Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.
• Abdulaziz .
• 3 year old boy case of congenital nephrotic
syndrome ,HIE, ESRD.thrombocytopenia.
• On multiple medication...
• zainab .
• 3 year old girl case of intractable seizure
,HIE.
• On multiple medication.
• TFT showed:
• TSH: 2.3→ 1.7 →1....
• wesam .
• 9 Month old boy case of :
Neurodegenerative disorder.
• On multiple medication.
• TFT showed:
• TSH: 0.2 → 8.7...
Introduction
• Graves’ disease account for most of the
cases of thyrotoxicosis.
• there are more than 20 less common cause...
‘‘hyperthyroidism’’ Vs ‘‘thyrotoxicosis
•thyrotoxicosis refers to the manifestations of
excessive quantities of circulatin...
Introduction
•Thyrotoxicosis :
high (free T4) and suppresed (TSH).
•T3 toxicosis :
free T4 normal, high (free T3) and TSH ...
•Thyrotoxicosis is the syndrome caused by an
excess of free thyroid hormones.
•The symptoms and signs depend on :
1- the d...
Decreased uptake of radioiodineIncreased uptake of radioiodine
Thyroiditis
Abscess: acute thyroiditis
Subacute thyroiditis...
• very uncommon
• Pathophsiology :
Due to passive transplacental transfer of TSI
thyroid-stimulating antibodies from mothe...
•Premature closure of cranial sutures.
• reduced mentality.
•Diarrhea, vomiting, poor weight gain.
•exophthalmos may be se...
Neonatal Graves’ disease
Management:
•Careful monitoring of the fetal size and heart
rate and the size of the fetal thyroi...
•In high risk mothers, serum thyroid tests
should be performed on cord blood upon birth
and then measured monthly in the o...
Activated TSH receptor
• also called familial non autoimmune hereditary
hyperthyroidism.
•rare condition
•an autosomal dom...
•Patient usually hyperthyroid from birth.
• associated with preterm delivery and low
birth-weight
• No evidence of graves ...
TSI in milk
•transfer of thyroid-stimulating antibodies in the
mother’s milk.
•TSH-secreting pituitary tumors are rare.
•TSH-secreting adenoma have been
associated with both multiple endocrine
neoplas...
•Visual field defects (classically bitemporal
hemianopia) are present in approximately
40%–50%.
•Treatment:
•The most effe...
•In one case report .
•The TSH was secreted by an ectopic
nasopharyngeal pituitary tumor.
• that was identified when the p...
•Familial.
•an autosomal dominant pattern of inheritance.
•may represent forms of the syndrome of
generalized resistance t...
•Criteria essential for the diagnosis of this
disorder include the following:
•evidence of increased peripheral metabolism...
•Trophoblastic disease and germ cell
tumors
•Hyperthyroidism can occur in adolcenent with
a hydatidiform mole or choriocar...
•Hydatidiform moles secrete large amounts of
hCG.
•Increased thyroid function in patients with
hydatidiform moles can occu...
• Struma ovarii :
• is a teratoma of the ovary that is composed
primarily of thyroid epithelium which comprises
more than ...
•Treatment of struma ovarii causing
thyrotoxicosis is surgical excision.
• Antithyroid drugs can be used preoperatively
to...
•Thyroid cancer can cause thyrotoxicosis
through 3 mechanisms:
•first, when there is a large volume of
functioning cancer ...
•there have been a few reports of elevated
thyroid function in patients with ectopic thyroid.
• Sites of ectopic thyroid i...
•An inflammation of the thyroid gland.
•It Include a diverse group of disorders:
•Acute
•Hashimoto’s .
•Subacute.
• silent...
•also known as autoimmune or chronic
lymphocytic thyroiditis .
•Or Hashitoxicosis
•the most common form of thyroiditis
•Bi...
•thyrotoxic phase ranged from 31 to 168 days.
•This is followed by the development of
hypothyroidism or recovery.
•an eosi...
•also known as De Quervain’s or
granulomatous thyroiditis.
•This entity is rarely seen in children,
•The hallmark of this ...
•Pathophysiology :
•the destructive thyroiditis is caused by direct
viral infection of the gland
.or by the host’s respons...
•Also called suppurative thyroiditis,
•It is rare.
•caused by Staphylococcus and Streptococcus
•The symptoms and signs are...
• occasionally in patient Graves' disease, who
is treated with radioiodine.
• develops thyroid pain and tenderness 5 to 10...
•Direct blunt or surgical trauma can cause
transient hyperthyroidism.
•This has been described after laryngectomy,
needle ...
•is a mild form of traumatic thyroiditis .
• It results from vigorous palpation of the
thyroid during physical exam.
•Afte...
silent thyroiditis.
•Also called Painless thyroiditis.
•It is characterized primarily by transient
hyperthyroidism, follow...
•thyrotoxicosis factitia
•thyrotoxicosis medicamentosa
•Thyrotoxicosis insistiates
Thyrotoxicosis Attributable to Exogenou...
• refers to a condition of thyrotoxicosis caused
by the ingestion of exogenous thyroid
hormone.
•It can be the result of m...
•The symptoms and sign: similar to those in
patients with hyperthyroidism from other
causes.
•No Exophthalmos or opthamopa...
•Diagnosis depends on clinical suspicion
•biochemical thyrotoxicosis with high free T4
and/or free T3 and suppressed TSH ....
•The source of thyroid might even be
unrecognized as in the case of diet pills that
contain thyroid hormones.
•Also it can...
•Patients with thyroid cancer prescribed
suppressive doses of thyroxine .
•Patients with goiter prescribed excessive
doses...
•iodine to food.
•Radiographic contrast.
•Drugs: Amiodarone.
Thyrotoxicosis Attributable to Excess
Iodine
•several outbreaks of thyrotoxicosis
attributable to thyroid gland being included
with neck trimmings that were used to ma...
Topical iodine preparations
Diiodohydroxyquinolone
Iodine tincture
Povidone iodine
Iodochlorohydroxyquinolone
Iodoform gau...
Radiological contrast
agents
Diatrizoate
Ipanoic acid
Ipodate
Iothalamate
Metrizamide
Diatrozide
•is an effective antiarrhythmic medication
but it has several side effects, including effects
on thyroid function.
•It tha...
•The effect on thyroid function is somewhat
dependent on the quantity of iodine ingested.
• In regions of iodine deficienc...
•Type 1 amiodarone–induced
thyrotoxicosis: there is increased synthesis
of thyroid hormone (usually in patients with a
pre...
•Iodine-induced thyrotoxicosis is also called
Jod Basedow disease.
•Usually an increase in plasma inorganic
iodine causes ...
•Treatment: Antithyroid medication such as
methimazole been effective
•Potassium perchlorate has been used as a
competitiv...
Thyrotoxicosis Attributable to Nonthyroid
Medications
•interferon-alpha.
• lithium,
•Interleukin-2
• leuprolide acetate
•interferon-alpha.
•.used for viral Hepatitis
•.The most common thyroid abnormality is the
development of de novo antithyr...
Lithium
• used for depression .
•lithium have an increased incidence of
hyperthyroidism.
•Mostly in form of painless thyro...
Interleukin-2
•Used in Patients with metastatic cancer and
leukemia
•a syndrome mimicking painless thyroiditis
occurred in...
Decreased uptake of radioiodineIncreased uptake of radioiodine
Thyroiditis
Abscess: acute thyroiditis
Subacute thyroiditis...
PathogenesisEntity
TSH receptor-stimulating antibodiesGraves’ disease
Somatic gain-of-function mutations in
the TSH recept...
• How should overt drug-induced thyrotoxicosis
be managed?
• Recommendation 88
• Beta-adrenergic blocking agents alone or ...
• Recommendation 90
• We suggest monitoring thyroid function tests before
and at 1 and 3 months following the initiation o...
• Recommendation 92
• The decision to stop amiodarone in the setting of
thyrotoxicosis should be determined on an
individu...
• Recommendation 94
• Combined antithyroid drug and anti-inflammatory
therapy should be used to treat patients with overt
...
How should thyrotoxicosis due to
destructive thyroiditis be managed?
Recommendation 96
Patients with mild symptomatic suba...
How should thyrotoxicosis due to unusual
causes be managed?
Recommendation 97
The diagnosis of TSH-secreting pituitary tum...
Recommendation 98
Patients with TSH-secreting pituitary adenomas
should undergo surgery performed by an
experienced pituit...
•Prevalence of goiter and hypothyroidism was
observed high in patients with ESRD .
•Hyperthyroidism is rare in patients on...
.
thyrotoxicosis: uncommon causes
thyrotoxicosis: uncommon causes
thyrotoxicosis: uncommon causes
thyrotoxicosis: uncommon causes
thyrotoxicosis: uncommon causes
thyrotoxicosis: uncommon causes
thyrotoxicosis: uncommon causes
thyrotoxicosis: uncommon causes
Prochain SlideShare
Chargement dans…5
×

thyrotoxicosis: uncommon causes

907 vues

Publié le

thyrotoxicosis: uncommon causes

Publié dans : Santé & Médecine
  • Soyez le premier à commenter

thyrotoxicosis: uncommon causes

  1. 1. • Abdulaziz . • 3 year old boy case of congenital nephrotic syndrome ,HIE, ESRD.thrombocytopenia. • On multiple medication. • Intially was hypothyroid on thyroxine then euthyroid with no medication. • Finally TFT showed: • TSH: <0.005 → <0.005 → <0.005 • FT4: >100 → >100 → >100 • FT3: 17.8 → 9 → 7. • TSH receptor Antibodies: positive.
  2. 2. • zainab . • 3 year old girl case of intractable seizure ,HIE. • On multiple medication. • TFT showed: • TSH: 2.3→ 1.7 →1.32 → 0.39 • FT4: 66 → 41 → 46 → 47.6 • Nuclear SCAN and uptake : normal
  3. 3. • wesam . • 9 Month old boy case of : Neurodegenerative disorder. • On multiple medication. • TFT showed: • TSH: 0.2 → 8.7→1.5 → 0.64 → 0.08 • FT4: >100 → 28 → 39 → >100 → 52 • TSH receptor Antibodies: positive
  4. 4. Introduction • Graves’ disease account for most of the cases of thyrotoxicosis. • there are more than 20 less common causes of elevated free thyroid hormones. • Most of these conditions are self-limited. • Usually Lasting for for <8 wk.
  5. 5. ‘‘hyperthyroidism’’ Vs ‘‘thyrotoxicosis •thyrotoxicosis refers to the manifestations of excessive quantities of circulating thyroid hormone. •hyperthyroidism means that the thyroid gland is functioning more than normal. • Therefore, a hyperthyroid patient is thyrotoxic, but a thyrotoxic patient need not have an overactive thyroid and is therefore not actually hyperthyroid.
  6. 6. Introduction •Thyrotoxicosis : high (free T4) and suppresed (TSH). •T3 toxicosis : free T4 normal, high (free T3) and TSH is low •subclinical thyrotoxicosis both free hormones are normal but TSH is low,
  7. 7. •Thyrotoxicosis is the syndrome caused by an excess of free thyroid hormones. •The symptoms and signs depend on : 1- the degree of elevation of the hormones. 2- the length of time that they have been elevated 3- the rate at which the hormone levels rose. 4- individual variations of patients manifestations. Introduction
  8. 8. Decreased uptake of radioiodineIncreased uptake of radioiodine Thyroiditis Abscess: acute thyroiditis Subacute thyroiditis Silent thyroiditis Graves’ disease Toxic Multinodular goiter Toxic adenoma Postpartum thyroiditisNeonatal thyrotoxicosis Neonatal Graves’ disease Activated TSH receptor TSI in milk Traumatic thyroiditis Radiation thyroiditis Exogenous thyroid hormone Thyrotoxicosis factitia Thyrotoxicosis medicamentosa Thyrotoxicosis insistiates Hamburger thyrotoxicosis Medication for weight loss Excess TSH Pituitary tumor Resistance to thyroid hormone Excess TSH-like material Choriocarcinoma Hydatidiform mole Excess iodine (jod basedow) Radiographic contrast Amiodarone types I and II Iodine supplementation Increased uptake in abnormal site Metastatic thyroid cancer Struma ovarii Lingual thyroid Other :Lithium, Interferon, Interleukin Denileukin diftitox, Leuprolide acetate Marrow transplant
  9. 9. • very uncommon • Pathophsiology : Due to passive transplacental transfer of TSI thyroid-stimulating antibodies from mother to baby . Neonatal Graves’ disease
  10. 10. •Premature closure of cranial sutures. • reduced mentality. •Diarrhea, vomiting, poor weight gain. •exophthalmos may be seen. • Arrhythmias and/or congestive heart failure. Neonatal Graves’ disease
  11. 11. Neonatal Graves’ disease Management: •Careful monitoring of the fetal size and heart rate and the size of the fetal thyroid . •The presence of fetal goiter, tachycardia, and intrauterine growth retardation suggests fetal hyperthyroidism. •TSH receptor antibodies should be obtained during pregnancy.
  12. 12. •In high risk mothers, serum thyroid tests should be performed on cord blood upon birth and then measured monthly in the offspring until 3 months of age. •antithyroid drugs are administered to the mother to control fetal Hyperthyroidism in some patients. Neonatal Graves’ disease
  13. 13. Activated TSH receptor • also called familial non autoimmune hereditary hyperthyroidism. •rare condition •an autosomal dominant . •The cause is a mutation, usually substitution of one base in the DNA responsible for the production of the TSH receptor or the related G protein complex. • This mutation results in activation of the TSH- receptor–G-protein–effector system complex.
  14. 14. •Patient usually hyperthyroid from birth. • associated with preterm delivery and low birth-weight • No evidence of graves disease in the mother. • no evidence of thyroid autoimmunity . •no response to antithyroid medications. • Treatment: total ablation of the gland, either surgically or with RAI Activated TSH receptor
  15. 15. TSI in milk •transfer of thyroid-stimulating antibodies in the mother’s milk.
  16. 16. •TSH-secreting pituitary tumors are rare. •TSH-secreting adenoma have been associated with both multiple endocrine neoplasia type I and McCune–Albright syndrome. •The thyroid gland is palpably enlarged and often multinodular because of sustained TSH stimulation. Excess TSH
  17. 17. •Visual field defects (classically bitemporal hemianopia) are present in approximately 40%–50%. •Treatment: •The most effective therapy is transsphenoidal resection of the pituitary tumor. •External radiation. • octeriotide and long-acting somatostatin lanreotide analogs also effective. Excess TSH
  18. 18. •In one case report . •The TSH was secreted by an ectopic nasopharyngeal pituitary tumor. • that was identified when the patient developed nasal obstruction. . Excess TSH
  19. 19. •Familial. •an autosomal dominant pattern of inheritance. •may represent forms of the syndrome of generalized resistance to thyroid hormone . •The syndrome is caused by a mutation in THRB . resistance to thyroid hormone RTH
  20. 20. •Criteria essential for the diagnosis of this disorder include the following: •evidence of increased peripheral metabolism, • diffuse thyromegaly, •Elevated free thyroid hormone levels, •inappropriately elevated serum levels of TSH • •The TRH and T3 suppression tests may help differentiate it from adenoma. •A number of agents including L-T3, D-T4, bromocryptine, and triiodothyroacetic acid (Triac) have been advocated for treatment in case of throtoxicosis. pituitary resistance to thyroid hormone
  21. 21. •Trophoblastic disease and germ cell tumors •Hyperthyroidism can occur in adolcenent with a hydatidiform mole or choriocarcinoma or in male with testicular germ cell tumors. •Human chorionic gonadotropin (hCG) is a glycoprotein hormone that shares a common a-subunit with TSH. •hCG has confirmed thyroid-stimulating activity when present at high concentrations in serum Excess TSH-Like Material
  22. 22. •Hydatidiform moles secrete large amounts of hCG. •Increased thyroid function in patients with hydatidiform moles can occur in 25%–64% of cases. •but only 5% of cases have clinically significant thyrotoxicosis. •Therapy is directed against cause. Thionamides are useful adjunctive therapy. Excess TSH-Like Material and Gestational
  23. 23. • Struma ovarii : • is a teratoma of the ovary that is composed primarily of thyroid epithelium which comprises more than 50% of its structure . • Most struma ovarii lesions are benign, and it has been estimated that fewer than 3% are malignant . High Uptake in Ectopic Sites
  24. 24. •Treatment of struma ovarii causing thyrotoxicosis is surgical excision. • Antithyroid drugs can be used preoperatively to ameliorate thyrotoxic symptoms and signs. High Uptake in Ectopic Sites
  25. 25. •Thyroid cancer can cause thyrotoxicosis through 3 mechanisms: •first, when there is a large volume of functioning cancer (usually of the follicular type). •second, when there are activated receptors on the cancer cells • third, when the cancer grows rapidly within the thyroid, invading and destroying thyroid follicles and releasing thyroid hormones Thyrotoxicosis from Functioning Thyroid Cancer
  26. 26. •there have been a few reports of elevated thyroid function in patients with ectopic thyroid. • Sites of ectopic thyroid include the tongue, neck and abdomen . •The treatment is surgical. Thyrotoxicosis from Ectopic Thyroid.
  27. 27. •An inflammation of the thyroid gland. •It Include a diverse group of disorders: •Acute •Hashimoto’s . •Subacute. • silent thyroiditis •drug-induced, •radiation-related. Thyroiditis
  28. 28. •also known as autoimmune or chronic lymphocytic thyroiditis . •Or Hashitoxicosis •the most common form of thyroiditis •Biochemically and clinically, there is an initial period of thyrotoxicosis secondary to the release of thyroid hormones from the inflamed gland. Hashimoto’s thyroiditis
  29. 29. •thyrotoxic phase ranged from 31 to 168 days. •This is followed by the development of hypothyroidism or recovery. •an eosinophil to monocyte ratio (Eo/Mo): •below 0.2 •Eo/Mo multiplied by serum free T3 (pmol/l) below 4.5 •Treatment of these disorders is symptomatic Hashimoto’s thyroiditis
  30. 30. •also known as De Quervain’s or granulomatous thyroiditis. •This entity is rarely seen in children, •The hallmark of this variant is a painful and tender thyroid •prodrome of myalgias, pharyngitis, low-grade fever, and fatigue •The most accepted etiology of subacute thyroiditis is a viral illness. subacute thyroiditis
  31. 31. •Pathophysiology : •the destructive thyroiditis is caused by direct viral infection of the gland .or by the host’s response to the viral infection. • is associated with several viruses, including: • influenza virus, •adenovirus, • mumps virus, •coxsackievirus.. •The erythrocyte sedimentation rate is consistently elevated. subacute thyroiditis
  32. 32. •Also called suppurative thyroiditis, •It is rare. •caused by Staphylococcus and Streptococcus •The symptoms and signs are similar to those of severe subacute thyroiditis with thyrotoxicosis. •Treatment : Drainage, culturing, and appropriate antibiotics . Acute thyroiditis
  33. 33. • occasionally in patient Graves' disease, who is treated with radioiodine. • develops thyroid pain and tenderness 5 to 10 days later. • due to radiation-induced injury and necrosis of thyroid follicular cells and associated inflammation. •usually mild and subside spontaneously in a few days to one week. Radiation thyroiditis
  34. 34. •Direct blunt or surgical trauma can cause transient hyperthyroidism. •This has been described after laryngectomy, needle aspiration of the thyroid, and parathyroidectomy •Martial arts thyroiditis has been described after a karate blow to the thyroid . •The process is self-limited and resolves in approximately 2 wk as the inflammation subsides. traumatic thyroiditis
  35. 35. •is a mild form of traumatic thyroiditis . • It results from vigorous palpation of the thyroid during physical exam. •After manipulation of the gland during thyroid biopsy. Palpation thyroiditis
  36. 36. silent thyroiditis. •Also called Painless thyroiditis. •It is characterized primarily by transient hyperthyroidism, followed sometimes by hypothyroidism, and then recovery . •It is considered a variant form of chronic autoimmune thyroiditis. •Also it could be secondary to medication.
  37. 37. •thyrotoxicosis factitia •thyrotoxicosis medicamentosa •Thyrotoxicosis insistiates Thyrotoxicosis Attributable to Exogenous Thyroid Hormones
  38. 38. • refers to a condition of thyrotoxicosis caused by the ingestion of exogenous thyroid hormone. •It can be the result of mistaken ingestion of excess drug, such as L-thyroxine • or as a symptom of Munchausen syndrome. thyrotoxicosis factitia
  39. 39. •The symptoms and sign: similar to those in patients with hyperthyroidism from other causes. •No Exophthalmos or opthamopathy. •Usually no goitre. CLINICAL FEATURES
  40. 40. •Diagnosis depends on clinical suspicion •biochemical thyrotoxicosis with high free T4 and/or free T3 and suppressed TSH . •low uptake of radioiodine. •serum thyroglobulin is usually low or undetectable. • antithyroglobulin antibodies should be performed at the same time •Some recommended to measure the ratio of T4 to T3 to help make the diagnosis. thyrotoxicosis factitia
  41. 41. •The source of thyroid might even be unrecognized as in the case of diet pills that contain thyroid hormones. •Also it can be used in case of depression, infertility or menstural problem. •Exogenous Thyroid Hormones
  42. 42. •Patients with thyroid cancer prescribed suppressive doses of thyroxine . •Patients with goiter prescribed excessive doses in an attempt to shrink the thyroid gland. •Patients with a psychiatric disorder who may take excessive doses of thyroid hormone. thyrotoxicosis medicamentosa.
  43. 43. •iodine to food. •Radiographic contrast. •Drugs: Amiodarone. Thyrotoxicosis Attributable to Excess Iodine
  44. 44. •several outbreaks of thyrotoxicosis attributable to thyroid gland being included with neck trimmings that were used to make meat. ground beef Hamburger thyrotoxicosis
  45. 45. Topical iodine preparations Diiodohydroxyquinolone Iodine tincture Povidone iodine Iodochlorohydroxyquinolone Iodoform gauze Solutions Saturated potassium iodide (SSKI) Lugol solution Iodinated glycerol Echothiopate iodide Hydriodic acid syrup Calcium iodide Drugs Amiodarone Expectorants Vitamins containing iodine Iodochlorohydroxyquinolone Diiodohydroxyquinolone Potassium iodide Benziodarone Isopropamide iodide
  46. 46. Radiological contrast agents Diatrizoate Ipanoic acid Ipodate Iothalamate Metrizamide Diatrozide
  47. 47. •is an effective antiarrhythmic medication but it has several side effects, including effects on thyroid function. •It that contains 37 % iodine. •Deiodination of amiodarone produces about 12 mg of free iodine daily when a patient ingests 400 mg. •Amiodarone is fat soluble and has a half-life of many months. Amiodarone
  48. 48. •The effect on thyroid function is somewhat dependent on the quantity of iodine ingested. • In regions of iodine deficiency amiodarone is more likely to cause thyrotoxicosis, •in iodine-sufficient regions hypothyroidism is more likely. Amiodarone
  49. 49. •Type 1 amiodarone–induced thyrotoxicosis: there is increased synthesis of thyroid hormone (usually in patients with a preexisting nodular goiter),. •The excess iodine from amiodarone provides the raw material for the nodules to produce excess thyroid hormones. •type 2, which is attributable to destruction of follicles producing a thyroiditis-like picture. Amiodarone
  50. 50. •Iodine-induced thyrotoxicosis is also called Jod Basedow disease. •Usually an increase in plasma inorganic iodine causes reduced trapping of iodine, organification (Wolff–Chaikoff effect) and reduced release of preformed thyroid hormones Amiodarone
  51. 51. •Treatment: Antithyroid medication such as methimazole been effective •Potassium perchlorate has been used as a competitive inhibitor of trapping iodine by the sodium–iodide symporter. •Corticosteroids such as prednisone are effective in the destructive type 2 syndrome. • Thyroidectomy can be undertaken when antithyroid therapy is ineffective. Amiodarone
  52. 52. Thyrotoxicosis Attributable to Nonthyroid Medications •interferon-alpha. • lithium, •Interleukin-2 • leuprolide acetate
  53. 53. •interferon-alpha. •.used for viral Hepatitis •.The most common thyroid abnormality is the development of de novo antithyroid antibodies without clinical disease . •Approximately 5 to 10 percent of patients develop clinical thyroid disease, •including painless thyroiditis, Hashimoto's thyroiditis, or Graves' disease.
  54. 54. Lithium • used for depression . •lithium have an increased incidence of hyperthyroidism. •Mostly in form of painless thyroiditis .
  55. 55. Interleukin-2 •Used in Patients with metastatic cancer and leukemia •a syndrome mimicking painless thyroiditis occurred in about 2 percent of the patients
  56. 56. Decreased uptake of radioiodineIncreased uptake of radioiodine Thyroiditis Abscess: acute thyroiditis Subacute thyroiditis Silent thyroiditis Graves’ disease Toxic Multinodular goiter Toxic adenoma Postpartum thyroiditisNeonatal thyrotoxicosis Neonatal Graves’ disease Activated TSH receptor TSI in milk Traumatic thyroiditis Radiation thyroiditis Exogenous thyroid Thyrotoxicosis factitia Thyrotoxicosis medicamentosa Thyrotoxicosis insistiates Hamburger thyrotoxicosis Medication for weight loss Excess TSH Pituitary tumor Excess TSH-like material Choriocarcinoma Hydatidiform mole Excess iodine (jod basedow) Radiographic contrast Amiodarone types I and II Iodine supplementation Increased uptake in abnormal site Metastatic thyroid cancer Struma ovarii Lingual thyroid Other :Lithium, Interferon, Interleukin Denileukin diftitox, Leuprolide acetate Marrow transplant
  57. 57. PathogenesisEntity TSH receptor-stimulating antibodiesGraves’ disease Somatic gain-of-function mutations in the TSH receptor or Gs Toxic adenoma Toxic multinodular goiter Hyperthyroid thyroid carcinoma Germline gain-of-function mutations in the TSH receptor Familial non-autoimmune hyperthyroidism Sporadic non-autoimmune hyperthyroidism Increased stimulation by inappropriate TSH secretion TSH secreting pituitary adenoma Increased stimulation of the TSH receptor by hCG hCG-induced gestational hyperthyroidism TSH receptor mutation with increased sensitivity to hCG Familial hypersensitivity to hCG Increased stimulation of the TSH receptor by hCG Trophoblast tumors (hydatiform mole, choriocarcinoma) Autonomous function of thyroid tissue in ovarian teratoma Struma ovarii Increased synthesis of thyroid hormone in autonomously functioning thyroid Iodine-induced hyperthyroidism
  58. 58. • How should overt drug-induced thyrotoxicosis be managed? • Recommendation 88 • Beta-adrenergic blocking agents alone or in combination with methimazole should be used to treat overt iodine-induced hyperthyroidism. • Recommendation 89 • Patients who develop thyrotoxicosis during therapy with interferon-α or interleukin-2 should be evaluated to determine etiology (thyroiditis vs. GD) and treated accordingly
  59. 59. • Recommendation 90 • We suggest monitoring thyroid function tests before and at 1 and 3 months following the initiation of amiodarone therapy, and at 3–6-month intervals thereafter. • Recommendation 91 • We suggest testing to distinguish type 1 (iodine- induced) from type 2 (thyroiditis) varieties of amiodarone-induced thyrotoxicosis.
  60. 60. • Recommendation 92 • The decision to stop amiodarone in the setting of thyrotoxicosis should be determined on an individual basis in consultation with a cardiologist, based on the presence or absence of effective alternative antiarrhythmic therapy. 1/+00 • Recommendation 93 • Methimazole should be used to treat type 1 amiodarone-induced thyrotoxicosis and corticosteroids should be used to treat type 2 amiodarone-induced thyrotoxicosis. 1/+00 •
  61. 61. • Recommendation 94 • Combined antithyroid drug and anti-inflammatory therapy should be used to treat patients with overt amiodarone-induced thyrotoxicosis who fail to respond to single modality therapy, and patients in whom the type of disease cannot be unequivocally determined.
  62. 62. How should thyrotoxicosis due to destructive thyroiditis be managed? Recommendation 96 Patients with mild symptomatic subacute thyroiditis should be treated initially with beta- adrenergic-blocking drugs and nonsteroidal anti-inflammatory agents. Those failing to respond or those with moderate-to-severe symptoms should be treated with corticosteroids.
  63. 63. How should thyrotoxicosis due to unusual causes be managed? Recommendation 97 The diagnosis of TSH-secreting pituitary tumor should be based on an inappropriately normal or elevated serum TSH level associated with elevated free T4 estimates and T3 concentrations, usually associated with the presence of a pituitary tumor on MRI and the absence of a family history or genetic testing consistent with thyroid hormone resistance in a thyrotoxic patient.
  64. 64. Recommendation 98 Patients with TSH-secreting pituitary adenomas should undergo surgery performed by an experienced pituitary surgeon. Recommendation 99 Patients with struma ovarii should be treated initially with surgical resection. Recommendation 100 Treatment of hyperthyroidism due to choriocarcinoma should include both methimazole and treatment directed against the primary tumor.
  65. 65. •Prevalence of goiter and hypothyroidism was observed high in patients with ESRD . •Hyperthyroidism is rare in patients on dialysis •The clinical diagnosis of hyperthyroidism in ESRD may be delayed due to overlap of symptoms. • is not clear whether the excess iodine stimulates the gland to a hyperactive state (Jod-Basedow effect). •Treatment: • antithyroid,Surgery, I-131 ablation. Gravs disease in ESRD on dialysis
  66. 66. .

×