Thyrotoxicosis Explained: Clinical Features, Diagnosis, And Management

Thyrotoxicosis Explained: Clinical Features, Diagnosis, And Management

Question. Outline the management of thyrotoxicosis and etiology, Investigations, and clinical features of thyrotoxicosis.

Answer.

The management of thyrotoxicosis is divided into four parts as follows:

General Management Of Thyrotoxicosis:

• Allow the patient to take mental and physical rest.
• Maintain the nutrition of the patient by giving a nutritious diet.
• If the patient is anxious alprazolam 0.25 to 0.5 mg BD is given.

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Drug Therapy Of Thyrotoxicosis

• Anti-thyroid drugs such as carbimazole, i.e. 40 to 60 mg/day, methimazole, i.e. 100 to 150 mg 8 hourly, and propylthiouracil, i.e. 300 to 450 mg/ day can be given depending on the severity of the disease.
  Drugs should be gradually decreased for 4 to 8 weeks based on FT4 levels. When FT4 levels are normal, carbimazole 5 to 15 mg/day or propylthiouracil 50 mg/day is given.
  Drugs can be given for 1 to 2 years by regular checking of FT4 and TSH levels.
• For symptomatic relief, beta­blockers such as propanolol 80–160 mg daily are given.
  It is given for 2 to 3 weeks along with anti-thyroid treatment.
  It relieves symptoms such as anxiety, tremors, and tachycardia.

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• Dexamethasone 8 mg/day may be used to inhibit the conversion of T4 to T3 in severe forms of thyrotoxicosis.
• Lithium carbonate 300–450 mg TDS inhibits thyroid hormone secretion temporarily in patients who are allergic to iodides and thioamides.
• Potassium perchlorate 500 mg BD inhibits iodine uptake by the thyroid gland. It is combined with thioamides.
• Surgery: Subtotal thyroidectomy is done in severely affcted cases.
  • Before surgery patient should be made euthyroid by beta blockers and anti-thyroid drugs.
  • Two weeks before the surgery drugs should be stopped and lugol iodine is given to reduce the vascularity.
• Radioiodine treatment: Radioactive iodine, i.e. 131I leads to the destruction of thyroid cells and is given with anti­thyroid drugs to prevent thyroid storm.
  • Anti­thyroid drugs must be stopped for a minimum of 3 to 5 days before 131I to allow uptake of isotope 555 MBq to ablate the thyroid.
  • High doses are needed for large goiter in severely thyrotoxic patients.

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Etiology Of Thyrotoxicosis

Common causes:

• Grave’s disease
• Toxic nodular goiter
• Multinodular
• Solitary nodule

Less common:

• Thyroiditis
• Drug­induced
• Factitious
• Iodine excess

Rare:

• Pituitary or ectopic TSH
• Thyroid carcinom

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Investigations Of Thyrotoxicosis

• Serum TSH level is decreased and is the initial diagnostic test. Normal TSH levels exclude clinical hyperthyroidism.
• Serum total and unbound (free) T3 and T4 are increased in hyperthyroidism.
• In some cases, only T3 levels are raised whereas T4 is normal (T3 toxicosis).
• TSH­R antibody levels are increased in about 75% of cases.
• ESR may be increased in subacute thyroiditis.
• The uptake of radioactive iodine by the thyroid is increased in Graves’ disease and toxic nodular goiter, whereas it is low in subacute thyroiditis.
• Ultrasonography of the thyroid gland reveals diffuse enlargement of the thyroid gland which helps differentiate.
• Graves’ disease from nodular goiter.

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Clinical Features Of Thyrotoxicosis

• Goiter is present, i.e. either diffuse or nodular.
• Gastrointestinal features: Vomiting, diarrhea, and weight loss
• Cardiovascular features: Arrhythmia, i.e. atrial fibrillation, dyspnea, wide pulse pressure
• Dermatological manifestations: Clubbing, loss of hair, palms becoming red, increased sweating
• Reproductive features: Amenorrhea, infertility, abortion, impotence
• Ophthalmological features: Exophthalmos, Diplopia, lid retraction, staring look, excessive watering from eyes
• Neuromuscular features: Tremors in hand, psychosis, irritability, restlessness, nervousness, high tendon reflexes
• Miscellaneous: Fatigue, polydipsia, heat tolerance.