Weight loss

ERWEB case

History

• A 45-year-old lady attends surgery with a three months history of hot sweats, palpitations, tremor and weight loss of 1 stone.

• Also having diarrhoea

• She has no significant past medical history and is on no treatment.

What are the possible causes of her symptoms?

What are the possible causes of her symptoms?

1. Thyrotoxicosis

What are the possible causes of her symptoms?

1. Thyrotoxicosis

2. Anxiety neurosis

What are the possible causes of her symptoms?

1. Thyrotoxicosis

2. Anxiety neurosis

3. Lymphoma – but palpitations and tremor less likely

What are the possible causes of her symptoms?

1. Thyrotoxicosis

2. Anxiety neurosis

3. Lymphoma – but palpitations and tremor less likely

4. Colitis

What are the possible causes of her symptoms?

1. Thyrotoxicosis

2. Anxiety neurosis

3. Lymphoma – but palpitations and tremor less likely

4. Colitis

5. Carcinoid – but rare – also flushing and wheezing

What other symptoms might have been produced by this disorder?

What other symptoms might have been produced by this disorder?

1. Hair loss

2. Swelling in neck

3. Anxiety

4. Amenorrhea

5. Tiredness

What might you find on examination?

What might you find on examination?

Graves’ eye disease

•Heavy lymphocytic infiltrate

•Compresses optic nerve

•Not related to degree of thyrotoxicosis

•Treatment

•High dose steroids

•Surgical decompression

Eye disease

• Exopthalmos

• Proptosis

• Risk of blindness as optic nerve compressed

Goitre

Palmar erythema

Tachycardia

Proximal myopathy

Test by standing from seated position with arms folded…

Pre-tibial myxoedema

Other auto-immune conditions

What tests could you perform to confirm the presence of an

endocrine disorder?

What tests could you perform to confirm the presence of an

endocrine disorder?1. TSH (less that 0.03)

2. T3/T4• Free T4 > 30 symptomatic• Free T4 >100 v. symptomatic

3. Thyroid auto-antibodies

What is the aetiology of this disorder?

What is the aetiology of this disorder?

1. Graves’s disease• autoimmune disease• associated with thyroid stimulating antibodies

2. Toxic multi nodular goitre

3. Toxic adenoma

4. Drugs

5. Post-partum thyroiditis

6. Sub acute thyroiditis

Natural history of Graves’ disease

. What are the possible treatment options and what are the side

effects?

. What are the possible treatment options and what are the side

effects?• Drugs

– Carbimazole– Propylthiouracil

. What are the possible treatment options and what are the side

effects?• Drugs

– Carbimazole– Propylthiouracil

• Radio iodine

. What are the possible treatment options and what are the side

effects?• Drugs

– Carbimazole– Propylthiouracil

• Radio iodine

• Surgery

Side effects

•Drug rash

•Agranulocytosis

•idiosyncratic

How do you titrate drugs?

• EitherTitrate to biochemistry

• OrBlock and replace

What if you don’t treat…

• High output cardiac failure and death

• Atrial fibrillation

• Amenorrhea

• Thyrotoxic storm– associated with superadded infection/illness

• Osteoporosis

• Some people feel great – some go mad (or drive their families mad)

She thinks she may be six weeks pregnant. How does this affect your

choice of treatment?

She thinks she may be six weeks pregnant. How does this affect your

choice of treatment?

Is she really!

Not radio iodine

Surgery not recommended

Carbimazole will cross placenta and make baby hypothyroid

So use lowest dose propylthiouracil possible

She asks you if there is any chance the baby might have the same

disorder. What would you tell her?

She asks you if there is any chance the baby might have the same

disorder. What would you tell her?

• Measure thyroid stimulating antibodies

• Monitor foetus– signs growth retardation– foetal heart rate – tachycardic?

• Consider treating with carbimazole if signs foetus thyrotoxic