Hyperthyroidism

Symptoms and signs

• Signs of hypermetabolic state: restlessness, tachycardia, diaphoresis, hyper-defecation, weight loss, palpitation
• Apathetic hyperthyrodism: elderly patients often don't have classic symptoms, but may present with lethargy, weight loss, SOB and afib
• Thyroid Storm: Fever, delirium, stupor, coma, tachycardia, arrhytmias, CHF, vomiting/diarrhea, hepatic failure

Work up

• TSH suppressed (except in pituitary disease), T4 and/or T3 increased
• ESR can be increased in subacute thyroiditis
• Anti TPO Ab often positive in silent thyroiditis
• Radioactive iodine uptake can be useful to differentiate between causes (contraindicated in pregnant patients): diffuse high uptake in graves', focal high uptake with toxic nodule, very low uptake in subacute thyroiditis.
• Burch-Wartofsky Point Scale (BWPS) is a scoring system to help identify thyroid storm

Management

Medical Therapy

Symptom Management: Propanolol to control symptoms and tachycardia (blocks adrenergic effects and peripheral conversion of T4 to T3). Beta blockade can be stopped once anti-thyroid treatment takes effect.

Inhibition of hormone synthesis: Methimazole or PTU. Methimazole is generally preferred due to better side effect profile (PTU preferred in pregnancy). Obtain baseline CBC and LFT's

Definitive therapy: Radioactive iodine ablation

Thyroid storm

• Consult endocrinology
• Supportive therapy with IVF, Oxygen and acetaminophen, likely ICU
• Avoid ASA as it can displace T4 from TBG
• Immediately start PTU 200-300mg PO q406hr
• Follow with saturated solution of potassium iodide to inhibit conversion of T4 to T3
• Consider propanolol 60-80mg PO q4-6hr to control tachycardia (caution in Heart Failure)
• Consider hydrocortisone 50-100mg IV q6-8hrs x48 hrs (blocks conversion of T4-T3)

Hospitalist Handbook