Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
CONTENTS
FOREWORD
LIST OF ABBREVIATIONS
1. THYROTOXICOSIS
1.1 Clinical Features
1.2 Laboratory Investigations
1.3 Management
1.3.1 Medical Treatment
1.3.2 Surgery
1.3.3 Radioiodine Therapy
1.4 Management of Complications
1.4.1 Thyrocardiac complications
1.4.2 Hypokalaemic periodic paralysis
1.4.3 Ophthalmopathy
1.4.4 Dermopathy
2. THYROID CRISIS
2.1 Clinical Features
2.2 Management
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3. HYPOTHYROIDISM
3.1 Clinical Features
3.2 Laboratory Investigations
3.3 Management
3.3.1 Overt Hypothyroidism
3.3.2 Subclinical Hypothyroidism
3.3.3 In pregnancy
3.4 Monitoring
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4. MYXOEDEMA COMA
4.1 Management
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5. CONGENITAL HYPOTHYROIDISM
5.1 Clinical Features
5.2 Laboratory Investigations
5.3 Management
5.4 Monitoring
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22
23
23
6. THYROIDITIS
6.1 Clinical Features
6.1.1 Hashimotos thyroiditis
6.1.2 Riedels thyroiditis
6.1.3 Subacute (De Quervains) thyroiditis
6.1.4 Postpartum thyroiditis
6.1.5 Painless thyroiditis
6.1.6 Acute pyogenic thyroiditis
6.2 Laboratory Investigations
6.3 Management
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8. MULTINODULAR GOITRE
8.1 Clinical Features
8.2 Laboratory Investigations
8.3 Management
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STATEMENT OF INTENT
32
REFERENCES
33
TASKFORCE
AND
CONTRIBUTORS
Malaysian Endocrine and Metabolic Society
1. Professor Dato Dr Mustaffa Embong
Department of Medicine, School of Medical Sciences,
University Science Malaysia (USM)
2. Assoc Prof Dr Mafauzy Mohamed
Dean, School of Medical Sciences ,USM
3. Assoc Prof Dr Wan Mohamad Wan Bebakar
Head, Department of Medicine, School of Medical Sciences, USM
4. Dr Fuziah Md Zain
Department of Paediatrics, School of Medical Sciences,USM
3. Professor Dato Dr Anuar Zaini Mohd Zain
Dean, Faculty of Medicine, University of Malaya (UM)
6. Professor Dr Amir S Khir
Deputy Dean, Faculty of Medicine, UM
7. Assoc Prof Dr Chan Siew Pheng
Department of Medicine, Faculty of Medicine, UM
8. Assoc Prof Dr Ikram Shah Ismail
Department of Medicine, Faculty of Medicine, UM
9. Assoc Prof Dr Fatimah Harun
Department of Paediatrics, Faculty of Medicine, UM
10. Dr Rokiah Pendek
Department of Medicine, Faculty of Medicine, UM
3. Dr Hisham Abdullah
Consultant Surgeon, Hospital Kuala Lumpur (HKL)
College of Physicians
1. Dato Dr (Mrs) ST Kew
Consultant Physician, Hospital Kuala Lumpur (HKL)
2. Dr Liew Yin Mei
Consultant Physician, Hospital Kuala Lumpur (HKL)
3. Dr Wong Wing Keen
Consultant Physician, Pantai Medical Centre
LIST
OF
ABBREVIATIONS
AF
CMZ
CNS
CT
ESR
FNAC
fT4
fT3
IHD
K+
MEN
MNG
MRI
MTC
NSAID
PTU
SSKI
TSH
TRH
T4
T3
Atrial fibrillation
Carbimazole
Central Nervous System
Computerised Tomography
Erythrocyte Sedimentation Rate
Fine-Needle Aspiration Cytology
Free T4
Free T3
Ischaemic Heart Disease
Potassium ion
Multiple Endocrine Neoplasia
Multinodular Goitre
Magnetic Resonance Imaging
Medullary Thyroid Carcinoma
Non-Steroidal Anti-inflammatory Drug
Propylthiouracil
Saturated Solution of Potassium Iodide
Thyroid-stimulating Hormone, Thyrotropin
Thyrotropin-releasing Hormone
Thyroxine
Tri-iodothyronine
1. THYROTOXICOSIS
Thyrotoxicosis is a clinical state due to excess thyroid hormones. Two hormones
tri-iodothyronine (T3) and thyroxine (T4) are produced by the thyroid gland of which
T3 is the active hormone. The causes include:
*
*
*
*
1.3 Management
Three forms of therapy are available: antithyroid drugs, surgery and radioiodine.
Treatment may also be necessary for complications e.g. atrial fibrillation,
cardiac failure, ophthalmopathy. The methods used will vary according to the
cause and severity of the disease, the patients age and resources available.
Subclinical hyperthyroidism which is characterised by normal fT4 and fT3 and
suppressed TSH levels, is a recognised entity. The need to treat this condition
remains controversial. Close monitoring of clinical and biochemical status is
indicated.
10
11
30-45 mg/day
300-450 mg/day
Maintenance therapy
(gradual reduction over
3-6 months from initial dose)
5-10 mg/day
50-100 mg/day
12
1.3.2 Surgery
Thyroidectomy may be performed in Graves' disease, toxic multinodular
goitre or toxic adenoma.
Indications:
Failed medical treatment i.e. relapse after one or more courses of
antithyroid drugs, non-compliance or development of side-effects.
Those with large goitres, especially with pressure effects.
Patients who prefer surgery.
A relative indication is severe progressive ophthalmopathy.
13
14
15
2. THYROID CRISIS
Thyroid crisis is a life threatening exacerbation of the hyperthyroid state with
evidence of decompensation in one or more organ systems. The mortality is 20 - 30 %.
It may be precipitated by stress including concurrent infections, surgery or pregnancy.
2.2 Management
Rehydration
Treat hyperpyrexia (use fans, tepid sponging and oral paracetamol)
Do NOT use aspirin or NSAIDs
Beta sympathetic blocking agents
Oral propanolol 40 mg qid, or I/V 1-2 mg 4-6 hourly
Iodide
Oral saturated solution of potassium iodide (SSKI) 5 drops 6-hourly
or I/V Sodium Iodide 500 mg 8 hourly
or oral Lugol's iodine 5-10 drops, 6-hourly
Antithyroid Drugs
Carbimazole 15-20 mg 6-hourly
or propylthiouracil 150-200 mg 6-hourly
Corticosteroids
I/V dexamethasone 2 mg 6-hourly
or I/V hydrocortisone 200 mg 6-hourly
16
17
3. HYPOTHYROIDISM
Hypothyroidism is due to deficiency of thyroid hormones resulting in a hypometabolic state. The causes are:
*
18
3.3 Management
The aim is to make the patient clinically and biochemically euthyroid.
Treatment is life long and patient needs to be informed of this to ensure
good compliance. Omission of L-thyroxine for a few days, for example,
in the perioperative period does not result in any deleterious consequences.
3.3.1 Overt Hypothyroidism
The usual starting dose for L-thyroxine is 50 or 100 ug/day increasing
at 1 - 2 weeks interval to a maintenance dose of 100 - 200 ug/day.
Hypothyroidism of recent onset can be given the full replacement dose
immediately.
In patients with ischaemic heart disease (IHD), gross hypothyroidism and in
the elderly, the usual starting dose of L-thyroxine is 25 ug/day. The dosage
should be increased slowly (i.e. every 2-4 weeks) according to the patients
response. If angina occurs, reduce to previous dosage or withhold treatment
temporarily, while management of IHD is optimised.
In hypopituitarism, L-thyroxine therapy should be initiated only after
cortisol replacement to avoid possible adrenal crisis.
3.3.2 Subclinical hypothyroidism
In such cases, patients are not overtly hypothyroid and serum fT4 is
normal but TSH is elevated. Treatment with L-thyroxine is recommended
as such patients are more prone to coronary artery disease due to hyperlipidaemia, if left untreated. Treat initially with L-thyroxine 50-100 ug/day
and adjust dosage to maintain normal TSH levels.
19
3.3.3 In pregnancy
There may be a need to increase the dose of L-thyroxine, particularly
during the second and third trimesters.
3.4 Monitoring
The patient should be monitored clinically and biochemically with serum
TSH and fT4 measurements.
Measurements of serum TSH and fT4 should be done 2-3 months after
initiation of therapy to determine the maintenance dose and subsequently
every 6 months to 1 year.
20
4. MYXOEDEMA COMA
Myxoedema
coma
be precipitated by stress, infection, or
drugs
(e.g. CNS suppressants). This is not a common condition but urgent treatment is
required because the mortality is high.
4.1 Management
The treatment consists of:
Gradual rewarming with blankets.
Accurate core temperatures should be recorded with a low reading
Rectal thermometer.
Thyroid hormone replacement with L-thyroxine 300-400 ug given
orally via nasogastric tube or parenterally if available. Alternatively,
doses of tri-iodothyronine 10 ug 8-hourly (IV or orally)
may
be used.
I/V hydrocortisone should be given, 200 mg stat and 100 mg 6-hourly
until patient regains consciousness
Ensure adequate hydration and nutrition;
Use 5-10% dextrose solution to maintain normal blood glucose levels.
Correct electrolyte imbalance (patients tend to be hyponatraemic).
Ensure adequate ventilation.
Patients tend to hypoventilate, resulting in hypercapnoea.
Treat precipitating cause.
Infection may be masked by the hypothyroid state.
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5. CONGENITAL
HYPOTHYROIDISM
An endocrine disorder resulting from inadequate thyroid hormone for the
metabolic needs of a newborn infant. Incidence is between 1:4000 to 1:5000 in
Malaysia. Most infants with the disease have no obvious clinical manifestations at
birth, therefore neonatal screening of thyroid function should be performed on all
newborns. Intellectual impairment can be prevented by early diagnosis and
treatment. The causes include:
*
*
*
22
5.3 Management
Treatment should commence as soon as the diagnosis is made.
With early adequate thyroid replacement therapy, patients are expected to
have normal intellectual and physical development.
Starting dose of L-thyroxine is 10-12 ug/kg/day.
The aim is to maintain serum TSH levels within the normal range and fT4
at the upper limit of the normal range adjusted for age.
Treatment should be life-long except in children suspected of having
transient hypothyroidism whereby therapy is stopped at 2 years of age for
re-evaluation.
5.4 Monitoring
Patients should be monitored clinically and biochemically at monthly intervals
for the first 6 months then 3-monthly until one year of age; and thereafter
6 monthly.
Checklist for monitoring include growth parameters (weight, height,
head circumference), developmental milestones and bone age progression.
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6. THYROIDITIS
Thyroiditis is inflammation of the thyroid gland with destruction of the thyroid
tissues to a variable degree. The presentation, functional disturbance and prognosis
depend on the aetiology of the thyroiditis. Presentation may be acute, subacute or
chronic. The causes are:
Autoimmune Infection
Physical
Idiopathic
-
Hashimotos thyroiditis
post-partum thyroiditis
atrophic thyroiditis
viral thyroiditis (De Quervains thyroiditis)
radiation to the neck
painless thyroiditis
Riedels thyroiditis
Postpartum thyroiditis is an autoimmune disorder presenting with thyrotoxicosis followed by euthyroid and hypothyroid phases a few months after
delivery. A proportion of patients may present at the hypothyroid phase. Unlike
De Quervains, there is no pain in the thyroid which is enlarged in about 50% of
cases. The thyrotoxic phase lasts for about 2 months but the hypothyroid phase
may last for 2-9 months. About 5% of the patients develop permanent
hypothyroidism.
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25
6.3 Management
NSAIDs to relieve pain.
In de Quervains thyroiditis, if pain persists after 1 week of NSAIDs
treatment, steroid therapy (prednisolone 30 mg/day for 1 week) is
useful.
Antithyroid drugs (e.g. carbimazole) are not indicated.
Beta-blockers may be useful to alleviate symptoms.
L-thyroxine is indicated for hypothyroidism. It may be withdrawn after
6-12 months in postpartum or painless thyroiditis to determine whether
there is recovery of thyroid function.
In Hashimotos thyroiditis,
hypothyroidism is likely to be permanent and patients require life-long thyroid
hormone replacement.
Antibiotics are indicated in pyogenic thyroiditis.
Surgical drainage may be required.
26
The incidence of malignancy in solitary nodule may be as high as 10%. The sudden
appearance of a painful thyroid nodule is usually due to bleeding into a colloid cyst;
this resolves spontaneously.
.
7.1 Diagnosis
The history and physical examination are essential in the initial assessment
of thyroid swelling. The suspicion of malignant disease would be high in
the following:
Age groups of <20 years and >50 years have the highest incidence
of thyroid cancer in a palpable nodule
Male gender
History of rapid increase in size and local pressure symptoms
e.g. dysphagia and hoarseness of voice
History of external neck irradiation during childhood or adolescence
A firm/hard irregular and fixed nodule
Ipsilateral cervical lymphadenopathy (probability of malignancy
increases from about 10% to 70%)
Family history is important Familial medullary thyroid carcinoma has
an autosomal dominant inheritance while papillary thyroid carcinoma is
familial in only 3% of cases
Dominant nodule in a multinodular goitre
27
7.2.2
7.2.3
7.2.4
in the
should
7.3 Management
In colloid cyst, aspiration may be therapeutic.
Surgery should be considered for recurrence.
Toxic adenoma is treated surgically or with radioiodine.
The use of L-thyroxine to reduce the size of thyroid nodules is seldom
effective.
In papillary and follicular carcinoma, total thyroidectomy followed
by ablative radioiodine and L-thyroxine therapy are potentially curative.
28
29
8.
MULTINODULAR
GOITRE
iodine deficiency
goitrogen ingestion
autoimmune disorders
dyshormonogenesis (usually diffuse in the initial stages)
30
Thyroid scintiscans are not useful except in cases where toxic (hot)
nodules are suspected.
Fine needle aspiration cytology (FNAC) should be performed when
malignancy is suspected.
8.3 Management
No treatment is required when the goitre is small
symptoms. Reassurance is usually adequate.
and
not
causing
31
as
STATEMENT OF INTENT
This report is not intended to be construed or to serve as a standard of
medical care.
clinical data available for an individual case and are subject to change as
knowledge and technology advance and patterns evolve.
32
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Copyright Malaysian Endocrine and Metabolic Society
Academy of Medicine Malaysia
Ministry of Health Malaysia
Published By
Malaysian Endocrine and Metabolic Society
January 2000
Distributed By
Malaysian Endocrine and Metabolic Society
c/o Department of Medicine, Faculty of Medicine
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