Hyperthyroidism Awareness

It is important to remember that hyperthyroidism can occur at any age. While most may present with a rather typical constellation of symptoms, many may present with exacerbation of pre-existing conditions which may make the diagnosis initially elusive. Worsening anxiety, insomnia, fatigue, panic attacks, palpitations, hypertension or diarrhea may not initially signal that the thyroid is involved. Clinicians must have a low threshold to check thyroid function early to rule out a component of hyperthyroidism.

Once a suppressed thyrotropin (TSH) has been detected, further investigation with serum triiodothyronine (T3) and free thyroxine (free T4) can help delineate overt from subclinical disease. A thorough history of past thyroid disease, as well as current medications and supplements, can help detect any pre-existing diagnoses or exogenous sources of thyroid hormone or over supplementation with iodine. More commonly, hyperthyroidism is due to either Graves diseasetoxic multinodular goiter or toxic adenoma. Distinction between these can usually be made with the assistance of a thyroid uptake scan, TSH receptor antibody measurement, and thyroid ultrasound. An additional physical exam finding of exophthalmos can further support the diagnosis of Graves’ disease. Understanding the etiology can help guide patient expectations. A small percentage of patients with Graves’ Disease may undergo spontaneous remission after 1 to 2 years, which may prompt patients to wait before considering a definitive treatment option.

With confirmation of the diagnosis of hyperthyroidism, focus is on hormonal control with an antithyroid medication (ATM, most commonly Methimazole in the United States). This may be augmented with beta-blockade, steroids, cholestyramine or SSKI for those who are difficult to control.

Many patients may need further consideration for definitive management with either radioactive iodine ablation (RAI) or thyroidectomy. Your local resources may also influence these options, but it is critical to understand that all three treatments (ATM, RAI and thyroidectomy) are possible options. Certain patient factors and priorities may alter the preferred definitive treatment. Smaller gland size, easy to control hormones, and lack of eye symptoms are factors that may favor continued ATM management. A large goiter with compressive symptoms, difficult to control hormones requiring high dose medications/ multiple modalities, pregnancy, severe eye disease, multiple nodules within the thyroid with or without thyroid cancer, or desire for rapid and reliable hormone control may favor thyroidectomy. RAI is a good option for patients with a smaller gland size, and a desire to pursue definitive management but avoid surgery.

There are also relative contraindications for treatment options. ATMs may have serious side effects, like agranulocytosis or liver failure, which prevent further use, or may cause skin eruptions making long term use intolerable. Additionally, high dose requirements or fluctuating doses may make long term use of ATMs not reliable. Women who are pregnant, wanting to become pregnant in the next 6 months to 1 year, breast feeding or have small children in the home will want to avoid RAI. Patients with severe eye involvement, have a large goiter with compressive symptoms, or are smokers should also avoid RAI. Thyroidectomy will be a poor option for patients with multiple previous neck operations on or around the thyroid due to internal scarring, or who are high risk for general anesthesia. Additionally, if they have a history of previous gastric bypass surgery, they are higher risk for major complications from hypocalcemia/hypoparathyroidism after thyroidectomy.

To help the patient navigate these decisions, it is important to allow them the opportunity to discuss each treatment option with respective physician experts – medical management with endocrinology, RAI with endocrinology and potentially nuclear medicine as well, and thyroidectomy with the thyroid surgeon.

In summary, patients with hyperthyroidism require medical control, as well as a clear understanding of the etiology of their hyperthyroidism. Patients with Graves disease, toxic multinodular goiter and toxic adenoma have more than one treatment option, and it is important for patients to be educated and engaged in treatment decisions.

For Further Reference:
American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and other causes of Thyrotoxicosis| by the American Thyroid Association

Life Lessons from ‘The Happy Prince’ by Oscar Wilde.

“The Happy Prince never dreams of crying for anything.” 

The quote sounds ironic when one completely reads the short story, ‘The Happy Prince’ by Oscar Wilde. The short story is a beautiful tale of love, tears and a portrayal of cold reality. The statue of the Happy Prince is erected in the city.

“He was gilded all over with thin leaves of fine gold, for eyes he had two bright sapphires, and a large red ruby glowed on his sword hilt.” 

Though all conceive the Happy prince to be happy, the Sparrow catches him weeping. When asked why he was weeping, the Happy Prince tells,

“When I was alive and had a human heart, I did not know what tears were, for I lived in the Palace of Sans Souci, where sorrow is not allowed to enter….And now that I am dead they have set me up here so high that I can see all the ugliness and all the misery of my city, and though my heart is made of lead yet I cannot choose but weep.”

Sometimes, we too, like the Happy Prince, turn a blind eye to people in misery around us. We are intent on satiating our own greed and desires that we don’t hear the wailing cries for help. 

So the Happy Prince asks the Swallow to help him and the people by taking the rubies and sapphires out of him. When the Swallow helps the poor mother and child for the first time, the Swallow says,

“It is curious but I feel quite warm now, although it is so cold”.

Although the night was freezing, the Swallow felt warm because he had done a good deed. Nothing equals the happiness we get from committing a good deed. Share with others and serve for a good cause and so no matter how sad you are, you will be embraced by the warmth of love. 

The Happy Prince gives away his eyes, beauty and luster for the welfare of the people in the town. So the Swallow becomes the Prince’s eyes for he tells what goes on in the town. The Swallow instead of joining his friends in Egypt remains by the Prince and tells him of Egypt. But the Happy Prince tells him to tell what he sees in the town for

“more marvelous than anything is the suffering of men and of women. There is no Mystery so great as Misery.”

Misery, as Wilde says, is mysterious as it is sometimes caused by external factors and sometimes by ourselves; we don’t know how long it will last and how bad we will be affected; we don’t know what we will gain and what we will lose. All we can do is cling on to hope as no dark sky rains forever.

The story also brings out the theme of class difference. It shows how the rich are busy making merry in their luxurious houses while the poor and the needy suffer for a morsel. The greediness of the Town Councillors shown in the story proves that nothing had changed in our society since then. 

The story ends with the death of the Swallow and also of the Happy Prince who though a statue had his leaden heart broken into two. Though they both helped people, there was no one to bid them proper farewell. But they were given the best merit – the place in Paradise. We shouldn’t expect honor, fame and laurels in return for our good deeds. For we won’t be awarded by worldly standards but by Heavenly standards. Don’t wait for the Happy Prince to change the society but become that Happy Prince to promote goodness and welfare in the society.

All the quotes are taken from the short story “The Happy Prince” by Oscar Wilde.

Read the short story at https://www.gutenberg.org/files/902/902-h/902-h.htm