Professional Documents
Culture Documents
2020
DISORDERS OF THE Thyroid Gland
Lecturer: Gherald Bermudez, M.D. (February 21, 2019)
THYROID GLAND
ANATOMY AND PHYSIOLOGY
" Consists of right and left pear-shaped lobes connected by an
isthmus
" Located anterior to the trachea between the cricoid cartilage
and the suprasternal notch
" Usually weighs around 15-25 g (Caucasians) or 15-20 g
(Asians)
" Produces two related hormones: thyroxine (T4) and
triiodothyronine (T3)
o 80% of the hormones produced by the thyroid gland
is T4
o The biologically active/potent form, T3, is converted
peripherally by the enzyme, deiodinase
Page 1 of 10
DISCLAIMER: I only placed what was emphasized in the lecture. Use at your own risk!
MED 3B (ENDO): DISORDERS OF THE THYROID GLAND
GHERALD BERMUDEZ, M.D. (FEB 21, 2019)
§ In Primary Hypothyroidism, the main culprit is the thyroid gland From: The Philippine Thyroid Diseases Study (PhilTiDeS 1): Prevalence
o Cellular infiltration of the thyroid (as seen in infiltrative of Thyroid Disorders Among Adults in the Philippines by Josephine
disorders such as amyloidosis, sarcoidosis, Carlos-Raboca, et.al.
hemochromatosis) can cause failure and eventually alter
the production of T3 and T4 CONGENITAL HYPOTHYROIDISM
o Consumptive hypothyroidism due to overexpression of " Occurs in about 1 in 4000 newborns and neonatal screening is
type 3 deiodinase performed in most industrialized countries
- Type 3 deiodinase converts T4 and T3 to the " Neonatal hypothyroidism may be due to:
inactive form à Hypothyroidism o Thyroid gland dysgenesis (80–85%)
§ Secondary Hypothyroidism involves the pituitary gland (Central) o Inborn errors of thyroid hormone synthesis (10–15%)
§ Transient Hypothyroidism is common in cases of inflammation o TSH-R antibody-mediated (5%)
(thyroiditis) because sometimes patients will not manifest with
AUTOIMMUNE HYPOTHYROIDISM
symptoms of permanent hypothyroidism
o Patients will revert back to normal after several months " Types:
or years v Hashimoto’s/Goitrous thyroiditis
o Subacute thyroiditis usually occurs after viral infections - Associated with goiter
(granulomatous thyroiditis) v Atrophic thyroiditis
- Acute cases arise from bacterial infections - Characterized by absence of goiter
- With minimal residual thyroid tissue at the later
NOTE: PRIMARY vs SECONDARY HYPOTHYROIDISM stages of Hashimoto’s (ultimate product of
- Primary: Dec T3 & T4, Inc TSH (due to the compensatory fibrosis and destruction of cells)
response of the pituitary gland)
- Secondary: Dec T3 & T4, Dec TSH
o If N TSH but Dec T3, T4 à Inappropriate response
Page 2 of 10
REFERENCES: Lecture notes & handouts + Harrison’s, 20th ed
MED 3B (ENDO): DISORDERS OF THE THYROID GLAND
GHERALD BERMUDEZ, M.D. (FEB 21, 2019)
" The mean annual incidence rate of autoimmune CLINICAL MANIFESTATIONS
hypothyroidism is up to 4 per 1000 women and 1 per 1000
men
o Men obtaining this disorder signifies poor prognosis
" The mean age at diagnosis is 60 years, and the prevalence of
overt hypothyroidism increases with age
" Subclinical hypothyroidism is found in 6–8% of women (10%
over the age of 60) and 3% of men
o Subclinical/Mild hypothyroidism is characterized as N
T3 & T4 but dec TSH
PATHOGENESIS
v Hashimoto’s/Goitrous thyroiditis
" Characterized by marked lymphocytic infiltration of the
thyroid with germinal center formation, atrophy of the
thyroid follicles accompanied by oxyphil metaplasia,
absence of colloid, and mild to moderate fibrosis
v Atrophic thyroiditis
" Fibrosis is much more extensive, lymphocyte infiltration LABORATORY EVALUATION
is less pronounced, and thyroid follicles are almost " Recently, there has been dissociation of clinical and laboratory
completely absent diagnosis in hypothyroidism
v Susceptibility is determined by a combination of genetic and o Therefore, we should not only rely on the signs and
environmental factors symptoms but perform biochemical and laboratory
o HLA-DR polymorphisms are the best documented testing to confirm the diagnosis
genetic risk factors for autoimmune hypothyroidism, o Only 20% are truly hypothyroid when we base on
especially HLA-DR3, DR4, and DR5 in Caucasians symptoms alone
v Environmental susceptibility factors are poorly defined at o 50% were euthyroid and may be related with other
present causes (eg. adrenal insufficiency)
o A high iodine or low selenium intake and decreased o 30% are inconclusive
exposure to microorganisms in childhood increase the " There are certain conditions with compelling evidence to
risk of autoimmune hypothyroidism support case finding/screening:
o Smoking cessation transiently increases incidence o We do not perform screening tests in all populations
whereas alcohol intake seems protective o Screening is recommended in the following:
v Antibodies to TPO (more common) and thyroglobulin (Tg) are § Autoimmune diseases (eg. Type 1 DM) à May
clinically useful markers of thyroid autoimmunity, but any be accompanied with other autoimmune
pathogenic effect is restricted to a secondary role in amplifying disorders as well
an ongoing autoimmune response § If with family history of autoimmune diseases
o Almost all patients have antibodies to TPO and Tg § Prior history of thyroid surgery
v Up to 20% of patients with autoimmune hypothyroidism have § Psychiatric disorders
antibodies against TSH-R § Amiodarone & Lithium intake
o More commonly encountered in hyperthyroidism § Thyroiditis
(Graves’ disease) but may still occur in cases of
hypothyroidism
IATROGENIC HYPOTHYROIDISM
" Common cause of hypothyroidism and can often be detected
by screening before symptoms develop
" In the first 3–4 months after radioiodine treatment for Graves’
disease, transient hypothyroidism may occur due to reversible
radiation damage
GRAVES’ DISEASE
" Accounts for 60–80% of thyrotoxicosis
" Occurs in up to 2% of women but is one-tenth as frequent in
men
" Rarely begins before adolescence
" Typically occurs between 20-50 years of age (during
reproductive age of females)
PATHOGENESIS
" Caused by thyroid-stimulating immunoglobulin (TSI) that are
synthesized in the thyroid gland as well as in bone marrow and
lymph nodes
o Such antibodies can be detected by bioassays or by
using the more widely available thyrotropin-binding
inhibitory immunoglobulin (TBII) assays
§ In Primary Hyperthyroidism, the most commonly encountered o The presence of TBII in a patient with thyrotoxicosis
condition is Graves’ disease implies the existence of TSI, and these assays are useful
o Classic Triad: in monitoring pregnant Graves’ patients in whom high
- Hyperthyroidism levels of TSI can cross the placenta and cause neonatal
- Proptosis/Exophthalmos thyrotoxicosis (Not commonly requested among non-
- Goiter pregnant patients)
o Mutations are less common " Thyroid peroxidase (TPO) and thyroglobulin (Tg) antibodies
o Drugs (eg. Amiodarone) can elicit: occur in up to 80% of cases
§ Jod-Basedow phenomenon (Inc T3, T4) " Involves combination of environmental and genetic factors
- Thyroid hormone synthesis becomes including polymorphisms in:
excessive as a result of increased iodine o HLA-DR
exposure o Immunoregulatory genes CTLA-4, CD25, PTPN22,
§ Wolff-Chaikoff phenomenon (Dec T3, T4) FCRL3, and CD226
- The initiation of amiodarone treatment o Gene encoding the thyroid-stimulating hormone
is associated with a transient decrease of receptor (TSH-R)
T4 levels, reflecting the inhibitory effect " Smoking is a minor risk factor for Graves’ disease and a major
of iodine on T4 release risk factor for the development of ophthalmopathy
- Most individuals escape from iodide- " There is a threefold increase in the postpartum period
dependent suppression (shutting down of o Pregnancy is characterized as a state of
inhibitory processes) of the thyroid (Wolff- immunosuppression à Patients do not experience
Chaikoff effect), and the inhibitory effects hyperthyroidism
on deiodinase activity and thyroid
o During the postpartum period, rebound
hormone receptor action become
hyperthyroidism occurs
predominant
Page 5 of 10
REFERENCES: Lecture notes & handouts + Harrison’s, 20th ed
MED 3B (ENDO): DISORDERS OF THE THYROID GLAND
GHERALD BERMUDEZ, M.D. (FEB 21, 2019)
§ Graves’ ophthalmopathy
- aka Thyroid-associated ophthalmopathy (occurs in the
absence of hyperthyroidism in 10% of patients
- Onset occurs within th eyear before or after the " In Graves’ disease (Primary): Inc T3 & T4, Dec TSH
diagnosis of thyrotoxicosis in 75% of patients " In 2–5% of patients (and more in areas of borderline iodine
- Mechanism: Fibroblast activation and increased intake), only T3 is increased (T3 toxicosis)
synthesis of glycosaminoglycans à Proteins are able to
hold water à Fluid retention remains at the posterior
of the eye à Proptosis
Page 6 of 10
REFERENCES: Lecture notes & handouts + Harrison’s, 20th ed
MED 3B (ENDO): DISORDERS OF THE THYROID GLAND
GHERALD BERMUDEZ, M.D. (FEB 21, 2019)
Page 7 of 10
REFERENCES: Lecture notes & handouts + Harrison’s, 20th ed
MED 3B (ENDO): DISORDERS OF THE THYROID GLAND
GHERALD BERMUDEZ, M.D. (FEB 21, 2019)
Page 8 of 10
REFERENCES: Lecture notes & handouts + Harrison’s, 20th ed
MED 3B (ENDO): DISORDERS OF THE THYROID GLAND
GHERALD BERMUDEZ, M.D. (FEB 21, 2019)
Page 9 of 10
REFERENCES: Lecture notes & handouts + Harrison’s, 20th ed
MED 3B (ENDO): DISORDERS OF THE THYROID GLAND
GHERALD BERMUDEZ, M.D. (FEB 21, 2019)
MEDULLARY
" Can be sporadic or familial
" Accounts for about 5% of thyroid cancers
" There are three familial forms:
o MEN 2A (Pheochromocytoma, MTC, Parathyroid)
o MEN 2B (Pheochromocytoma, MTC,
Neurofibromatosis)
o Familial MTC without other features of MEN
" In general, MTC is more aggressive in MEN 2B than in MEN
2A, and familial MTC is more aggressive than sporadic MTC
" Elevated serum calcitonin provides a marker of residual or
recurrent disease
" Management: Primarily surgical
" Tumors do not take up radioiodine
o External radiation treatment and targeted kinase
inhibitors may provide palliation
Page 10 of 10
REFERENCES: Lecture notes & handouts + Harrison’s, 20th ed