A patient with a hyperthyroidism/ Un paciente con...
- 2. Index of CONTENTS 01. Introduction and Etiopathogenesis 02. Diagnosis and Initial Evaluation 03. Complementary Tests and Differential Diagnosis 04. Treatment and Therapeutic Approach 05. Management of Thyroid Storm and Precautions.
- 3. Case Personal Information: Conchita, a 20-year-old woman, from a rural community (Ejido belonging to the municipality of Minatitlán, located in Cerro Grande at an altitude of about 2200 meters). Reason for emergency consultation: A six-month evolution characterized by intense hunger, hand tremors, palpitations, and intermittent diarrhea, recently accompanied by nervousness, difficulty concentrating, and heat intolerance. Family history: Mother, father, 3 sisters, and 2 brothers are apparently healthy. Non-pathological personal history: She lives in an urban house with all amenities, with her parents and 3 siblings, sharing a room with her younger sister. Gynecological and obstetric history: Menarche at age 12, 0 pregnancies, irregular menstruation in recent months. Pathological personal history: Conchita has been very healthy, with only occasional colds and diarrhea. Physical examination: Vital signs: BP 130/90 mmHg, HR 110 bpm, Temp. 37.5°C, RR 18 bpm. The doctor observes exophthalmos with a fixed gaze, moderate swelling in the anteroinferior region of the neck, fine tremor, profuse hand sweating, and purplish induration of the skin in the pretibial region. Medical management: Methimazole tablets 20 mg, one every 12 hours orally, and propranolol tablets 40 mg, one tablet every 8 hours orally. Scheduled for follow-up in one month. Observation: Conchita did not attend the follow-up appointment but continued taking her medications. Five months later, Conchita returns for a consultation. Reason for the new consultation: Conchita now complains of weight gain, memory issues, swelling of hands, feet, and face, hair loss, drowsiness, menstrual irregularities, and constipation, despite having taken her methimazole and propranolol treatment throughout this time. Her current vital signs are BP 80/58 mmHg, HR 60 bpm, RR 12 bpm, Temp. 35.8°C.
- 5. Introduction Hyperthyroidism is a functional disorder of the thyroid characterized by the secretion and subsequent release into the bloodstream of excessive amounts of thyroid hormones relative to the body's needs.
- 6. Several theories explain its etiopathogenesis, but the most accepted is the immunological theory. It posits that antibodies targeting thyroid-stimulating hormone (TSH) lead to increased hormone production by interacting with it. GRAVES-BASEDOW DISEASE
- 7. Representing 6% of cases, this condition is characterized by its independence from the hypothalamic-pituitary axis, though its exact cause remains unknown. TOXIC MULTINODULAR GOITER
- 8. This constitutes 13% of cases and involves a thyroid nodule that becomes autonomous within a multinodular goiter. Current theories suggest the presence of autonomous follicular cells and other growth factors. TOXIC ADENOMA
- 9. These can be: 1.Acute or Suppurative: A rare condition where pyogenic germs, typically staphylococci, colonize from the upper respiratory tract or bloodstream. 2.Subacute: ⚬ Granulomatous or de Quervain’s Thyroiditis ⚬ Painless Lymphocytic Thyroiditis THYROIDITIS
- 11. Investigation Ask about the existence of: • Thyroid disease • Autoimmune diseases • Radiation to the upper hemisphere • Ingestion of drugs • Family history of goiter PERSONAL HISTORY We will start the anamnesis asking about the signs and symptoms of hyperthyroidism. The symptoms are very varied but at the same time very characteristic of the picture. which initially helps us to make a syndromic diagnosis of hyperthyroidism. REASON FOR CONSULTATION
- 12. Physical examination It must begin with inspection and palpation, describing the gland. Describe its size, consistency, mobility, presence or no pain Differentiate thyroid nodules from the cysts of the thyroglossinus duct. Cyst will move under the skin Collect data on : • Check for exophthalmos • Dehydration • Cardiorespiratory auscultation to detect murmurs • Rule out painful hepatomegaly • Edema in the lower limbs • Pretibial myxedema • Pressure arterial • Pulse
- 13. Characteristics according to the different pathologies GRAVES - BASEDOW DISEASE • Moderate goitre • Smooth surface • Soft consistency • Thyroid murmur by increased vascularization • Sign of Graefe (eyelid) TOXIC MULTINODULAR GOITR • Diffuse hyperplasia of the thyroid • Nodules of varying sizes, firm or hard consistency • No thyroid murmur is present.
- 14. THYROIDITIS • If it is acute or suppurated, palpation is painful and signs of inflammation are seen. • In subacute forms such as granulomatous or de Quervain’s, the thyroid is painful and firm in consistency. • In case of painless lymphocytic is asymptomatic. TOXIC ADENOMA • Medium to small thyroid nodule • Painless • Firm consistency but not hard
- 16. Complementary Tests • TSH, FT4, general analysis, microsomal and antithyroglobulin antibodies. GRAVE ´´ S DISEASE: • TSH, FT4, general analysis, scintigraphy. • TOXIC NODULAR GOITER: • TSH, FT4, general analysis, scintigraphy. • TOXIC ADENOMA: 1.Acute: TSH, FT4, general analysis (if there is leucocytosis), blood cultures, culture in case of abscess • THYROIDITIS:
- 17. Complementary Tests 2. Subacute: TSH, FT4, general analysis (if there is leucocytosis), scintigraphy. 3. Painless lymphocytic: TSH, FT4, general analysis (there is no leucocytosis) and scintigraphy.
- 18. Differential diagnosis • Diffuse goiter, hyperthyroidism and ophthalmopathy. In some cases, pretibial myxedema. GRAVE ´´ S DISEASE: • In people over 50 years of age, hyperthyroidismr, without ophthalmopathy and myxedema. TOXIC MULTINODULAR GOITER: • Solitary palpable nodule without ophthalmopathy or myxedema. TOXIC ADENOMA:
- 19. Differential diagnosis 1. Acute: Sudden pain in irradiated thyroid region, fever. 2. Subacute: accompanied by fever, goiter, pain radiating to the pharynx, rarely more than 6 months. 3. Painless lymphocytic: hyperthyroidism maximum 4 months, painless goiter without ophthalmopathy or myxedema. THYROIDITIS:
- 21. Hyperthyroidism Treatment Antithyroid Drugs Methimazole: 10-60 mg/day. Reduced to 5-20 mg/day after improvement in 4-6 weeks. Treatment lasts 12-24 months, with follow-up every 3 months. Remission: 10-75%. Recurrences are frequent in the first 6 months. Sometimes combined with levothyroxine to prevent hypothyroidism.
- 22. Other Treatments Beta blockers: Propranolol (40-120 mg/day) or atenolol (50-100 mg/day) for symptoms like tremors and tachycardia. Dexamethasone: 2 mg every 6 hours for rapid relief. Radioactive iodine: Recommended for elderly or recurrent cases. Contraindicated during pregnancy. Hyperthyroidism Treatment
- 23. Surgery and Special Conditions Surgery: Subtotal thyroidectomy for young patients unresponsive to treatment or with large goiter. Toxic multinodular goiter: Radioactive iodine; surgery if large. Toxic adenoma: Radioactive iodine; surgery as an alternative. Hyperthyroidism Treatment
- 24. Thyroiditis and Side Effects Thyroiditis: Antibiotics or aspirin for acute or subacute thyroiditis. Levothyroxine for hypothyroidism. Side effects: Itching, rash, and leukopenia. Agranulocytosis and hepatotoxicity require treatment discontinuation. Hyperthyroidism Treatment
- 25. 05 and Precautions. Management of Thyroid Storm
- 26. Thyroid Storm
- 27. Treatment a) Monitoring b) Fluid therapy c) Vitamin B1 (100 mg/8 h, due to possible hypovitaminosis caused by catabolism)
- 28. Treatment d) Reduce fever (use cooling blankets if available, or paracetamol 1 g intravenously/6 h, or chlorpromazine (Largactil®), 25-50 mg/6 h intramuscularly to prevent tremors) e) Reduce circulating hormone levels with antithyroid drugs
- 29. Precautions • Acetylsalicylic acid should not be used to reduce fever as it binds to transport proteins and increases the concentration of free hormone. • Iodides should not be administered until at least one hour after starting treatment with antithyroid drugs, as they may serve as a substrate for thyroid hormone synthesis. • Do not administer diltiazem together with propranolol.
- 30. Word Meaning Translation Subacute A condition with symptoms less severe than acute but more severe than chronic. Subagudo Pharynx Part of the throat behind the mouth and nasal cavity. Faringe Agranulocytosis A serious condition where the body has a dangerously low number of granulocytes. Agranulocitosis Multinodular Having or involving multiple nodules. Multinodular Pyogenic Producing or caused by pus. Piógeno Lymphocytic Related to or consisting of lymphocytes (a type of white blood cell). Linfocítico Syndromic Related to or characteristic of a syndrome. Sindrómico Goiter An abnormal enlargement of the thyroid gland. Bocio Cysts A sac-like pocket of tissue containing fluid, air, or other substances. Quistes Murmurs Abnormal sounds heard during a heartbeat, indicating potential heart issues. Soplos VOCABULARY
- 31. ARTICLE Orloff, L. A., & Shindo, M. L. (2021). Surgical Management of Hyperthyroidism. En Elsevier eBooks (pp. 79-88.e2). https://doi.org/10.1016/b978-0-323-66127-0.00008-9