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Thyroid Diseases

Medical Perspective
THYROID GLAND DISORDERS
 GENERAL ASPECTS OF THYROID GLAND

 Anatomy: weight range from 12 to 30g

 Located in the neck, anterior to the


traquea

 Produces: T4 & T3 (active hormone)

 Regulation: “negative Feed-back” axis


THYROID GLAND DISORDERS
 THYROID GLAND REGULATION
“negative Feed-back” axis

 Hypothalamus
(negative
effect)
(TRH positive effect)

 Pituitary gland

(TSH, positive effect)

 Thyroid gland

T3 & T4
THYROID GLAND DISORDERS
 Thyroid hormones:

 T3: (Triiodothyronine) main source is


peripheral deiodination:

• Ratio of T3 to T4 ; 1::5

• Potency of T3 to T4; 10::1

• T3 is the most important because more than


90% of the thyroid hormones physiological
effects are due to the binding of T3 to
Thyroid receptors in peripheral tissues.
THYROID GLAND DISORDERS
 MECHANISMS OF THYROID
HORMONE ACTION

 Act by binding to Nuclear receptors,


termed Thyroid Hormone Receptors
(TRs), Increasing synthesis of proteins

 At mitochondrial level increases


number and activity to increasing ATP
production

 At Cell membrane increases ions and


substrates transmembrane flux
THYROID GLAND DISORDERS
 THYROID HORMONE EFFECTS

 CALORIGENESIS
• Controls the Basal Metabolic Rate (BMR)

 CHO METABOLISM

• Increases:
• Glucose absorption of the GI tract
• Glucose consumption by peripheral tissues
• Glucose uptake by the cells
• Glycolysis
• Gluconeogenesis
• Insulin secretion
THYROID GLAND DISORDERS
 THYROID HORMONE EFFECTS

 ELECTROLYTE BALANCE

• Low Thyroid hormones could induce


hyponatremia

 VITAMIN METABOLISM

• Modulates vitamin consumption

 HEMATOPOIETIC SYSTEM

• Could induce anemia


Aspects That Will Be
Addressed
 Hyperthyroidism
 Hypothyroidism
 Thyroiditis
 Thyroid is composed of spherical follicles
 Follicle cells: produce thyroglobulin, the
precursor of thryoid hormone (thyroxin)
 Colloid lumen is of thyroglobulin

 Parafollicular “C” cells: produce calcitonin

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THYROID GLAND DISORDERS
 DIVIDED INTO:

 THYROTOXICOSIS (Hyperthyroidism)
• Overproduction of thyroid hormones

 HYPOTHYROIDISM (Gland destruction)


• Underproduction of thyroid hormones

 NEOPLASTIC PROCESSES
• Beningn
• Malignant
Nontoxic Goitre
 Symptoms and Signs:
 Thyroid enlargement, diffuse or multinodular
 Huge goitres may produce a positive Pemberton sign (facial flushing
and dilation of cervical veins on lifting the arms over the head)
especially when they extend inferiorly retrosternally
 Pressure symptoms in the neck with upward or downward movement
of the head
 Difficulty swallowing, rarely vocal cord paralysis
 Most pts are euthyroid but some are mildly hypothyroid
 RAI uptake and scan:
 Uptake may be normal, low, or high depending on the iodide pool
 Scan reveals patchy uptake with focal areas of increased and
decreased uptake corresponding to “hot” and “cold” nodules
respectively
Hyperthyroidism
Hyperthyroidism Symptoms
 Hyperactivity/ irritability/ dysphoria
 Heat intolerance and sweating
 Palpitations
 Fatigue and weakness
 Weight loss with increase of appetite
 Diarrhoea
 Polyuria
 Oligomenorrhoea, loss of libido
Hyperthyroidism Signs
 Tachycardia (AF)
 Tremor
 Goiter
 Warm moist skin
 Proximal muscle
weakness
 Lid retraction or
lag
 Gynecomastia
Causes of Hyperthyroidism
Most common Rarer causes
causes  Thyroiditis or other
causes of destruction
 Graves disease
 Thyrotoxicosis factitia
 Toxic multinodular  Iodine excess (Jod-
goiter Basedow phenomenon)
 Autonomously  Struma ovarii
functioning nodule  Secondary causes (TSH
or ßHCG)
Graves Disease
 Autoimmune disorder
 Abs directed against TSH receptor
with intrinsic activity. Thyroid and
fibroblasts
 Responsible for 60-80% of
Thyrotoxicosis
 More common in women
THYROID GLAND DISORDERS
 Hashimoto´s Thyroiditis or
Goitrous thyroiditis

 Mean anual incidence:
• Women 4:1000 Men 1:1000
• Risk factors; TPO antibodies (90%)
Japanese, previous history, high I
intake
• Average age: 60
• Frequently associated to other
autoimmune disorders such as: AR,
SLE, Sjogren´s so-on.
• Treatment: Levothyroxine
Graves Disease Eye Signs
N - no signs or symptoms
O – only signs (lid retraction
or lag) no symptoms
S – soft tissue involvement
(peri-orbital oedema)
P – proptosis (>22
mm)(Hertl’s test)
E – extra ocular muscle
involvement (diplopia)
C – corneal involvement
(keratitis)
S – sight loss (compression
of the optic nerve)
Graves Disease Other
Manifestations
 Pretibial mixoedema
 Thyroid acropachy
 Onycholysis
 Thyroid enlargement
with a bruit
frequently audible
over the thyroid
Diagnosis of Graves Disease
 TSH , free T4 
 Thyroid auto
antibodies
 Nuclear thyroid
scintigraphy (I123,
Te99)
Treatment of Graves
Disease
 Reduce thyroid hormone production or
reduce the amount of thyroid tissue
 Antithyroid drugs: propyl-thiouracil,
carbimazole
 Radioiodine
 Subtotal thyroidectomy – relapse after
antithyroid therapy, pregnancy, young
people?
 Smptomatic treatment
 Propranolol
Hypothyroidism
Hypothyroidism Symptoms
 Tiredness and  Weight gain with
weakness poor appetite
 Dry skin  Hoarse voice
 Feeling cold  Menorrhagia, later
 Hair loss oligo and
 Difficulty in amenorrhoea
concentrating and
poor memory  Paresthesias
 Constipation  Impaired hearing
Hypothyroidism Signs
 Dry skin, cool extremities
 Puffy face, hands and feet
 Delayed tendon reflex
relaxation
 Carpal tunnel syndrome
 Bradycardia
 Diffuse alopecia
 Serous cavity effusions
Causes of Hypothyroidism
 Autoimmune  Drugs: iodine excess,
hypothyroidism lithium, antithyroid
(Hashimoto’s, drugs, etc
atrophic thyroiditis)  Iodine deficiency
 Iatrogenic  Infiltrative disorders
(I123treatment, of the thyroid:
thyroidectomy, amyloidosis,
external irradiation of sarcoidosis,haemochr
the neck) omatosis,
scleroderma
THYROID GLAND DISORDERS
 CONGENITAL HYPOTHYROIDISM

 Prevalence: 1 in 3000 to 4000 newborns


 Cause: Dysgenesis 85%

 Dx: Blood screning (TSH &/or T4)

 Treatment:
 Supplemental Tx. With Levothyroxine is
“essential” for a normal C.N.S.
Development and prevention of mental
retardation
Lab Investigations of
Hypothyroidism

 TSH , free T4 
 Ultrasound of thyroid – little value
 Thyroid scintigraphy – little value
 Anti thyroid antibodies – anti-TPO
 S-CK , s-Chol , s-Trigliseride 
 Normochromic or macrocytic anemia
 ECG: Bradycardia with small QRS
complexes
Treatment of
Hypothyroidism
 Levothyroxine
 If no residual thyroid function 1.5 μg/kg/day
 Patients under age 60, without cardiac
disease can be started on 50 – 100 μg/day.
Dose adjusted according to TSH levels
 In elderly especially those with CAD the
starting dose should be much less (12.5 – 25
μg/day)
Thyroiditis
Thyroiditis
 Acute: rare and due to suppurative
infection of the thyroid
 Sub acute: also termed de
Quervains thyroiditis/
granulomatous thyroiditis – mostly
viral origin
 Chronic thyroiditis: mostly
autoimmune (Hashimoto’s)
Acute Thyroiditis
 Bacterial – Staph, Strep
 Fungal – Aspergillus, Candida,
Histoplasma, Pneumocystis
 Radiation thyroiditis
 Amiodarone (acute/ sub acute)
Painful thyroid, ESR usually elevated,
thyroid function normal
Sub Acute Thyroiditis
Viral (granulomatous) – Mumps,
coxsackie, influenza, adeno and
echoviruses
Mostly affects middle aged women,
Three phases, painful enlarged
thyroid, usually complete resolution
Rx: NSAIDS and glucocorticoids if
necessary
Sub Acute Thyroiditis (cont)
Silent thyroiditis
No tenderness of thyroid
Occur mostly 3 – 6 months after
pregnancy
3 phases: hyperhyporesolution,
last 12 to 20 weeks
ESR normal, TPO Abs present
Usually no treatment necessary
Clinical Course of Sub Acute
Thyroiditis
Chronic Thyroiditis
Hashimoto’s
 Autoimmune
 Initially goiter later
very little thyroid tissue
 Rarely associated with
pain
 Insidious onset and
progression
 Most common cause of
hypothyroidism
 TPO abs present (90 –
95%)
Chronic Thyroiditis
Reidel’s
 Rare
 Middle aged women

 Insidious painless

 Symptoms due to compression

 Dense fibrosis develop

 Usually no thyroid function impairment


Thyroiditis
 The most common form of
thyroiditis is Hashimoto thyroiditis,
this is also the most common cause
of long term hypothyroidism
 The outcome of all other types of
thyroiditis is good with eventual
return to normal thyroid function

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