usually preceded by upper •Pain radiating to ears, neck
respiratory infection & arm
Treatment
• Thionamides (PTU & methimazole) to inhibit thyroid hormone
synthesis; PTU also inhibits peripheral conversion of T4 to T3
– Mechanism: Inhibits oxidation & organification of iodine, a required step in
thyroid hormone synthesis
– Both cross the placenta & are contraindicated in pregnancy; PTU is used
during lactation
– Side effects=rash, urticaria, fever, nausea; major effects=agranulocytosis,
thrombocytopenia, acute hepatic necrosis & vasculitis
• β-Blockers (propanolol) to control the adrenergic symptoms
(sweating, tachycardia, tremor)
• Radioactive Iodine to destroy thyroid function
– Side effects=metallic taste, excessive salivation, diarrhea, rash
• Surgery
Signs & Sypmtoms
Hyperthyroidism Hypothyroidism
Symptoms Hyperactive, irritable Difficulty concentrating, Poor memory
Heat intolerance, sweating Cold intolerance
Palpitations Dyspnea
Fatigue, weakness, Insomnia Fatigue, weakness, lethargy
Diarrhea, polyuria Constipation
Oligomenorrhea, loss of libido Menorrhagia
Weight loss Weight gain, poor appetite
Impaired hearing, hoarse voice (deep voice)
Parasthesias
Tachycardia Bradycardia
Signs
Tremor Delayed Tendon reflex relaxation
Goiter Peripheral edema
Warm, moist skin Dry, coarse skin & Hair loss (Diffuse alopecia)
Proximal muscle weakness Carpal tunnel syndrome
Lid retraction, lid lag Puffy face, hands, & feet (myxedema)
Gynecomastia Diastolic Hypotension
Hypothyroidism
• 95% cases are 1°: Hashimoto’s thyroiditis, Riedel’s
thyroiditis, iodine deficiency, & surgical destruction
• 2° causes=failure of the pituitary gland
• 3° causes=failure of the hypothalamus
• Diagnosis
– T3/T4/TSH/TRH
• All are helpful to diagnose & distinguish among 1°, 2°, and 3° causes
– Antimicrosomal antibodies to test for Hashitmoto’s Thyroiditis
– Imaging of Pituitary & hypothalamus for tumor
Treatment
• Levothyroxine (T4) replacement
– Levothyroxine is a T4 analog that binds to nuclear
receptors. This leads to ↑ protein synthesis, ↑
metabolic rate,↑ β-receptorsincreased
sensitivity to catecholamines
– Side effects=signs & symptoms of hyperthyroidism
• Use emperic adrenal replacement therapy &
Liothyronine when myxedema coma is involved
– Liothyronine can precipitate heart failure
