Sandbox:ddx graves

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Suspected Graves' disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure serum TSH and free T4
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal TSH & free T4
 
↓ TSH & ↑ free T4
 
 
 
 
 
 
 
↓ TSH & Normal free T4
 
Normal or ↑ TSH & ↑ free T4
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hyperthyroidism ruled out
 
Hyperthyrodism
 
 
 
 
 
 
 
Measure free T3
 
TSH secreting pituitary tumor,
Thyroid hormone resistance
or Assay interference
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure TSH receptor antibodies
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
↑ free T3
 
Normal free T3
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Present
 
Absent
 
 
 
T3 Toxicosis
 
Sub-clinical Hyperthyrodism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Graves' Disease
 
Assess radioiodine uptake
obtain radionuclide scan
or both
 
 
 
 
 
 
 
Evolving Graves' disease
Evolving toxic nodular goiter
Excess thyroid hormone intake
Non thyroidal illness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Homogeneous
increased uptake
 
Patchy uptake
or single nodule
 
Low or no uptake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Graves' disease
 
Toxic nodular goiter
 
Subacute thyroiditis
Excess thyroid hormone intake
HCG secreting tumor
 
 
 
 
 
 
 
 



Cause of thyrotoxicosis TSH receptor Antibodies Thyroid US Color flow Doppler Radioactive iodine uptake/Scan Other features
Graves' disease Present Hypoechoic pattern Ophthalmopathy, dermopathy, acropachy
Toxic nodular goiter Absent Multiple nodules - Hot nodules at thyroid scan -
Toxic adenoma Absent Single nodule - Hot nodule -
Subacute thyroiditis Absent Heterogeneous hypoechoic areas Reduced/absent flow Neck pain-fever and
elevated inflammatory index
Painless thyroiditis Absent Hypoechoic pattern Reduced/absent flow -
Amiodarone induced thyroiditis-Type 1 Absent Diffuse or nodular goiter ↓/Normal/↑ ↓ but higher than in Type 2 High urinary iodine
Amiodarone induced thyroiditis-Type 2 Absent Normal Absent ↓/absent High urinary iodine
Central hyperthyroidism Absent Diffuse or nodular goiter Normal/↑ Inappropriately normal or high TSH
Trophoblastic disease Absent Diffuse or nodular goiter Normal/↑ -
Factitious thyrotoxicosis Absent Variable Reduced/absent flow ↓ serum thyroglobulin
Struma ovarii Absent Variable Reduced/absent flow Abdominal RAIU


Severity Therapy Mechanism Advantages/disadvantages Common Doses
Mild active disease Topical solutions
Artificial tears
Glucocorticoids
Avoidance of wind, light, dust, smoke
Elevation of head during sleep
Avoidance of eye cosmetics
Selenium

Maintain tear film
Reduce inflammation
Reduces ocular surface desiccation, reduces irritation
Reduces orbital congestion
Reduces irritation
Uncertain
Rapid action, minimal side effects
Rapid action, minimal side effects

Benefits not yet confirmed
Benefits not yet confirmed
Moderate or severe active disease Systemic glucocorticoids
Oral
Intravenous

Reduce inflammation and orbital congestion
Reduce inflammation and orbital congestion

Hyperglycemia, hypertension, osteoporosis
Rapid onset of anti-inflammatory effect, fewer side, liver damage

Up to 100 mg of oral prednisone daily, followed by tapering of the dose
Methylprednisolone, 500 mg/wk for 6 wk followed by 250 mg/wk for 6 wk
Orbital irradiation Reduces inflammation Can induce retinopathy 2 Gy daily for 2 wk (20 Gy total)
B-cell depletion Reduces autoreactive B cells Very expensive; risks of infection, cancer, allergic reaction Two 1000-mg doses of intravenous rituximab 2 wk apart
Emergency orbital decompression Reduces orbital volume
Stable disease (inactive) Orbital decompression (fat removal) Reduces orbital volume Postoperative diplopia, pain
Bony decompression of the lateral and medial walls Reduces proptosis by enlarging orbital space Postoperative diplopia, pain, sinus bleeding, cerebrospinal fluid leak
Strabismus repair Improves eye alignment, reduces diplopia
Eyelid repair Improves appearance, reduces lagophthalmos and improves function