Hyperthyroidism is a set of disorders - Thyroid-stimulating hormone (TSH)

that involve excess synthesis and - Free thyroxine (FT4) or free

secretion of TH by the thyroid gland, thyroxine index (FTI)
which leads to the hypermetabolic - Total triiodothyronine (T3)
condition of thyrotoxicosis. Most
common forms: diffuse toxic goiter Results:
(Graves disease), TMN goiter (Plummer - marked by suppressed TSH levels
disease), and toxic adenoma.  and elevated T3 and T4 levels
- milder hyperthyroidism may have
Etio: elevation of T3 only w a suppressed
Genetic Iodine intake TSH level
Graves disease TMN goiter - Subclinical hyperthyroidism features
decreased TSH and normal T3 & T4
Subacute thyroiditis Toxic adenoma

Common symptoms: Autoantibody tests:

- Nervousness - Anti–thyroid peroxidase (anti-TPO)
- Anxiety antibody - Elevation with AI thyroid
- Increased perspiration diz found in 85% of Graves patients
- Heat intolerance - Thyroid-stimulating antibody (TSab) -
- Hyperactivity Also known as thyroid-stimulating
- Palpitations immunoglobulin (TSI), long-acting
thyroid stimulator (LATS), or TSH-
Common signs: receptor antibody (TRab); found in
- Tachycardia or atrial arrhythmia 63-81% of Graves disease; a + ve
- Systolic hypertension with wide test is dx and specific for Graves diz
pulse pressure
- Warm, moist, smooth skin Autoantibody titers:
- Lid lag Graves disease - Significantly elevated
- Stare anti-TPO, elevated TSI ab
- Hand tremor Toxic multinodular goiter - Low or
- Muscle weakness absent anti-TPO and -ve TSI ab
- LOW despite increased appetite Toxic adenoma - Low or absent anti-
(although a few may gain weight, if TPO and negative TSI ab
excess intake outstrips weight loss) Patients without active thyroid diz may
- Reduction in menstrual flow or have mildly +ve anti-TPO and TSI ab
oligomenorrhea Subacute thyroiditis - Low or absent
anti-TPO and negative TSI ab
DDx:
Diffuse Toxic Goiter (Graves Disease) If the etiology of elevated TH levels is
Euthyroid Hyperthyroxinemia not clear after physical examination and
Goiter other laboratory tests, it can be
Graves Disease confirmed by scintigraphy: the degree
Struma Ovarii and pattern of isotope uptake indicate
Thyrotoxicosis Imaging the type of thyroid disorder. Findings:
Graves disease – Diffuse enlargement
Thyroid function tests:
of both thyroid lobes, with uniform
uptake of isotope and elevated
radioactive iodine uptake
TMN goiter -- Irregular areas of
relatively diminished and occasionally
increased uptake; overall radioactive
iodine uptake is mildly to moderately
increased
Subacute thyroiditis – Very low
radioactive iodine uptake, either with a
painful thyroid (subacute granulomatous
thyroiditis) or occurring w/in a year of
pregnancy (postpartum subacute
thyroiditis)
Mx
Symptomatic tx:
- ORS  dehydrated
- Beta-blockers for relief of neurologic
and cardiovascular symptoms
- Mild ophthalmopathy, saline eye
drops as needed and tight-fitting
sunglasses for outdoors
- For vision-threatening
ophthalmopathy, high-dose
glucocorticoids, with consideration of
orbital decompression surgery,
ocular radiation therapy, or
teprotumumab-trbw
Antithyroid drug:
- Used for long-term control of
hyperthyroidism in children,
adolescents, and pregnant women
- In adult men and nonpregnant
women, used to control
hyperthyroidism before definitive
therapy with radioactive iodine
- Methimazole is more potent and
longer-acting than propylthiouracil
- PTU is reserved for use in thyroid
storm, first tri of pregnancy, and
methimazole allergy or intolerance
- Patients with Graves disease may
experience remission after treatment
for 12-18 months, but recurrences
are common within the following year
- Toxic multinodular goiter and toxic
adenoma will not go into remission
Radioactive iodine:
- Preferred therapy for
hyperthyroidism
- Admin P/O as a single dose in
capsule or liquid form
- Causes fibrosis and destruction of
the thyroid over weeks to months
- Hypothyroidism is expected
- CI: Pregnancy, breast feeding, and
recent lactation
- should be avoided in children
younger than 5 years
- usually not given to patients with
severe ophthalmopathy or to patients
who cannot comply with physician
restrictions for avoidance of radiation
exposure to others
Thyroidectomy:
- Severe hyperthyroidism in children
- Pregnant who are noncompliant with
or intolerant of antithyroid medication
- Patients with very large goiters or
severe ophthalmopathy
- Patients who refuse radioactive
iodine therapy
- Refractory amiodarone-induced
hyperthyroidism
- Patients who require normalization of
thyroid fx quickly: pregnant women,
women who desire pregnancy in the
next 6 months, or patients with
unstable cardiac conditions
Follow up
Patho
Synthesis of thyroid hormone requires
iodine.
Any process that causes an increase in the
peripheral circulation of unbound TH can
cause thyrotoxicosis.