Sandbox:ddx graves: Difference between revisions
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{{familytree/start}} | |||
{{familytree | | | | | | | | | | | | | | A01 | | | | | |A01=Suspected Graves' disease}} | |||
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | }} | |||
{{familytree | | | | | | | | | | | | | | B01 | | | | | |B01=Measure serum TSH and free T4}} | |||
{{familytree | | | | | |,|-|-|-|v|-|-|-|-|^|-|-|-|-|v|-|-|-|.| }} | |||
{{familytree | | | | | C01 | | C02 | | | | | | | | C03 | | C04 | | | |C01=Normal TSH & free T4|C02=↓ TSH & ↑ free T4|C03=↓ TSH & Normal free T4|C04= Normal or ↑ TSH & ↑ free T4}} | |||
{{familytree | | | | | |!| | | |!| | | | | | | | | |!| | | |!| }} | |||
{{familytree | | | | | D01 | | D02 | | | | | | | | D03 | | D04 | | | |D01= Hyperthyroidism ruled out|D02=Hyperthyrodism|D03=Measure free T3|D04=TSH secreting pituitary tumor,<br> Thyroid hormone resistance<br> or Assay interference }} | |||
{{familytree | | | | | | | | | |!| | | | | | | | | |!| | | | || | | }} | |||
{{familytree | | | | | | | | | E03 | | | | | | |,|-|^|-|.| | |E03=Measure TSH receptor antibodies }} | |||
{{familytree | | | | | | | | | |!| | | | | | | F01 | | F02 | |F01=↑ free T3|F02=Normal free T3 }} | |||
{{familytree | | | | | | | |,|-|^|-|.| | | | | |!| | | |!| |}} | |||
{{familytree | | | | | | | G01 | | G02 | | | | G03 | | G04 | |G01=Present|G02=Absent|G03=T3 Toxicosis|G04=Sub-clinical Hyperthyrodism}} | |||
{{familytree | | | | | | | |!| | | |!| | | | | | | | | |!| | | | }} | |||
{{familytree | | | | | | | H01 | | H02 | | | | | | | | H03 | |H01='''Graves' Disease|H02=Assess radioiodine uptake<br>obtain radionuclide scan<br> or both|H03=Evolving Graves' disease<br>Evolving toxic nodular goiter<br>Excess thyroid hormone intake<br>Non thyroidal illness }} | |||
{{familytree | | | | | | | | | | | |!| | | | | | | | | | | | | | }} | |||
{{familytree | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | }} | |||
{{familytree | | | | | | | I01 | | I02 | | I03 | | | | | | | | |I01=Homogeneous<br>increased uptake|I02=Patchy uptake<br>or single nodule|I03=Low or no uptake}} | |||
{{familytree | | | | | | | |!| | | |!| | | |!| | | | | | | | | | }} | |||
{{familytree | | | | | | | J01 | | J02 | | J03 | | | | | | | | |J01=Graves' disease|J02=Toxic nodular goiter|J03=Subacute thyroiditis<br>Excess thyroid hormone intake<br>HCG secreting tumor}} | |||
{{familytree/end}} | |||
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|Cause of thyrotoxicosis}} | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|TSH receptor Antibodies}} | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|Thyroid US}} | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|Color flow Doppler}} | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}} | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|Other features}} | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Graves' disease}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Present | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↑ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↑ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Toxic nodular goiter}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules | |||
| style="padding: 5px 5px; background: #F5F5F5;" | - | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan | |||
| style="padding: 5px 5px; background: #F5F5F5;" | - | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Toxic adenoma}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule | |||
| style="padding: 5px 5px; background: #F5F5F5;" | - | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule | |||
| style="padding: 5px 5px; background: #F5F5F5;" | - | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Subacute thyroiditis}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↓ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain-fever and<br> elevated inflammatory index | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Painless thyroiditis}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↓ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | - | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Amiodarone induced thyroiditis-Type 1}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Diffuse or nodular goiter | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↓/Normal/↑ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↓ but higher than in Type 2 | |||
| style="padding: 5px 5px; background: #F5F5F5;" | High urinary iodine | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Amiodarone induced thyroiditis-Type 2}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Normal | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↓/absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | High urinary iodine | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Central hyperthyroidism}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Diffuse or nodular goiter | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Normal/↑ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↑ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Inappropriately normal or high TSH | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Trophoblastic disease}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Diffuse or nodular goiter | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Normal/↑ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↑ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | - | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Factitious thyrotoxicosis}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Variable | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↓ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↓ serum thyroglobulin | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Struma ovarii}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Variable | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow | |||
| style="padding: 5px 5px; background: #F5F5F5;" | ↓ | |||
| style="padding: 5px 5px; background: #F5F5F5;" | Abdominal RAIU | |||
|} | |||
{| style="border: 0px; font-size: 80%; margin: 3px;" align=center | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|Severity}} | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|Therapy}} | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|Mechanism}} | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|Advantages/disadvantages}} | |||
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 | {{fontcolor|#FFFFFF|Common Doses}} | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|Mild active disease}} | |||
| style="background: #F5F5F5; padding: 5px 5px;" rowspan=1 colspan=1 | Topical solutions <br>Artificial tears<br>Glucocorticoids<br>Avoidance of wind, light, dust, smoke<br>Elevation of head during sleep<br>Avoidance of eye cosmetics<br>Selenium | |||
| style="background: #F5F5F5; padding: 5px 5px;" rowspan=1 colspan=1 | <br>Maintain tear film<br>Reduce inflammation<br>Reduces ocular surface desiccation, reduces irritation<br>Reduces orbital congestion<br>Reduces irritation<br>Uncertain | |||
| style="background: #F5F5F5; padding: 5px 5px;" rowspan=1 colspan=1 | Rapid action, minimal side effects<br>Rapid action, minimal side effects<br> <br>Benefits not yet confirmed<br>Benefits not yet confirmed<br> | |||
| style="background: #F5F5F5; padding: 5px 5px;" rowspan=1 colspan=1 | | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=4 colspan=1 |{{fontcolor|#FFFFFF|Moderate or severe active disease}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Systemic glucocorticoids <br>Oral<br>Intravenous | |||
| style="padding: 5px 5px; background: #F5F5F5;" |<br>Reduce inflammation and orbital congestion <br>Reduce inflammation and orbital congestion | |||
| style="padding: 5px 5px; background: #F5F5F5;" |<br>Hyperglycemia, hypertension, osteoporosis<br>Rapid onset of anti-inflammatory effect, fewer side, liver damage | |||
| style="padding: 5px 5px; background: #F5F5F5;" |<br>Up to 100 mg of oral prednisone daily, followed by tapering of the dose<br>Methylprednisolone, 500 mg/wk for 6 wk followed by 250 mg/wk for 6 wk | |||
|- | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Orbital irradiation | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Reduces inflammation | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Can induce retinopathy | |||
| style="padding: 5px 5px; background: #F5F5F5;" |2 Gy daily for 2 wk (20 Gy total) | |||
|- | |||
| style="padding: 5px 5px; background: #F5F5F5;" |B-cell depletion | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Reduces autoreactive B cells | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Very expensive; risks of infection, cancer, allergic reaction | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Two 1000-mg doses of intravenous rituximab 2 wk apart | |||
|- | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Emergency orbital decompression | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Reduces orbital volume | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
|- | |||
| style="background: #4479BA; padding: 5px 5px;" rowspan=4 colspan=1 |{{fontcolor|#FFFFFF|Stable disease (inactive)}} | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Orbital decompression (fat removal) | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Reduces orbital volume | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Postoperative diplopia, pain | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
|- | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Bony decompression of the lateral and medial walls | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Reduces proptosis by enlarging orbital space | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Postoperative diplopia, pain, sinus bleeding, cerebrospinal fluid leak | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
|- | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Strabismus repair | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Improves eye alignment, reduces diplopia | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
|- | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Eyelid repair | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Improves appearance, reduces lagophthalmos and improves function | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
|} |
Latest revision as of 21:29, 20 December 2016
Suspected Graves' disease | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Measure serum TSH and free T4 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Normal TSH & free T4 | ↓ TSH & ↑ free T4 | ↓ TSH & Normal free T4 | Normal or ↑ TSH & ↑ free T4 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Hyperthyroidism ruled out | Hyperthyrodism | Measure free T3 | TSH secreting pituitary tumor, Thyroid hormone resistance or Assay interference | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Measure TSH receptor antibodies | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
↑ free T3 | Normal free T3 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Present | Absent | T3 Toxicosis | Sub-clinical Hyperthyrodism | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Graves' Disease | Assess radioiodine uptake obtain radionuclide scan or both | Evolving Graves' disease Evolving toxic nodular goiter Excess thyroid hormone intake Non thyroidal illness | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Homogeneous increased uptake | Patchy uptake or single nodule | Low or no uptake | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Graves' disease | Toxic nodular goiter | Subacute thyroiditis Excess thyroid hormone intake HCG secreting tumor | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Cause of thyrotoxicosis | TSH receptor Antibodies | Thyroid US | Color flow Doppler | Radioactive iodine uptake/Scan | Other features |
---|---|---|---|---|---|
Graves' disease | Present | Hypoechoic pattern | ↑ | ↑ | Ophthalmopathy, dermopathy, acropachy |
Toxic nodular goiter | Absent | Multiple nodules | - | Hot nodules at thyroid scan | - |
Toxic adenoma | Absent | Single nodule | - | Hot nodule | - |
Subacute thyroiditis | Absent | Heterogeneous hypoechoic areas | Reduced/absent flow | ↓ | Neck pain-fever and elevated inflammatory index |
Painless thyroiditis | Absent | Hypoechoic pattern | Reduced/absent flow | ↓ | - |
Amiodarone induced thyroiditis-Type 1 | Absent | Diffuse or nodular goiter | ↓/Normal/↑ | ↓ but higher than in Type 2 | High urinary iodine |
Amiodarone induced thyroiditis-Type 2 | Absent | Normal | Absent | ↓/absent | High urinary iodine |
Central hyperthyroidism | Absent | Diffuse or nodular goiter | Normal/↑ | ↑ | Inappropriately normal or high TSH |
Trophoblastic disease | Absent | Diffuse or nodular goiter | Normal/↑ | ↑ | - |
Factitious thyrotoxicosis | Absent | Variable | Reduced/absent flow | ↓ | ↓ serum thyroglobulin |
Struma ovarii | Absent | Variable | Reduced/absent flow | ↓ | Abdominal RAIU |
Severity | Therapy | Mechanism | Advantages/disadvantages | Common Doses |
---|---|---|---|---|
Mild active disease | Topical solutions Artificial tears Glucocorticoids Avoidance of wind, light, dust, smoke Elevation of head during sleep Avoidance of eye cosmetics Selenium |
Maintain tear film Reduce inflammation Reduces ocular surface desiccation, reduces irritation Reduces orbital congestion Reduces irritation Uncertain |
Rapid action, minimal side effects Rapid action, minimal side effects Benefits not yet confirmed Benefits not yet confirmed |
|
Moderate or severe active disease | Systemic glucocorticoids Oral Intravenous |
Reduce inflammation and orbital congestion Reduce inflammation and orbital congestion |
Hyperglycemia, hypertension, osteoporosis Rapid onset of anti-inflammatory effect, fewer side, liver damage |
Up to 100 mg of oral prednisone daily, followed by tapering of the dose Methylprednisolone, 500 mg/wk for 6 wk followed by 250 mg/wk for 6 wk |
Orbital irradiation | Reduces inflammation | Can induce retinopathy | 2 Gy daily for 2 wk (20 Gy total) | |
B-cell depletion | Reduces autoreactive B cells | Very expensive; risks of infection, cancer, allergic reaction | Two 1000-mg doses of intravenous rituximab 2 wk apart | |
Emergency orbital decompression | Reduces orbital volume | |||
Stable disease (inactive) | Orbital decompression (fat removal) | Reduces orbital volume | Postoperative diplopia, pain | |
Bony decompression of the lateral and medial walls | Reduces proptosis by enlarging orbital space | Postoperative diplopia, pain, sinus bleeding, cerebrospinal fluid leak | ||
Strabismus repair | Improves eye alignment, reduces diplopia | |||
Eyelid repair | Improves appearance, reduces lagophthalmos and improves function |