SUMITHRA APPAVA A4-08

12th century In 1786 In 1835 In 1840

Persian physician Sayyid Ismail al-Jurjani noted the association of goiter & exophthalmos in his "Thesaurus of the Shah of Khwarazm" The symptoms of thyrotoxicosis first described by Caleb Hillier Parry included palpitations, irregular pulse & dyspneoa Robert James Graves identified a disorder that is characterized by the triad of goiter, palpitations, & exophthalmos

German Karl Adolph von Basedow

 Thyrotoxicosis
State of thyroid hormone excess of any etiology

Hyperthyroidism
State of thyroid hormone excess due specifically

to excessive thyroid gland function

Causes of Thyrotoxicosis

Primary hyperthyroidism

Thyrotoxicosis without hyperthyroidism

Secondary hyperthyroidism

Graves disease Toxic multinodular goiter Toxic adenoma

Drugs: iodine excess (Jod-Basedow phenomenon) Functioning thyroid carcinoma metastases Struma ovarii

Subacute thyroiditis Silent thyroiditis Other causes of thyroid destruction: amiodarone, radiation, infarction of adenoma

Ingestion of excess thyroid hormone (thyrotoxicosis factitia) or thyroid tissue

TSH-secreting pituitary adenoma Chorionic gonadotropin-secreting tumours Gestational thyrotoxicosis

60-80% of thyrotoxicosis Prevalence varies depending on iodine

intake
F:M ratio is 10:1
Age: 20-50 years

Combination of genetic & environmental factors

HLA-DR,CTLA-4, PTPN22 Psychological stress Smoking

Exposure to iodine
Dietary

Postpartum period
3- fold increase in Graves disease

Caused by TSI directed against TSH receptor Antibodies bind to &

activate the receptor

Autonomous production of thyroid hormones & thyroid growth

Presentation of Graves disease often observed in elderly persons

Paucity of classic symptoms of thyrotoxicosis Predominantly fatigue & weight loss Often accompanied by atrial fibrillation Manifestations may be mistaken for depression

Features common to any cause of thyrotoxicosis

Symptoms

Unexplained weight loss, despite an enhanced appetite Hyperactivity, nervousness, irritability Heat intolerance and excessive sweating Palpitations Tremulousness Fatigue & weakness Insomnia Impaired concentration Increased stool frequency often with diarrhoea Women - Oligomenorrhea or amenorrhea Men - impaired sexual function

Signs
Thyroid examination
Variable findings depending on the etiology of thyrotoxicosis

Cardiovascular
Sinus tachycardia Bounding pulse/widened pulse pressure Aortic systolic murmur Atrial fibrillation

 Neurologic/musculoskeletal
Hyperreflexia Fine tremor Muscle wasting Proximal myopathy without fasciculation

Rarely: chorea, hypokalemic periodic paralysis

 Dermatologic
Warm, moist skin Palmar erythema Onycholysis Finer hair texture diffuse alopecia (up to 40% of patients)

 Ophthalmologic
Lig retraction (Dalrymples sign) or lag (von Graefes sign) Stare Rarified blinking

Graves ophthalmopathy
Thyroid associated ophthalmopathy
Characterized by edema & inflammation of the EOM & an

increase in orbital connective tissue & fat

Edema - hydrophilic action of glycosaminoglycans secreted by fibroblasts

Inflammation - infiltration of EOM & orbital connective

tissue by lymphocytes and macrophages

Symptoms
Earliest symptoms include sensation of grittiness,

eye discomfort & excessive tearing

Later symptom: diplopia

Signs
Proptosis Periorbital edema Conjunctival injection Chemosis

Papilledema
Peripheral field defects

 NO SPECS
0 = No signs or symptoms 1 = Only signs (lid retraction/lag), no symptoms 2 = Soft tissue involvement (periorbital edema) 3 = Proptosis (>22mm) 4 = Extraocular muscle involvement (diplopia) 5 = Corneal involvement 6 = Sight loss

Thyroid dermopathy
<5% of patients Almost always in presence of

moderate/severe ophthalmopathy
Most frequent over the anterior & lateral

aspects of the lower leg (pretibial myxedema)

Noninflamed, indurated plaque with a deep

pink/purple colour & an orange-skin appearance

Thyroid acropachy
<1% of patients Form of clubbing Strongly associated

with thyroid dermopathy

Rare but life threatening exacerbation of hyperthyroidism, usually

Signs & symptoms

Fever Delirium Seizures Coma Vomiting Diarrhea Jaundice

precipitated by acute illness

or surgery