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Thyroid: Clinical Cases

Thyroid: Clinical Cases. Dr Sunil Zachariah Consultant Endocrinologist Surrey and Sussex NHS Trust & Spire Gatwick Park Hospital. Thyroid is the only source of T4

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Thyroid: Clinical Cases

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  1. Thyroid: Clinical Cases Dr Sunil Zachariah Consultant Endocrinologist Surrey and Sussex NHS Trust & Spire Gatwick Park Hospital

  2. Thyroid is the only source of T4 • Thyroid secretes 20% of T3, remainder is generated in extra glandular tissues by conversion of T4 to T3

  3. Normal range • FT4 11.5-23 pmol/l • fT3 3-6.7 pmol/l • TSH 0.3-5.5 mu/L

  4. Case 1 • Female aged 40 years • Palpitations, weight loss and mild proptosis • Smallish smooth goitre • FT4 80 • TSH<0.01

  5. Graves Disease • TSH receptor antibodies • Carbimazole • Propylthiouracil • Treatment schedule • ?Block and replace • Permanent cure

  6. Case 2 • Female aged 76 years • Gradual weight loss • Solitary thyroid nodule • FT4 32 • TSH<0.01

  7. Management toxic Nodule • Radioactive iodine • ?FNA first if palpable nodule as low risk of malignancy in toxic nodule

  8. Case 3 • 60 year old female • 6 weeks post radioiodine treatment • FT4 11 • TSH 0.02

  9. Post radioiodine thyroid function • Check 6 weeks after treatment • TFTs may fluctuate • 50% risk of hypothyroidism

  10. Case 4 • Female aged 79 years with fast AF • FT4 19.5 • TSH 0.2

  11. This case probably not for antithyroid treatment • If overtly hyperthyroid treat • Subclinical hyperthyroidism: Normal FT4, Low TSH • Risk factor for Atrial fibrillation, osteoporosis

  12. Case 5 • 50 year old man • Ventricular tachycardia with poor LV function • Controlled on Amiodarone • FT4 50 • FT3 7 • TSH<0.01

  13. Amiodarone and Thyroid • Inhibits thyroidal iodide uptake • Inhibits conversion of T4 to T3 intracellularly • Inhibits T4 entry into cells • Direct T3 antagonism at level of cardiac tissue

  14. What does it do to TFTs? • Early[1-10 days]: TSH increase, FT3 decrease, then Ft4 increase after 4 days • Later[1-4 months]: Ft4 increase by 40%, FT3 remains low or normal, TSH levels normalise • Long term: TSH may suppress

  15. Amiodarone induced hyperthyroidism • 2-12% • Type 1: Iodine overload in abnormal gland, treat with carbimazole or lithium • Type 2: Glandular damage, release of preformed hormones, treat with prednisolone 0.5-1.25 mg/kg for 3-6 weeks • Management of tachyarrhythmia's: beta blockers if not in CCF • ?total thyroidectomy (not radioiodine)

  16. Case 6 • 30 year old female • Recent flu • tender enlargement thyroid • FT4 28 • TSH<0.01

  17. De Quervains thyroiditis • Recheck TFTs-probably hypothyroid by then • Thyroid antibodies and ESR • Thyroid scintigram-reduced uptake • Symptomatic treatment with NSAIDs • Warn the possibility of recurrence

  18. Case 7 • Female age 25 years • Hyperpyrexia • ITU admission • Profound muscle weakness requiring ventilation • FT4 210 • TSH<0.01

  19. Thyrotoxic crisis • Carbimazole 60-100 mg via NG tube • Propranolol infusion • Profound myopathy and even neuropathy can be associated with Grave’s

  20. Case 8 • 65 year old male • Pre coronary artery bypass surgery • Routine blood tests • FT4 3 mU/L • TSH 40 pmol/L

  21. Management hypothyroidism with Coronary artery disease • May need to put in stents to allow introduction of triodothyronine and then thyroxine • Some patients symptomatic when thyroxine started/increased

  22. Case 9 • Female aged 32 years • Weight gain and thyroid • FT4 13 • TSH 5.5

  23. Sub clinical hypothyroidism • TSH>10 • Antibody positive • Family history • Symptomatic • Monitor TFT 6 monthly

  24. Case 10 • Hypothyroid on replacement thyroxine 300 mcg • FT4 23 • TSH 15

  25. Hypothyroidism requiring high dose replacement • Check tablets each visit-check compliance • Check for malabsorption but unlikely • Probably continue to see but at infrequent intervals

  26. Case 11 • Female aged 60 years • Found collapsed at home • History of epilepsy • TFT checked in Causality • FT4 8.5 • TSH 4.0

  27. Low FT4, normal TSH • Sick euthyroid • Possibly hypopituitary-cortisol/FSH/LH • Check medication-can be secondary to carbamazepine

  28. Sick Euthyroid syndrome • Non thyroidal illness syndrome • Low FT4 and T3 • Inappropriately normal/suppressed TSH • Context: Starvation, ITU, severe infections, renal failure, cardiac failure, malignancy

  29. Case 13 Female aged 34 years • Secondary amenorrhoea • Low TSH • Low FT4

  30. Hypopituitarism • FSH/LH/Prolactin/cortisol • MRI Pitutary; ?empty fossa ?large adenoma • Start hydrocortisone first if needed, before thyroxine replacement

  31. Case 14 • 22 year old female • Admitted with hyper emesis gravidarum • Pulse 110 bpm • FT4 29 • TSH<0.01

  32. Management • Usually HCG induced in which case it will resolve spontaneously by around 14 weeks • If positive thyroid antibodies or history of grave’s disease then treat with PTU

  33. Case 14 • A] Palpitations, 10 weeks post partum • Ft4 32 • TSH 0.2 • B] Tired, 10 weeks post partum • FT4 9 • TSH 8

  34. POSTPARTUM THYROIDITIS • Incidence varies from 5-11% • More common in women with a family history of hypothyroidism and positive TPO antibodies

  35. CLINICAL FEATURES • Presentation is usually 3-4 months postpartum • Can be hypothyroidism (40%), hyperthyroidism (40%) or biphasic(20%) • Goiter is present in 50% of patients

  36. Pathogenesis • Destructive autoimmune thyroiditis causing first release of thyroxine and then hypothyroidism as the thyroid reserve is depleted • FNAC shows lymphocytic thyroiditis

  37. Diagnosis • Advise routine TFT in females who have positive TPO antibodies and type 1 diabetes • To distinguish from Graves disease use thyroid isotope scan and TSH receptor Ab

  38. Management • Most patients recover spontaneously without requiring treatment • If hyperthyroid use beta blockers rather than antithyroid drugs as the problem is increased release, not synthesis • Hypothyroid phase is more likely to require treatment • Only 3-4% remain permanently hypothyroid • 10-25% will recur in future pregnancies

  39. Case 15 • Female aged 30 years • New Thyroid enlargement

  40. New Thyroid swelling • FNAC if nodule size>1 cm • Repeat FNAC in 6 months • Impossible to differentiate between benign and malignant follicular neoplasm using FNAC

  41. Case 16 • Long standing goitre • FT4 28 • TSH 7

  42. Measurable TSH with raised FT4 • Heterophile antibodies • TSH resistance syndromes • TSH oma-very rare

  43. Thyroid hormone resistance • Syndrome characterized by reduced responsiveness to elevated circulating FT4 and FT3, non suppressed TSH • Short stature, hyperactivity, attention deficit • Differential diagnosis includes TSH secreting pituitary tumour

  44. Case 17 • 27 year old female • Follicular Cancer of Thyroid • Post surgery, post radioiodine ablation • On Thyroxine replacement (175 mcg) • FT4 19.8 • TSH 0.05

  45. Follow up of thyroid Cancer • Original diagnosis and treatment • If total thyroidectomy and ablative radioiodine, thyroglobulins usually undetectable if TSH unrecordable • Maintain TSH<0.05

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