Types of presentation Goitre Occurs in almost all presentations of Grave’s disease – in which case it is usually diffuse and symmetrical The eye signs – Ophthalmopathy Occurs in 50% of cases of Grave’s disease This is the typical presentation of Grave [almostadoctor.co.uk]

Case presentation A 59-year-old Caucasian man was admitted with lethargy and progressive weight loss for 6 to 8 months prior to presentation. [jmedicalcasereports.biomedcentral.com]

(apathetic hyperthyroidism) 100 results Apathetic thyrotoxicosis presenting with diabetes mellitus. [unboundmedicine.com]

Jaundice may be present, but is unusual. [ahcmedia.com]

`0 Precipitating event Absent 0 Present 10 Interpretation: Likelihood of Thyroid Storm Score: < 25 – Unlikely 25-44 – Impending >45 – Highly likely The patient’s presentation may reflect complications of thyroid storm (stroke, myocardial infarction, [cdemcurriculum.com]

• Weight Loss

  Lack of weight gain that is normal during pregnancy, or significant weight loss, despite having normal appetite. [hyperthyroidismsymptomsx.com]

  Case presentation A 59-year-old Caucasian man was admitted with lethargy and progressive weight loss for 6 to 8 months prior to presentation. [jmedicalcasereports.biomedcentral.com]

  Signs and SymptomsSigns and Symptoms – Tremulousness or jitteriness – Exophthalmos – Weight loss despite excellent appetite – hypermetabolic state – Insomnia – Fatigue – Palpitations – Heat intolerance – Sweating – Diarrhea – Deterioration in handwriting [slideshare.net]

  Hyperthyroidism can accelerate your body's metabolism, causing unintentional weight loss and a rapid or irregular heartbeat. Several treatments are available for hyperthyroidism. [mayoclinic.org]

  These apathetic patients were significantly older and had a longer duration of symptoms and greater weight loss. The study group had a rather typical apathetic, placid, or depressed appearance often thought to represent "old age depression." [annals.org]

• Myxedema

  […] and hypoxia is common 33 Myxedema Diagnosis Must have high clinical suspicion Commonly has Hx. [slideplayer.com]

  Diffuse pretibial myxedema Dysprealbuminemic euthyroidal hyperthyroxinemia Hypercalcemia due to hyperthyroidism Hypermelanosis due to hyperthyroidism Hypermelanosis of the eyelids due to hyperthyroidism Hyperthyroid (high level of thyroid hormone) in [icd9data.com]

  […] contrast dyes Hypertrichosis in hyperthyroidism Hypertrophic cardiomyopathy secondary to hyperthyroidism Myasthenic syndrome due to thyrotoxicosis Pretibial myxedema Subclinical hyperthyroidism T>3< thyrotoxicosis Thyroid acropachy Thyrotoxic chorea [emedcodes.com]

  Myxedema Coma. The hypothyroid crisis of myxedema coma is a life-threatening manifestation of the hypothyroid state. [ahcmedia.com]

  Thyroid Storm and Myxedema Coma BACKGROUND Thyrotoxicosis and myxedema coma are life-threatening syndromes representing the extremes of thyroid dysfunction. [aneskey.com]

• Congestive Heart Failure

  Cardiovascular symptoms, atrial fibrillation, and congestive heart failure were common. They typically had evidence of a moderately severe proximal myopathy. Thyromegaly, although usually present, was not prominent and was usually multinodular. [annals.org]

  Congestive heart failure should be treated with digitalis and diuretics even though congestive failure due to hyperthyroidism may be refractory to digitalis. Cardiac arrhythmias are treated with the usual antiarrhythmic agents. [emjournal.net]

  heart failure.  Cardiac hypertrophy has been reported in thyrotoxicosis of different etiologies.  Severe acropachy can be disabling and can lead to total loss of hand function - clubbing of fingers with osteoarthropathy, including periosteal new bone [slideshare.net]

  Sinus tachycardia, heart rate 100-140 2. Heart rate faster than 140 beats/min, hypotension, atrial dysrhythmias, congestive heart failure 3. Diarrhea, increased appetite with loss of weight 3. [emedicine.medscape.com]

  These include a rapid heart rate, a heart rhythm disorder called atrial fibrillation that increases your risk of stroke, and congestive heart failure — a condition in which your heart can't circulate enough blood to meet your body's needs. [mayoclinic.org]

• Fatigue

  Other symptoms of thyroid storm include chest pain,palpitations, shortness of breath,delirium,confusion, psychosis, stupor, and fatigue. Fatal health complications include heart attack and stroke. [hyperthyroidismsymptomsx.com]

  Fatigue B. Palpitations C. Weight Loss D. Heat intolerance E. All the above 42 2. The most common etiology of hyperthyroidism is A. Toxic Multinodular B. Graves C. Toxic Nodular D. Amiodarone induces 43 3. [slideplayer.com]

  Presentation Symptoms/Physical exam Hypothyroidism Hyperthyroidism Cold intolerance (↓ heat production) Heat intolerance (↑ heat production) Weight gain, ↓ appetite Weight loss, ↑ appetite Hypoactivity, lethargy, fatigue, weakness Hyperactivity Constipation [medbullets.com]

  In fact, I am normally fatigued, low mood etc. This matches the AT descriptions I have been reading. I don't remember any doctors mentioning this. I am wondering whether I should be having any different treatment, or test to confirm this. [healthunlocked.com]

  They may include Being nervous or irritable Mood swings Fatigue or muscle weakness Heat intolerance Trouble sleeping Hand tremors Rapid and irregular heartbeat Frequent bowel movements or diarrhea Weight loss Goiter, which is an enlarged thyroid that [icdlist.com]

• Surgical Procedure

  Common precipitating events include an acute infection, trauma, or a surgical procedure. [clinicaladvisor.com]

  Surgical procedures are more difficult in patients who previously underwent thyroidectomy or radioiodine therapy. A treatment regimen for thyroid storm is shown in Treatment of Thyroid Storm. The precipitating cause should also be addressed. [merckmanuals.com]

• Hepatomegaly

  His lungs were clear and his abdomen revealed two-finger breath tender hepatomegaly with smooth edges without any ascites or splenomegaly. [jmedicalcasereports.biomedcentral.com]

  Jaundice and tender hepatomegaly due to passive congestion of the liver, or even hepatic necrosis, have been reported. Jaundice is a poor prognostic sign. LABORATORY There are no laboratory tests that confirm thyroid storm. [emjournal.net]

  Thyroid storm causes abrupt florid symptoms of hyperthyroidism with one or more of the following: fever, marked weakness and muscle wasting, extreme restlessness with wide emotional swings, confusion, psychosis, coma, nausea, vomiting, diarrhea, and hepatomegaly [merckmanuals.com]

  In severe thyrotoxicosis, hepatomegaly and jaundice may develop due to liver damage. 10. [empendium.com]

• Tachycardia

  Circulation: Tachycardia is common, either sinus tachycardia (most common rhythm) or atrial fibrillation (most common dysrhythmia). Supraventricular and ventricular dysrhythmias, including ventricular fibrillation, may occur. [cdemcurriculum.com]

  Cardiac symptoms may include congestive heart failure, which is often refractory to therapy, tachycardia, and a widened pulse pressure. [thebigl.co]

  A life-threatening thyrotoxic crisis (ie, thyroid storm) can occur: fever, tachycardia, neurologic abnormalities, and hypertension, followed by hypotension and shock. [slideshare.net]

  The most common cardiac manifestations of thyrotoxicosis are resting sinus tachycardia, supraventricular tachycardia including atrial fibrillation and atrial flutter with or without cardiac failure. [jmedicalcasereports.biomedcentral.com]

  Tachycardia, fever, hyperkinesis, tremor, proximal myopathy, periodic paralysis, bulbar palsy and hypercalcaemia respond. [aic.cuhk.edu.hk]

• Cardiomegaly

  His chest X-ray showed cardiomegaly but no pulmonary oedema. However his 12-lead electrocardiogram showed complete heart block with underlying atrial fibrillation (Figure 1 ). [jmedicalcasereports.biomedcentral.com]

  Most patients will have weight loss, evidence of cardiomyopathy, myopathy and may have atrial fibrillation, congestive heart failure, cardiomegaly and muscle weakness. Thyroid storm. [ocw.tufts.edu]

  The chest radiographic finding noted in some of these patients was essentially that of increased cardiothoracic ratio suggestive of cardiomegaly. [pjms.com.pk]

  - Echocardiography, which may disclose a pericardial effusion associated to cardiomegaly, increased thickness of all cardiac walls and reduced cardiac output. - Computed tomography (CT) of the brain that is normal in most patients with primary hypothyroidism [frontiersin.org]

• Fracture

  Brittle Bones Osteoporosis associated with brittle bones and frequent fractures, is common in postmenopausal women with hyperthyroidism. Infertility Hyperthyroidism hinders a woman’s chances to conceive. [hyperthyroidismsymptomsx.com]

  Patients with serum TSH 0.1 mU/L have an increased incidence of atrial fibrillation (particularly elderly patients), reduced bone mineral density, increased fractures, and increased mortality. [merckmanuals.com]

  There is a small increase in fracture rate in patients with a previous history of thyrotoxicosis. [webedcafe.com]

  Even after successful treatment, there is a threefold increased risk of death from osteoporotic fracture and a 1.3-fold increased risk of death from cardiovascular disease and stroke. [enetmd.com]

  Complications Top Indirect (eg, a stroke in a patient with atrial fibrillation caused by hyperthyroidism) or direct and acute (thyrotoxic crisis—a life-threatening complication) or chronic (atrial fibrillation, osteoporotic fractures) consequences of [empendium.com]

• Chemosis

  Suggestive of Graves disease: Proptosis Periorbital edema Chemosis Diplopia Neck. [cdemcurriculum.com]

  Other manifestations include: chemosis (swelling of the conjunctiva), extraocular muscle dysfunction (most commonly the inferior rectus limiting upward gaze), keratitis (inflammation of the cornea) and loss of vision from optic nerve involvement. [ocw.tufts.edu]

  Figure 1b: Active Graves’ orbitopathy with eyelid erythema, severe injection of the conjunctiva, and chemosis. Additionally, an orbital fat prolapse is present. [webedcafe.com]

  There may be lid lag, chemosis, exophthalmos, and vasodilatation of the conjunctiva with edema of the lids. Visual acuity may be compromised by compressive optic neuropathy. [ahcmedia.com]

• Blurred Vision

  vision, protrusion of the eyes, characteristic gaze or stare, double vision (diplopia), all together termed asophthalmopathy. [hyperthyroidismsymptomsx.com]

• Skin Disease

  Also, patients with dermopathy have higher TSI serum levels compared with those with Graves’ thyroidal disease only [33]. It is recommended to rule out other skin diseases if Graves’ dermopathy without eye involvement is present. [webedcafe.com]

• Withdrawn

  Usually, these subjects have previously been taking l -thyroxine substitution therapy, unless they have subsequently withdrawn it on their own initiative. [frontiersin.org]

  Although β-blockers will rapidly alleviate symptoms in all types of hyperthyroidism, definitive treatment is also necessary, and when euthyroidism is restored β-blockers can be gradually withdrawn. [enetmd.com]

  The patient is mentally slow and withdrawn. The skin is dry, coarse, cool, and wrinkled. There may be muscle wasting and proximal myopathy. 53 Weakness in respiratory and skeletal muscles may be factors in decreased exercise tolerance and dyspnea. [ahcmedia.com]

• Psychomotor Retardation

  Dementia and severe psychomotor retardation may be the most prominent findings. 60 The Heart in Thyrotoxicosis. Thyrotoxicosis increases the work of the heart. [ahcmedia.com]

• Renal Injury

  […] central nervous system sensitivity to hypoxia and hypercarbia, as well as airway problems from macroglossia, respiratory muscle weakness, and nonpitting edema (myxedema) of the nasopharynx. 41 Altered vascular permeability leads to effusions and ascites; renal [aneskey.com]

• Confusion

  Other symptoms of thyroid storm include chest pain,palpitations, shortness of breath,delirium,confusion, psychosis, stupor, and fatigue. Fatal health complications include heart attack and stroke. [hyperthyroidismsymptomsx.com]

  On examination, the patient appeared ill, prostrated, and confused. Blood pressure was 190/120 mm Hg, pulse was 148/min and irregular, and respiratory rate was 20/min. Mucous membranes were dry and a pulse deficit of 20 was present. [thefreelibrary.com]

  Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma Certain unusual presentations include chest pain, acute abdomen, status epilepticus, stroke, acute renal failure due to rhabdomyolysis, and apathetic thyroidism. [emedicine.medscape.com]

  Skin usually moist and warm - confusion, fits, coma, muscle weakness. Very common. Features of UMN lesions have been described as has rhabdomyolysis and sudden onset of thyrotoxic periodic paralysis - arrhythmias, cardiac failure. [aic.cuhk.edu.hk]

  About 1 percent of patients with Graves’ disease develop myasthenia gravis, producing an occasional confusing clinical situation. [emjournal.net]

• Apathy

  The patient had a recent history of decreased mentation and apathy, and laboratory findings were found to be consistent with hyperthyroidism. [thefreelibrary.com]

  Apathy, or symptoms of depression? Often seen in elderly – apathetic hyperthyroidism. Are there associated cardiovascular complaints? Dyspnea? Chest pain? Acute myocardial infarction can trigger or be triggered by thyroid storm. [cdemcurriculum.com]

  Overt thyrotoxic crisis : Fever; extreme agitation and worsening of psychotic symptoms; sometimes somnolence, apathy, or even coma; in some cases, status epilepticus; sudden worsening of cardiovascular symptoms (severe tachycardia, atrial fibrillation [empendium.com]

  Apathy, stupor and coma may occur. Laboratory evaluation of thyrotoxicosis begins with a measurement of TSH. If TSH is suppressed ( Figure 1. [ocw.tufts.edu]

• Fine Tremor

  Sinus Tachycardia or A-fib Hyperdynamic precordium Widened pulse pressure Rub Neuro\psychiatric Anxiety to agitation to psychosis to coma Fine tremor, especially on extension of arms Paralysis Stroke Thyrotoxic periodic paralysis (Especially Asian men [cdemcurriculum.com]

  They will reduce symptoms such as: Tachycardia Dysrhythmias Tremor Agitation Beta-blockers also decrease peripheral conversion of T4 to T3. [almostadoctor.co.uk]

  Fine tremor is a very frequent finding, best elicited by asking patients to stretch out the fingers and feeling the fingertips with the palm. [webedcafe.com]

  altered mood Heat intolerance, sweating Palpitations Fatigue, weakness Weight loss with increased appetite Diarrhoea, steatorrhoea Polyuria Oligomenorrhoea, amenorrhoea, loss of libido Signs Sinus tachycardia, atrial fibrillation in older patients Fine [enetmd.com]

  Neuropsychiatric symptoms : Anxiety, irritability, hyperactivity (hyperkinetic behavior), concentration problems, insomnia; rarely, psychotic symptoms (suggestive of schizophrenia or bipolar disorder); fine tremor and hyperreflexia. 3. [empendium.com]

• Agitated Delirium

  Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma Certain unusual presentations include chest pain, acute abdomen, status epilepticus, stroke, acute renal failure due to rhabdomyolysis, and apathetic thyroidism. [emedicine.medscape.com]

  […] or delirium to extreme lethargy or coma, and, rarely, seizures. [clinicaladvisor.com]

HYPERTHYROIDISM (THYROTOXICOSIS) Workup This disorder is the result of an excessive concentration of circulating thyroid hormone. [thebigl.co]

Truly refractory disease is rarely found in a properly conducted workup. Postgraduate Medicine 2000;107:123-45. 33. Klein I, Ojomata K. Thyroid hormone and blood pressure regulation. [pjms.com.pk]

[…] with thyrotoxicosis demonstrate no clinical signs or symptoms of a goiter and may even have depressive signs, such as apathy and fatigue. 7 This genre of clinical symptoms is termed “apathetic hyperthyroidism” and is often diagnosed after a lengthy workup [aneskey.com]

PubMed PMID: 11589682. 2) Serum antibodies to thyroperoxidase ( TPO )—TPO Ab—and antibodies to thyroglobulin ( Tg )—Tg Ab—(least specific): Measurement of TPO Ab and Tg Ab is not suggested for the workup of patients with low TSH values, Weak recommendation [empendium.com]

The American College of Emergency Physicians lists thyroid screening tests in its guidelines for the workup of the elderly patient with lethargy, agitation, or any alteration in level of consciousness. 20 Weight loss results in depletion of fat stores [ahcmedia.com]

Significant updates on bariatric surgery, Barrett's esophagus, endoscopic ultrasound, endosonography, treatment of liver disease, and much more keep you current on the latest advances. [books.google.com]

Patients must be monitored for side effects of anti-thyroid drug treatment (see above); any major adverse effects require discontinuation of anti-thyroid drug treatment and selection of another treatment option. [clinicaladvisor.com]

Up to 30% of women can cease treatment by the third trimester. The baby should be checked straight after birth, as treatment in this way can cause a goitre. [almostadoctor.co.uk]

Surgical Treatment (Thyroidectomy) 1. [empendium.com]

Decreasing pulse rate and BP with the development of shock are associated with poor prognosis - vomiting, diarrhoea. [aic.cuhk.edu.hk]

Presence of jaundice suggests especially poor prognosis. Ultimately, thyroid storm is a clinical diagnosis and requires prompt recognition and treatment. [mdcalc.com]

(Textbook chapter presenting clinical manifestations, treatment options, and prognosis of hyperthyroidism in children.) Bahn Chair, RS, Burch, HB, Cooper, DS. [clinicaladvisor.com]

The nature and prognosis of heart disease in thyrotoxicosis. Q J Med 1959;28:347-70. 30. Yang YS, Chang CC, Su DH. Unusual presentation of thyrotoxicosis as bradycardia, acute renal failure and hyperuricaemia in an elderly patient. [pjms.com.pk]

The disease mainly affects female gender and the prognosis is usually favorable, except for malignancies ( 106, 107 ). [frontiersin.org]

[…] most common) Idiopathic causes Ablative therapy Iodine deficiency May be transient Pathophysiology is unclear but may be viral in nature 23 Hypothyroidism Etiologies of Hypothyroidism Primary Autoimmune etiologies Hashimotos is the most common Idopathic [slideplayer.com]

 Cardiac hypertrophy has been reported in thyrotoxicosis of different etiologies.  Severe acropachy can be disabling and can lead to total loss of hand function - clubbing of fingers with osteoarthropathy, including periosteal new bone formation, [slideshare.net]

However, these patients are often critically ill and the complications or inciting etiology of the patient’s thyroid storm may require active airway intervention. [cdemcurriculum.com]

Therapy for hyperthyroidism depends on the etiology. [thebigl.co]

Ongoing controversies regarding etiology, diagnosis, treatment Thyroid storm is a rare complication of thyrotoxicosis. [clinicaladvisor.com]

Epidemiology/Pathophysiology Graves' disease is the most common form of hyperthyroidism accounting for 60-70% of all cases. It occurs in up to 3% of the population. [ocw.tufts.edu]

These antibodies stimulate the thyroid gland to produce more T3 and T4 Epidemiology Can occur at any age Peak onset age 40-60 F:M 5-10 : 1 Aetiology Environment triggers include: High iodine intake Stress Smoking Smoking is also a major risk factor in [almostadoctor.co.uk]

Amer J Epidemiology 2003;157:1101-7. 17. Rojeski MT, Gharib H. Nodular thyroid disease. New Eng J Medicine 1985;4:249-53. 18. Czarkowski M, Hilgertner L, Powalowski T, Radomski D, Mikulska M. [pjms.com.pk]

Epidemiology The prevalence of thyrotoxicosis in white people is 2 to 3% in women and 0.2 to 0.3% in men. The peak age of onset for Graves’ disease is between 20 and 50 years of age, whereas toxic multinodular goitre occurs more often in later life. [enetmd.com]

Epidemiology Graves’ disease occurs in approximately 1:5,000 children. There is no seasonal variation. The peak age of Graves’ disease is in adolescence; it is more common in females (~5:1 female:male ratio). [clinicaladvisor.com]

12 - 912 ページ Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text, 10th Edition has been extensively revised and streamlined to deliver the most comprehensive coverage of the thyroid including anatomy, development, biochemistry, physiology, pathophysiology [books.google.com]

Epidemiology/Pathophysiology Graves' disease is the most common form of hyperthyroidism accounting for 60-70% of all cases. It occurs in up to 3% of the population. [ocw.tufts.edu]

[…] secretion Occurs more frequently in women (0.6 to 5.9 %) The most common etiologies are Primary thyroid failure due to autoimmune diseases (Hashimoto thyroiditis is the most common) Idiopathic causes Ablative therapy Iodine deficiency May be transient Pathophysiology [slideplayer.com]

PATHOPHYSIOLOGY The exact pathogenesis of thyroid storm has not been defined. It is attractive to attribute storm to excess thyroid hormone production or secretion. [emjournal.net]

In Laragh JH, Brenner BM, editors, Hypertension, pathophysiology, diagnosis and management. 2nd Edition, New York Raven Press 1995;2247-62. Professional Medical Publications Room No. 522, 5th Floor, Panorama Centre Building No. 2, P.O. [pjms.com.pk]

Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets [books.google.com]

In brief: The management strategy for thyroid storm revolves around preventing peripheral effects of raised thyroid hormone levels, and preventing the ongoing increase of said levels by inhibiting the synthesis and release of thyroid hormone. [derangedphysiology.com]

Chlorpromazine 25-50 mg 4-6 hrly to prevent shivering - fluid replacement. [aic.cuhk.edu.hk]

[…] relases of hormone (after synthesis blockade intiated) Iodine Iaponoric acid (Telepaque) 1 gm IV q8h for the first 24 h, then 500 mg bid or Potassium iodide (SSKI) 5 drops PO q6h or Lugol solution 8-10 drops PO q6h Lithuim mg PO every day Prevent peripheral [slideplayer.com]