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Dharma Lindarto
Div. Endokrin-Metabolisme dan Diabetes. Dep Ilmu Penyakit
Dalam FK USU / RSUP HAM Medan
Hypothyroidism
Prevalence of Hypothyroidism
Prevalence is 14/1000 females and
1/1000 males.
Other autoimmune diseases.
Family history of autoimmune
diseases
Grade 3:
Grade 4:
Secondary hypothyroidism-causes
Hypothalamic disease
Pituitary disease
Clinical features
General and CVS
Tiredness
Weight gain
Cold intolerance
Goitre
Constipation
Bradycardia
Angina
Cardiac Failure
Pericardial effusion
Clinical Features
Neurological and Haematological
Iron deficiency A
Pernicious Anemia
Clinical Features
Dry skin
Erythema
Vitiligo
GOITROGENS
DRUGS
Anti-thyroid
Cough medicines
Sulfonamides
Lithium
Phenylbutazone
PAS
Oral hypoglycemic agents
GOITROGENS
FOOD
Soybeans
Millet
Cassava
Cabbage
Laboratory Diagnosis
T4/FT4 reduced
T3/FT3
TSH elevated
Thyroid Antibodies may indicate
aetiology.
If TSH is reduced or normal in the
presence of a low T4, pituitary
function necessary.
Treatment
Thyroxine. Usual maintenance dose is
150ug.
Compliance and adequacy of dose
checked by TSH measurements.
Try to maintain TSH in normal range.
TIROIDITIS
An approach to Thyroiditis
Neck Pain
Yes
No
RAIU
Hyperthyroid
Increased
Decreased
RAIU
RAIU
Inflammatory
De Quervains
Graves
Subacute
Lymphocytic
Hypothyroid
Chronic
Lymphocytic
Thyroiditis
Group of inflammatory thyroid disorders
Comprise:
1) Chronic Lymphocytic/Hashimotos
2) Subacute Granulomatous/De Quervains
3) Subacute Lymphocytic
4) Acute (Suppurative)
5) Invasive Fibrous/Riedels
Chronic
Lymphocytic/Hashimotos
Most common thyroiditis
Most common goitre in USA
Autoimmune condition - Ab Titres
to thyroid peroxidase and
thyroglobulin
Association with other AI conditions
(SLE, RA, DM, Sjgrens)
Usually women, 30-50yrs of age
Chronic
Lymphocytic/Hashimotos
Clinically: Firm, irregular, non-tender
goitre
ESR, WCC (N)
Presence of Thyroid Specific AutoAbs
>200 IU/ml
RAIU variable
Treat with T4 only if hypothyroid
(to decrease goitre) or in high risk pts
Subacute Lymphocytic
2 Subgroups Postpartum vs Sporadic
29-50% of all Thyroiditis
Women 30-50yrs of age
Initially Hyper-, then Hypo- then
Euthyroid
Postpartum thyroiditis carries risk for
recurrence in subsequent pregnancies
Antibodies: Antimicrosomal, Anti TPO
Subacute Lymphocytic
Subacute Granulomatous /
De Quervains
Most common cause of a painful thyroid
Most likely cause Viral infection, often
from a preceding viral URTI
Agents implicated include: Mumps,
Coxsackie, Echo, EBV, Adeno, Fluviruses
Women > Men (3-5x)
Geographical and seasonal distribution
(Summer, Autumn)
Subacute Granulomatous /
De Quervains
Acute onset thyroid area pain
Pain with swallowing, head turning
Radiation to jaw, ear or chest
ESR
Thyroid: Firm, nodular, exquisitely
tender
T4
T3
Subacute Granulomatous /
De Quervains
Thyroglobulin
RAIU
< 2%
4 Phases
1)Acute pain, thyrotoxicosis (3-6
weeks) 2)Transient euthyroidism
3)Hypothyroidism (weeks to months)
4)Recovery
Rx: -Blockers, NSAIDs, Prednisone
Inflammatory/Suppurative
Rare, mostly Gr+ infection of the thyroid
Staph aureus
Other causes: Syphilis, mycobacterial,
parasitic, fungal
Mainly women 20-40yrs of age, with
pre-existing thyroid nodules
Sx of infection and inflammation, worse
on swallowing. ESR , WCC
TSH, T4, T3 usually (N)
Invasive Fibrous/Riedel
Rarest, 83% Females
Dense thyroid fibrosis
Association with multifocal fibrosclerosis
Hard Thyroid mass which may involve
surrounding structures, usually
unilateral
ESR , TFT (N)
Diagnosis Open biopsy.
Hashimotos Thyroiditis
Chronic lymphocytic thyroiditis
Chronic autoimmune thyroiditis
Caused by:
Antithyroid peroxidase antibodies
Antithyroglobulin antibodies
Postpartum Thyroiditis
Usually presents as overt
hypothyroidism
May have associated goiter
Occurs within first 6 postpartum
months
Non-tender gland
Self-limiting
No treatment required usually
Subacute Thyroiditis
May be associated with a viral infection
Gland usually tender
Fever, sore throat, malaise may be
present
Elevated ESR
Self-limiting
Lasts 1-3 months
NSAIDs for pain, fever prn
Riedels Thyroiditis
Rare
Middle-aged or elderly women
Enlarged, asymmetric, stony hard
gland adherent to neck structures
Local pain, dysphagia, dyspnea,
hoarseness
Treated with Tamoxifen [generic]
Myxedema Coma
Medical emergency
High mortality rate
Rare
Occurs in older women as a
consequence of poorly controlled or
untreated hypothyroidism
Hospitalization, sepsis, exposure to
cold, trauma
Myxedema Coma
Altered consciousness, coma
Hypothermia
Bradycardia
Hypotension
Reduced ventilatory rate
Hypoglycemia, hyponatremia,
elevated TSH
Myxedema Coma
Treatment:
Intubation and mechanical ventilation
Control hypothermia
Volume expansion
Large dose of Levothyroxine (synthetic
T4) [generic], then daily therapy
Hypothyroid Face
Notice the apathetic
facies, bilateral ptosis,
and absent eyebrows
Iodine Deficiency
Consequences of Iodine
Deficiency
220
290
110
130
90
120
Iodine excess
Sources of US Iodine
Dairy products
Medicines
Vitamin/mineral preparations
Antiseptics
Seafood, meat
Bread
Iodized salt
B. Nodules
Can be multiple or single, hot or cold
Overall 5-10%% are malignant
95% of solitary nodules are cold and 85% of
those are benign
5% of patients who had neck radiation as
child (esp. w/>100 rads) get malignant
nodules (papillary carcinoma)
3. Thyroid Adenoma
Benign area of hyperfunctioning autonomous
thyroid tissue
Most are follicular type; occur as single nodule
Starts off small, grows slowly, and becomes large
Adenomas may : hemorrhagic necrosis with
associated pain and subsequent loss of function.
Treatment of Thyroid
Adenomas
Ablative therapy with high-dose I131
surgery
4. Thyroid carcinoma
Either Parafollicular or Follicular
Parafollicular CA is called medullary thyroid cancer
(MTC)
Affects parafollicular C-cells---serum calcitonin is
increased
15% in MEN 2A or MEN 2B
Thyroid carcinoma
Follicular cancer has three histologic
types:
Papillary
Follicular
Anaplastic carcinoma
Papillary
Most common, indolent
Spreads via lymphatics
Patients present with thyroid mass and
cervical lymphadenopathy
Follicular
Less rare
Mimics normal thyroid tissue
Has early hematogenous spread
especially to bone and lungs
Patients present with a thyroid mass
and distinct metastasis
Anaplastic cancer
Rare and highly malignant
Present with a rapidly growing mass
Treatment
Near-total thyroidectomy (parathyroid
spared)
Diagnostic Algorithm
Suspect
Hypothyroid?
REPEAT TSH and Treat
Test TSH,free T4
TSH
<0.3
U/mL
Hyperthyroid?
TSH
0.3 to 3.5
U/mL
Euthyroid
TSH 3.5-9.0
U/mL, NL free
T4
Overt Hypothyroidism
1. Adapted from: Singer PA, Cooper DS, et al. Treatment guidelines for patients with hyperthyroidism and
hypothyroidism. ATA. JAMA. 1995;273:808-12. 2. Natl. Academy of Clinical Biochemistry. Laboratory Med.
Practice Guidelines. Lab. support for the diagnosis and monitoring of thyroid disease. 2002.