What are the symptoms and treatment options for a patient presenting with hyperthyroidism?

Hyperthyroidism: Symptoms and Treatment

Clinical Presentation

Hyperthyroidism presents with a constellation of cardiovascular, neurological, and metabolic symptoms that require prompt recognition and treatment with beta-blockers as first-line therapy, followed by definitive management with antithyroid medications, radioactive iodine, or surgery. 1

Cardinal Symptoms

Cardiovascular manifestations:

• Tachycardia and palpitations are hallmark features 1, 2
• Hypertension with decreased systemic vascular resistance and increased cardiac output 1, 2
• Atrial fibrillation occurs more commonly in hyperthyroid patients 1
• Heart failure can develop in severe, long-standing cases, particularly with persistent tachycardia or rapid atrial fibrillation 1, 2

Neuropsychiatric symptoms:

• Tremors, nervousness, and anxiety 1, 2
• Insomnia and hyperactivity 1, 2
• Weakness is one of the most common presenting complaints 3

Metabolic and systemic features:

• Unintentional weight loss despite normal or increased appetite 3, 4
• Heat intolerance and excessive sweating 1, 2
• Hair loss 2
• Palpable goiter 1, 3

High-Risk Populations Requiring Vigilant Screening

• Elderly patients (cardiovascular complications are the chief cause of death after treatment, especially in patients over 50 years) 1
• Post-partum women 1
• Patients with high levels of radiation exposure (>20 mGy) 1
• Patients with Down syndrome 1

Treatment Approach

Immediate Symptomatic Management

Beta-blockers (atenolol or propranolol) should be initiated promptly to control heart rate, reduce tremors, and mitigate cardiovascular complications. 1, 2 The goal is to lower heart rate to nearly normal, which improves tachycardia-mediated ventricular dysfunction 1.

Definitive Treatment Options

Antithyroid medications:

• Methimazole is the preferred first-line antithyroid drug for most patients with Graves' disease, toxic multinodular goiter, or toxic adenoma 5, 3, 4
• Propylthiouracil is reserved for patients intolerant of methimazole, and specifically indicated during the first trimester of pregnancy due to methimazole's association with rare fetal abnormalities 6
• Critical caveat: Propylthiouracil carries significant risk of severe hepatotoxicity, including hepatic failure requiring liver transplantation or resulting in death, particularly in pediatric populations 6
• Treatment duration typically ranges from 12-18 months for Graves' disease with the goal of inducing remission 3, 7

Radioactive iodine therapy:

• Resolves hyperthyroidism in more than 90% of patients with Graves' disease and toxic multinodular goiter 3
• Hypothyroidism develops in most patients within 1 year after treatment 3
• Contraindicated in pregnancy, lactation, and Graves' disease with active ophthalmopathy (may cause deterioration of eye disease) 8, 7
• Pregnancy should be avoided for 4 months following administration 7
• Growing as first-line therapy due to high efficacy and tolerability 4, 7

Surgery (thyroidectomy):

• Treatment of choice for patients with compressive symptoms from obstructive goiter 3
• Indicated for concurrent thyroid cancer, pregnancy (when antithyroid drugs are contraindicated), and Graves' disease with ophthalmopathy 8
• Total thyroidectomy for Graves' disease and toxic multinodular goiter; thyroid lobectomy for toxic adenomas 8
• Patients must be rendered euthyroid with antithyroid medications preoperatively and maintained on beta-blockers for cardiovascular symptoms 8

Critical Monitoring and Safety Considerations

Laboratory surveillance:

• Patients on antithyroid drugs require immediate reporting of sore throat, skin eruptions, fever, headache, or general malaise due to risk of agranulocytosis 6, 5
• White blood cell and differential counts should be obtained if these symptoms develop 6, 5
• Monitor for hepatic dysfunction with propylthiouracil (anorexia, pruritus, jaundice, right upper quadrant pain) particularly in the first 6 months 6
• Prothrombin time monitoring before surgical procedures due to potential hypoprothrombinemia 6, 5

Life-threatening complications:

• Thyroid storm is a rare but life-threatening emergency requiring multidisciplinary treatment and definitive management of hyperthyroidism 1, 2, 8
• Cardiovascular complications including heart failure and atrial fibrillation can occur with untreated disease 4, 8
• Pregnancy complications include severe preeclampsia, preterm delivery, stillbirth, and maternal heart failure 1, 2

Drug interactions requiring dose adjustments:

• Oral anticoagulants (warfarin) may have increased activity; monitor PT/INR closely 6, 5
• Beta-blockers may require dose reduction as patient becomes euthyroid 6, 5
• Digitalis glycosides and theophylline clearance changes necessitate dose adjustments when transitioning to euthyroid state 6, 5