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Thyrotoxicosis
Diagnosis/Definition
Thyrotoxicosis is the complex of findings that arise when the peripheral tissues are presented with and respond to an excess of thyroid hormone. Disorders associated with thyrotoxicosis may be broadly categorized as follows:
- Thyrotoxicosis associated with hyperthyroidism:
- States of TSH excess: Tumorous and nontumorous
- Abnormal thyroid stimulator: Grave’s Disease and trophoblastic tumor.
- Intrinsic thyroid autonomy: Toxic adenoma and toxic multinodular goiter.
- Thyrotoxicosis not associated with hyperthyroidism:
- Inflammatory disease: Subacute thyroiditis/Chronic (painless) thyroiditis/Postpartum thyroiditis.
- Extrathyroid source of hormone:
- Hormone ingestion/Ectopic thyroid tissue.
Initial Diagnosis and Management
- Suppressed TSH in the patient with an intact hypothalamic-pituitary-thyroid axis.
- Elevated peripheral products (e.g. T4, T3) in the patient without an intact hypothalamic-pituitary-thyroid axis.
- Patients with iatrogenic thyrotoxicosis need not be referred. Their dose of thyroid hormone should be reduced; a TSH should be measured six weeks later.
Ongoing Management and Objectives
- Major objective is the long-term resolution of thyrotoxicosis. Frequently, definitive therapies (i.e., surgery, radioiodine treatment) lead to iatrogenic hypothyroidism.
- Certain conditions (i.e., subacute thyroiditis, postpartum thyroiditis) are self-limiting.
- A multidisciplinary approach is often required.
Indications for Specialty Care Referral
Active thyrotoxicosis which is not due to the administration of thyroid hormone.
Patients with all other forms of thyrotoxicosis should be referred to someone familiar with the management of said disorders. Obtaining a radioactive iodine uptake (RAIU), in a non-pregnant patient, prior to specialty referral may help expedite treatment. Appropriate therapy may involve the use of B-blockers, antithyroid medications, surgery or radioactive iodine. (Women of childbearing age should be counseled regarding effective contraception.)
Criteria for Return to Primary Care
Resolution of thyrotoxicosis.
