1. Hyperthyroidism Clinical Applications Gail Nunlee-Bland, M.D. Division of Endocrinology

2. Hyperthyroidsim Clinical condition resulting from overactivity of the thyroid gland an an excess of circulating thyroid hormone

4. Hyperthyroidism Causes 2 categories Sustained hormone overproduction No associated overproduction

5. Hyperthyroidism Overproduction Graves’ disease Toxic multinodular goiter Toxic adenoma Iodine-induced Increase TSH secretion

6. Hyperthyroidism No Sustained Overproduction Thyrotoxicosis factitia Subacute thyroiditis chronic thyroiditis with transient thyrotoxicosis (painless thyroiditis, silent thyroiditis, post-partum thyroiditis Ectopic thyroidtissue (struma ovarii, functioning metastatic thyroid cancer)

7. Graves’Disease Diffuse goiter Thyrotoxicosis Infiltrative orbitopathy Infiltrative dermopathy

8. Graves’ Disease Autoimmune Antibodies against thyroid peroxidase, thyroglobulin and the TSH receptor Associated with other autoimmune disorders

9. Graves’ Disease Prevalence ~ 2.7% Incidence 1 case 1000/yr Most common cause of spontaneous hyperthyroidism in patients younger than age 40

10. Organ Specific Effects of Graves’ Disease Eyes –Infiltrative orbitopathy Skin –Dermopathy

19. Clinical Manifestations Thyrotoxicosis

22. Toxic Multinodular Goiter Generally seen in the elderly Multiple nodules are felt on exam - few of the nodules may be hyperfunctioning on thyroid uptake scan Signs and symptoms of hyperthyroidism are less pronounced Less increase in thyroid hormone overproduction

23. Toxic Adenoma Hyperfunctioning solitary nodule Occurs in a younger age group 30s or 40s Long-standing slowly growing lump in neck Manifestations of hyperthyroidism - less severe than in Graves’ disease Uptake scan may show hyperfunctioning nodule

24. Transient Hyperthyroidism Subacute thyroiditis –thyroid pain –Elevated sedimentation rate Silent thyroiditis –no thyroid pain Postpartum thyroiditis Factitious hyperthyroidism –ingestion of thyroid hormone Decreased iodide uptake on thyroid scan

25. Laboratory Investigations TSH Free T4 T3RIA Thyroid antibodies –Thyroid stimulating immunoglobulins Thyroid uptake scan

26. TBG Resin T4 Euthyroid

27. TBG Resin Hyperthyroid T4  T3RU  TSH 

28. Increase Uptake Scan Hyperthyroidism Iodine deficiency

31. Decrease Uptake Scan Subacute thyroiditis Factitious thyroiditis Antithyroid agents

32. Treatment Antithyroid drugs –Propylthiouracil –Methimazole Beta blockers Surgery Radioactive iodine

33. Thank You