Differential Diagnosis

Thyrotoxicosis

PRIMARY
HYPERTHYROID
Toxic Multinodular Goiter

Rule In

Rule Out

Burch-Wartofsky-Score
Increased T4
Temp: afebrile 36.7 C or 98.06 F 5
CNS: Severe (seizure, coma) n/a
Gastro:(+)nausea and vomiting 10
Cardio:
Tachycardia:>140: 15
CHF: Severe (pulmonary edema) 15
Atrial fibrillation 10
=55 > 45 thus suggestive of thyroid storm
USE TABLE 1 in powerpoint!!!

Epidemiology:
Common among
elderly patients (Age:
68 years old)
Mimics Thyrotoxicosis
in clinically:
Palpitations
Tachycardia
Fatigue
Weakness
Atrial fibrillation
Chest pain
Bipedal edema
Family history of goiter
in 2 children

Clinical signs and

symptoms mimicking
Thyrotoxicosis not seen
in the patient:
Nervousness
Tremors
Weight loss despite
increased appetite
Hyperactivity
Irritability
Dysphoria
Heat intolerance
and sweating
Diarrhea
Polyuria
Oligomenorrhea
(patient is
presumed
menopause: 68
years old)
Loss of libido
Goiter
Warm moist skin
Lid retraction
gynecomastia
No recent exposure to

Notes
Their criteria are useful, but the approach taken, by utilizing the
summation of multiple clinical manifestation scores, may often
reach the threshold for the diagnosis of TS in thyrotoxic
patients with severe nonthyroid illness, BUT NOT
NECESSARILY WITH THYROID STORM. Furthermore, the scores
that are allocated to signs and symptoms in this diagnostic scheme
are complex and have not been validated.

TSH level is low

T4 level may be NORMAL OR SLIGHTLY INCREASED
T3 often ELEVATED TO A GREATER DEGREE THAN T4

Graves Disease

Atrial fibrillation
Congestive heart failure
More common in females
than males
Tachycardia
Dyspnea on exertion
Chest pain
Edema
Hyperdynamic
precordium

Papillary Carcinoma of
the Thyroid

Dyspnea
More common in females
than males
Age range of 15-84
years old
Propensity to spread
to lungs and bone

iodine including contrast

material that may lead
to exacerbation of
illness
No food preference for
seafoods or high iodine
intake mentioned in
history
No palpable neck mass
(PE supple neck)
Bipedal edema may or
may not be
representative of
pretibial myxedema
(edema on anterior and
lateral aspects of the
leg)
Absence
of
ophthalmopathy
Disease of young women
(range: 20-40 years old)
Absence
of
pretibial
myxedema

Absence
of
persistent
cough, dysphagia
Weight loss is absent
Absence
of
palpable
thyroid mass
No family history of thyroid
cancer
No history of prior
exposure to ionizing
radiation

In the elderly, features of thyrotoxicosis may be subtle or masked,

present mainly with fatigue and weight loss APATHETIC
THYROTOXICOSIS
MC CVS manifestation is sinus tachycardia
Atrial fibrillation is most common in patients with >50 years old
High cardiac output produces bounding pulse, widened pulse
pressure, an aortic systolic murmur, can lead to WORSENING
ANGINA or HEART FAILURE in the ELDERLY or those with
previous heart disease.
May experience amenorrhea/oligomenorrhea
Some patients may have LITTLE CLINICAL EVIDENCE OF
OPHTHALMOPATHY periorbital edema, scleral injection,
chemosis. May explain dirty looking sclera
ORPHAN ANNIE

sSubacute Thyroiditis /
de Quervains /
granulomatous / viral
thyroiditis

Epidemiology:
common among
Females
Past medical history:
gastroenteritis
related viruses that
can act as trigger (GE
and non-GE related):
mumps, influenza,
adenovirus,
coxsackievirus,
echovirus
Malaise
Fatigability
Anorexia
Signs and symptoms
began 5 weeks prior
to admission

SECONDARY
HYPERTHYROID
Pituitary adenoma (TSH
secreting)
McCune Albright
Syndrome

Symptoms mimic pharyngitis

Painful enlarged thyroid
Malaise and symptoms of URTI precede the thyroid related features

Epidemiology: Common
among 30-50 years old
No signs of upper
respiratory infection that
can mimic pharyngitis
Temporal History of
mumps in childhood
inconsistent as trigger
for the disease
No thyroid biopsy done
should reveal
granulomatous changes
with fibrosis in follicles
and patchy
inflammatory infiltrates
with mulitinucleated
giant cells
No fever and thyroid
enlargement noted
No thyroid function tests
done

Struma ovarii

Polyostotic fibrous dysplasia PLUS caf au lait spots + autonomous

endocrine hyperfunction (hyperthyroidism)
NO PRECOCIOUS PUBERTY in case
Final diagnosis is histopathological
Abdominal pain, palpable abdominal mass, abnormal uterine
bleeding, ascites, pseudomeigs syndrome

Mineralocorticoid Excess
/ Conns Syndrome

Hypokalemia possibly
induced by
Furosemide (Lasix)
administration during
2nd hospital day (ward
and ICU) (Potassium
wasting loop diuretic)

No hypertension or
history of cardiac
disease
No weight loss,
palpable mass, marked
change in urinary
function characteristic of

Potassium depletion, and increased sodium retention NOT

EVIDENT in case
Clinical hallmark is HYPOKALEMIC HYPERTENSION
Screened for in patients wth hypokalemia, adrenal mass, drug
resistance, hypertension before age 40

Lymphatic Filariasis

may have led to

arrhythmia (ventricular
tachycardia), loss of
consciousness and
worsening of condition
Bipedal edema
secondary to fluid
retention
Aggravating factor:
CXR revealed
atherosclerotic
cardiovascular
disease
Previous smoker: 5.1
pack years
Dysuria
Muscle weakness
Epidemiology:
Endemic in Samar
Bipedal edema
Malaise
Fatigability
CXR shows evidence
of congestion with
beginning pulmonary
edema
Shortness of breath
2-pillow orthopnea
crepitant rales on
lower 2/3 of the lungs
crackles on both lung
fields
RR: 34 cpm
(tachypnea)

adrenocortical adenoma
No hypokalemia
No family history of
early-onset
hypertension or
cerebrovascular events
before 40 years old

No urinalysis result to
reveal proteinuria or
hematuria
No high fever, chills,
myalgia, headache,
dermal changes and
periodicity of symptoms
No lymphadenopathies
mentioned
Edema is more often
localized to the involved
lymphatic channel
Insufficient to diagnose
Tropical Pulmonary
Eosinophilia due to
absence of: paroxysmal
cough and wheezing
usually nocturnal,
weight loss, low grade
fever,
lymphadenopathy,
blood eosinophilia, CXR
of increased

Schistosomiasis

Epidemiology:
Endemic in Samar
Intestinal phase may
mimic gastroenteritis
on past medical
history: diarrhea,
colicky abdominal
pain, and anemia,
fatigue
Pulmonary congestion
on CXR and
consistent clinical
findings such as
shortness of breath,
paroxysmal nocturnal
dyspnea,
cardiopulmonary
distress, crackles and
rales may suggest
pulmonary extension
of S. haematobium

Phemochromocytoma

THE
GREAT
MASQUERADER
Classic triad: episodes of
palpitations, headaches,
and profuse sweating
(classic triad)
Can be asymptomatic for
years, some tumors grow

bronchovascular
markings or diffuse
lesions/opacities in
middle and lower lung
fields
No dermopathies
No signs and symptoms
of Katayama fever:
Fever,
lymphadenopathies,
hepatosplenomegaly,
peripheral blood
eosinophilia
Intestinal phase and
associated symptoms
may last for years
No signs of portal
hypertension:
esophageal varices,
hepatomegaly,
splenomegaly, elevated
LFTs, nutritional
deficiencies
No urinary symptoms
characteristic of S.
haematobium infection:
dysuria, hematuria,
bladder pain,
Initial signs of
pulmonary extension
not presented: cough,
fever, dyspnea

to a considerable size
before
patients
note
symptoms
DOMINANT SYMPTOM
is HYPERTENSION
Catecholamine
crisis
leads to heart failure,
pulmonary
edema,
intracranial hemorrhage
and arrhythmias
During
episodes
of
hormone release, they
experience tachycardia
and palpitations
Paroxysms precipitated
by surgery, positional
changes,
exercise,
pregnancy, urination
headaches, sweating
attacks, palpitations or
tachucardia,
hypertension
(paroxysmal or
sustained), nausea,
weakness, weight
loss, paradoxical
response to
antihypertensive
drugs, polyuria,
polydipsia,
constipation,
orthostatic
hypotension, dilated
cardiomyopathy,
erythrocytosis,
elevated blood sugar
Multiple endocrine
neoplasia 2
(phemochromocytoma +
medullary thyroid

There is an association between medullary thyroid

cancer and phaeochromocytoma. MEN2 is further
divided into MEN2A and MEN2B, with the following

carcinoma)

distinctions

IMPRESSION: CONGESTIVE HEART FAILURE SECONDARY TO TOXIC NODULAR GOITER

Toxic nodular goiter is more common in elderly adults. It occurs more commonly in women than in men. Most patients with this disease are 50 years old and
above. Thyrotoxicosis often occurs in patients with long-standing goiter. The toxicity usually peaks during the sixth and seventh decades of life, especially in
persons with a family history of multinodular goiter.
Clinical Presentation:
Elderly patients usually have atypical symptoms like:
- Weight loss which is the most common complaint in elderly patients with hyperthyroidism
- Anorexia and constipation
- Dyspnea or palpitations may be a common occurrence
- Tremors may also occur but this can be confused with essential senile tremor
- Cardiovascular complications commonly occur like atrial fibrillation, congestive heart failure, angina
Aside from the metabolic and thermoregulatory tissue effects of the thyroid hormone, it also regulates cardiac performance by acting on the heart and vascular
system. Triiodothyronine (T3) is the biological active thyroid hormone and it is mostly generated by 5-monodeiodination of thyroxine (T4) in peripheral tissues.
The availability of T3, which is the active form of thyroid hormone in the heart, is controlled by the deiodinases, which regulate cardiac levels of T3. The heart
is particularly vulnerable to the reduction in local T3 levels because T3 is essential to preserve both cardiac morphology and performance in adult life. Thyroid
hormones also have a pro-angiogenic effect in the adult heart. They can stimulate arteriolar growth in normal hearts as well as after myocardial infarction.
(http://www.eje-online.org/content/167/5/609.full/)
THYROID STORM

THYROTOXICOSIS
Rule ou thyrotoxicosis

One of the common findings in thyrotoxicosis is weight loss, despite having

the same or greater caloric intake. The hypermetabolic state results in an
imbalance of greater energy production compared with energy use, resulting
in increased heat production and elimination. The thermogenesis leads to increased
perspiration and heat intolerance. Other constitutional symptoms
reported are generalized weakness and fatigue not evidence in this case thus rule out?

Burch-Wartofsky-Score
Synonym: Burch-Wartofsky point scale German: Burch-Wartofsky-Score
Contents
1 Overview and Definition

2 Calculation
2.1 Temperature
2.2 Central Nervous Effects
2.3 Hepatogastroinestinal Dysfunction
2.4 Cardiovascular Dysfunction 1
2.5 Cardiovascular Dysfunction 2
2.6 Cardiovascular Dysfunction 3
2.7 Suggestive History
3 Assessment
4 References
5 Web-Links

1 Overview and Definition

The Burch-Wartofsky-Score is a point scale that halps to assess of the probability of thyrotoxicosis independently from the
level of thyroid hormones. It is solely based on clinical and physical criteria.
The point scale covers body temperature, central nervous effect, hepatogastrointestinal symptoms, cardiovascular dysfunction
and the patient's history.

2 Calculation
2.1 Temperature
Celsius
< 37,7 C
37.8 - 38.3 C
38.4 - 38.8 C
38.9 - 39.4 C
39.5 - 39.9 C
>= 40 C
2.2 Central Nervous Effects

Fahrenheit
< 99,9 F
100 - 100.9 F
101 - 101.9 F
102 - 102.9 F
103 - 103.9 F
>= 104 F

Points
5 Points
10 Points
15 Punkte
20 Points
25 Points
30 Points

Symptoms
Points
Missing
0 Points
Mild (agitation)
10 Points
Moderate (delirium, psychosis, extreme lethargy) 20 Points
Severe (seizures, coma)
30 Points

2.3 Hepatogastroinestinal Dysfunction

Symptoms
Missing
Moderate (diarrhea, nausea, vomiting,
abdominal pain)
Severe (unexxplained jaundice)
2.4 Cardiovascular Dysfunction 1

Points
0 Points
10 Points

Pulse frequeny
90 - 109 / Minute
110 - 119 / Minute
120 - 129 / Minute
130 - 139 / Minute
>= 140 / Minute
2.5 Cardiovascular Dysfunction 2

Points
5 Points
10 Points
15 Points
20 Points
25 Points

Symptoms
Mssing
Mild (pedal edemas)
Moderae (bibasilar rales)
Severe (pulmonary edema)
2.6 Cardiovascular Dysfunction 3

Points
0 Points
5 Points
10 Points
15 Points

Arrhythmia
Missing
Present
2.7 Suggestive History

Points
0 Points
10 Points

History
Mssing
Present
The summed up point values deliver the score.

Points
0 Points
10 Points

20 Points

3 Assessment
With a score over 25 points thyrotoxicosis is possible, a score over 45 points renders it probable.

4 References

Burch, H. B. und L. Wartofsky (1993). "Life-Threatening Thyrotoxicosis. Thyrotoxic storm. " Endocrinology and Metabolism
Clinics of North America 22(2): 263-77. (>> Abstract)