Thyroid disorders (hyperthyroidism & hypothyroidism)
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This document provides information on thyroid disorders including their regulation, metabolism, function tests, clinical examination, classifications of hypothyroidism, its multi-system effects and signs. It also discusses hyperthyroidism including its causes, symptoms, signs, diagnosis, complications and treatment options such as anti-thyroid drugs, radioactive iodine, surgery and symptom relief medications. Specific conditions like Graves' disease, thyroid storm, congenital hypothyroidism and myxedema coma are explained.
Thyroid disorders (hyperthyroidism & hypothyroidism)
- 1. 1 THYROID DISORDERS By Dr Nadia Shams Professor of Medicine
- 2. Thyroid Regulation 2 PLASMA T4 + FT4 HYPOTHALAMUS - TRH ANT. PITUITARY - TSH THYROID T4 and T3 PLASMA T3 + FT3 TISSUES FT4 to FT3, rT3 TSH -R
- 3. Metabolism of Thyroid Hormones 4 Thyroid Gland Thyroxine FT4 Reverse T3 (rT3) Triiodothyronine (FT3) Tertrac etc., 100 nm 5 nm < 5 nm 45 nm 35 nm 20 nm
- 4. Thyroid Function Tests 1. TSH 2. Free T4 3. Free T3 4. Anti-Thyroid Antibodies 5. Nuclear Scintigraphy 6. FNAC of nodule 6
- 5. Clinical Examination of Thyroid Palpate from behind the patient Remember the rule of finger tips Pemberton’s sign for retrosternal Goitre.
- 6. Clinical Exam of Thyroid
- 7. Clinical Exam of Thyroid
- 8. THYROID HORMONES TEST REFERENCE RANGE TSH Normal Range 0.3 - 4.0 mU/L Free T4 Normal Range 0.7-2.1 ng/dL 10
- 9. Thyroid Antibodies ⚫ Anti Microsomal ⚫ Anti Thyroglobulin ⚫ Anti Thyroxine Per Oxidase ⚫ Anti Thyroxine antibodies ⚫ Thyroid Stimulating Antibodies 11
- 10. CASE ⚫ A 30 years old girl presents with 3 months history of lethargy, excessive weight gain, swelling of feet, cold intolerance and hoarseness of voice… ⚫ The most likely diagnosis is ???
- 12. Hypothyroidism ⚫ Epidemiology – Most common endocrine disease – Females > Males – 8 : 1 ⚫ Presentation – Often unsuspected and grossly under diagnosed – 90 % of the cases are Primary Hypothyroidism – Menstrual irregularities, miscarriages, growth retard. – Vague pains, anaemia, lethargy, gain in weight – In clear cut cases - typical signs and symptoms – Low free T4 and High TSH – Easily treatable with oral Levo-thyroxine 14
- 13. Classification of Hypothyroidism A. Primary 1. Autoimmune - Hashimoto’s 2. Iatrogenic - radioactive iodine 3. thyroiditis - Subacute (Dequervain’s) - Postpartum 4. Iodine deficiency 5. Secondary / Central Pituitary/ hypothalamic 15
- 14. Thyroid Failure - Organ Systems Cardiovascular • Decreased ventricular contractility • Increased diastolic blood pressure • Decreased heart rate Central Nervous • Decreased concentration • General lack of interest • Depression Gastro-instestinal • Decreased GI motility • Constipation 16
- 15. 17 Thyroid Failure - Organ Systems Musculoskeletal ⚫ Muscle stiffness, cramps, pain, weakness, myalgia ⚫ Slow muscle-stretch reflexes, muscle enlargement, atrophy Renal ⚫ Fluid retention and oedema ⚫ Decreased glomerular filtration
- 16. Reproductive ⚫ Arrest of pubertal development ⚫ Reduced growth velocity ⚫ Menorrhagia, Amenorrhea ⚫ Anovulation, Infertility Hepatic ⚫ Increased LDL / TC ⚫ Elevated LDL + triglycerides 18 Thyroid Failure - Organ Systems
- 17. 19 Thyroid Failure - Organ Systems Skin and Hair ⚫ Thickening and dryness of skin ⚫ Dry, coarse hair, Alopecia ⚫ Loss of scalp hair and / or lateral eyebrow hair
- 18. 20 Multi system effects - Hypothyroidism General •Lethargy, Somnolence, Weight gain, Goitre, Cold Intolerence Cardiovascular •Bradycardia, Angina,CHF, Pericardial Effusion •HyperlipIdemia, Xanthelasma Haematological Iron def. Anaemia, Normocytic/chromic Anaemia Reproductive system •Infertility, Menorrhagia,Impotence, Inc. Prolactin
- 19. 21 Multi system effects - Hypothyroidism Neuromuscular •Aches and pains, Muscle stiffness •Carpel tunnel syndrome, Deafness, Hoarseness •Cerebellar ataxia,Delayed DTR, Myotonia •Depression, Psychosis Gastro-intestinal •Constipation, Ileus, Ascites Dermatological •Dry flaky skin and hair •Myxoedema, Malar flushes •Vitiligo, Carotenimia, Alopecia
- 20. 22 Clinical Signs of Hypothyroidism ⚫ Coarse Hair; Dry cool and pale skin ⚫ Goitre ⚫ Hoarseness of voice ⚫ Non-pitting oedema (myxoedema) ⚫ Puffiness of eyes and face ⚫ Delayed relaxation of deep tendon reflexes ⚫ Slow hoarse speech and slow movements ⚫ Thinning of lateral 1/3 of eye brows ⚫ Bradycardia, pericardial effusion
- 21. Myxedema Coma ⚫ Precipitating factors : ⚫ Infection, trauma, stroke, cardiovascular, hemorrhage, drug overdose, diuretics ⚫ Signs and Symptoms : ⚫ Mental confusion, hypothermia, bradycardia ⚫ ↓ Na, ↓ glucose, ↑ CO2, ↓ WBC, ↓ Hct, ↑ CPK ⚫ ↓ EKG voltage, myxedema, b-carotnenemia ⚫ Treatment ⚫ ICU transfer, T3 100 µg IV sixth hourly, 500 µg of T4 , antibiotics, ventilation, hydrocortisone IV, passive warming, careful volume management 23
- 26. Macroglossia 28
- 31. 33 Pituitary Tumor – Secondary Hypo Normal Pituitary Fossa
- 32. 34 Massive Pericardial Effusion in Hypothyroidism
- 33. Investigations ⚫ Low T4 ⚫ High TSH ⚫ ECG shows sinus bradycardia ⚫ TPO antibodies
- 34. Many Causes, One Treatment ⚫ Levothyroxine sodium (1.6µg/kg/day) approx.100 mcg per day ⚫ Monitor TSH levels at 6 to 8 weeks, after initiation of therapy or dosage change 36
- 35. Over-replacement risks ⚫ Reduced bone density / osteoporosis ⚫ Tachycardia, arrhythmia. atrial fibrillation ⚫ In elderly or patients with heart disease, angina, arrhythmia, or myocardial infarction Under-replacement risks ⚫ Continued hypothyroid state ⚫ Long-term end-organ effects of hypothyroidism ⚫ Increased risk of hyperlipidemia 37 Inappropriate Dosage
- 36. Diet in Iodine deficiency ⚫ Iodized salt ⚫ Selenium supplementation ⚫ Avoid cabbage (goitrogens) ⚫ Avoid formula milk ⚫ Fish, meat, milk & eggs 38
- 38. Case A 55 year old woman is anxious, irritable with history of frequent semi solid stools and she reports weight loss of 5 kgs in the past six months. She was having a painless swelling in her neck for past 20 years. The most likely diagnosis is ???
- 39. Hyperthyroidism A hyper metabolic biochemical state It is a multi system disease with elevated levels of FT4 or FT3 or both Because of negative feed back TSH will be suppressed
- 40. Causes of Hyperthyroidism 1. Graves Disease – Diffuse Toxic Goiter 2. Plummer’s Disease – Toxic MNG 3. Sub Acute Thyroiditis 4. Toxic Single Adenoma 5. Pituitary Tumors – excess TSH
- 41. Common Symptoms 1. Nervousness 2. Anxiety 3. Increased sweating 4. Heat intolerance 5. Tremors 6. Hyperactivity 7. Palpitations 8. Weight loss despite increased appetite 9. oligo-menorrhea/ infertility
- 42. Common Signs 1. Hyperactivity 2. Sinus tachycardia /AF/ CHF 3. Systolic hypertension, wide pulse pressure 4. Warm, moist, soft and smooth skin/warm handshake
- 43. Signs 1. Excessive perspiration, palmar erythema, Onycholysis 2. Lid lag and stare (sympathetic over activity) 3. Fine tremor of out stretched hands – format's sign 4. Large muscle weakness(proximal myopathy) 5. Gynaecomastia
- 44. Specific to Graves Disease 1. Diffuse painless firm enlargement of thyroid gland 2. Thyroid bruit 3. Eye manifestations – 50% of cases. 4. Skin/limb manifestations – 20% of cases ➢ non pitting edema, associated with erythema and thickening of the skin, without pain or pruritus - called pretibial myxedema
- 45. Non specific changes 1. Hyperglycemia, Glycosuria 2. Osteoporosis and hypercalcemia 3. ↓ LDL and Total Cholesterols 4. Atrial fibrillation, LVH, ↑ LV EF 5. Hyper dynamic circulatory state 6. High output heart failure 7. H/o excess Iodine, amiodarone, contrast dyes
- 46. Diagnosis and investigations 1. Suppressed TSH (<0.05 µIU/mL) 2. Elevated FT4 3. Thyroid antibodies – anti-TPO, TSI, TRAb. 4. ECG 5. Nuclear Scintigraphy
- 47. Completely irregular rhythm Atrial fibrillation
- 48. Graves Disease I 123 or TC 99m Normal v/s Graves
- 49. Treatment Options 1. Symptomatic & supportive 2. Anti Thyroid Drugs – ATD ➢ Methimazole, Carbimazole ➢ Propylthiouracil (PTU) 3. Radio Active Iodine treatment – RAI Rx. 4. Thyroidectomy – Subtotal or Total 5. NSAIDs and Corticosteroids – for SAT
- 50. Symptom Relief 1. Rehydration 2. β – blockers ➢ Propranalol, Atenelol, Metoprolol 3. Treatment of CHF, Arrhythmias 4. Calcium supplementation 5. Lugol solution for ↓ vascularity of the gland
- 51. Radio Active Iodine (RAI Rx.) It is effective, safe, and does not require hospitalization. Given orally as a single dose
- 52. Graves Disease The most common cause of thyrotoxicosis (50-60%). Organ specific auto-immune disease The most important autoantibody is Thyroid Stimulating Immunoglobulin (TSI) or TSA TSI acts as proxy to TSH and stimulates T4 and T3 Anti-TPO antibodies Anti thyro globulin (anti-TG) Anti Microsomal and other Autoimmune diseases - Pernicious Anemia RA, Myasthenia Gravis, Vitiligo, Adrenal insufficiency.
- 53. Surgical Treatment Subtotal Thyroidectomy, Total Thyroidectomy Hemi Thyroidectomy with contra-lateral subtotal
- 54. Thyroid Storm ⚫ Symptoms ⚫ Fever ⚫ Agitation ⚫ Confusion ⚫ Tachycardia ⚫ Atrial fibrillation ⚫ CHF ⚫ Treatment ⚫ Rehydration ⚫ Propranolol 80 mg 6Hrly ⚫ Sodium Ipodate (500 mg/day) ⚫ Dexamethasone 2mg 6Hrly
- 56. MNG and Graves Huge Toxic MNG Diffuse Graves Thyroid
- 58. Ophthalmopathy in Graves Periorbital edema and chemosis
- 59. Ophthalmopathy in Graves Occular muscle palsy
- 61. Thyroid Dermopathy Pink and skin coloured papules, plaques on the shin
- 62. Clubbing and Osteoarthropathy Thyroid Acropathy
- 63. Onycholysis
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