Diagnostic Evaluation of Hyperthyroidism

• Thyrotoxicosis:
  • Is the common feature of both:
    • Toxic nodular goiter (TNG) and Graves’ disease
  • It may be clinical or subclinical:
    • Subclinical hyperthyroidism:
      • Presents few, if any, mild symptoms ;
        • In the presence of a suppressed TSH with normal free thyroid hormones (T3 and T4)
  • Early in Graves’ disease:
    • Hyperthyroidism may be from:
      • Preferential T3 secretion:
        • So-called T3 toxicosis
• History and Physical Examination:
  • The clinical presentation ranges from:
    • No symptoms and a suppressed sensitive serum TSH level to overt or obvious clinical hyperthyroidism:
      • The latter includes symptoms associated with:
        • Increased adrenergic tone and resting energy expenditure and other hormonal effects
        • Features related to increased adrenergic tone include:
          • Nervousness
          • Tremor
          • Increased frequency of defecation
          • Palpitations
          • Diaphoresis
          • Irritability
          • Insomnia
          • Headaches
          • Lid retraction and lid lag
          • Muscle weakness
          • Tachycardia
          • Hyperreflexia, and widened pulse pressure
        • Those related to increased energy expenditure include:
          • Heat intolerance
          • Unintentional weight loss without anorexia
          • Warm, moist skin
      • In elderly subjects, the presentation may be subtle, with:
        • Atrial fibrillation
        • Weight loss
        • Weakness
        • Depression
    • Goiter may be detected in patients with either TNG or Graves’ disease:
      • Nodular irregularity is characteristic of TNG:
        • Whereas Graves’ disease is more typically:
          • Diffuse, soft, and rubbery and may have an overlying thyroid region bruit
  • Patients with Graves’ disease often have a:
    • Goiter:
      • Diffuse, soft, and rubbery:
        • May have an overlying thyroid region bruit
    • May present with hyperthyroidism alone, or
    • May have one or more extra-thyroidal manifestations
  • Clinically apparent eye disease may occur in up to a third of patients with Graves’ disease:
    • But orbital CT may detect changes in a majority of patients
    • Signs of eye disease include:
      • Proptosis or exophthalmos
      • Lid lag and retraction
      • Impaired extraocular muscle function
    • Eye symptoms and signs generally begin about six months before or after the diagnosis of Graves’ disease:
      • It is generally uncommon for eye involvement to develop after the thyroid disease has been successfully treated:
        • There is great variability, however, and in some patients with eye involvement, hyperthyroidism may never develop
      • The severity of eye involvement is not related to the severity of hyperthyroidism
      • Early signs of eye involvement may be:
        • Red or inflamed eyes
      • Ultimately, proptosis may develop from the inflammation of retro-orbital tissues
      • Diminished or double vision is a rare problem:
        • That usually occurs later
      • It is not well known why, but problems with the eyes occur much more often in people with Graves’ disease who smoke cigarettes than in those who do not smoke
  • Other features of Graves’ disease include:
    • Onycholysis, acropachy, and pretibial myxedema
    • Pretibial myxedema:
      • Is a rare, reddish lumpy thickening of the skin of the shins
      • This skin condition is usually painless and is not serious
      • Like the eye disorders of Graves’ disease, the skin manifestation does not necessarily begin precisely when hyperthyroidism starts
      • Its severity is not related to the level of thyroid hormones
      • It is not known why this problem is usually limited to the lower leg or why so few people have it
  • Occasionally symptoms related to the mass effect of a large goiter may occur:
    • Very large goiter may extend retrosternally or substernally, resulting in symptoms and signs of tracheoesophageal pressure:
      • These may include:
        • Dysphagia
        • Cough
        • Choking sensation
        • Stridor:
          • Particularly if severe tracheal narrowing exists
        • The development of facial plethora, cyanosis, and distention of neck veins:
          • With raising both arms simultaneouslymay result from deep goiter compression of the structures located within the bony confines of the thoracic inlet (Pemberton sign)

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