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Hyperthyroidism

Hyperthyroidism. Defintion. THYROTOXICOSIS Increased thyroid hormone levels with biological effects on tissues and systems HYPERTIROIDISM Hyperfunction of thyroid gland. History. Have described different forms of hyperthyroidism Parry (1786), Flajani (1808), Graves (1835),

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Hyperthyroidism

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  1. Hyperthyroidism

  2. Defintion • THYROTOXICOSIS • Increased thyroid hormone levels with biological effects on tissues and systems • HYPERTIROIDISM • Hyperfunction of thyroid gland

  3. History • Have described different forms of hyperthyroidism • Parry (1786), • Flajani (1808), • Graves (1835), • Basedow (1840), • Moebius (1886), • Plummer (1913 – adenomul toxic), • Adams, Purves, Mc Kenzie (1956 – long-acting thyroid stimulator immunoglobulins – LATS)

  4. MIT T4 T4 T4 fT4 fT4 fT4 T4 DIT T3 T3 T3 fT3 fT3 fT3 T3 Thyrotropic axe TRH TRH piytuitary TSH TSH TBG I- I- I2 thyroglobulin I - I-

  5. HYPERTIROIDISM Etiolology : incidence other (< 1%) Autonomic - >40 ani - b=f • Graves disease • < 40 ani • f / b = 10 / 1

  6. HYPERTIROIDISM Most frequent forms Basedow-Graves disease Toxic adenoma Plummer Toxic multinodular goiter TSH TSH TSH T4 T4 T4

  7. 1.Thyroid stimulation TSI Graves disease TSH thyrotropinoma Resistance to thryoid hormone action Refetoff syndromes Human Chorionc Gonadotropin Trophoblastic tumors hiperemesis gravidarum 2.Autonomous thyroid function Toxic adenoma Toxic multinodular goiter Non-autoimmune difuse hyperthyroidism(familiala, sporadic?) Thyroid carcinoma follicular struma ovarii Hypertiroidism – etiologyA. tirotoxicosis with hyperthyroidism 3.Iodine induced • Jod-Basedow • Iodine contrast media, amiodarone (thyroid excess and autonomous thyroid function)

  8. Hypertiroidism - etiology B. Thyrotoxicosis without hyperfunction of the thyroid gland 4. Distruction • thyroiditis • subacute de Quervain thyroiditis • Silent thyroiditis • Drug induced (amiodarone, interferon-alfa) • Irradiation, 5. External intake • Iatrogenic • Factitia • foods (« hamburger thyrotoxicosis »)

  9. HYPERTIROIDISM / THYROTOXICOSISsigns and symptoms • Simptoms due to increased number of cathecolamine receptors • palpitation (tachicardia, atrial fibrilation) • Increasd perspiration • tremor , hiperreflexia, eyelids retraction • Simptoms due to metabolic actons of thyroid hormones • Weight loss with increased appetite , decreased fat and muscle mass • termofobia • Warm skin, fine, moist; onicholisis • Muscle weakness, • osteoporosis • Menstrual problems in women and gynecomastia in men • Simptoms induced by thyrpid hormone effects on central nervous system • Nervousness , irritability, psychological labillity,

  10. Clinical signs

  11. Clinical symptoms

  12. Hypertiroidism - simptoms

  13. signs Tachicardis, continous, nocturnal + effort associated dyspnea Systolic Hypertension Increased cardiac output  FC  peripheral resistance  miocardial contractility Cardiotireosis Atrial fibrilation : 10% Rarely < 40 ani Corrected by euthyroid state Anticoagulant treatment Embolic risk (8%) Congestive hearth failure Fibrilation, Aged patients Worsening coronary hearth disease Cardio-vascular signs and symptoms

  14. Nervosness, irritability, Emotional disturbance Disturbance of attention and mood. Pseudo psychotic forms Tremor Muscle weakness Rapid reflexes, Amiotrophy (pseudo miopathic forms) Hypokaliemic periodic paralysis Neuro muscular signs

  15. Tranzit accelerat (motor) pseudodiaree = poli exoneratie Anomalii hepatice   Icter, citoliza, hipocolesterolemie men gynecomastia (40%) Erectile dysfunction infertility women Menstrual abnormalities disovulation Digestive signs Genital abnormalities

  16. Bone abnormalities Decreased BMD : distruction>formation Spontaneous fractures Hypercalcemia, hypercalciuria  alkaline phosphatase and osteocalcin Skin problems pruritus Localized edema Alopecia Metabolic abnormalities Hypocholesterolemia Hyperglicemie, worsening of diabetes mellitus

  17. Positive diagnosis • Clincal signs and symptoms • TSH: suppressed (excepton TSH-secreting pituitary adenoma) •  FT4 and/or FT3 • Etiologic diagnosis • history • pregnancy • Painfull thyroid • drugs • Clinical signs • goiter • Extrathyroidal signs • TSH receptor stimulating immunoglobulins (TRAb) • Scintigraphy • Urinary iodine

  18. HYPERTIROIDISM Peripheral metabolism

  19. HYPERTIROIDISM / TIROTOXICOSIS Paraclinical diagnosis TSH, fT4 TSH↓, fT4↑ TSH↓, fT4= TSH ↑, fT4↑ fT3 TSH adenoma Syndrome Refetoff Hyipertiroidism T3 tirotoxicosis fT3↑ fT3↓ Exoftalmie + Exophtalmos - Euthyroid sick syndrome Critical diseases Dopamine, Ultrasound Scintigram I123 TS-Ab TS-Ab + hypoechoic TS-Ab + Multiplee hot nodules TS-Ab - Hypoechoic thyroid TS-Ab - Subacute thyroiditis Hashimoto’s thyroiditis Jod-Basedow Tirotoxicosis factitia Struma ovarii (rarely) Toxic adenoma Toxic multinodular goiter Graves’s disease

  20. HYPERTIROIDIS / THIROTOXICOSIS Imagery: Graves’disease Thyroid ultrasound

  21. HYPERTIROIDISM / THYROTOXICOSIS Imagery : toxic adenoma Thyroid ultrasound Scintigram

  22. HYPERTIROIDISM / THYROTOXICOSIStests: toxic adenoma Studer Wyss PTU TSH T4

  23. HYPERTIROIDISM / THYROTOXICOSIStests: toxic adenoma Studer Wyss PTU TSH Querido TSH TSH T4

  24. HYPERTIROIDISM / THYROTOXICOSIStests: toxic adenoma Studer Wyss PTU fT4 TSH Querido TSH Werner fT4 T4

  25. HYPERTIROIDISM / THYROTOXICOSISComplications • Hearth • atrial fibrilation resistant to treatment • hyperkinetic hearth failure • Infertility / amenorrhea • Osteoporosis (postmenopausal) • Thyrotoxic periodic paralysis • flaccid paralysis and hypokalemia • asian men • reversible on treatment • Apathetic hyperthyroidism • Aging patients

  26. Thyrotoxic crisis (thyrotoxic storm) • Etiology • determinant factors • Undertreated thyrotoxicosis • Recently developed untreated hyperthyroidism • Precipitating factors • medical • infecţions • Diabetic ketoacidosis • Lung embolism • Labor or pregnancy • Premature stopping treatment • I131 treatment • surgery

  27. Thyrotoxic crisis • severe signs and symptoms of thyrotoxicosis • severe hipermetabolism • fever • over >38oC (til 41-42oC) • Neuro-psychological symptoms • “thyrotoxic encephalopathy" - • cardio-vascular symptoms • tachicardia - >140/min, • arhitmias (atrial fibrillation ) • Hearth failure (left, global) • Variations of arterial blood pressure • gastro-intestinal symptoms • Mimikin acute abdomena • Jaundice (index of severity)

  28. Graves disease • Most frequent cause of hyperthyroidism • Prevalence 1% • 19/1000 ♀ • 1,6/1000 ♂ (Sex ratio 7 / 10) • Incidence 2 - 3 cases / year /1000 ♀ • Young female patient, psychological trauma • Autoimmune, familial • Asociated with other autoimune diseases: • tip 1DM, adrenal insufficiency, vitiligo, miastenia gravis • Stimulating immunoglobulins

  29. nervosness, emotional instability perspiration flushes exophtalmos < 40 years Lymp node enlargement goiter (± thrill) amiotrophie Hot, mois skin dispnea palpitations, tachicardia, low response to digytalis  Gynecomastia in ♂ apetit  Weigh loss diarheea tremor acropachia oligo/amenorrea Muscle weakness, fatigability Local mixedoema Graves’ disease

  30. Graves’ disease goiter

  31. Graves’ disease GOITER • Difuse • Elastic • Homogenous • painless • Vascular (thrill)

  32. Graves exophtalmos

  33. Graves ophtamopathy • Eyelid edema, periorbital edema, proptosis • Increase tears production • Incomplete close eyelids during night • Fotofobia, • Eye disconfort, pruritus, “alergy • Painfull eyes, associated or not with eye mouvments • Dyplopia • Intermitent: when patinets is tired • Inconstant • Constant: when reading

  34. Graves ophtalmopathy NOSPECS

  35. Severity of Graves ophtalmopathy

  36. Clinical Activity Score (CAS) • Spontaneous retroocular pain • Pain at eye mouvments • Eyelid erithema • Corneal increased vascularity • Chemosis • Edema of caruncula • Eyelid edema • Every item has 1 point. Active ophtalmopathy: >3 poins

  37. Graves’ ophtalmopathy Eyelid retraction

  38. Graves’ ophtalmopathy • Eyelid edema

  39. Graves’ ophtalmopathy • Superioar eyelid edema

  40. Graves’ ophtalmopathy Eyelid edema

  41. Graves’ ophtalmopathy Enlarged eyelid opening

  42. Graves’ ophtalmopathy • Corneal involvment

  43. Graves’ ophtalmopathy Corneal and conjunctival problems

  44. Graves’ ophtalmopathy • Exophtalmos

  45. Graves’ ophtalmopathy • Exophtalmos

  46. Graves’ ophtalmopathy Ophtalmoplegia

  47. Graves’ ophtalmopathy

  48. Graves’ ophtalmopathy CT of orbotal area

  49. Nodous eritema • Pretibial mixoedema

  50. Acropachy

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