ThyroidDiseaseAndOsteoporosis专业知识课件

ThyroidDisease

AndOsteoporosisLisaHays,MDEndocrinologyFellowOutlineSignsandsymptomsofhyperthyroidismDiagnosticstudiesforhyperthyroidismCausesandtreatmentsofhyperthyroidismGeneraloverviewofhypothyroidismEvaluationofthyroidnodulesOverviewofosteoporosisCellulareffectsofthyroidHyperthyroidismSymptomsAnxiety/irritabilityWeaknessTremorsDifficultysleepingPalpitationsIncreasedbowelmovementsFatigueWeightlossHyperkineticmovementsHeatintoleranceCasePresentation37yomalepresentedtoPCPw/complaintoffeelingpoorlyforpastmonthAlsocomplainedofweakness,difficultysleeping,increasedheartrate.10stoolsperday.Whatelsedoweneedtoknowbeforeexamining?CasePresentationT99.1,HR92irregular,RR20,BP153/75PhysicalexaminationMildproptosisNontendergoiterwiththyroidbruitpresentCV:IrregularlyirregularrhythmExt:BriskDTR’s,mildrestingtremorWhatlabsorstudiesdoweneed?LaboratoryStudiesTSH<0.010uIU/ml(nl0.47-5.0)FreeT4>6ng/dl(nl0.71-1.85)TotalT3>600ng/dl(nl72-170)ThyroidStimulatingAntibody130%(nl0-125%)NegativeThyroidperoxidaseandthyroglobulinantibodiesCasePresentationPatientwasdiagnosedwithGraves’DiseaseStartedonMethimazole10mgTIDPropranololforsymptommanagementAnticoagulationforatrialfibrillationThyroidAntibodiesTSHreceptorantibodiesCanbestimulatingorinhibitoryThyroglobulinantibodiesThyroidperoxidaseantibodies(formerlyknownasmicrosomal)Anythingelse?RadioactiveIodineUptakeMeasurestheamountofiodinetakenupbythethyroidin24hoursNormal15-30%ThyroidScanGivesananatomicviewofthethyroidTechnetiumusedtoimageDifferentialDiagnosisHighuptakeGraves’DiseaseMultinodularGoiterToxicsolitaryNoduleTRHsecretingPituitaryTumorHCGsecretingtumorLowuptakeSubacuteThyroiditisSilentThyroiditisIodineinducedExogenousL-ThyroxineStrumaovariiAmiodaroneGraves’DiseaseMostcommoncauseofhyperthyroidism60-80%ofcasesAutoimmunediseaseCausedbythyroidstimulatingimmunoglobulinsBindtoTSHreceptorsonthyroidCausehypersecrectionofthyroidhormoneCausehypertrophy&hyperplasiaofthyroidfolliclesWeetman,A.P.NEnglJMed2023;343:1236-1248PathogenesisofGraves'DiseaseClinicalManifestationsSymptomsandsignsofhyperthyroidismOphthalmopathyPresentin50%ofpatientsEyelidretractionPeriorbitaledemaProptosis(exopthalmos)DiplopliaDermopathy(myxedema)Weetman,A.P.NEnglJMed2023;343:1236-1248ClinicalManifestationsofGraves'DiseaseGraves’DiseaseAssociatedConditionsTypeIDiabetesMellitusAddison’sDiseaseVitiligoPerniciousanemiaAlopeciaAreataMyastheniaGravisCeliacDiseaseGravesTreatmentAntithyroiddrugs(Thionamides)Proplythiouracil(PTU)300-400mgdailyMethimazole30-40mgdailyDecreasesynthesisofhormone,PTUalsodecreasesconversionofT4toT3Permanentremissionin40-50%oftreatedpatientsRiskofagranulocytosisPTUusedinpregnancyBeta-BlockersforsymptomsGravesTreatmentThyroidectomyRapidcurebutrequiresthyroidreplacementRadioactiveIodineIodine(131I)isgivenEffectistypicallyseenin3-6monthsHypothyroidismoftendevelopsMultinodularGoiterLesscommonthanGravesandeffectsolderindividualsDiscretenodulesbecomeautonomousandhyperfunctionTreatmentwiththyroidectomy(oftenpoorsurgicalcandidates)oriodine,thionamidesSubacuteThyroiditisEtiologyistypicallyviralKnownasDeQuervain’sthyroiditisorgranulomatousthyroiditisThyroidisoftenenlarged,tender,painfulVerylowradioactiveiodineuptakeSelf-resolvingwithinweekstomonthsTreatmentwithNSAIDS,steroids,Beta-blockersSilentThyroiditisAlsocalledpainlessorlymphocyticthyroiditisNotpainfullikesubacuteTransientLowiodineuptakeHypothyroidismWeaknessFatigueLethargy,sleepinessSlownessofspeechandthought“Puffy”appearanceDryskin,coarsehairColdintoleranceConstipationPhysicalFindingsPuffyfeaturesDryskinNonpittingedemaHypothermiaBradycardiaSlowreturnofdeeptendonreflexesLossoflateralportionofeyebrowsCausesofHypothyroidismPrimaryHypothyroidismIodinedeficiencyIatrogenic-surgery,radioablationAutoimmunethyroiddestructionDrugsinterferingwithhormonesynthesisInfiltrativediseasehemochromotosis,sarcoidosis,neoplasticdiseaseCongenitalthyroidagensisordefectsinhormonesynthesisHashimotosThyroiditisMostcommontypeofthyroiddiseaseAutoimmunedamageLymphocyticinfiltrate,fibrosis,decreasedthyroidhormoneproductionAutoantibodies(thyroglobulinandperoxidase)CanalsobeassociatedwithpolyglandularautoimmunediseaseAdrenalinsufficiency,ovarianfailure,vitiligo,diabetesThyroidReplacementSyntheticlevothyroxine(T4)ConvertedtoT3inthebodyStudiesvaryonutilityofusingT3Typicalreplacementdoseis1.6micrograms/kg(100-150mcgtypical)StartwithreduceddoseinelderlyandpatientswithhistoryofheartdiseaseMyxedemaComaSevereuntreatedhypothyroidismHypothermia,hypoglycemia,shock,hypoventilation,ileus50%mortalityTreatwithIVlevothyroxine,steroidsThyroidNodule21yomalew/nopastmedicalhistorypresentstohisPCPcomplainingofgraduallyenlarging“knot”inhisneckWhatquestionsdoyouhave?Examinationrevealsafirm3cmnoduleinrightlobeofthyroidWhatisthenextstep?ThyroidNodulesLifetimeriskofpalpablenodule5-10%50%ofthepopulationhasanoduleonautopsyorultrasoundOnly1in20ismalignantDifferentialDiagnosisMalignancyPapillaryFollicularMedullaryAnaplasticMetastasisBenignfollicularadenomaCystColloidNoduleHegedus,L.NEnglJMed2023;351:1764-1771AlgorithmfortheCost-EffectiveEvaluationandTreatmentofaClinicallyDetectableSolitaryThyroidNoduleHegedus,L.NEnglJMed2023;351:1764-1771ClinicalFindingsSuggestingtheDiagnosisofThyroidCarcinomainaEuthyroidPatientwithaSolitaryNodule,AccordingtotheDegreeofSuspicionEvaluationofNoduleMeasureTSHIfHyperthyroid(lowTSH),douptakeandscanTreatwithsurgeryorI-131ablationIfnormalthyroidfunction,nextstepisfineneedleaspiration(FNA)CheckCalcitoninleveliffamilyhistoryofMEN2ormedullarycarcinomaexists.Hegedus,L.NEnglJMed2023;351:1764-1771AlgorithmfortheCost-EffectiveEvaluationandTreatmentofaClinicallyDetectableSolitaryThyroidNoduleFineNeedleAspirationFNAismosteffectivewaytodistinguishbetweenbenignandmalignantnodulesInexpensive,performedasoutpatientUltrasoundguidedFNAifnotpalpableorlessthan1.5cmindiameterWhatresultswillIsee?Benign-75%ofthetimeMalignant-4%ofcasesSuspiciousorinadequate-22%Hegedus,L.NEnglJMed2023;351:1764-1771AlgorithmfortheCost-EffectiveEvaluationandTreatmentofaClinicallyDetectableSolitaryThyroidNoduleManagementofNodulesMalignantTotalthyroidectomySuspiciousThyroidectomyBenignDiscusswiththepatientUltrasoundsurveillanceSurgeryConsiderlevothyroxinesuppression(varyingresults)CasePresentationFNArevealedpapillarythyroidcarcinomaPatientunderwenttotalthyroidectomyTreatmentwithI-131ablationaftersurgeryOsteoporosisCasePresentation70yearoldfemaleasksherPCPifsheshouldhaveabonedensitydone.WhatquestionsshouldherPCPask?NohistoryoffracturesMenopausewassurgicalatageof55Motherfracturedherhipat74OsteoporosisDefinitionMicroarchitecturaldeteriorationofbonetissueleadingtodecreasedbonemassBonefragilitySusceptibilitytofractureAproblemofdecreasedpeakbonemassandacceleratedbonelossAffects10millionintheUnitedStates1.ConsensusDevelopmentConference.AmJMed.1993;94:646-650.2.RiggsBL,MeltonLJIII.Bone.1995;17:505S–511S.3.RayNFetal.JBoneMinerRes.1997;12(1):24–35.4.CummingsSRetal.ArchInternMed.1989;149:2445–2448.HipFracturesCanLeadtoDisability,LossofIndependence,andEvenDeathHipfractureisassociatedwithincreased

riskof:Disability:50%neverfullyrecover1,2

Long-termnursinghomecarerequired:25%2Increasedmortalitywithin1yearduetocomplications:upto24%3Lifetimeriskofdeath:comparabletothat

ofbreastcancer4OsteoporosisPrimaryosteoporosisUnrelatedtochronicillnessRelatedtoaginganddecreasedgonadalfunctionSecondaryosteoporosisSecondarytochronicillnessesthatcauseacceleratedbonelossExamples:Glucocorticoiduse,celiacsprue,hyperthyroidismRiskFactorsforOsteoporoticFractureNonmodifiablePotentiallyModifiablePersonalhistoryoffracture

asanadultHistoryoffracturein

first-degreerelativeCaucasianraceAdvancedageFemalesexDementiaPoorhealth/frailtyCurrentcigarettesmokingLowbodyweight(<127lbs)Estrogendeficiency,including

menopauseonset<age45Lowcalciumintake(lifelong)AlcoholismImpairedeyesightdespite

adequatecorrectionRecurrentfallsInadequatephysicalactivityPoorhealth/frailtyGoldcolordenotesriskfactorsthatarekeyfactorsforriskofhipfracture,independentofbonedensity.NationalOsteoporosisFoundation,Physician’sGuidetoPreventionandTreatmentofOsteoporosis.BelleMead,NJ:ExcerptaMedica,Inc.;1998.DiagnosisofOsteoporosisHistoryandphysicalexaminationtoexcludesecondaryosteoporosisLaboratorystudiesifsuspectsecondaryosteoporosisMeasurementofBoneMineralDensity(BMD)DualX-rayAbsorptiometry(DEXAscan)Providesmostreproduciblevaluesofbonedensityg/cm26070809010030405060708090AgeRelativeBMD(%)ForearmSpineHipandHeel0100020233000400035-3985+Colles'VertebraeHipAgeAnnualFractureIncidenceCooperC.BaillièresClinRheumatol.1993;7:459–477.FaulknerKG.JClinDensitom.1998;1:279–285.BMDandFractureRiskAreInverselyRelatedCentralDXAMeasurementMeasuresmultiple

skeletalsitesSpineProximalfemurForearmTotalbodyOfficebasedConsideredthe

clinicalstandardNationalOsteoporosisFoundation,Physician’sGuidetoPreventionandTreatmentofOsteoporosis.

BelleMead,NJ:ExcerptaMedica,Inc.;1998.NationalOsteoporosisFoundationGuidelinesWhoShouldBeConsideredforBMDTesting?Women65yearsofageregardlessofadditionalriskfactorsPostmenopausalwomen<65yearsofagewithatleastoneriskfactorforosteoporosis(inadditiontomenopause)Postmenopausalwomen65yearsofagewithfractures

(toconfirmdiagnosisanddeterminediseaseseverity)Womenconsideringtherapyforosteoporosis,ifBMD

testingwouldfacilitatethedecisionWomenwhohavebeenonHRTforprolongedperiodsOtherPopulationsToConsiderforAssessmentofOsteoporosisMenPatientsonlong-termhigh-doseglucocorticoidsT-ScoreIsKeyInterpretingBMDMeasurementReportsAclinicallyrelevantvalueontheBMDreportDescribesbonemasscomparedwiththemeanpeak

bonemassofhealthyyoungadultwomenintermsof

StandardDeviation(SD)CanhelpconfirmthediagnosisoflowbonemassorosteoporosisForeverySDbelowtheyoungadultnormal,therisk

offractureapproximatelydoubles

1.NationalOsteoporosisFoundation,Physician’sGuidetoPreventionandTreatmentofOsteoporosis.

BelleMead,NJ:ExcerptaMedica,Inc.;1998.2.MarshallD.JohnellO,WedelH.Meta-analysisofhowwellmeasuresofbonemineraldensitypredictoccurrenceofosteoporoticfractures.BMJ.1996;312:1254–1259.SDAge(years)210–1–2–3–4–5–62030405060708090T-score=–3.0PeakBoneMassVisualizingaPatient’sT-ScoreT-score=Numberofstandarddeviations(SDs)bywhichthepatient’s

bonemassfallsaboveorbelowthemeanpeakbonemassfornormal

youngadultwomen=T-scoreforpatient,a60-year-oldwoman;here,T=–3.0Lightline:ChangeinmeanbonemassovertimeinwomenHeavyline:MeanpeakbonemassforyoungnormaladultwomenNationalOsteoporosisFoundation,Physician’sGuidetoPreventionandTreatmen