questions 17

Graves Disease

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Topic updated on 11/13/17 5:33pm

Introduction
  • Most common cause of hyperthyroidism
  • An autoimmune disease with stimulating anti-TSH receptor antibodies
    • a type II hypersensitivity
    • anti-microsomal, anti-thyroglobulin antibodies also present
  • Female dominant
    • HLA-B8, Dr3 association
  • Often incited during stress
    • e.g. childbirth, infection, steroid withdrawal
Presentation
  • Symptoms
    • heat intolerance
    • weight loss
    • hyperactive
    • diarrhea
    • hyperreflexia
    • tachycardia, palpitations, arrhythmias
      • thyroid hormone increases heart rate and contractility and decreases SVR 
    • warm moist skin and sweating
    • hypertension
  • Physical exam
    • symmetrical, non-tender thyroid enlargement 
    • ophthalmopathy (proptosis, exophthalmos)
      • due to glycosaminoglycan deposition
    • pretibial myxedema 
    • digital swelling
Evaluation
  • Serology 
    • ↑ total serum T4
    • ↑ free T4
    • ↓ serum TSH
    • diffusely ↑ 123I uptake 
Treatment
  • Medical
    • β-blockers
    • thionamides 
      • result in reduced hormone synthesis
      • PTU and methimazole
        • discontinue if agranulocytosis occurs as these are side effects of these medications
    • during pregnancy, first-line is propranolol, followed by propylthiouracil
      • if these treatments do not work and symptoms are severe, thyroidectomy is the treatment of choice
        • complications include
          • recurrent laryngeal nerve injury
          • hypocalcemia
            • due to PTH gland removal resulting in the classic findings of hypocalcemia (tetany, QT prolongation, etc.)
    • 131I ablation   
      • hypothyroidism may result 
      • contraindicated in pregnancy 
      • may cause transient worsening of exophtalmos or hyperthyroid symptoms due to release of thyroid hormone with thyroid cell destruction
        • prevention: pretreatment with glucocorticoids 
Prognosis, Prevention, and Complications
  • Stress-induced catecholamine surge
    • may be fatal by arrhythmia
  • Pregnancy complications
    • anti-TSH receptor antibodies may cross placenta and produce hyperthyroidism in the fetus


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Qbank (9 Questions)

TAG
(M3.EC.5) A 32-year-old woman presents to your office with a one month history of heat intolerance, racing heart, unintentional 4 pound weight loss, and sweating. On physical examination there is a non-tender enlarged thyroid without evidence of proptosis or exophthalmos. Lab tests return with increased total T4, decreased TSH, and increased free T4. A radioactive iodine uptake exam is ordered and the imaging is displayed in Figure A. What is the most appropriate definitive treatment option for this patient? Topic Review Topic
FIGURES: A          

1. Watchful waiting for symptom progression or recession
2. Beta-blockade alone
3. Anti-thyroid medications alone
4. Radioactive iodine ablation alone
5. Radioactive iodine ablation and prophylactic glucocorticoids

PREFERRED RESPONSE ▶
TAG
(M2.EC.9) A 45-year-old female presents to general medical clinic with a chief complaint of a growth on her neck. Physical exam reveals proptosis, pretibial myxedema, and a diffuse goiter. If the patient's symptoms are due to thyroid-stimulating TSH receptor antibodies, what treatment would provide the best long term outcome for her symptoms? Topic Review Topic

1. Levothyroxine
2. Propylthiouracil
3. Methimazole
4. Radioactive Iodine
5. Propranolol

PREFERRED RESPONSE ▶
TAG
(M2.EC.20) A 45-year-old female presents to her primary care clinic with symptoms of palpitations, hyperhidrosis, tremor and general hyperactivity. A radioactive iodine update scan of this patient showing decreased thyroid uptake would effectively rule out which condition? Topic Review Topic

1. Subacute painless thyroiditis
2. Subacute granulomatous thyroiditis
3. Graves' disease
4. Iodine-induced thyroid toxicosis
5. Levothyroxine overdose

PREFERRED RESPONSE ▶
TAG
(M2.EC.38) A 61-year-old man presents to the emergency room complaining a racing heart, sweats, and diarrhea for 2 weeks. Review of systems is positive for unintentional weight loss of 10 pounds in 1 month. Serum TSH is found to be 0.02 mIU/L (normal 0.5 - 5.0 mIU/L). The patient is shown in Figure A. If the patient is treated with I-131 radioiodine therapy, which of the following is the most likely long term complication? Topic Review Topic
FIGURES: A          

1. Agranulocytosis
2. Increased total cancer mortality
3. Hyperthyroidism
4. Hypothyroidism
5. Hypoparathyroidism

PREFERRED RESPONSE ▶
TAG
(M2.EC.75) A 69-year-old man presents to the general medical clinic with palpitations. He has a history of an endocrine disorder that he reports has caused him to have chronic diarrhea and weight loss. His vital signs are temperature 37 degrees Celsius, blood pressure 130/85, heart rate 141, and respiratory rate of 18 with an oxygen saturation of 99% on room air. His pulse is irregular on physical examination. He is mentating normally and is in no acute distress. His exam is also notable for hyperreflexia and enlargement around his neck. An EKG reveals the following in figure A. What would be the next best step in management of this patient's chief complaint? Topic Review Topic
FIGURES: A          

1. Emergent cardioversion
2. Administration of propranolol
3. Administration of amiodarone
4. Iodine 131 ablation
5. Administration of methimazole

PREFERRED RESPONSE ▶
TAG
(M2.EC.83) A 36-year-old G1P0 female presents to labor and delivery in the 38th week of her pregnancy and undergoes an uncomplicated spontaneous vaginal delivery. Shortly after birth, the child is noted to have dysphagia, irritability, frequent stooling, and increased appetite. The mother notes no history of drug or medication use during the pregnancy. The newborn's CBC is within normal limits. Thyroid studies reveal an increased free T4 in the newborn. Which of the following is the most likely the cause of this infant's presentation? Topic Review Topic

1. Initial presentation of DiGeorge syndrome
2. Intrauterine toxoplasmosis infection
3. Maternal iodine deficiency
4. Maternal history of Graves' disease treated with radioactive thyroid ablation 10 years ago
5. Maternal history of Hashimoto's thyroiditis

PREFERRED RESPONSE ▶
TAG
(M2.EC.98) A 32-year-old woman with Graves' disease is undergoing treatment with radioactive iodine. Her initial presentation consisted of symptoms of sweating, weight-loss, and intermittent palpitations along with a physical examination significant for mild-to-moderate exophthalmos. After completing one week of radioactive iodine therapy, she reports worsening of her proptosis, with increased pain and worsened periorbital edema. Which of the following could have prevented the worsening of this patient's exophthalmos? Topic Review Topic

1. Giving a larger dose of radioiodine therapy
2. Initiation of beta-blocker at time of radioiodine therapy
3. Begin methimazole concurrent with initiating radioiodine therapy
4. Pre-treatment with prednisone prior to initiating radioiodine therapy
5. This is an expected outcome from radioactive iodine therapy, no preventive options are available

PREFERRED RESPONSE ▶
TAG
(M2.EC.103) A 33-year-old man is found to have lymphocytic infiltration of his extraocular muscles secondary to an autoimmune process. Fibroblasts in the orbits of his eyes are dysregulated and large amounts of glycosaminoglycans are deposited. Which of the following is most likely present in this patient? Topic Review Topic

1. Infection of the orbit
2. Decreased reabsorption of aqueous humor
3. Autoimmune destruction of the lacrimal glands
4. Anti-TSH receptor antibodies
5. Inflammation of the axial skeleton

PREFERRED RESPONSE ▶
TAG
(M2.EC.4754) A 25-year-old female with a history of childhood asthma presents to clinic complaining of a three month history of frequent, loose stools. She currently has three to four bowel movements per day, and she believes that these episodes have been getting worse and are associated with mild abdominal pain. She also endorses seeing red blood on the toilet tissue. On further questioning, she also endorses occasional palpitations over the past few months. She denies fevers, chills, headache, blurry vision, cough, shortness of breath, wheezing, nausea, or vomiting. She describes her mood as slightly irritable and she has been sleeping poorly. A review of her medical chart reveals a six pound weight loss since her visit six months ago, but she says her appetite has been normal. The patient denies any recent illness or travel. She is a non-smoker. Her only current medication is an oral contraceptive pill.

Her temperature is 37°C (98.6°F), pulse is 104/min, blood pressure is 95/65 mmHg, respirations are 16/min, and oxygen saturation is 99% on room air. On physical exam, the physician notes that her thyroid gland appears symmetrically enlarged but is non-tender to palpation. Upon auscultation there is an audible thyroid bruit. Her cranial nerve and ocular exam are normal. Her abdomen is soft and non-tender to palpation. Deep tendon reflexes are 3+ throughout. Lab results are as follows:

Serum:
Na+: 140 mEq/L
K+: 4.1 mEq/L
Cl-: 104 mEq/L
HCO3-: 26 mEql/L
BUN: 18 mg/dL
Creatinine 0.9 mg/dL

Hemoglobin: 14.0 g/dL
Leukocyte count: 7,400/mm^3
Platelet count 450,000/mm^3
TSH & Free T4: pending

A pregnancy test is negative. The patient is started on propranolol for symptomatic relief. What is the most likely best next step in management for this patient? Topic Review Topic

1. IV hydrocortisone
2. Propylthiouracil
3. Adalimumab
4. Thyroid scintigraphy with I-123
5. Surgical thyroidectomy

PREFERRED RESPONSE ▶
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