Podcast Episode 005 –A Physician Assistant Review of Hypothyroidism & Thyroiditis

Summary: Hypothyroidism Causes of Hypothyroidism Thyroiditis (see complete listing below) Hashimoto’s thyroiditis - the most common thyroid condition in the U.S. Patient has no thyroid Radioactive iodine ablation Surgical removal of the thyroid Congenital Medications Amiodarone which is structurally similar to thyroxine Lithium Propylthiouracil (PTU) and Methimazole - used to control hyperthyroidism Clinical Presentation And you thought the hyperthyroid symptom list was long and vague.... cold intolerance puffy face fatigue changes in menstrual cycle, typically heavier pale, cool, dry skin thin brittle nails and hair poor memory depression psychosis dementia weakness muscle stiffness anorexia constipation weight gain edema bradycardia hyporeflexia Labs and studies TSH -- elevated in primary hypothyroidism. total T4 -- decreased free T4 -- decreased T3 -- may be normal Antithyroid peroxidase Antithyroglobulin antibodies CBC -- may show anemia BMP -- low sodium CT or MRI can be done but not typically necessary Treatment Thyroid hormone replacement Levothyroxine is the most commonly used medication.  It is a synthetic T4. Patients are started with the lowest dose and it is slowly moved up while monitoring symptoms and TSH levels. Once the dose is set yearly levels should be checked Treatment is forever Watch for symptoms of hyperthyroidism Myxedema This is the mirror of thyroid storm.   This is extremely severe hypothyroid and a true life threatening emergency   Clinical Presentation Patients with myxedema will have symptoms of hypothyroid as well as mental changes from confusion to coma convulsions hypotension hypothermia hypoventilation rhabdomyolysis and acute kidney damage hyponatremia Treatment IV levothyroxine intubation if necassary slow warming with warm blankets if necessary Thyroiditis All are far more common in females.  For the PANRE I would focus on Hashimoto’s and really have a good understanding of it. Categories of thyroiditis Hashimoto’s thyroiditis This is also known as chronic lymphocytic thyroiditis. Subacute thyroiditis also known as granulomatous thyroiditis, de Quervain’s thyroiditis and giant cell thyroiditis.   It is thought to be caused by a virus. Postpartum thyroiditis believed to be autoimmune in nature occurs in 7.2% of women post delivery Suppurative Thyroiditis nonviral infection of the thyroid rare Reidel thyroiditis invasive fibrous, woody, ligneous are all terms used to describe this typically as part of a systemic fibrosis rarest form of thyroiditis Clinical Presentation Hashimoto’s thyroiditis -- symptoms of hypothyroidism, these patients have a high rate of other autoimmune problems like Sjogren’s, myasthenia gravis, celiac disease, addison’s disease etc. thyroid enlarged, firm, nodular neck tightness mental changes depression chronic fatigue Autoimmune about 33% have Sjogren’s syndrome xerostomia -- dry mouth keratoconjuctivitis -- dry eyes myasthenia gravis is often a concomitant autoimmune problem Subacute Thyroiditis acute pain (really? this seems like a bit of an oxymoron) painless is called silent thyroiditis glandular enlargement → dysphagia low grade fever fatigue 50% will have thyrotoxicosis followed by hypothyroid followed by euthyroid Postpartum Thyroiditis beings 1-6 months postpartum hyperthyroid followed by hypothyroid painless palpable goiter Suppurative Thyroiditis  (remember this is typically a bacterial infection) painful tender red fluctuant Reidel thyroiditis hypothyroid symptoms the thyroid becomes enlarged and  hard dysphagia hoarseness pain dyspnea typically goes along with systemic fibrosis