Download morning-report-10-3-16

MORNING REPORT
Johana Rodriguez
Thyrotoxicosis
Thyrotoxicosis
Many cellular metabolic processes affected by excess
thyroid hormone production
Whereas hyperthyroidism is defined as excessive thyroid
gland function and thyrotoxic crisis or thyroid storm refers
to the life-threatening exacerbation of thyrotoxicosis
accompanied by fever, delirium, seizures, coma,
vomiting, diarrhea, jaundice
Thyroid hormone modulates O2 consumption, maturation
and cell differentiation, turnover of vitamins, hormones,
proteins, fats.
Thyrotoxicosis
Causes
• Primary Hyperthyroidism: Grave’s disease, toxic
multinodular goiter, toxic adenoma, thyroid carcinoma
mets, mutation of TSH receptor, excess iodine
• Secondary Hyperthyroidism: TSH-secreting pituitary
adenoma, thyroid hormone resistance syndrome,
chorionic gonadotropin-secreting tumor, gestational
thyrotoxicosis
• Thyrotoxicosis without hyperthyroidism: subacute
thyroiditis; silent thyroiditis; other causes of thyroid
destruction including amiodarone, radiation, infarction
of adenoma; exogenous/factitia
Thyrotoxicosis
•
•
•
•
•
•
•
•
•
•
Clinical Presentation
Tachycardia, tremor, goiter, warm skin, lid retraction,
exophthalmos, pretibial myxedema
Hyperactivity
Irritability
Heat intolerance and sweating
Palpitations
Dysphoria
Fatigue and weakness
Weight loss with increased appetite
Diarrhea
Polyuria
Thyrotoxicosis
•
•
•
•
•
Atypical Clinical Manifestation
Nausea, vomiting, and abdominal pain are common
complaints in the ED, but uncommon signs of
thyrotoxicosis
Thyrotoxicosis has an annual incidence of 30 cases per
100, 000 persons per year
Male-to-female ratio of 1:5
Women in their third through sixth decade of life are at
highest risk
Other rarely reported presentations include DKA, nearfatal cardiac arrhythmias, and hypokalemic periodic
paralysis
Atypical clinical manifestations of graves' disease: an analysis in depth. J Thyroid Res. Epub 2011 Nov 1.
Thyrotoxicosis
•
•
•
•
•
Atypical Clinical Manifestation
Significant delay in diagnosis when vomiting is the main
symptom, 7 years in one case report
Vomiting does not improve until hyperthyroidism has been
detected and treated
In a review of 25 newly diagnosed thyrotoxicosis, 44%
complained of vomiting
Mechanism uncertain, one pathway involves increased levels
of estrogen in both sexes, which may act as an emetic agent
with varying susceptibility
Effects of excess thyroid hormones on gastric motility. In a
study of 23 patients with hyperthyroidism, 50% had delayed
gastric emptying
Atypical clinical manifestations of graves' disease: an analysis in depth. J Thyroid Res. Epub 2011 Nov 1.
Thyrotoxicosis
Atypical Clinical Manifestation
• Since beta blockers ameliorate vomiting, the increased beta
adrenergic activity (more receptors) has been considered,
but vomiting is more likely to be linked to hypo-, rather than
hyper-adrenalism.
• Intestinal hypermotility reduces small bowel transit time,
especially when diarrhea is present
• Diarrhea may be related to a hypersecretory state within the
intestinal mucosa
• thyroid hormone stimulation of a chemoreceptor trigger zone
in the central nervous system
Consequences of dysthyroidism on the digestive tract and viscera. World J Gastroenterol. 2009 Jun 21
Thyrotoxicosis
Treatment
Decreasing thyroid hormone synthesis:
• Methimazole, Propylthyouracil
• Radioiodine
• Thyroidectomy
Reducing thyroid hormone effects:
• Propranolol
• Glucocorticoids
• Benzodiazepines
A 32-year-old man is evaluated for a 1-week history of severe neck pain. He also has heat intolerance,
palpitations, and insomnia. Medical history is significant only for a viral upper respiratory tract infection 3
weeks ago. He takes no medications.
On physical examination, he appears anxious and is sweating. There is no proptosis or lid lag.
Examination of the thyroid reveals a normal-sized gland that is very tender to palpation. There are no
thyroid nodules. The heart rate is regular but tachycardic. The lungs are clear.
Laboratory studies:
Thyroid-stimulating hormone
<0.008 µU/mL (0.008 mU/L)
Free thyroxine (T4)
3.2 ng/dL (41.3 pmol/L
Total triiodothyronine (T3)
310 ng/dL (4.8 nmol/L)
Thyroid-stimulating immunoglobulin index
<1.3 (normal, <1.3)
24-Hour radioactive iodine uptake
5% (low)
• Which of the following is the most appropriate treatment?
A. Methimazole
B. Metoprolol
C. Propylthiouracil
D. Radioactive iodine