Diagnostic Considerations

A summary of the differential diagnoses for thyrotoxicosis is as follows:

Graves disease: Special features include a diffusely enlarged thyroid gland, thyroid bruits, ophthalmopathy, pretibial myxedema, and the presence of TSIs.
Subacute thyroiditis: Special features include a history of antecedent respiratory tract infection, neck tenderness, elevated sedimentation rate, low or absent radioactive iodine uptake, and a self-limited course.^[4]
Silent thyroiditis: Special features include painless thyroiditis, which may be seen in postpartum women (postpartum thyroiditis); a self-limited course; and low radioiodine uptake.
Multinodular toxic goiter: Special features include a propensity to occur in elderly individuals and multiple nodules palpated or observed after thyroid scanning.
Toxic adenoma: Special features include a solitary palpable nodule and a hot nodule observed after thyroid scanning.
Factitious thyrotoxicosis: Special features include no goiter, a low thyroglobulin level, and low radioiodine uptake.
Iatrogenic thyrotoxicosis: The special feature is a history of thyroid hormone intake.
Iodide-induced thyrotoxicosis: The special feature is a propensity to occur in patients with a history of nodular thyroid disease who have been exposed to iodine-containing contrast agents or drugs such as amiodarone.
TSH-secreting pituitary adenoma: Special features include inappropriately elevated or normal TSH levels in the setting of elevated free levothyroxine (T4) and free triiodothyronine (T3) levels, evidence of other pituitary hormone deficiencies, elevated alpha subunit level, and compressive symptoms.
Beta-human choriogonadotropin–induced thyrotoxicosis: Special features include a positive pregnancy test result, a history of hydatidiform mole, choriocarcinoma, and embryonal carcinoma of the testis. Also, rarely, it may be observed in normal gestation.

Differential Diagnoses

Abnormal thyroid-binding protein (eg, thyroxine autoantibodies, abnormal concentration or binding of thyroxine-binding globulin or transthyretin)
Anxiety Disorders
Cocaine Toxicity
Drug-induced hyperthyroidism (eg, iodinated contrast, amiodarone, iodine supplements)
Drug-induced thyroiditis (eg, amiodarone, interferon-alfa)
Exogenous thyroid hormone (intentional or unintentional)
Hashimoto Thyroiditis
Hyperemesis Gravidarum
Papillary Thyroid Carcinoma
Pheochromocytoma
Pituitary resistance to thyroid hormone
Postpartum thyroiditis
Radiation-induced thyroiditis
Silent thyroiditis
Struma Ovarii
Subacute Thyroiditis
Thyrotropin-producing pituitary adenomas
Toxic multinodular goiter
Trophoblastic tumors
Wolff-Parkinson-White Syndrome

Workup

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Media Gallery

Pathophysiologic mechanisms of Graves disease relating thyroid-stimulating immunoglobulins to hyperthyroidism and ophthalmopathy. T4 is levothyroxine. T3 is triiodothyronine.
Graves disease. Varying degrees of manifestations of Graves ophthalmopathy.

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Author

Sai-Ching Jim Yeung, MD, PhD, FACP Professor of Medicine, Department of Emergency Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center

Sai-Ching Jim Yeung, MD, PhD, FACP is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Medical Association, American Thyroid Association, Endocrine Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Celgene, Inc.<br/>Received research grant from: DepoMed and Bristol-Myer-Squibb.

Coauthor(s)

Mouhammed Amir Habra, MD Endocrine Fellow, Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center

Mouhammed Amir Habra, MD is a member of the following medical societies: American College of Physicians, American Thyroid Association, Endocrine Society

Disclosure: Nothing to disclose.

Alice Cua Chiu, MD Associate Affiliate, Department of Internal Medicine, Division of Endocrinology, Bayshore Medical Center

Alice Cua Chiu, MD is a member of the following medical societies: American Medical Association, Endocrine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Kent Wehmeier, MD Professor, Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, St Louis University School of Medicine

Kent Wehmeier, MD is a member of the following medical societies: American Society of Hypertension, Endocrine Society, International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

Chief Editor

Romesh Khardori, MD, PhD, FACP (Retired) Professor, Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Additional Contributors

Steven R Gambert, MD Professor of Medicine, Johns Hopkins University School of Medicine; Director of Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center

Steven R Gambert, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Physician Leadership, American College of Physicians, American Geriatrics Society, Endocrine Society, Gerontological Society of America, Association of Professors of Medicine

Disclosure: Nothing to disclose.

Sections Graves Disease
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Graves Disease Differential Diagnoses

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