Dz	uptake	character
Grave’s	⤴️	diffuse
Toxic adenoma	⤴️	local
Mutinodular goiter	⤴️	nodular patter
thyroiditis	⤵️	⤴️ thryroglobulin
Iodine	⤵️	⤴️ thryroglobulin
Exogenous	⤵️	⤵️ thryroglobulin

Thyrotoxicosis with ⓝ or ⤴️ RAIU	Thyrotoxicosis with ⤵️ RAIU
–        Graves’ disease –        Toxic multinodular goiter –        Toxic nodule	–        Painless (silent) thyroiditis –        Subacute (de Quervain) thyroiditis –        Amiodarone-induced thyroiditis –        Excessive dose (or surreptitious intake) of levothyroxine –        Iodine-induced

Hyperthyroidism Clx manifestations
Sx	–        Anxiety & insomnia –        Palpitations –        Heat intolerance –        ⤴️ perspiration –        Weight loss without ⤵️ appetite
PEx	–        Goiter –        HTN –        Tremors including fingers/hands –        Hyperreflexia –        Proximal muscle weakness/atrophy –        Lid lag –        Atrial fibrillation

Hypothyroidism effects

⤴️ lipids ⤵️ Na ⤴️ CK ⤴️ LFTs

·       Clx of Grave’s disease
General	Heat intolerance, weight loss, sweating
Eyes	Lid lag, proptosis, diplopia
Skin	Hair loss, infiltrative dermopathy (pretibial myxedema)
Cardiovascular	Tachycardia, HTN, atrial fibrillation
Nails	Onycholysis, clubbing (acropachy)
Endocrine	Hyperglycemia, hypercalcemia, bone loss, menstrual irregularities
Gastrointestinal	Diarrhea
Neurology	Tremors, hyperreflexia, proximal muscle weakness

Graves Tx complications
Antithyroid drugs	·       Agranulocytosis ·       Methimazole: First trimester teratogen, cholestasis  ·       Propylthiouracil: Liver failure, ANCA- related vasculitis
Radioiodine ablation	·       Permanent Hypothyroidism ·       Worsens Ophthalmopathy ·       Possible Radiation side effects
Surgery	·       Permanent Hypothyroidism ·       Risk Of persistent laryngeal nerve damage ·        hypoparathyroidism

	TSH	Sx/PE findings	Tests	Tx
Graves’ disease	⤵️	Exophthalmos, visual deficits, pretibial myxedema, Autoimmune diseases	Thyroid- stimulating Ig (+)	Propranolol, PTU/ methimazole, RAI ablation. subtotal thyroid removal
Toxic nodular goiter	⤵️	Nodules	RAIU scan	RAI ablation
Thyroiditis	⤵️	subacute Pain, postpartum (< I year)	RAIU scan (low uptake); among them It differs	Propranolol for symptoms; differs depending on nature
Factitious hyperthyroidism	⤵️	Absence of goiter	Thyroglobulin (low)	Psychotherapy
Struma ovarii	⤵️	Abdominal mass	Abdominal CT	Resection
2ndry hyperthyroidism	⤴️	Bitemporal hemianopsia	MRI	Resection
Amiodarone-induced hyperthyroidism	⤴️	On amiodarone	Clinical Dx.	D/c

Thyroiditis Types
Autoimmune (Hashimoto)	–        Main hypothyroid features –        Diffuse goiter	(+ve) Anti-TPO antibody
Painless (silent thyroiditis)	–        Chronic autoimmune thyroiditis –        Mild, short-term hyperthyroid phase –        Small, nontender goiter –        Spontaneous recovery	Positive TPO antibody RAIU: Low uptake
Subacute (de Quervain)	–        Possible post-viral inflammatory process –        Prominent fever & hyperthyroid symptoms –        Sore/tender goiter	Elevated ESR & CRP RAIU: Low uptake

Thyroiditis
	Clx	Tests
Chronic autoimmune thyroiditis (Hashimoto thyroiditis)	–        Major hypothyroid features –        Diffuse goiter	–        TPO antibody –        Variable radioiodine uptake
Painless thyroiditis (Silent thyroiditis)	–        Different of chronic autoimmune thyroiditis –        Minor, brief hyperthyroid stage –        Small, nontender goiter –        Self-limited	–        (+ve) TPO antibody –        ⤵️radioiodine uptake
Subacute Thyroiditis (de Quervain thyroiditis)	–        Possible post-viral inflammatory process –         Protruding fever & hyperthyroid s/s –        Sore/tender goiter	–        ⤴️ ESR & CRP –        ⤵️ radioiodine uptake

Causes of Thyroiditis
	Subacute granulomatous thyroiditis	Hashimoto thyroiditis
Clx	–        Usually following a viral illness –        Painful thyroid expansion –        Transient hyperthyroid symptoms	–        Autoimmune causes –        nontender thyroid enlargement –        Major hypothyroid features
Dx	–        ⤴️ ESR & CRP(C-reactive protein) –        ⤵️ radioiodine uptake	–        (+ve) TPO antibody –        Variable uptake of radioiodine
Path	–        macrophages & giant cells infiltration.	–        Lymphocytic infiltration with  well-developed germinal centers –        Hürthle cells (eosinophilic epithelial cells)

Thyroid Storm
Causes	–        Surgical procedure Thyroid or non-thyroid –        Acute sickness (eg, trauma, infection), child delivery –        Acute iodine load (eg, iodine contrast)
S/S	–        High grade fever. –        Tachycardia, HTN, CHF, cardiac arrhythmias (eg, atrial fibrillation) –        Anxiety, delirium, seizure and coma –        Goiter, lid lag, tremor –        Nausea, vomiting, diarrhea, jaundice

Neonatal Thyrotoxicosis
Path	–        Transplacental passing of maternal anti- TSH receptor antibodies –        Antibodies bind to infant’s TSH receptors & cause excessive thyroid hormone release
S/S	–        Warm, moist skin –        Tachycardia –        Poor feeding, irritability, poor weight gain –        preterm birth or low birth weight
Dx	–        Maternal anti-TSH receptor antibodies equal or more than 500% normal
Tx	–        Self-resolves within 3 months (disappearance of maternal antibody) –        Methimazole PLUS ß blocker

CVS Effects of Thyrotoxicosis
Rhythm	–        Sinus tachycardia. –        Premature atrial & ventricular complexes –        Atrial fibrillation/flutter
Hemodynamic effects	–        Systolic HTN & ⤴️ pulse pressure –        ⤴️ Contractility & cardiac output –        ⤵️Systemic vascular resistance –        ⤴️ Myocardial oxygen demand
Heart failure	–        High-output failure –        Exacerbation of pre-existing low-output failure
Angina symptoms	–        Coronary vasospasm –        Pre-existing coronary atherosclerosis