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    • Basic and Clinical Science Course - Excerpt
  • 2020–2021 BCSC Basic and Clinical Science Course™

    Go to Academy Store Learn more and Purchase.

    1 Update on General Medicine

    Chapter 2: Endocrine Disorders

    Thyroid Disease

    Hyperthyroidism

    Hypermetabolism caused by excessive quantities of circulating thyroid hormones leads to the clinical syndrome of hyperthyroidism (thyrotoxicosis). Clinical findings include exophthalmos, chest palpitations, excessive sweating, diarrhea, weight loss, and sensitivity to heat. Graves hyperthyroidism accounts for approximately 85% of cases of thyrotoxicosis. Toxic nodular goiter and thyroiditis account for most of the remaining cases.

    Thyroid storm is a rare, acute hypermetabolic state that is fatal if untreated. It is often precipitated by surgery, infection, or trauma in a patient with otherwise mild hyperthyroidism. Patients typically present with fever, tachycardia, nausea, vomiting, agitation, and psychosis; and they may become comatose secondary to hypotension. Modern treatments aimed at controlling the process have dramatically reduced mortality.

    Graves hyperthyroidism

    Thyroid eye disease (TED) is discussed in BCSC Section 5, Neuro-Ophthalmology, and Section 7, Oculofacial Plastic and Orbital Surgery. This section focuses on the thyroid disease.

    Patients with Graves hyperthyroidism (also known as diffuse toxic goiter) exhibit various combinations of hypermetabolism, diffuse enlargement of the thyroid gland, TED, and infiltrative dermopathy. Graves hyperthyroidism is an autoimmune disorder. Up to 90% of patients have circulating TSH receptor antibodies; furthermore, the level of TSI has been shown to correlate with the severity of clinical disease.

    Graves hyperthyroidism is common, with a lifetime risk of 3.0% for women and 0.5% for men. The incidence peaks in the third to fifth decades of life, and there is a strong familial component. Risk factors including stress and smoking are associated with increased incidence of thyroid eye disease.

    Common clinical symptoms include fatigue, tremor, weight loss, palpitations, and heat intolerance. Manifestations can vary by age of patient at the onset of hyperthyroidism. For instance, atrial fibrillation is rare in patients younger than 60 years but occurs in more than 10% of patients 60 years or older. A palpable goiter develops in most patients younger than 60 years old compared with less than 50% of patients older than 60 years. Approximately one-third of patients with Graves hyperthyroidism have clinically obvious TED at the time of diagnosis of the hyperthyroidism.

    Treatment of Graves hyperthyroidism is aimed at returning thyroid function to normal. A significant proportion of patients (30%–50%) experience remission in association with drug treatment directed at the thyroid. Later in the course of the disease, patients may experience relapse, hypothyroidism, or both.

    Thyroid secretion is suppressed using one of the thiourea derivatives, propylthiouracil or methimazole. The drugs inhibit the use of iodine by the gland. Treatment is continued until clinical and laboratory indexes show improvement. Adverse effects include rash (common), liver damage (rare), vasculitis (rare), and agranulocytosis (occurs in 0.02%–0.05% of patients).

    There are several options for long-term management of Graves hyperthyroidism: the aforementioned antithyroid drugs can be continued for 12–24 months in hopes of remission; part of the gland can be surgically removed, although approximately half of such patients eventually become hypothyroid; or radioactive iodine can be used. Iodine 131 (131I) is highly effective, resulting in hypothyroidism in 80% of patients within 6–12 months; some require a second treatment. Although adverse effects of 131I are minimal, its use is associated with worsening of TED.

    Ophthalmic considerations A new drug, teprotumumab, has been shown to slow progression of ophthalmopathy in patients with moderate to severe thyroid eye disease and is currently undergoing clinical trials. The drug, which inhibits insulin-like growth factor I receptor, represents a new therapeutic strategy for treating the underlying autoimmune pathogenesis of TED. Teprotumumab has been granted orphan drug status by the US Food and Drug Administration, and clinical trials will determine if it slows the progression of ophthalmopathy in patients with newly diagnosed TED.

    • Smith TJ, Hegedüs L. Graves’ disease. N Engl J Med. 2016;375(16):1552–1565.

    • Smith TJ, Kahaly GJ, Ezra DG, et al. Teprotumumab for thyroid-associated ophthalmopathy. N Engl J Med. 2017;376(18):1748–1761.

    Toxic nodular goiter

    In toxic nodular goiter, thyroid hormone–producing adenomas (either single or multiple) make enough hormone to cause hyperthyroidism. These so-called hot nodules are almost never carcinomatous and often result in hyperthyroidism. Toxic nodules may be treated with radioactive iodine or surgery.

    Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.

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  • The Academy Store
    2022-2023 Basic and Clinical Science Course, Complete Print Set
    2022-2023 Basic and Clinical Science Course, Complete eBook Set
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    2022-2023 Basic and Clinical Science Course, Residency eBook Set
    2022-2023 Basic and Clinical Science Course Complete Set
    2022-2023 Basic and Clinical Science Course Residency Set
    2022-2023 Basic and Clinical Science Course, Section 01: Update on General Medicine
    2022-2023 Basic and Clinical Science Course, Section 02: Fundamentals and Principles of Ophthalmology
    2022-2023 Basic and Clinical Science Course, Section 03: Clinical Optics and Vision Rehabilitation
    2022-2023 Basic and Clinical Science Course, Section 04: Ophthalmic Pathology and Intraocular Tumors
    2022-2023 Basic and Clinical Science Course, Section 05: Neuro-Ophthalmology
    2022-2023 Basic and Clinical Science Course, Section 06: Pediatric Ophthalmology and Strabismus
    2022-2023 Basic and Clinical Science Course, Section 07: Oculofacial Plastic and Orbital Surgery
    2022-2023 Basic and Clinical Science Course, Section 08: External Disease and Cornea
    2022-2023 Basic and Clinical Science Course, Section 09: Uveitis and Ocular Inflammation
    2022-2023 Basic and Clinical Science Course, Section 10: Glaucoma
    2022-2023 Basic and Clinical Science Course, Section 11: Lens and Cataract
    2022-2023 Basic and Clinical Science Course, Section 12: Retina and Vitreous
    2022-2023 Basic and Clinical Science Course, Section 13: Refractive Surgery
    2022 IRIS Registry (Intelligent Research in Sight) Preparation Kit
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    2022 Coding Coach: Complete Ophthalmic Coding Reference 
    2022 CPT: Complete Pocket Ophthalmic Reference
    2022 Retina Coding: Complete Reference Guide
 
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