LAST Moffitt PEARLS of 2015: approach to hyperthyroidism!

It has been an incredible half year of learning with all of you. As our last Moffitt report pearls of 2015, we want to thank you for all of your incredible cases and shared learning!! Also, wordpress let us know yesterday that we have received 10,000 views on our blog – incredible!! Remember, you can subscribe to our blog to get regular pearls from all 3 sites, and search the site by category for pearls of interest!

Best wishes for 2016, and we are excited for what’s in store!!


Your chieves 🙂

Take-home PEARL: remember that elderly patients with hyperthyroidism may not present with classic s/sx (like sweating, palpitations, and other e/o sympathetic activity) (aka they may have apathetic hyperthyroidism)!!

Another take-home point: Grave’s hyperthyroidism is associated with pancytopenia! Although major cases of pancytopenia in Graves are seen as a complication of antithyroid drugs, it is also associated with untreated hyperthyroidism. The mechanism of this can be multifactorial, including splenic sequestration of platelets, hypercellular bone marrow with peripheral destruction, or hypocellular marrow. For those of you who are curious, here is a paper (thanks HH!).


Workup and management of hyperthyroidism

  • We did not discuss this in depth during report, but here is a helpful approach to workup and management for hyperthyroidism (once you diagnose hyperthyroidism, always look for an etiology!). Thyroid acropachy and a ddx for saddle nose deformity to follow! J
  • hyperthyroid
  • Consider TPO for Hashimoto thyroiditis, graves, or any autoimmune thyroid disease
  • Medications implicated in hyperthyroidism: amio, IFN-alpha, lithium, IL-2
  • Treatment for Grave’s disease:
  • Methimazole and PTU (inhibit thyroid hormone synthesis)
    • Complications to remember: agranulocytosis (0.1-0.4%), liver disease, lupus-like syndromes
  • Radioactive iodine (considered treatment of choice. But contraindicated in pregnancy)
  • Thyroid surgery is an option for pregnant women who can’t tolerate medications


Thyroid acropachy: according to one case series (thanks for this one too, HH!), “Thyroid acropachy is an extreme manifestation of autoimmune thyroid disease. It presents with digital clubbing, swelling of digits and toes, and periosteal reaction of extremity bones”

thyroid acropachy

Saddle nose deformity

  • Many google images for this, but here is one!
  • saddle nose
  • Ddx:
    • Congenital syphilis
    • Wegeners
    • Relapsing polychondritis
    • Sarcoid
    • Malignancy (esp lethal midline granuloma, an NK cell cancer)
    • Other infectious things: leprosy, leishmaniasis
    • Trauma/surgery




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