Sandbox: hyperthyroidism 2

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Differentiating hyperthyroidism from other diseases

According to the origin of the abnormality

Primary hyperthytoidism

Secondary hyperthyroidism

Tertiary hyoperthyroidism

• Grave’s disease • Toxic thyroid nodule • Thyroid adenoma • Multinodular goiter

• Pituitary adenoma • Intracranial tumors pressing pituitary gland

• Excess thyroxin production due to disorders of the hypothalamus which may be due to intracranial tumors or masses.

According to iodine uptake

Hyperthyroidism can be classified according to the results of iodine uptake test into

High iodine uptake

• Graves' disease
• Toxic multinodular goiter
• Toxic thyroid adenoma

High or normal uptake:

• Iodine caused hyperthyroidism
• Hashitoxicosis
• Germ cell tumors (choriocarcinoma in males and testicular germ cell tumors)
• Pituitary TSH producing adenoma

Low uptake:

• Subacute thyroiditis
• Hyperthyroidism due to ectopic thyroid tissue
• Factitious thyrotoxicosis
• Struma ovarii
• Painless thyroiditis
• Amiodarone induced thyroiditis-Type 1
• Amiodarone induced thyroiditis-Type 2

Disease	Prominent clinical features	Lab findings	Images
Hyperthyroidism	The main symptoms include: Palpitations Insomnia Anxiety Weight loss Heat intolerance Diarrhea Depending on the underlying diagnosis, the patient might have exophthalmus or goiter	The patient usually has elevated T3 and T4 TSH might be increased or decreased depending on the underlying cause Thyroid stimulating antibodies (TSI) might be increased in cases of Graves’ disease	By Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center - The Eyes Have It, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=16115992
Essential hypertension	Most patients with hypertension are asymptomatic at the time of diagnosis. Common symptoms are listed below: Headache Blurry vision Dyspnea Epistaxis Tinnitus Fatigue Drowsiness	JNC 7 recommends the following routine laboratory tests before initiation of therapy for hypertension: 12-Lead electrocardiogram (ECG) Urinalysis, including urinary albumin excretion or albumin/creatinine ratio Blood glucose Blood hematocrit Serum electrolytes, especially potassium Serum calcium Lipid profile: Total cholesterol, LDL, HDL, triglycerides Creatinine or estimated GFR	-
Generalized anxiety disorder	DSM-V Diagnostic Criteria for Generalized Anxiety Disorder “ A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). AND B. The individual finds it difficult to control the worry. AND C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months); Note: Only one item is required in children. 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). AND D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. AND E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g.,hyperthyroidism). AND F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder social phobia, contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in post traumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder). ”	-	-
Menopausal symptoms	The perimenopause symptoms are caused by an overall drop, as well as dramatic but erratic fluctuations, in the levels of estrogens, progestin, and testosterone. Some of these symptoms such as formication etc may be associated with the hormone withdrawal process. Vasomotor instability Hot flashes, hot flushes, including night sweats Sleep disturbances Urogenital atrophy Itching Dryness Bleeding Watery discharge Urinary frequency Urinary urgency Urinary incontinence Skeletal Osteoporosis gradually developing over time Joint pain, muscle pain Back pain Skin, soft tissue Breast atrophy Skin thinning Decreased elasticity Formication, a sensation of pins and needles, or ants crawling on or under the skin Psychological Mood disturbance Irritability Fatigue Memory loss Depression Sexual Decreased libido Vaginal dryness Problems reaching orgasm Dyspareunia	B-HCG should always be done first to rule out pregnancy especially in women under the age of 45 years FSH can be measured but it can be falsely normal or low TSH, T3 and T4 to rule out thyroid abnormalities Prolactin can be measured to rule out prolactinoma as a cause of menopause	-
Opioid withdrawal disorder	DSM-V Diagnostic Criteria for Opioid Withdrawal “ A. Presence of either of the following; 1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e.,several weeks or longer). 2. Administration of an opioid antagonist after a period of opioid use. AND B. Three (or more) of the following developing within minutes to several days after Criterion A: 1. Dysphoric mood. 2. Nausea or vomiting. 3. Muscle aches. 4. Lacrimation or rhinorrhea. 5. Pupillary dilation, piloerection, or sweating. 6. Diarrhea. 7. Yawning. 8. Fever. 9.Insomnia. AND C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. AND D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. ”	Urine drug screen to rule out any other associated drug abuse Routine blood work such as electrolytes and hemoglobin to rule out any associated disease explaining the symptoms	-
Pheochromocytoma	The hallmark symptoms of a pheochromocytoma are those of sympathetic nervous system hyperactivity, symptoms usually subside in less than one hour and they may include: Palpitations especially in epinephrine producing tumors. Anxiety often resembling that of a panic attack Sweating Headaches occur in 90 % of patients. Paroxysmal attacks of hypertension but some patients have normal blood pressure. It may be asymptomatic and discovered by incidence screening especially MEN patients. Please note that not all patients with pheochromocytoma experience all classical symptoms.	Diagnostic lab findings associated with pheochromocytoma include: Elevated plasma and urinary catecholamines and metanephrines Elevated urinary vanillyl mandelic acid	Left sided pheocromocyroma - Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 44813