thyrotoxicosis in special situation the let.ppt

this is a shot talk about symptoms and signs of thyrotoxicosis in children and in elderly How they can differ from adult presentation

2. HAMED RASHAD
Professor of Surgery BanhaFaculty of Medicine

3. Thyrotoxicosisshouldbetreatedfirst
inanysituation.
Ithaspriorityovereverythingatanyage
exceptemergenciesInwhicheven
itshouldbeatleastcontrolledfirst
withI.Vbetablocker
Introduction

4. THYROTOXICOSIS
IN NEONATES

5. Neonatal Graves disease
Neonatal Graves disease is rareeven among
mothers with known hyperthyroidism
Neonatal Graves disease is caused by the
transplacental passage of TSI (Thyroid
Stimulating Immunoglobulin)
Only 1 in 70 infants of thyrotoxicmothers has
clinical symptoms

6. Neonatal Graves disease
If the mother is taking antithyroid drugs, infants
are usually born asymptomatic
Signs include tachycardia, wide pulse pressure,
irritability, tremor, and hyperphagiawith poor
weight gain
The baby may have exophthalmos and goiter

7. Neonatal Graves disease
Neonates have a much higher risk of morbidity
and mortality from cardiac disease
In severe cases, CHF can be observed
Goitercan occasionally be large enough to cause
airway compression
Long-term effects can include craniosynostosis
and developmental delay

8. THYROTOXICOSIS
IN CHILDREN

9. Hyperthyroidism is a relatively
rare condition in children
Graves disease accounts for more
than 95% of childhood cases of
hyperthyroidism

10. Causes
Transient
•Neonatal thyrotoxicosis
•Infectious : Acute & Subacutethyroiditis
•Drug –induced: Amiodarone, interferon
&interleukin
Hashitoxicosis
•Iatrogenic: over dose of L-Thyroxin

11. Permanent causes
Graves disease
Toxic adenoma/ carcinoma
Toxic nodular goiter
McCune-Albright syndrome
Pituitary causes of thyrotoxicosis
Pituitary adenoma
Pituitary resistance to T4

12. Other causes:
Exogenous thyroid hormone
Iodine-induced hyperthyroidism (i.e., Jod-
Basedowphenomenon)
Human chorionic gonadotropin (hCG)–
secreting tumors

13. Symptoms and signs
Unusualbeforeage5.
Female5timesthanmale.
Symptoms arelikeadultsbutBehavioral
symptomspredominate(Hyperkineticchild).
Thyrotoxicchildrenaretallerfortheirage.
Permanentbraindamageandcraniostenosisare
reported.

15. Exophthalmos

16. Diagnosis
Suppressed TSH
Elevated T4, Free T4, T3 levels
Positive Thyroid Stimulating Antibodies:
–Thyroid Peroxidase
–Thyroglobulin
–Thyroid Stimulating Immunoglobulin

17. Isotope scan is very important

18. Graves Disease
I
123
orTC
99m
Normal v/s Graves

19. Toxic Multinodular Goiter (TMG)

20. Toxic Single Adenoma (TSA)
Nucleotide
Scintigraphy

21. Treatment
Three modalities for more than last 50
years
Radioactive iodine, anti-thyroid drugs &
surgery
None is optimal
None interrupts the autoimmune process

22. Treatmentchoices
Clinical considerations
Age of the patient
Goiter size
Urgency of treatment
RAIU by the thyroid
Physician preference
Patient choice

23. Therapy:
???I
131
Choiceisbetweenantithyroiddrugsandsubtotal
thyroidectomy.
Antithyroiddrugs
Preferableinitialtherapy
Apermanentremissionisexpectedin
50%.
Twoyeartreatmentisrecommended 
recurrenceanotheroneyearcourse.

24. Resultsofmedtreat:
Decreaseinsizeofgoiter=remission
Progressiveenlargementofgoiter=
hypothyriodism
reductionofdose
or
thyroxinereplacement

25. AntithyroidDrugs
Highriskfactorsofrelapseinchildren
Largegoiter
Historyofpreviousrelapse
HighTRABtiter
Ophthalmopathy
T3predominantgrave’sdisease
Lowdosesorshortduration(31%remissionrate
for6m.treatmentand82%for2years)

26. AntithyroidDrugs
Thionamidegroup
Methimazole –Neomecazol-Cabemazol
Fewer doses / day (once daily), no bad taste and
no compliance problems
Propylthiouracil -Thyrocil
More doses /day, bad taste, and no compliance
problems

27. Surgical treatment
Subtotal thyroidectomy was the most common
procedure Now Total Thyroidectomy
Indications
Large goiter
Severe thyrotoxicosis
Failure of medical therapy
Reaction or neutropenia to med. therapy.
No permanent remission till age 15
Exophthalmos not responding to treatment

28. I
131
Radioactive iodine
There is no evidence to suggest that such
therapy has any adverse effects
No effect on fertility
No increased incidence of congenital
malformations
No increase risk of cancer in-patients treated
with radioactive iodine or in their offspring
But nobody can dare

29. Radioiodine
Necessaryif
-Surgeryiscontraindicated
-Priortosurgery
Potentialriskaftertheage15
islow

31. Thyrotoxicosisin Elderly
PrevalenceofTDincreasewithage
Hyperthyroidismabove60rangesfrom
0.5to2.3%.twicethatinyoungerpopulations
Fewersigns.
Anorexiaandatrialfibrillationarecommoner.
Tachycardia,fatigueandweightlossinmorethan
half.

32. Hyperthyroidism in the elderly
Causes differ:
y young<50 old>70y
M. Graves 92 % 33%
Multinod.Goiter 4% 23 %
Solit.Tox.Nod 4% 7%
Iodine.ind.Thyrotox.0% 37%

33. Symptoms differ
Tachycardia, fatigue and weight loss are the
most frequent presenting symptoms in the
elderly.
In more than 50 % one of these symptoms
Triad in 32 %
Next 5 most frequent symptoms in elderly:
Tremor, Dyspnea, Apathy, Anorexia,
Nervousness

34. In summary
Presentation of hyperthyroidism in the
elderly:
Less symptoms
Nonspecific symptoms
Less typical (adrenergic) symptoms

35. Symptoms differ
Classical symptoms are less frequent :
Old Young
Hyperactive reflexes 28 vs 96%
Increased sweating 24 vs 95%
Heat intolerance 15vs92%
Tremor 44 vs 84%
Nervousness 31 vs 84%
Polydipsia 21 vs 67%
Increased appetite 0 vs 57%

36. Symptoms/signs more
frequent in the elderly
Atrial fibrillation:32vs2 %
Anorexia: 32vs4 %

37. Apathetichyperthyroidism
FirstdescribedbyLahey1931
Occursin10-15%ofelderlywiththyrotoxicosis
Features Weakness
Lethargy
Depression
Absent hyperkinesis
Apathetic appearance of the face
Lack of ocular signs
Lack of palpitation
Agerelatedattenuationoftheadrenergictoneandtissue
resistancetoeffectofthyroidhormone.

38. TREATMENT OPTIONS
Doesnotdifferfromthoseinyoungwithsome
precautions:
1-Alagof1-2monthsinimprovementwithI
131
therapy=Betablockerstocontrol.
2-Patientswithcoronaryarterydiseaseshould
becontrolledwithantithyroiddrugsto
achievenormalT4levelsbeforeundergoing
radioablation.
3-Medicationshouldbegivenwiththelowest
effectivedose.

39. TREATMENT OPTIONS
4-Recurrenceaftercontrolbymedical
treatmentinGrave’sismuchlower.
5-Lowriskpatientswithalargenodular
goitersurgeryisconsideredagood
choice.
6-Inflailpatientsradioiodinetreatmentis
preferred.

41. Thyroid disease in pregnancy
Thyroid disease is present in 2-5% of women.
2
nd
more common endocrinal problem in pregnancy.
Overt hypothyroidism occurs in 0.3-0.5%.
Sub-clinical hypothyroidism in 2-3%.
Hyperthyroidism in 0.1-0.4%.

42. Autoimmunethyroid dysfunctions remain a common cause
of both hypo and hyperthyroidism.
Grave’s disease accounts for more than 80% of all cases
of hyperthyroidism.
Hashimoto thyroiditis the most common cause of
hypothyroidism.
Postpartum thyroiditisaffects 4-10% of women again is
an autoimmune disease.

43. THYROTOXICOSIS IN PREGNANCY
(1-2 per 1000 pregnancies)
Planning pregnancy for women with
thyrotoxicosis:
Never use I
131
for scanning or treatment
Control thyrotoxicosis before proceeding to
pregnancy (takes 3 -6 months).
Accidental use of I
131
(Diagnostic) during
pregnancy is of no major harm.

44. Thyroid Functions in Pregnancy
Thyroid functions are normal
Although normal pregnant women may have
Rapid heart rate.
Sweating.
Hot intolerance.
Total T3 & T4 levels are increased
high level of estrogen increases TBG

45. It has been observed that patients with known history
of Graves disease tend to undergo remission during
pregnancy and exacerbation during the post partum
period.
!! The overall down regulation of thematernal immune
system during pregnancy.

46. Diagnosis of hyperthyroidism in pregnancy:
Symptoms:
May simulate euthyroid pregnant women ( tachycardia….
Sings:
-Weightlossobscuredbyweightgaininpregnancy.
-Eyesigns.
-Thyroidswelling.
-Restingpulseabove100/m.(ThatfailtoslowduringValsalva)
-ThepresenceofONYCHOLYSIS(Separationofthedistalnailfromthenailbed).

47. Lab Tests
The markedly elevated TBG during pregnancy
makes the standard free T
4not accurate
estimation of the true free T
4.
Newer non equilibrium dialysis method of free
T
4may be helpful.
If in doubt repeat after 3-4 weeks.

48. Morbidity and mortality of
gestational thyrotoxicosis
Fetal
-↑ Neonatal mortality
-↑ Low birth weight infants .
Maternal
-↑ risk of premature labour
-↑ frequency of pre-eclampsia.
-↑ CHF.

49. Treatment of hyperthyroidism during
pregnancy
There is no evidence that pregnancy makes
hyperthyroidism more difficult to cure.
Therapy:
-Antithyroiddrugsorsurgery.
-I
131
iscontraindicated.

50. 1.Propylthiouracil(PTU):
-Drugofchoice
-100-150mg/8hrs.
-Maximum600daily.
-Taperedto100mgdaily.
-Doesnotcrossplacenta.
Methimazol(carbimazol):
-Stillsafe
-5-15mg/8hr.
-Taperedto10mgdaily.
NB:
DiseasebecomesmilderorremittotallyNeartermdrugstaperedor
discontinued.

51. 2.Blockingagents:
Arenotrecommendedforlongterm
treatmentduringpregnancy.
Adverseoutcomes:
Smallplacenta.
Intrauterinegrowthretardation.
Neonatalresp.distress.
Impairedresponsetoanoxicstress.
Postnatal:
oBradycardia.
ohypothermia.
ohypoglycemia.

52. 3-Surgery
-Forpatientswith:
Antithyroiddrugreaction
Poorcompliance
Drug dosage needed above the safe level.• Persistently
high dosages (PTU > 600 mg/d, Cab > 40 mg/d) are
required to control maternal disease
Compressive symptoms

53. 3-Surgery
Prepared with a β-adrenergic blocking agent and
a 10-to 14-day course of potassium iodide
Total thyroidectomy
•Better done after first trimester (↓↓ risk of abortion)
•Observe for post operative(hypothyroidism)
•Immediate replacement with 0.05 T4.

54. مكل اركش