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Thyroid: Clinical Cases

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Presentation on theme: "Thyroid: Clinical Cases"— Presentation transcript:

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 FT pmol/l fT pmol/l TSH mu/L

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


6 Graves Disease TSH receptor antibodies Carbimazole Propylthiouracil
Treatment schedule ?Block and replace Permanent cure

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


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

10 Case 3 60 year old female 6 weeks post radioiodine treatment FT4 11
TSH 0.02

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

12 Case 4 Female aged 79 years with fast AF FT4 19.5 TSH 0.2

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

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

15 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

16 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

17 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 mg/kg for 3-6 weeks Management of tachyarrhythmia's: beta blockers if not in CCF ?total thyroidectomy (not radioiodine)

18 Case 6 30 year old female Recent flu tender enlargement thyroid FT4 28

19 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

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

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

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

23 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

24 Case 9 Female aged 32 years Weight gain and thyroid FT4 13 TSH 5.5

25 Sub clinical hypothyroidism
TSH>10 Antibody positive Family history Symptomatic Monitor TFT 6 monthly

26 Case 10 Hypothyroid on replacement thyroxine 300 mcg FT4 23 TSH 15

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

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

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

30 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

31 Case 13 Female aged 34 years Secondary amenorrhoea Low TSH Low FT4


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

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

35 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

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

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

38 Presentation is usually 3-4 months postpartum
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

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

40 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

41 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

42 Case 15 Female aged 30 years New Thyroid enlargement

43 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

44 Case 16 Long standing goitre FT4 28 TSH 7

45 Measurable TSH with raised FT4
Heterophile antibodies TSH resistance syndromes TSH oma-very rare

46 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

47 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

48 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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