Discussion in 'Spot Diagnosis' started by Egyptian Doctor, Nov 6, 2012.
What is the differential diagnosis for this case ?
grave disease. hyperhyroidism
Bilateral and pronounced, so it looks like Grave's, but if the other physical and lab findings of Grave's comes back negative then we have to think of the differentials
Related to the thyroid itself
1) - hashimoto's thyroiditis although common in women can be seen in men as well
2) - papillary cancer of thyroid with an inflamatory component ( since most cancers of thyroid are cold / non -functional and it's only inflammation that can lead to hyperthyroidism sec to spillage of the stored hormones into circulation).
3) Toxic multinodular goiter (esp in females and if it sets in b4 overt hypothyroidism develops)
4) post partum thyroiditis (of course not in this case)
Related to other endocrine conditions
1) Pituitary adenomas ( macro and micro )
2) Pheochromocytoma ( sec. to lid retraction from excess epinephrine in circulation, but becos the pheochromocytoma is not like an open tap - there will be a waxing and waning of hormone levels and so the lid retraction will also vary, but still won't be as pronounced as in this case )
3) trophoblastic tumors ( Special features include a positive pregnancy test result, a history of hydatidiform mole, choriocarcinoma ). Note - it can follow normal pregnancy also.
4) Embryonal carcinoma of the testis -is another example of Beta-human choriogonadotropin–induced thyrotoxicosis
- think of acute cocaine or amphetamine toxicity
Other conditions ( unrelated to endocrine )
Idiopathic inflammatory pseudotumor, Wegener's granulomatosis/vasculitis, metastatic neuroblastoma, leukemia/lymphoma etc.
most probably grave's disease
Related Self Assessment Question
You are screening a 35-year-old woman who presents with tachycardia, nervousness, tremor, palpitations, heat intolerance, and weight loss. You suspect Graves disease. What single test is best for differentiating Graves disease from other causes of hyperthyroidism?
B. TSH with free T4 and free T3
C. Thyroid receptor antibodies
D. Radionucleotide imaging of the thyroid
E. Thyroid ultrasound
Thyroid receptor antibodies are very specific, and differentiate Graves disease from other causes of hyperthyroidism. The TSH and free thyroid hormones are nonspecific, and only identify hyperthyroidism. Radionucleotide imaging is helpful in Graves, showing diffuse uptake, but is not necessarily specific. Thyroid ultrasonography can identify nodules, but is also a nonspecific test for differentiating causes of hyperthyroidism.
The answer is C.
Graves disease as evident from clinical picture showing exopthalmos, anterior neck swelling indicating thyroid origin (confirmed by movement on deglutition and negative tounge tug test on physical exam) ,
Patient seems to be anxious, irritable and sweating.
Differential will include:
1) Toxic nodular goitre
2) Papillary carcinoma
3) Hashimoto thyroiditis
Self Assessment Question ( Difficulty level - Step 3 type )
A 29-year-old woman with a history of difficulty becoming pregnant presents to her primary care physician and is diagnosed with Grave disease on iodine uptake scan; her thyrotropin (TSH) level is markedly suppressed and her free thyroxine (T4) level is elevated. She desires to conceive as soon as possible and elects to undergo thyroidectomy. After she is rendered euthyroid with medications preoperatively, which of the following management strategies should also be employed to reduce the risk of developing thyroid storm in the operating room?
A. Drops of Lugol iodine solution daily beginning 10 days preoperatively
B. Preoperative treatment with phenoxybenzamine for 3 weeks
C. Preoperative treatment with propranolol for 1 week
D. Twenty-four hours of corticosteroids preoperatively
E. No other preoperative medication is required
Drops of Lugol iodide solution daily beginning 10 days preoperatively should be prescribed to decrease the likelihood of postoperative thyroid storm, a manifestation of severe thyrotoxicosis.
If thyroid storm occurs, treatment is β-blockade, for example, propranolol.
The answer is A.
Note : the closest differential to Grave's disease or sec. thyrotoxicosis is Pheochromocytoma. So always keep that in mind and phenoxybenzamine is used preop in Pheochromocytoma patients
2 self assessment questions on pheochromocytoma ( 1 adult and 1 child )
A 36-year-old woman presents with palpitations, anxiety, and hypertension. Workup reveals a pheochromocytoma. Which of the following is the best approach to optimizing the patient preoperatively?
A. Fluid restriction 24 hours preoperatively to prevent intraoperative congestive heart failure
B. Initiation of an α-blocker 24 hours prior to surgery
C. Initiation of an α-blocker at 1 to 3 weeks prior to surgery
D. Initiation of a β-blocker 1 to 3 weeks prior to surgery
E. Escalating antihypertensive drug therapy with β-blockade followed by α-blockade starting at least 1 week prior to surgery
Patients with pheochromocytomas should be treated preoperatively with α-blockade using phenoxybenzamine 1 to 3 weeks before surgery. β - blockade may be necessary in addition to α - blockade for optimal blood pressure control, but should not be started in the absence of α - blockade because of the risk of cardiovascular collapse. With α - blockade, patients also require volume expansion.
The answer is C.
During a routine well-child examination a 10-year-old girl reports that she has occasional headache, "racing heart," abdominal pain, and dizziness. Her mother states that she has witnessed one of the episodes, which occurred during an outing at the mall, and reported the child to be pale and to have sweating as well. Other than some hypertension, she has a normal physical examination. Evaluation of this child is most likely to result in which of the following diagnoses?
A. Hysterical fainting spells
C. Diabetes mellitus
E. Migraine headache
The child in the question has all of the classic symptoms of childhood pheochromocytoma. In adults, the episodes of hypertension are more paroxysmal than in children, where the hypertension is more sustained. While it is an unusual diagnosis in children, pheochromocytoma must be considered in the evaluation of a patient with hypertension who has intermittent symptoms described.
Pheochromocytoma can be associated with tuberous sclerosis, Sturge-Weber syndrome, ataxia-telangiectasia, and it can be inherited as an autosomal dominant trait.
All of the other answers are possibilities in an adolescent-age child, but the concurrent finding of hypertension suggests an alternative diagnosis. Pregnancy would be unusual because of her age, but the diagnosis must be considered for practically all complaints in an adolescent of childbearing age. Migraine headache would be unlikely to produce the cardiac finding of "racing heart" reported in this child. Diabetes can produce a variety of findings, but important clues missing from this case include frequency of urination, weight loss, and other classically seen symptoms. Adolescent fainting spells (vasovagal reaction) are common, and many of the symptoms reported can occur during an episode. They commonly are seen during stressful situations, in groups of adolescents, or sometimes with minor symptoms; hypertension is not one of the features.
The answer is D.
Message - Imp. to make integrations while studying and that's the best way to come up with differentials and not mugging up differentials for every condition ( most of us do it for the exams...but it will not help in the long run )
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