HYPOTHYROIDISM

HYPOTHYROIDISM
Etiology
Primary:
Hashimoto thyroiditis, radio active iodine
therapy for graves disease, subtotal
thyroidectomy, subacute thyroiditis, iodide
deficiency
Secondary :
Hypopituitarism due to pituitary adenoma
Tertiary :
Hypothalamic disfunction (rare)
 HYPOTHYROIDISM
Clinical finding
Incidence : Various causes depending
geographic & enviromental factors
Hashimoto thyroiditis the most common
cause of hypothyroidism
Newborn infants (Cretinism)
Fatigue, coldness, weight gain, constipation,
menstrual irregularities, muscle cramps
 HYPOTHYROIDISM

Physical findings:
Cool, rough n dry skin, puffy face and hands,
hoarse voice, slow reflexes
Cardiovascular sign: bradycardia, diminished CO,
low voltage QRS, cardiac enlargement
Pulmonary function: Respiratory failure
Intestinal paralysis slowed , chronic constipation,
ileus
Renal function: decresed GFR, renal impairement
Haematology : anemia,
CNS symptoms: fatigue, inability to concentrate
 Pituitary- thyroid relationships in primary
hypothyroidism
TRH Hypothalamus

Dopamine Somatostatin

Pituitary
TSH

Tissues

T3, T4

THYROID
 Complication
Myxedema coma end stage of
untreated hypothyroidism, cause
radiotherapy in Graves Disease
Myxedema & Heart disease CAD
Hypothyroidism Neuropsychiatric
disease depression, confuse,
paranoid, manic
 Treatment Hypothyroidism
Levothyroxine (T4), not liothyronine (T3)
because rapid absorption, short half life,
transient effect.
Dosage : 1 x in the morning to avoid
insomnia 0.05 mg-0.2 mg/d
Mixedema coma ICU, intubation &
mechanical ventilation, Treat infection, heart
failure, IV drips with caution, levothyroxin IV
EXAMPLES OF THYROID DISEASES

1 Hypothyroidism Hyperthyroidism
www.hsc.missouri.edu/~daveg/thyroid/thy_dis.html
 Definition
Thyroiditis heterogenous group of
inflamatory disorders the thyroid gland
Etiologies range from autoimmune to
infectious origins
Clinical course Acute, subacute, or
chronic. Can be euthyroid, transient phase
thyrotoxicosis and / or hypothyroidism.
Painless or painfull
 Classification of thyroiditis
I. Autoimmune thyroiditis
Chronic autoimune thyroiditis
Hashimotos thyroiditis
Atrophic thyroiditis
Focal thyroiditis
Juvenile thyroiditis
Silent thyroiditis / Postpartum thyroiditis
II. Subacute thyroiditis
III. Acute suppurative thyroiditis
IV. Riedels thyroiditis
 Classification of thyroiditis
Hystologic classification Synonims
Chronic lymphocytic Chronic lymphocytic thyroiditis,
Hashimotos thyroiditis
Subacut lymphocytic thyroiditis,

Subacute lymphocytic Postpartum thyroiditis,

Granulomatous Sporadic painless thyroiditis
Subacut granulomatous thyroiditis
De Quervains thyroiditis

Suppurative thyroiditis
Microbial inflamatory Acute thyroiditis

Riedels struma
Invasive fibrosis Riedels thyroiditis
Terminology for Thyroiditis.
Type
Hashimotos thyroiditis
Painless postpartum thyroiditis
Painless sporadic thyroiditis
Painful subacute thyroiditis
Synonim
Chronic lymphocytic thyroiditis
Chronic autoimmune thyroiditis
Lymphadenoid goiter
Postpartum thyroiditis
Subacute lymphocytic thyroiditis
Silent sporadic thyroiditis
Subacute lymphocytic thyroiditis
Subacute thyroiditis
de Quervains thyroiditis
Giant-cell thyroiditis
Subacute granulomatous
thyroiditis
Pseudogranulomatous thyroiditis
Terminology for Thyroiditis.
Type
Suppurative thyroiditis
Drug-induced thyroiditis
(amiodarone, lithium, interferon
alfa, interleukin-2)
Riedels thyroiditis
Synonim
Infectious thyroiditis
Acute suppurative thyroiditis
Pyogenic thyroiditis
Bacterial thyroiditis
-
Fibrous thyroiditis
 Hashimotos thyroiditis
(Chronic thyroiditis)
Hakaru Hashimoto (1912)
4 patients chronic
disorder of the thyroid
diffuse lymphocytic
infiltration, fibrosis,
parenchymal atrophy,
and eosinophilic change
in some acinar cells

Dr Hakaru Hashimoto
Hashimotos thyroiditis

Hashimoto thyroiditis
is the most common
cause of hypothyroidism &
goiter
in the United States

Statosky J et al. Am Acad of Family physicians 2000;61:1054

 Hashimotos thyroiditis
Etiology & pathogenesis
HT is immunologic disorder which lymphocytes
become sensitized to thyroidal antigens and
autoantibodies are performed.
Thyroid antibodies in HT are:
1. Thyroglobulin antibody (Tg Ab)
2. Thyroid peroxidase antibody (TPO Ab)-AMA
3. TSH Receptor blocking antibody (TSH-
R Ab block)
 Clinical Manifestation
Hashimotos Thyroiditis

Symptom & Signs

HT usually presents with
goiter , euthyroid or mild
hypothyroidism.
Sex distribution : F/M 4:1
Painless & patients may be
anware of the goiter
 Laboratory findings
T4 N/ low, TSH will be elevated.
RAIU may be high, normal or low
Tg Ab & TPO Ab positif
Fine needle aspiration biopsy
large infiltration lymphocytes
Hurtle cells
Diagnostic procedures
Test of thyroid autoimmunity:
TPOAb 95% + in Hashimoto
thyroiditis & 90% Atrophic thyroiditis
TgAb less frequently +
Diagnostic specificity of thyroid
antibody tests is not absolute.
Test for thyroid function TSH, fT4
RAIU: normal, low or high.
USG:diffusely reduced echogenecity.
FNAB not necessary,excep. rapidly
enlarging goiter
Diagnosis of Hashimotos thyroiditis
Diffuse goiter
Anti microsomal (or TPO) antibody
Anti-thyroglobulin antibody Positive

Sign symptom of
hypothyroidism
Hashimotos
Negative thyroiditis

US Biopsy Positive
*Simple goiter,
adenomatous goiter etc

Negative Other diseases*

Treatment Hashimotos
thyroiditis
 Treatment
Goiter small & asymptomatic not
require therapy
Levo-thyroxine is given over
hypothyroidism to supress TSH &
decreased serum thyroid antibody.
Levo-thyroxine in euthyroid, still
controversial
 Treatment
Corticosteroids : regression pain,
reduction in size of the goiter,
thyroid antibody , not
recommended in benign disease.
Surgery indicated pain,
cosmetic, or pressure
symptoms after levothyroxine
and corticosteroid therapy.
 Riedels thyroiditis
Rare 1,06/100.000, middle age or elderly
women
Etiology unknown (autoimmune
process or primary fibrotic disorder)
Characterized fibrosis replaces
normal thyroid parenchyma,1/3 cases
multifocal fibrosclerosis
 Riedels thyroiditis
Thyroid fibrosis (stony hard,woody),
painless, progressive anterior neck mass,
Generalized fibrosing (1/3 patients), pressure
symptoms laryngeal nerve paralysis or
hypoparathyroidism (rare)
Usually euthyroidism, hypothyroidism (30%)
Laboratorium : non spesific
USG/CT-Scan inconclusive
Difinitive diagnosis open Biopsy
 Riedels thyroiditis
Treatment:
Corticosteroids medical treatment of choice
Tamoxipen, methotrexate inhibitor fibroblast
proliferation ( early stages)
Levothyroxine hypothyroidism
Surgical care diagnosis, relieving tracheal
compression
Mortality asphyxia (6-10%), extrathyroidal
fibrotic lesions may complicate the prognosis
 Subacute thyroiditis
Cause unknown ( viral infection
(?) preceded URT infection,
coincidence viral disease (mumps,
measles, Echo virus, adeno virus,
epst. Barr virus, influenza)
Women : Men (3-5:1)
Onset: 20-60 yr
Summer
 Subacute thyroiditis
Palpation thyroid: enlarged, asymetrical,
nodul, firm, tender & painful.
Thyrotoxicosis during inflamatory phase
euthyroidism hypothyroidism
euthyroidism (4th phases)
Laboratorium: ESR increase, leukocyt N/
increase, fT4,,TSH, RAIU
Recovery 4-6 months, spontaneous
remitting
 Changes in serum T4 & Radiactive iodine uptake in
patients with subacute Thyroiditis 24-hour
T4 131 I
ug/dL uptake %

20 T4 40

15 30

10 20

5 10

0 131 I 0
Phase : Hyper Eu Hypo Eu
Weeks: 1 4 11 -
Woolf PD, Daly R :Am J Med 197;60:73
Laboratory findings during different phases of subacute thyroiditis

Phase T4 &/T3 Level TSH level RAIU value

Thyrotoxicosis High Low <5%

Hypothyroid Low Normal,or high Normal to high

Recovery Normal High to normal High to normal

 Treatment Subacute
thyroiditis
Symptomatic: Acetaminophen 4X 0,5g, NSAID or
glucocorticoid (prednison 3 X 20 mg (7-10 days)
Betablockers symptoms of thyrotoxicosis
L-thyroxine 0.1-0.15 mg /daily hypothyroid
phase. Long-term L-thyroxine permanent
hypothyroidism (10%)
Antibioticsno value
Thyroidectomy rarely
 Clinical Differentiating of the Subtype Thyroiditis

NECK PAIN

YES N0

RAIU PRESENTING SYMPTOMS

INCREASED DECREASED HYPERTHYROIDISM HYPOTHYROIDISM

CHRONIC
MICROBIAL SUBACUTE RAIU LYMPHOCYTIC
INFLAMMATORY GRANULOMATOUS THYROIDITIS
THYROIDITIS THYROIDITIS

GRAVES DISEASE SUBACUT

LYMPHOCYTIC
THYROIDITIS

Statosky J et al. Am Acad of Family physicians 2000;61:1054

 Acute suppurative
thyroiditis
Rare, serious, bacterial inflamatory
disease, children, 20-40 yr, sex ratio
1:1
Etiologi: Infectious: Staph. aureus,
strep.pyogenes, strep. pneumonia,
esch.coli, pseudomonas aeruginosa
Infection by hematogenous, direct
trauma
 Symptoms & signs
Neck pain, warm, tenderness, the
neck unable to extend
Dysphagia, dysphonia, referred to
ear, mandibula, lymphadenopathy
Systemic manifestation: fever,
chills, tachycardia, malaise
Palpation: unilateral, erythematous
 Acute suppurative
thyroiditis
Thyroid function : Euthyroidism
Laboratorium :TPO antibodies
absent, ESR high, PMN leukocytosis
24-hour 123I uptake normal
FNA Biopsy: purulent material
Treatment: antibiotics or surgical
drainage
 Chronic-pyogenic thyroiditis
Etiology : Salmonella typhosa,
syphilis,
tuberculosis,echinococcus,
actinomyces
Symptoms: Suppurative, non
suppurative
Treatment: antibiotic, drainage
Thyroid nodules &
Thyroid cancer
Thyroid nodules - prevalence
Thyroid nodules common, increase
with age

30-60% of thyroids have nodules at

autopsy

Palpation: 5-20% ( > 1 cm )

USG : 15-50% ( >2 mm )

 Diagnostic approach
Fine Needle Aspiration (FNA)
10-20% risk of suspicious cytology, therefore thyroid
surgery
95% of histology will be benign, and surgery
unnecessary
Isotop Scann(CT)
rarely used for evaluation 80% of nodules are
cold
small cold nodules may be missed
COLD nodules may be malignant
Ultrasonography (USG)
Diagnostic approach - ultrasound
Identifies solid vs cystic nodules

Identifies MNG

May aid FNA

Does not exclude malignancy

Diagnostic approach - other tests

Calcitonin
very high results diagnostic for MTC
risk of borderline false positives
not for routine use
Thyroglobulin
not helpful for exclusion of carcinoma:
overlap with benign disease
best for follow-up after thyroidectomy
 Thyroid nodules & Thyroid
cancer
In 95% of cases , thyroid cancer
presents as a nodule or lump in the
thyroid nodul thyroid.
Thyroid nodule extremely
common, particularly
women.Prevelance in USA 4% in
adult population. F:M ratio 4:1.
Thyroid cancer rare. Incidence
0.004% per year
 Diffrentiation benign & Malignant
lesions
History : Family history of goiter suggests
benign disease, endemic goiter
Physical characteristics:
Benign: older age, woman, soft nodule, multi
nodular goiter.
Malignant: Children, young, male, solitary,
firm nodule, vocal cord paralysis, firm lymph
nodes, distant metastasis
 Malignant thyroid
Carcinoma
Papillary Carcinoma 75 %
Folliculare Carcinoma 16 %
Medullary Carcinoma 5%
Anaplastic Carcinoma 3%
Lymphoma 5 -10 %
Management of the solitary
nodule
True solitary nodule?

No Yes

FNAC

Benign Malignant Indeterminate Follicular

Watch? Surgery Repeat FNAC Surgery

Indeterminate

Surgery
 Treatment
Thyroidectomi
Jodium 131Radioactive
Thyroxine supression
 FNA POSITIF
MALIGNANCY

Differenteated Undifferenteated
Over 2cm, or
Under 2cm, no invasion multicentric, or invasive
Local removal to prevent
obstruction (palliative
Lobectomy and Near total thyroidectomy and therapy)
isthmusectomy modified neck dissection
X-ray therapy or
Levothyroxine for life Liothyronine, 75-100 chemotherapy (or both)
mcg/d for 3 mos, plus levothyroxine
discontinue 2 week. replacement therapy
Low iodine diet

Scan with 2-5 mCi 131 I Repeat after 12 months

Negatitive scan Positive scan

Levothyroxine for 50-150 mCi131 I (therapeutic dose)

life

No recurence X Ray therapy or chemo therapy (or both)

Recurrence + - Scan
cure
Treatment of thyroid cancer
Papillary cancer
< 1.5 cms Lobectomy & isthmusectomy
> 1.5 cms Total thyroidectomy

Follicular cancer Total thyroidectomy

Hurthle Total thyroidectomy

Medullary Total thyroidectomy & central neck

dissection