Thyroid Disorders

Thyroid Disorders

Grave’s Disease (hyperthyroid with goiter)

• – Pathway/Axis:
  • Hypothalamic/ Pituitary/Thyroid axis
    
• – Major cause:
  • environmental factors, a genetic disorder that causes antibody, thyroid-stimulating immunoglobulin (TSI), to signal the thyroid gland into producing excess thyroid hormone.
• Management:
  • Propanolol for sx tx
    Plus
    
  • Methimazole or PTU
    
  • If refractory:
    
    • Ablation or surgery

Myxedema

• Management:
  • IV Levothyroxine and supportive care

Hypothyroidism

Hashimoto’s Disease (Autoimmune Thyroiditis)

• – Pathway/Axis:
  • Hypothalamus/ Pituitary/Thyroid (HPT) Axis
• – Major cause:
  • genes, gender/sex hormones, pregnancy, too much iodine, some drugs and radiation exposure
• – Major symptoms:
  • Fatigue, weight gain, pale, puffy face, feeling cold, muscle pain, constipation, dry and thinning hair, heavy menstrual flow or irregular periods, depression, slowed heart rate, problems getting pregnant.
• Management:
  • Levothyroxine PO

Primary Hypothyroidism

• Management:
  • Levothyroxine PO qd begin at 1.6 mcg/kg then increase by 12.5 every 4-6 weeks
    
  • Monitor TSH at week 4-6

Secondary Hypothyroidism

• Management:
  • Levothyroxine PO
  • Endocrine Consult -> Tumor removal
    
  • Monitor T4 (high ideal)

Thyroid Storm (Thyrotoxicosis Crisis)

• Management:
  • Propanolol
    
  • IV PTU
    
  • Hydrocortisone
    
  • Potassium Iodide

Thyroiditis

de Quervain’s Thyroiditis

• – Pathway/Axis:
  • hypothalamic/Pituitary/Thyroid (HPT) axis
• – Major cause:
  • viruses such as mumps, influenza, and other respiratory viruses infect the thyroid gland and cause inflammation which damages the follicular cells of the thyroid.
• – Major symptoms:
  • Neck pain, fever, fatigue.
  • Damage to the thyroid follicular cells can cause hyperthyroidism which leads to weight loss and anxiety.

Infectious (Suppurative) Thyroiditis

• Management:
  • Abx +/- drainage, lobectomy, fistula removal (esp kids)
    
  • Monitor for immune reconstitution inflammatory syn.

Painful Subacute Thyroiditis

• Management:
  • For throat pain:
    • ASA or NSAIDs
      
  • Hyperthyroid stage:
    • BB, steroids
      
  • Hypothyroid stage:
    • Levothyroxine
      
  • [Return to baseline in 12-18 months in most without tx]

Painless Lymphocytic Thyroiditis

• Management:
  • Hyperthyroid stage: BB, CCB, steroids
    
  • Hypothyroid stage: Levothyroxine
    
  • [Return to baseline in 12-18 months in most without tx]
  • Refractory? Surgery or Iodine ablation

Riedel Thyroiditis

• Management:
  • Tamoxifen (for years)
    
  • Sx tx with steroid
    
  • Refractory: Rituxan

Silent Thyroiditis

• – Pathway/Axis:
  • Hypothalamic/Pituitary/Thyroid (HPT) Axis:
• – Major cause:
  • unknown, but related to immune attack against the thyroid, leading to the hyperthyroid phase.
  • Once stores on thyroid hormones are depleted the hypothyroid phase beings.
  • Usually occurs in postpartum women, but can be caused by medicines such as interferon and amiodarone.
• – Major symptoms:
  • “silent” refers to the absence of thyroid tenderness that occurs in subacute thyroiditis.
  • thyroid enlargement with a self-limited hyperthyroid phase several weeks, followed by a hypothyroid phase during which many women are diagnosed.
  • Eventually, recovery to the euthyroid state occurs but the hypothyroid can occasionally become permanent.
  • Eye signs and pretibial myxedema do not occur

Thyroid Mass

Goiter

• Diffuse Non-Toxic Goiter
  • Management: Observe unless large, then surgery
• Non-Toxic Multinodular Goiter
  • Management:
    • Observe unless large/compressive sx, then hydrocortisone or surgery.
      
    • Surgery CI? Radioiodine ablation
• Toxic Multinodular Goiter
  • Management:
    • PTU (Antithyroid)
      Plus
      
    • Radioiodine ablation
      
    • If refractory:
      
      • Surgery

Non-Palpable (Incidental) Thyroid Nodule

• Management:
  • Observation to monitor growth and re-biopsy PRN to follow morphological changes

Solitary thyroid nodule

• Management:
  • Varies based on pathology
    
  • Treating hyper/hypothyroidism
    
  • Aspiration of fluid if cystic
    
  • Surgery if malignant
    
  • Observation if benign

Anaplastic Thyroid Carcinoma

• Management:
  • Palliative resection, radiation, and chemotherapy

Follicular carcinoma

• Management:
  • Total thyroidectomy
    PLUS
    
  • Radioactive Iodine Ablation
    PLUS
    
  • TSH suppression (via levothyroxine)

Medullary Thyroid Carcinoma

• Management:
  • Total thyroidectomy
    PLUS
    
  • Radioactive Iodine Ablation
    PLUS
    
  • TSH suppression (via levothyroxine)

Papillary Carcinoma

• Management:
  • Total thyroidectomy
    PLUS
    
  • Radioactive Iodine Ablation
    PLUS
    
  • TSH suppression (via levothyroxine)

Toxic Thyroid Adenoma

• Management:
  • Radioactive iodine ablation (unless prego, then PTU)
    
  • Subtotal thyroidectomy
    
  • Propanolol