Learning Objectives Hyperthyroidism Graves Disease Thyroiditis Thyroid Nodules Hypothyroidism Thyroid cancer Multiple Endocrine Neoplasia Carcinoid syndrome Acromegaly Hypogonadism ID: 1044728
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1. ThyroidMeghna Irukulla
2. Learning ObjectivesHyperthyroidism*Grave’s DiseaseThyroiditisThyroid NodulesHypothyroidism*Thyroid cancerMultiple Endocrine NeoplasiaCarcinoid syndromeAcromegaly*Hypogonadism* Menti: 86 21 18 3
3. Disclaimer“MedED does not represent the ICSM Faculty or Student Union. This lecture series has been designed and produced by students. We have made every effort to ensure that the information contained is accurate and in line with Learning Objectives featured on SOFIA, however, this guide should not be used to replace formal ICSM teaching and educational materials.”
4. SBA 1A 45-year-old female was referred to the endocrinology clinic following complaints over the past month of always feeling very hot, sweating constantly and experiencing palpitations. The endocrinologist had requested blood tests to investigate the underlying cause. The findings are as follows: Thyroid Stimulating Hormone (TSH) lowFree thyroxine (T4) highTSH receptor stimulating antibodies positiveWhat further finding would support the likely diagnosis?Multinodular goitrePretibial myxoedemaSmoothly enlarged tender goitreThinning of hairWeight lossMenti: 86 21 18 3
5. SBA 2A 66-year-old woman is admitted to A/E with acute confusion. On examination, she is overweight, there is non-pitting oedema affecting the eyes and legs, and she has dry skin and coarse hair. She has a heart rate of 50 beats/min, blood pressure of 90/60mmHg, respiratory rate of 10 breaths/min, temperature of 30°C, and oxygen saturation of 90% on air.Which of these medications should she be started on?PropylthiouracilIV PropanalolEnalaprilIV Liothyronine sodiumOctreotideMenti: 86 21 18 3
6. ThyroidTRHTSHT3/T4Metabolic Effects
7. HyperthyroidismHypothyroidismGeneralWeight lossHeat intoleranceRestlessnessWeight gainCold intoleranceLethargyCardiacPalpitationsBradycardiaSkin/ hairIncreased sweatingDry Skin, brittle hairGIDiarrhoeaConstipationGynaeOligomenorrhoeaMenorrhagiaNeuroHyperreflexiaTremorDecreased reflexesCarpel TunnelThyroid
8. Hyperthyroidism1. Increased thyroid hormone synthesisAetiologyExcess circulating T3/T4 due to:2. Increased thyroid hormone release
9. Hyperthyroidism1. Increased thyroid hormone synthesisAetiology2. Increased thyroid hormone releaseToxic multinodular goitreAutonomously functioning thyroid nodules which secrete excess T3/T4Elderly and iodine deficient areasGraves DiseaseMost common cause of hyperthyroidismTSH Receptor Antibodies (TRAb) Grave’s triadExopthalmosThyroid AcropachyPretibial MyxoedemaToxic Adenoma: Nodule producing T3/4De Quervain’s ThyroiditisPost-viral infectionTransient hyperthyroidism hypo euthyroidPainful goitre, fever, ↑ESR
10. HyperthyroidismInvestigationsBedside: Thyroid exam, ECGBloods: ↓TSH, ↑T3/T4Imaging: Radioisotope scanDCAB
11. HyperthyroidismManagement Thyroiditis:Usually self-limiting NSAIDs for thyroid painMay require additional therapy if patient is severely hyper/hypothyroid Grave’s Disease:Beta-blockersAnti-thyroid drugs (carbimazole or propylthiouracil)Radioiodine therapyThyroidectomy
12. HyperthyroidismComplications:An acute and life-threatening presentation of thyrotoxicosis often caused by a precipitating event (infection, trauma, surgery etc.). Presentation: fever, tachycardia, confusion/agitation, nausea, HTNManagement: 4PsPropylthiouracilPotassium Iodide (Lugol’s solution)PropanalolPrednisalone (steroids)Thyroid StormThyrotoxic patients often have AF which may deteriorate into high-output heart failureAtrial Fibrillation
13. SBA 1 - AnswerA 43-year-old female was referred to the endocrinology clinic following complaints over the past month of always feeling very hot, sweating constantly and experiencing palpitations. The endocrinologist had requested blood tests to investigate the underlying cause. The findings are as follows: Thyroid Stimulating Hormone (TSH) lowFree thyroxine (T4) highTSH receptor stimulating antibodies positiveWhat further finding would support the likely diagnosis?Multinodular goitrePretibial myxoedemaSmoothly enlarged tender goitreThinning of hairWeight loss
14. HypothyroidismAetiologyAutoimmune Hashimoto’s Thyroiditis (commonest cause in developed countries)Iodine Deficiency (commonest cause worldwide) De Quervain’s Thyroiditis: Transient hypothyroidism hypothyroidismIatrogenic: post-thyroidectomy, amiodarone, lithiumCongenital thyroid syndromesInvestigations↑TSH, ↓T3/T4
15. HypothyroidismManagementLevothyroxine – adjust the dose to normalise TSH ComplicationsMyxoedema ComaSymptoms: hypothermia, confusionTreatment: IV thyroid replacement (liothyronine levothyroxine)IV corticosteroidsSupportive tx: fluids, electrolytes, rewarming
16. SBA 2- AnswerA 68-year-old woman is admitted to A/E with acute confusion. On examination, she is overweight, there is non-pitting oedema affecting the eyes and legs, and she has dry skin and coarse hair. She has a heart rate of 50 beats/min, blood pressure of 90/60mmHg, respiratory rate of 10 breaths/min, temperature of 30°C, and oxygen saturation of 90% on air.Which of these medications should she be started on?PropylthiouracilIV PropanalolEnalaprilIV Liothyronine sodiumOctreotide
17. SBA 3A 32-year-old woman presents to her GP with ongoing diarrhea and flushing. The GP carries out a full examination and finds a solitary thyroid nodule. The patient also has a strong family history of cancers and thyroid cancers. Which of these markers might be elevated in the bloods of this patient?CEACA15-3CalcitoninMetenephrines5-HIAAMenti: 86 21 18 3
18. SBA 4This patient is diagnosed with medullary thyroid cancer. Given she has a strong family history of thyroid and other cancers, it is thought she has a specific familial cancer syndrome. What two other conditions are associated with this cancer syndrome?Parathyroid hyperplasia and Addison’s diseaseParathyroid hyperplasia and phaeochromocytomaParathyroid hypoplasia and phaeochromocytomaProlactinoma and phaeochromocytomaToxic multinodular goitre and Conn's syndromeMenti: 86 21 18 3
19. SBA 5A 64-year-old man presents with a 6-month history of diarrhoea. Over the past month, his wife has noticed facial redness lasting for a few minutes. On investigation the patient also has a cardiac murmur, with a normal HR and BP. Given the potential diagnosis, which of the following would be the first line investigation?Urinary metenephrinesUrinary 5-HIAAPlasma catecholaminesEndoscopy USSMenti: 86 21 18 3
20. Thyroid CancerCancerPercentageFeaturesPapillary80%Young females- good prognosisFollicular10%Medullary4%Carcinoma of parafollicular (C) cellsSecrete CalcitoninPart of MEN IIa/b syndromesAnaplasticElderly womenNot responsive to treatmentCause compression symptoms: dysphagia, hoarsenessLymphomaAssociated with Hashioto’s thyroiditisAetiology
21. Thyroid CancerPresentation:Palpable thyroid noduleCompression symptoms: hoarseness, dyspnoea, dysphagiaCervical lymphadenopathyMost nodules are cold (hypo-functioning), can be hotFHx: Thyroid cancers or familial cancer syndromes (MEN2a/b)Investigations:TSHUltrasound neckFine needle biopsyLarygoscopy
22. Multiple Endocrine NeoplasiaAutosomal dominant hereditary tumour syndromes characterised bydevelopment of numerous endocrine tumours in multiple organs.PancreasPituitaryParathyroidPhaeochromocytomaMedullary thyroidMarfanoid habitusMucosal neuromasMEN 1MEN 2aMEN 2bMutation in MEN 1Mutation in RETMutation in RET
23. SBA 3A 32-year-old woman presents to her GP with ongoing diarrhea and flushing. The GP carries out a full examination and finds a solitary thyroid nodule. The patient also has a strong family history of cancers and thyroid cancers. Which of these markers might be elevated in the bloods of this patient?CEACA15-3CalcitoninMetenephrines5-HIAA
24. SBA 4This patient is diagnosed with medullary thyroid cancer. Given she has a strong family history of thyroid and other cancers, it is thought she has a specific familial cancer syndrome. What two other conditions are associated with this cancer syndrome?Parathyroid hyperplasia and Addison’s diseaseParathyroid hyperplasia and phaeochromocytomaParathyroid hypoplasia and phaeochromocytomaProlactinoma and phaeochromocytomaToxic multinodular goitre and Conn's syndro
25. Carcinoid Syndrome Neuroendocrine tumours of the GIT which release serotonin (5-HT) and other vasoactive peptides.
26. Carcinoid Syndrome Neuroendocrine tumours of the GIT which release serotonin (5-HT) and other vasoactive peptides. Signs and Symptoms: CARCinoid Syndrome:Cutaneous flushingAsthmatic wheezeRight sided murmurCramps + diarrhoeaOther: palpitations, hypotension,telangiectasiaInvestigations:24hr urine collection: ↑ urinary 5-HIAA levels(serotonin metabolite)CT/MRI to localise the tumourBronchoscopy/ endoscopy
27. SBA 5A 64-year-old man presents with a 6-month history of diarrhoea. Over the past month, his wife has noticed facial redness lasting for a few minutes. On investigation the patient also has a cardiac murmur, with a normal HR and BP. Given the potential diagnosis, which of the following would be the first line investigation?Urinary metenephrinesUrinary 5-HIAAPlasma catecholaminesEndoscopy USSMenti: 86 21 18 3
28. SBA 6A 49-year-old gentleman presents to his GP with a one-month history of headache, sweating and visual problems. He mentions that he has noticed a change in his appearance compared with old photos and that his wedding ring no longer fits.Given the likely diagnosis, which of the following would be the most appropriate first-line investigation?Pituitary MRISerum IGF-1Serum Growth HormoneSerum prolactinShort synaACTHen testMenti: 86 21 18 3
29. AcromegalyA disease caused by excess growth hormone production usually secondaryto a pituitary adenoma↑GH in children Gigantism↑GH in adults AcromegalySigns and Symptoms:“My rings and shoes don’t fit anymore”“I look different from my photos”
30. AcromegalySigns and Symptoms:
31. AcromegalySigns and Symptoms:
32. AcromegalySigns and Symptoms:
33. AcromegalySigns and Symptoms:
34. AcromegalySigns and Symptoms:
35. AcromegalyInvestigations:Serum IGF-1 (first line)Oral glucose tolerance test (OGTT)Failure to suppress GH Pituitary MRI
36. AcromegalyManagement:SurgeryTrans-sphenoidal hypophysectomy is first-line treatmentRadiotherapyRadiotherapy if resistant to surgical or medical treatmentMedicalIf the tumour is inoperable or surgery is unsuccessful:Somatostatin analogues (octreotide)Growth hormone-receptor antagonist (pegvisomant)Dopamine agonists (bromocriptine/cabergoline)
37. A 49-year-old gentleman presents to his GP with a one-month history of headache, sweating and visual problems. He mentions that he has noticed a change in his appearance compared with old photos and that his wedding ring no longer fits.Given the likely diagnosis, which of the following would be the most appropriate first-line investigation?Pituitary MRISerum IGF-1Serum Growth HormoneSerum prolactinShort synACTHen testSBA 6- Answer
38. A 19-year-old boy presents to the clinic concerned he hasn’t gone through puberty. He has a normal stature, has not developed facial hair and complains of an inability to smell. On examination his testes are undescended.Based on this information what is the likely diagnosis?Klinefelter’s syndromeKallman’s syndromePrader-Willi syndromeTurner’s SyndromePrecocious pubertySBA 7Menti: 86 21 18 3
39. Hypogonadism (Females)A clinical syndrome that presents with infertility and sex hormone deficiencyPresentation:Delayed pubertyAmenorrhoeaInfertility↓ LibidoNight sweats, hot flushes, dyspareuniaSymptoms of cause
40. Hypogonadism (Females)A clinical syndrome that presents with infertility and sex hormone deficiencyGnRHLH & FSHOestrogen + progesterone
41. Hypogonadism (Females)GnRHLH & FSHOestrogen + progesteroneAetiologyPHYSIOLOGICALPregnancy
42. Hypogonadism (Females)GnRHLH & FSHOestrogen + progesteroneAetiologyPRIMARYGonadal dysgenesis e.g Turner’s SyndromeGonadal damagePrimary ovarian failure PCOS
43. Hypogonadism (Females)GnRHLH & FSHOestrogen + progesteroneAetiologySECONDARYKallman’s syndrome- failed GnRH migrationPituitary/ hypothalamic tumoursHyperprolactinaemia Functional: stress, weight loss, eating disorderPost OCP
44. Hypogonadism (Females)SignsSigns of hypogonadismPRE-PUBERTAL: primary amenorrhoea, no 2o sexual characteristicsPOST-PUBERTAL: regression of 2o sexual characteristicsSigns of underlying causeKallman’s syndrome- ansomiaTurner’s sydrome- webbed neck, short statureHyperprolactinaemia- galactorrhoea, visual field defects
45. Hypogonadism (Females)InvestigationsPregnancy testBloods: ↓Oestrdiol1o hypogonadism: ↑LH/FSH2o hypogonadism: ↓LH/FSHProlactinTFTs1o: Genetic testing, pelvic MRI/USS2o: Pituitary function tests, MRI
46. Hypogonadism (Males)A clinical syndrome that presents with signs and symptoms of testosterone deficiencyPresentationDelayed pubertyErectile dysfunctionInfertility↓ LibidoSymptoms of cause
47. Hypogonadism (Males)A clinical syndrome that presents with signs and symptoms of testosterone deficiencyGnRHLH & FSHTestosteroneSperm
48. Hypogonadism (Males)GnRHLH & FSHTestosteroneSpermAetiologyPRIMARYGonadal dysgenesis e.g Klinefelter'sGonadal damagePost orchitis (mumps)
49. Hypogonadism (Males)GnRHLH & FSHTestosteroneSpermAetiologySECONDARYKallman’s syndromePituitary/ Hypothalamic lesionsHyperprolactinaemiaPrader-Willi syndrome
50. Hypogonadism (Males)SignsSigns of hypogonadism:PRE-PUBERTAL: no secondary sexual characteristicsPOST-PUBERTAL: hair loss, gynaecomastiaSigns of underlying cause:Klinefelter’s syndrome- low IQ, behavioural Kallman’s syndrome- anosmia
51. Hypogonadism (Males)InvestigationsBloods:Serum testosteroneSex hormone binding globulinLH/ FSHProlactinGenetic TestingMRI pituitary
52. A 19-year-old boy presents to the clinic concerned he hasn’t gone through puberty. He has a normal stature, no facial hair and complains of an inability to smell. On examination his testes are undescended.Based on this information what is the likely diagnosis?Klinefelter’s syndromeKallman’s syndromePrader-Willi syndromeTurner’s SyndromePrecocious pubertySBA 7
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