Diseases of the Thyroid Gland

Dr Masud Haq
Consultant in Diabetes & Endocrinology
Maidstone & Tunbridge Wells NHS Trust
 Topics to be covered
• Hyperthyroidism – Graves’ disease
• Thyroid storm
• Thyroiditis
• Suclinical hyperthyroidism
• Hypothyroidism – Hashimoto’s thyroiditis
• Subclinical hypothyroidism
• Thyroid nodules & cancer
 Case 1
65yr female
• Presents with a 6 month history of fatigue, weight
gain and constipation
• Previous heart attack
• Family history of coeliac’s disease

• Clinical examination – puffy face and hands

• Pulse 50, BP 140/70
 Case 1
What is the likely diagnosis?
• Hypothyroidism most likely Hashimoto’s thyroiditis

• Her thyroid tests are as follows:

• FT4 6 (12-22) and
Thyroid Stimulating Hormone (TSH) 34 (0.27-4.2)

What treatment does she require?

• Thyroxine but low dose titrated gradually
 ‘Myx’oedema

• Myxedema is the medical term for hypothyroidism

• ‘Myx’ - Greek word for mucin, accumulates in hypothyroidism
• ‘Oedema’ - means swelling
 Causes of Hypothyroidism
• Hashimoto’s thyroiditis*
• Iatrogenic – post surgery, radioiodine
• Drugs - amiodarone, lithium
• Post-thyroiditis
• Hypopituitarism (secondary hypothyroidism)
• Congenital
 Signs of hypothyroidism
• Myxoedematous
• Thinning hair
• Goitre
• Bradycardia (pulse < 60 beats per minute)
• Slow relaxing reflexes
 Treatment
• Thyroxine

• Aim to normalise TSH (lower end of normal)

• In patients with ischaemic heart disease (IHD), start

at 25mcg thyroxine and titrate slowly

• Combination therapy (Thyroxine and Liothyronine) in

selected cases
Questions ?
 Subclinical hypothyroidism

• Elevated TSH in the presence of a normal FT4

• There may be presence of mild symptoms of

hypothyroidism
 Natural history
• 5% prevalence rate

• Higher in females

• Substantial proportion of patients develop overt

hypothyroidism
 Causes of subclinical hypothyroidism
• Chronic autoimmune thyroiditis (Hashimoto’s) *
• Inadequate T4 treatment for overt hypothyroidism *
• Post thyroiditis
• Post surgery, radioiodine or radiotherapy
• Drugs – amiodarone, lithium
• Thyroid infiltration – Riedel’s thyroiditis, amyloidosis,
sarcoidosis, primary thyroid lymphoma
 Clinical consequences
• Subclinical hypothyroidism may be associated with an
increased risk of cardiovascular disease
eg., heart failure particularly when TSH levels >10

• Possible link with Alzheimer’s disease

 Diagnosis
• If TSH elevated, TSH should be repeated along
with FT4 after 2 - 3 months

• Consider checking thyroid antibodies

 Management
• Patients with TSH levels > 10mU/l, treat with T4

• For non-elderly, with TSH between 5 to 10mU/l who have

symptoms and/or positive antibodies, treat with T4

• For elderly, with TSH between 5 to 10mU/l, uncertain benefits

of starting T4

• Start T4 if pregnant and TSH >2.5mU/l or those who wish to

become pregnant
 Other causes of high TSH
• Recovery from non-thyroidal illness
• Post thyroiditis
• Heterophilic antibodies *
• TSH producing pituitary adenomas
• Resistance to thyroid hormones
• TSH receptor mutations
Questions ?
 Case 2
• 60 female
• 2 month history of weight loss, sweats, intermittent
palpitations, SOB

• Examination – confused, high fever, pulse 130, heart

failure

• FT4>100 (12-22), FT3 35 (3.5-5.5), TSH <0.01

 What’s the diagnosis?
• Thyroid storm (crisis) is rare, life threatening
manifestation of thyrotoxicosis

• Significant mortality

• Develops in patients with hyperthyroidism who develop an

acute infection, undergo surgery or following radioiodine
treatment
 Thyroid storm
• Altered mental state (confusion)
• High fever
• Tachycardia / Atrial fibrillation
• Vomiting, diarrhoea
• Dehydration +/- kidney failure
• Cardiac / respiratory failure
• Sometimes jaundice
 Management
• Seek senior help, transfer to intensive care
• Broad spectrum antibiotics if infection suspected
• High dose anti-thyroids – Propylthiouracil 200mg tds
• Propanolol 80 mg bd or tds
• Potassium iodide 60mg dqs
• Prednisolone 60mg od
Hyperthyroidism
 Causes of hyperthyroidism
(subclinical and overt)
Hyperthyroidism with normal or high Hyperthyroidism with absent uptake
thyroid uptake thyroid uptake

Autoimmune * Thyroiditis *
Graves’, Hashitoxicosis Sub-acute granulomatous (de Quervain’s)
Painless thyroiditis - post-partum
Autonomous thyroid tissue * Silent
Toxic adenoma Amiodarone
Toxic multinodular goitre Radiation

TSH-mediated hyperthyroidism Exogenous thyroid hormone intake

TSH-producing pituitary adenoma Excessive replacement *
Non-neoplastic TSH-mediated Intentional suppressive therapy
hyperthyroidism Factitious

HCG-mediated hyperthyroidism * Ectopic

Hyperemesis gravidarum Ovarian or metastatic thyroid cancer
Trophoblastic disease
 Hyperthyroidism –
clinical features
• General
– heat intolerance, fatigue, tremor
• Cardiovascular
– tachycardia, heart failure
• Gastrointestinal
– weight loss, diarrhoea
• Eyes
– lid lag, ophthalmopathy – Graves’ disease
 Hyperthyroidism –
clinical features
• Genitourinary
– Amenorrhoea (infrequent periods), infertility
• Neuromuscular
– proximal muscle weakness
• Psychiatric
– irritability, agitation, anxiety, psychosis
• Dermatological
– Pruritis (itchy skin), hair thinning, vitiligo
 Diagnosis
• Clinical suspicion

• High FT4, ± high FT3, suppressed TSH

• If TSH is unexpectedly high

- suspect pituitary tumour
- or thyroid hormone resistance
 Making the diagnosis
Thyroid antibodies limited value

A thyroid uptake scan helps to confirm the cause:-

Increased thyroid uptake:-

• Graves’ disease
• Toxic multinodular goitre (MNG)
• Toxic solitary adenoma (autonomous ‘hot’ nodule)
• Pituitary tumour
 Graves’ Disease
• Autoimmune (TPO / TSHR Ab)

• Uniform diffuse goitre

• Ophthalmopathy
Uptake scan of patient with
Graves’ disease

 Typically younger patients

 Smooth painless goitre
 +/- dysthyroid eye
disease
 Occasionally pre-tibial
myxoedema
Graves’ eye disease
 Graves’ eye disease
• Variable onset relative to hyperthyroidism
• Worse with smoking
• Pain, watering, diplopia
• Potential fall in visual acuity
 Graves’ eye disease
• If mild – anti-thyroids, protective glasses, lubricants

• If severe
– High dose steroids
– External beam radiotherapy
– Orbital decompression
 Toxic multinodular goitre (MNG)
• Older
• May have sub-clinical hyperthyroidism
• May have long standing goitre
Uptake scan seen in Toxic MNG
Toxic solitary adenoma

• Patients usually in 5th or 6th

decade

• Benign adenomas

• Uncommon cause (<2%

cases of hyperthyroidism)
 Managing hyperthyroidism
Graves’ disease
– antithyroids 1st line
– withdraw treatment after 12 months

Radioiodine
– May be used for refractory Graves’ disease
– First line - toxic MNG, toxic adenoma
– Risk of hypothyroidism

Surgery
– Cases refractory to medical treatment
– Large goitre
– Patient preference
– Cosmetic reasons
Thyroiditis
 Thyroiditis
1) Infectious 3) Painless (silent)
acute (suppurative)
Subacute (granulomatous; 4) Drug-induced
de Quervain’s) *
5) Riedel’s thyroiditis
2) Autoimmune
Hashimoto’s disease 6) Radiation-induced
Atrophic (primary
myxoedema) 7) Traumatic
Juvenile
Post-partum
 Subacute thyroiditis
Stage 1: painful tender thyroid, ± systemic features (malaise, fever, fatigue).
Inflammatory destruction of thyroid resulting in release of T4 and T3

Stage 2: transition to euthyroid state

Stage 3: with severe disease, patients may become hypothyroid

Stage 4: euthyroid state returns

Thyroid function during
subacute thyroiditis
Thyroiditis

• Painful (subacute De Quervain’s)

• Painless (post-partum)

• Different phases:- hyperthyroid,

hypothyroid, euthyroid phases

• Rx:-
- β-blockers
- no need for anti-thyroids
 Differences between subacute
and post-partum thyroiditis

Subacute Post-partum

Thyroid pain * yes no

ESR * raised normal

TPO Ab transient increase positive

only
Histology giant cells; lymphocytes
granulomas
Subclinical hyperthyroidism
 Subclinical hyperthyroidism
• Biochemical diagnosis:-
low TSH (<0.5mU/l) but normal FT4 & FT3

• Hyperthyroid symptoms may be present in patients with

subclinical disease
 Natural history
• Prevalence - 1-5%

• Females > Men and elderly

• Majority of cases - thyroid function returns to normal

• 20% patients progress to overt hyperthyroidism if TSH <0.1

 Subclinical hyperthyroidism
- symptoms & signs
Bone disease
Decreased bone density, especially in post-menopausal women

Heart disease
Increased incidence of AF (atrial fibrillation)

Lab abnormalities
↑ LFT and CK

Other
Disturbed sleep
 Subclinical hyperthyroidism
• Small increased risk of mortality, which increases with age
and degree of TSH suppression

• Possible increased risk of dementia

 Diagnosis
• FT4, FT3 and TSH

• If biochemical features of subclinical hyperthyroidism, repeat

test after 1-3 months

• Consider thyroid uptake scan if diagnosis uncertain

 Other causes of low TSH
and normal FT4 and FT3
1) Central hypothyroidism

2) Non-thyroidal illness

3) Treated hyperthyroidism

4) Thyroiditis
 Management
Patients at high risk – elderly, cardiac history, postmenopausal
women with or at risk of osteoporosis:
• If TSH <0.1, treat underlying cause

• If TSH is 0.1 to 0.5mU/l, consider treatment if cardiac disease, or low bone

density

Patients at low risk – younger patients, premenopausal:

• If TSH <0.1, treat underlying cause if symptoms and / or if increased
uptake

• If TSH between 0.1 to 0.5mU/l, observe, repeat TFT’s at 6 months

Questions ?
 Non-thyroidal illness
• Unwell patients may have low FT4/FT3 with a normal
TSH

• Aim to repeat thyroid function on recovery

• No treatment necessary
Simple non-toxic goitre

• Normal Thyroid function

• Treatment not usually

required

• Surgery if obstructive
symptoms (stridor or
dysphagia) or for cosmetic
reasons
 Thyroid nodules –
when to refer ?
• Thyroid lump
– new or enlargening
– family history of thyroid cancer
– previous neck irradiation
– very young (<10yr)
– old (>65yr)
– hoarse voice

• Cervical lymph nodes

• Stridor
Risk factors for malignancy in
palpable nodules

– Male gender
– Solitary or dominant nodule
– Rapid or recent nodule growth
– Firm, hard, irregular non-tender
nodules
– Fixation
Fine needle aspiration under
ultrasound guidance
Fine needle
aspiration
 Thyroid cancer
• Rare
• Approx 1400 cases in UK per yr
• Commonest endocrine cancer
• Potentially curable
• In general - very good prognosis
 Differentiated thyroid cancer
• Papillary / follicular tumours (>85% cases)

• Treatment: total thyroidectomy followed by radioiodine

ablation and long-term TSH suppression with thyroxine

• Surveillance using serum thyroglobulin (checked with anti-

thyroglobulin antibodies)

• Life-long follow-up
 Medullary thyroid cancer (MTC)
Parafollicular C cells
Sporadic or familial
Aggressive !!
Total thyroidectomy and lymph node
dissection preferred treatment
Poor prognosis if not detected early !!
 Anaplastic carcinoma

Rare
Elderly
Usually arises within a pre-existing MNG
Locally invasive
Dismal prognosis
 Thyroid lymphoma

Rare
Primary or secondary
Associated with Hashimoto’s thyroiditis
Rapid enlargement of thyroid