Thyroid Signs

General Signs

• anxious, restless, fidgety
• warm moist skin
• palmar erythema
• Plummer’s Nail (separation fingernail from nailbed)
• fine, silky hair
• premature grey hair, vitiligo
• fine tremor finger and tongue
• hyperreflexia (characteristic)

Ocular signs – may be unilateral early

• • mild: spastic (sympathetic overstimulation)
    • hold stare with widened palpebral fissures (infrequent blinking)
    • lid-lag and lid retraction
    • failure to wrinkle brow on upward gaze
  • moderate:
    • mechanical: proptosis with ophthalmoplegia (ocular muscle weakness)
      • impaired up-gaze and convergence
      • strabismus with diplopia
    • mechanical: congestive oculopathy
      • chemosis
      • conjunctivitis
      • periorbital swelling
        • corneal ulceration
        • optic neuritis / atrophy

Cardiovascular signs

• sinus tachycardia
• widened pulse pressure
• atrial arrhythmias (esp. atrial fibrillation)
• systolic murmurs
• cardiomegaly, congestive cardiac failure (CCF)

Dermopathy – in patients with past / present Grave’s Disease

• pretibial myxoedema – discrete to confluent
  • raised, thickened, peau d’orange-like (well demarcated)
  • may be pruritic and hyperpigmented
• clubbing fingers / toes
• thyroid acropachy

Goitre

• diffuse – may be asymmetric and lobular
• thrill / bruit
• absence of thyroid enlargement makes diagnosis less likely but does not exclude it

In a few, usually older patients, can get so-called apathetic thyrotoxicosis, with pronounced myopathic features.

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Differential Diagnosis of ophthalmopathy of Grave’s Disease

Think of other causes than thyrotoxicosis, especially if ophthalmopathy is unilateral or the bilateral ophthalmopathy in a euthyroid patient.

• cavernous sinus thrombosis
• sphenoidal ridge meningioma
• retrobulbar tumours
• pseudotumour cerebri

Differential Diagnosis of Exophthalmos

• uraemia
• accelerated hypertension
• chronic alcoholism
• chronic airflow limitation (CAL)
• superior mediastinal obstruction
• Cushing’s syndrome

Consider Thyroid stimulating immunoglobulin tests and CT scan

Thyrotoxic without ophthalmopathy (i.e. other causes besides Grave’s disease):

In these patients check thyroid stimulating immunoglobulin (TSI) and thyroxine binding globulin (TBG) levels.

• symmetric, diffuse moderately large to large goitre: Grave’s disease, but consider also:
  • pituitary tumour
  • abnormal thyroid stimulator:
    • hydatidiform mole
    • choriocarcinoma
• radioactive iodine studies
  • increased tracer uptake (“hot spot”): single / prominent nodule or occasional multiple hot spots
    • adenoma
    • multinodular goitre
  • decreased tracer uptake (“cold spot”):
    • tender, firm nodularity: subacute thyroiditis
    • small, firm, non-tender goitre: chronic thyroiditis with spontaneously resolving thyrotoxicosis
    • no palpable thyroid: extra-thyroidal source of thyroxine – rare
      • low TSH
        • ectopic thyroid (stroma ovarii)
        • thyrotoxic factitiae