Thyroid disease is relatively common, with a gender predisposition to females.

Diseases of the thyroid may result in hypersecretion, hyposecretion, or thyroid enlargement (goiter). A goiter refers to any enlargement of the thyroid and does not indicate any particular pathologic process or dysfunction. Hypersecretion: Hyperthyroidism This refers to elevated serum thyroid hormone levels and may be due to several causes. Thyrotoxicosis refers to the toxic effects or manifestations of excess thyroid hormone. The mildest form of hyperthyroidism is subclinical hyperthyroidism, which is generally devoid of symptoms and is characterized by normal free T4 and free T3 levels suppressed with TSH. Etiology and Epidemiology The causes of hyperthyroidism are summarized as: Classification Graves disease Toxic multinodular goiter Toxic solitary adenoma Hyperthyroidism caused by metastatic thyroid cancer TSH-secreting pituitary adenoma Chorionic hyperthyroidism Characteristics Autoimmune; genetic component (60% of all cases) Autonomous function of thyroid; multiply nodules Single adenoma of follicular cells that secretes and functions independent of thyroid-secreting hormone (TSH) May selectively hypersecrete T3, resulting in T3 toxicosis Rare; thyroid cancer cells do not usually concentrate iodine efficiently; may occure with large follicular carcinomas A rare form of pituitary adenoma; treatment involves surgical removal Chorionic gonadotropin has a weak thyrotropin activity. Tumors such as choriocarcioma, embryonal call carcinoma, and and hydatidiform mole have high concentrations of chorionic gonadotropins that can stimulate T4 and T3 secretion; hyperthyroidism resolves with treatment of tumor. Ovarian dermoid tumor made up partly of thyroid tissue that secretes thyroid hormone Central Nervous System Function Thyroid hormone synergizes with other centrally acting hormones and neurotransmitters, and this is accelerated in hyperthyroidism. Signs and symptoms include nervousness; anxiety; restlessness; decreased attention span; insomnia; emotional liability; and fine rhythmic tremors of the hands, tongue, and eyelids.

Struma ovarii

Common Signs and Symptoms Increased metabolic rate, heat production, and oxygen consumption caused by the overall increase in metabolism, characterized by: Heat intolerance Increased body temperature Warm, most skin Weight loss Muscle fatigue

Protein, Fat, and Carbohydrate Metabolism The entire cycle of synthesis, degradation, and clearance is accelerated. Because of the increased lipolysis and increased lipid metabolism, especially lipid degradation, serum cholesterol and triglyceride levels may decline. The patient with preexisting diabetes glycongenolysis, increased intestinal glucose absorption, and increasedinsulin degredation. Cardiovascular Function The hypermetabolic state coupled with increased sensitivity to catecholamines increases myocardial oxygen consumption, shortens the systolic interval, and increases cardiac output. Signs and symptoms include tachycardia, palpitations, elevated blood pressure with a widened pulse pressure, atrial fibrillation, angina, dyspnea, and high-output congestive heart failure.

Reproductive Function Secretion and metabolism of gonadotropins and gonadal steroids are altered. Signs and symptoms include delayed sexual development in the prepubertal patient and increased libido, decreased fertility, and altered menses in the pospubertal patient.

Calcium and Phosphorus Balance Thyroid hormone excess increases the mobilization of calcium from bone and the urinary excretion of calcium and phosphorus. Bone mass may decline, proximal muscle weakness may occur.

Gastrointestinal Function Increased motility of the gastrointestinal tract may lead to increased frequency of bowel movements. Thyroid Storm Thyroid storm is a medical emergency in which patients develop severe manifestations of the signs and symptoms of hyperthyroidism. These include an elevated temperature; increased tachycardia or onset of dysrhythmias; blood pressure and respiratory rate increased above baseline; worsening tremors and restlessness; worsening mental status, including a delirious or psychotic state or come; and sometimes abdominal pain. Collaborative Care Management The choice therapy is based on the patients age, gender, and reproductive status and the cause and severity of hyperthyroidism. The most toxic patients are treated with antithyroid drugs initially and thereafter with RAI therapy or ongoing antithyroid drug therapy. The potential for permanent remission with antithyroid drugs exists only for patients with Graves disease. Diagnostic Tests TSH level Ultrasound 24-hour radioactive iodine uptake (RAIU) Surgical Management

Hyperthyroidism is rarely managed surgically. Surgery is indicated for (1) failure of anythyroid drug therapy, (2) failure of or contraindication to RAI therapy, (3) large goiters with compressive symptoms, or (4) concurrent thyroid cancer. Subtotal thyroidectomy, removal of approximately 80% of the thyroid gland, is generally the procedure of choice; total thyroidectomy is reserved for thyroid cancer. The rate of hypothyroidism is less with subtotal thyroidectomy than with RAI therapy; however, the relapse rate may be higher over time. Before surgery, patients are given antithyroid medication to achieve a euthyroid state. The risks of thyroidectomy include damage to the recurrent laryngeal nerve, hypoparathyroidism, tracheal and esophageal injury, and the usual postoperative complications. Diet Increased food intake and weight loss are characteristic of untreated hyperthyroidism. Increased nutrient and calorie intake are necessary to meet the increased metabolic requirements. Cessation of weight loss with treatment can signal the return of the euthyroid state in older patients. While hyperthyroidism is present, calorie intake needs to be increased, with attention to appropriate distribution of calories from macronutrients. Supplemental vitamins and trace minerals may be prescribed. Hyposecretion: Hypothyroidism Hypothyroidism refers to low levels of thyroid hormone and encompasses: Congenital hypothyroidism (cretinism), which is detected through routine screening at birth Primary thyroid failure (e.g., Hashimotos disease, other types of thyroiditis) Secondary thyroid failure (pituitary disease causing TSH deficiency) Tertiary thyroid failure resulting from thyrotropin releasing hormone (TRH) deficiency with resultant TSH deficiency. External thyroid gland destruction (i.e., after surgery, after I therapy, from antithyroid drugs, or from medication side effects such as those from amiodarone or lithium) Miscellancous (i.e., environmental iodine deficiency and peripheral resistance to thyroid hormone, both of which are rare)