1. MORNING REPORT Johana Rodriguez

2. ThyrotoxicosisThyrotoxicosis

3. 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 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.

4. ThyrotoxicosisCauses Primary Hyperthyroidism : Grave’s disease, toxic multinodular goiter, toxic adenoma, thyroid carcinoma mets, mutation of TSH receptor, excess iodine 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 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 without hyperthyroidism : subacute thyroiditis; silent thyroiditis; other causes of thyroid destruction including amiodarone, radiation, infarction of adenoma; exogenous/factitiaThyrotoxicosisCauses Primary Hyperthyroidism : Grave’s disease, toxic multinodular goiter, toxic adenoma, thyroid carcinoma mets, mutation of TSH receptor, excess iodine 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 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 without hyperthyroidism : subacute thyroiditis; silent thyroiditis; other causes of thyroid destruction including amiodarone, radiation, infarction of adenoma; exogenous/factitia

5. Thyrotoxicosis Clinical Presentation Tachycardia, tremor, goiter, warm skin, lid retraction, exophthalmos, pretibial myxedema Tachycardia, tremor, goiter, warm skin, lid retraction, exophthalmos, pretibial myxedema Hyperactivity Hyperactivity Irritability Irritability Heat intolerance and sweating Heat intolerance and sweating Palpitations Palpitations Dysphoria Dysphoria Fatigue and weakness Fatigue and weakness Weight loss with increased appetite Weight loss with increased appetite Diarrhea Diarrhea Polyuria PolyuriaThyrotoxicosis Clinical Presentation Tachycardia, tremor, goiter, warm skin, lid retraction, exophthalmos, pretibial myxedema Tachycardia, tremor, goiter, warm skin, lid retraction, exophthalmos, pretibial myxedema Hyperactivity Hyperactivity Irritability Irritability Heat intolerance and sweating Heat intolerance and sweating Palpitations Palpitations Dysphoria Dysphoria Fatigue and weakness Fatigue and weakness Weight loss with increased appetite Weight loss with increased appetite Diarrhea Diarrhea Polyuria Polyuria

6. Thyrotoxicosis Atypical Clinical Manifestation Nausea, vomiting, and abdominal pain are common complaints in the ED, but uncommon signs of thyrotoxicosis 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 Thyrotoxicosis has an annual incidence of 30 cases per 100, 000 persons per year Male-to-female ratio of 1:5 Male-to-female ratio of 1:5 Women in their third through sixth decade of life are at highest risk Women in their third through sixth decade of life are at highest risk Other rarely reported presentations include DKA, near- fatal cardiac arrhythmias, and hypokalemic periodic paralysis Other rarely reported presentations include DKA, near- fatal cardiac arrhythmias, and hypokalemic periodic paralysisThyrotoxicosis Atypical Clinical Manifestation Nausea, vomiting, and abdominal pain are common complaints in the ED, but uncommon signs of thyrotoxicosis 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 Thyrotoxicosis has an annual incidence of 30 cases per 100, 000 persons per year Male-to-female ratio of 1:5 Male-to-female ratio of 1:5 Women in their third through sixth decade of life are at highest risk Women in their third through sixth decade of life are at highest risk Other rarely reported presentations include DKA, near- fatal cardiac arrhythmias, and hypokalemic periodic paralysis Other rarely reported presentations include DKA, near- fatal cardiac arrhythmias, and hypokalemic periodic paralysis Atypical clinical manifestations of graves' disease: an analysis in depth. J Thyroid Res. Epub 2011 Nov 1.J Thyroid Res.

8. Thyrotoxicosis Atypical Clinical Manifestation Significant delay in diagnosis when vomiting is the main symptom, 7 years in one case report 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 Vomiting does not improve until hyperthyroidism has been detected and treated In a review of 25 newly diagnosed thyrotoxicosis, 44% complained of vomiting 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 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 Effects of excess thyroid hormones on gastric motility. In a study of 23 patients with hyperthyroidism, 50% had delayed gastric emptyingThyrotoxicosis Atypical Clinical Manifestation Significant delay in diagnosis when vomiting is the main symptom, 7 years in one case report 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 Vomiting does not improve until hyperthyroidism has been detected and treated In a review of 25 newly diagnosed thyrotoxicosis, 44% complained of vomiting 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 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 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.J Thyroid Res.

9. 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 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 Intestinal hypermotility reduces small bowel transit time, especially when diarrhea is present Diarrhea may be related to a hypersecretory state within the intestinal mucosa Diarrhea may be related to a hypersecretory state within the intestinal mucosa thyroidhormone stimulation of a chemoreceptor trigger zone in the central nervous system thyroid hormone stimulation of a chemoreceptor trigger zone in the central nervous systemThyrotoxicosis 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 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 Intestinal hypermotility reduces small bowel transit time, especially when diarrhea is present Diarrhea may be related to a hypersecretory state within the intestinal mucosa Diarrhea may be related to a hypersecretory state within the intestinal mucosa thyroidhormone stimulation of a chemoreceptor trigger zone in the central nervous system 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 21World J Gastroenterol

10. ThyrotoxicosisTreatment Decreasing thyroid hormone synthesis: Methimazole, Propylthyouracil Methimazole, Propylthyouracil Radioiodine Radioiodine Thyroidectomy Thyroidectomy Reducing thyroid hormone effects: Propranolol Propranolol Glucocorticoids Glucocorticoids Benzodiazepines BenzodiazepinesThyrotoxicosisTreatment Decreasing thyroid hormone synthesis: Methimazole, Propylthyouracil Methimazole, Propylthyouracil Radioiodine Radioiodine Thyroidectomy Thyroidectomy Reducing thyroid hormone effects: Propranolol Propranolol Glucocorticoids Glucocorticoids Benzodiazepines Benzodiazepines

12. 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 (T 4 )3.2 ng/dL (41.3 pmol/L Total triiodothyronine (T 3 )310 ng/dL (4.8 nmol/L) Thyroid-stimulating immunoglobulin index<1.3 (normal, <1.3) 24-Hour radioactive iodine uptake5% (low)

13. Which of the following is the most appropriate treatment? A. Methimazole B. Metoprolol C. Propylthiouracil D. Radioactive iodine