Thyroid Disorders

THYROID
DISORDERS
1
INTRODUCTION
 Largest endocrine gland
 Located inferior to the cricoid cartilage
Butterfly shaped organ consisting of two lobes
- lobus dexter (right)
- lobus sinister (left)
 Weighs 18 – 60 gms in adults
 Histologically it is made up of follicular and
para follicular cells
2
 Blood supply
Arteial supply – superior thyroid artery
- inferior thyroid artery
Venous supply - superior thyroid vein
- inferior thyroid vein
Nerve supply - superior laryngeal nerve
- recurrent laryngeal nerve
Lymphatic drainage – lateral deep cervical
lymph node
pre tracheal / para
tracheal lymph nodes 3
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Hypothyroidism
 Epidemiology
– Most common endocrine disease
– Females > Males – 8 : 1
 Presentation
– Often unsuspected and grossly under diagnosed
– 90 % of the cases are Primary Hypothyroidism
– Menstrual irregularities, miscarriages, growth retard.
– Vague pains, anaemia, lethargy, gain in weight
– In clear cut cases - typical signs and symptoms
– Low free T4 and High TSH
– Easily treatable with oral Levo-thyroxine 8
Disease Burden
1. 5% of the general population are Sub-clinically

Hypothyroid
2. 15 % of all women > 65 yrs. are hypothyroid
3. Detecting sub-clinical hypothyroidism in pregnancy
is highly essential – order for TSH and FT4 routinely
in all pregnant women at the beginning of each
trimester
4. All persons aged above 60 years – Order for TSH
9
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Causes of Hypothyroidism
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Suspect Hypothyroidism
1. Amenorrhea
2. Oligomenorrhea
3. Menorrhogia
4. Galactorrhea
5. Premature ovarian failure
6. Infertility
7. Decreased libido
8. Precocious / delayed puberty
9. Chronic urticaria
12
Clinical Signs of Hypothyroidism
 Coarse Hair; Dry cool and pale skin
 Goitre (not in all cases), Hoarseness of voice
 Non-pitting oedema (myxoedema)
 Puffiness of eyes and face
 Delayed relaxation of Tendon Reflexes
 Slow hoarse speech and slow movements
 Thinning of lateral 1/3 of eye brows
 Bradycardia, pericardial effusion

13
Multi system effects of Hypothyroidism
General Neuromuscular
•Lethargy, Weight gain, Goitre •Aches and pains
•Cold Intolerence •Muscle stiffness
Cardiovascular •Carpel tunnel syndrome
•Bradycardia, Angina •Deafness, Hoarseness
•CHF, Pericardial Effusion •Cerebellar ataxia
•HyperlipIdemia, Xanthelsma •Delayed DTR, Myotonia
Haematological •Depression, Psychosis
Iron def. Anaemia, Gastro-intestinal
Normo cytic /chromic Anaemia •Constipation, Ileus, Ascites
Reproductive system Dermatological
•Infertility, Menorrhagia •Dry flaky skin and hair
•Impotence, Inc. Prolactin •Myxoedema, Malar flushes
•Vitiligo, Carotenimia, Alopecia
14
Thyroid Failure - Organ Systems
Cardiovascular
• Decreased ventricular contractility
• Increased diastolic blood pressure
• Decreased heart rate
• Pericardial effusion
Central Nervous
• Decreased concentration
• General lack of interest
• Depression
Gastro-intestinal
• Decreased GI motility
• Constipation
• Ileus
15
Musculoskeletal
 Muscle stiffness, cramps, pain,
weakness, myalgia
 Slow muscle-stretch reflexes,
muscle enlargement, atrophy
Renal
 Fluid retention and oedema
 Decreased glomerular filtration
16
Reproductive
 Arrest of pubertal development
 Reduced growth velocity
 Menorrhagia, Amenorrhea
 Anovulation, Infertility
 Hyperprolactinaemia &
Galactorrhoea
Hepatic
 Increased LDL / TC
 Elevated LDL + triglycerides 17
Skin , Hair and Subcutaneous Tissues

 Thickening and dryness of skin
 Dry, coarse hair, Alopecia
 Loss of scalp hair and / or lateral eyebrow hair
18
Lab Investigations of
Hypothyroidism
 TSH , free T4
 Ultrasound of thyroid – little value
 Thyroid scinitigraphy – little value
 Anti thyroid antibodies – anti - TPO
 S-CPK ,S-LDH , S-Chol , S-Triglyceride
 Normochromic or macrocytic anaemia
 ECG : sinus bradycardia with small QRS complexes . Non
specific ST-T changes
 Chest X – Ray – for effusion and cardiac shadow
 Photomotogram – (instrumental recording of jerks) – hung up
ankle jerk
19
Clinical Photographs
20
Congenital Hypothyroidism
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Endemic Goiter
23
Urine Iodine Conc. < 50 µg/L
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Myxedema
25
Myxedema
26
Macroglossia
27
Xanthomata
Tuberous Xanthoma
Xanthelasma
28
Solid Oedema Xanthomata
29
Myxoedema with Carotineamia
30
Recovery after Thyroxine
31
Normal Pituitary Fossa Pituitary Tumor – Secondary Hypo
32
20.2.98
Massive Pericardial Effusion in

Hypothyroidism
33
26.7.98
Clearing of Pericardial Effusion with

Treatment 34
14.9.99
Reappearance of Pericardial Effusion

after treatment is discontinued 35
Management of Hypothyroidism
 Goal : Normalize TSH level regardless of

cause of hypothyroidism
 Treatment : Once daily dosing with

Levothyroxine sodium (1.6µg/kg/day)
this comes to 100 mcg per day
 Monitor TSH levels at 6 to 8 weeks, after

initiation of therapy or dosage change
36
Dosage Adjustments
 Age (in elderly start with half dose)

 Severity and duration of hypothyroidism (↑ dose)
 Weight (0.5µg/kg/day ↑ upto 3.0µg/kg/day)
 Malabsorption (requires ↑ dose)
 Concomitant drug therapy (only on empty stomach)
 Pregnancy ( 25% ↑ in dose), safe in lactating mother
 Presence of cardiac disease (start alternative day )
37
Start Low and Go Slow
 Goal : normalize TSH level – 25, 50 and 100 mcg tablets avail.
 Starting dose for healthy patients < 50 years at 1.0 µg/kg/day
 Starting dose for healthy patients > 50 years should be < 50
µg/day. Dose ↑ by 25 µg, if needed, at 6 to 8 weeks intervals.
 Starting dose for patients with heart disease should be 12.5 to 25
µg/day and increase by 12.5 to 25 µg/day, if needed, at 6 to 8
weeks intervals
38
How the patient improves
 Feels better in 2 – 3 weeks

 Reduction in weight is the first improvement
 Facial puffiness then starts coming down
 Skin changes, hair changes take long time to regress
 TSH starts showing decrements from the high values
 TSH returns to normal eventually
39
Hyperthyroidism
 A clinical condition resulting from increased

levels of free thyroxine (T4) & or
Tri-idothyroxine (T3)
Causes of Hyperthyroidism
1. Plummer’s Disease – Toxic MNG

2. Graves Disease – Diffuse Toxic Goiter
3. Toxic phase of Sub Acute Thyroiditis - SAT
4. Toxic Single Adenoma – STA
5. Pituitary Tumours – excess TSH
6. Molar pregnancy & Choriocarcinoma (↑↑ βHCG)
7. Metastatic thyroid cancers (functioning)
8. Struma Ovarii (Dermoid and Ovarian tumours)
Graves Disease
 The most common cause of thyrotoxicosis (50-60%).
 Organ specific auto-immune disease
 The most important autoantibody is
 Thyroid Stimulating Immunoglobulin (TSI) or TSA
 TSI acts as proxy to TSH and stimulates T4 and T3
Toxic Multinodular Goiter (TMG)
 TMG is the next most common hyperthyroidism - 20%
 More common in elderly individuals – long standing goiter
 Lumpy bumpy thyroid gland
 Milder manifestations (apathetic hyperthyroidism)
 Mild elevation of FT4 and FT3
 Progresses slowly over time
 Clinically multiple firm nodules (called Plummer’s disease)
 Scintigraphy shows - hot and normal areas
Toxic Multinodular Goiter (TMG)
Sub Acute Thyroiditis (SAT)
 SAT is the next most common hyperthyroidism – 15%
 T4 and T3 are extremely elevated in this condition
 Immune destruction of thyroid due to viral infection
 Destructive release of preformed thyroid hormone
 Thyroid gland is painful and tender on palpation
 Nuclear Scintigraphy scan - no RIU in the gland
 Treatment is NSAIDs and Corticosteroids

Toxic Single Adenoma (TSA)
 TSA is a single hyper functioning follicular thyroid adenoma.
 Benign monoclonal tumor that usually is larger than 2.5 cm
 It is the cause in 5% of patients who are thyrotoxic
 Nuclear Scintigraphy scan shows only a single hot nodule
 TSH is suppressed by excess of thyroxines
 So the rest of the thyroid gland is suppressed
Toxic Single Adenoma (TSA)
Nucleotide Scintigraphy
Common Symptoms
1. Nervousness
2. Anxiety
3. Increased perspiration
4. Heat intolerance
5. Tremor
6. Hyperactivity
7. Palpitations
8. Weight loss despite increased appetite
9. Reduction in menstrual flow or oligo-menorrhea
Clinical Features
1. Goitre: In majority of cases, Systolic bruit may be heard

2. General Features: (a) Fever, Anxiety , Restlessness
(b) Fine tremor of out stretched hands – Format's sign
3. Cardiovascular :
(a) Tachycardia which persists during sleep
(b) Large pulse pressure with raised systolic pressure
© Flushing of face & Neck in warm atmosphere
(d) Capillary pulsations may be seen
(e) Cardiac arrhythmia- Ectopic beats, Sinus tachycardia or atrial
arrhythmia, AF, CHF
Metabolism
 a) Loss of weight in spite of increased appetite

 b) Liver is depleted of glycogen and transient or
persistent glycosuria appears
 c) fat depots tend to disappear
 d) Increased ability to stand cold & intolerance of
heat
Specific to Graves Disease
1. Diffuse painless and firm enlargement of thyroid gland
2. Thyroid bruit is audible with the bell of stethoscope
3. Ophthalmopathy – Eye manifestations – 50% of cases
 Sand in eyes, periorbital edema, conjunctival edema
(chemosis), poor lid closure, extraocular muscle dysfunction,
diplopia, pain on eye movements and proptosis.
4. Dermoacropathy – Skin/limb manifestations – 20% of cases
 Deposition of glycosamino glycans in the dermis of the lower
leg – non pitting edema, associated with erythema and
thickening of the skin, without pain or pruritus - called
(pre tibial myxedema)
Clinical Presentations
MNG and Graves
Huge Toxic MNG Diffuse Graves Thyroid

Higher grades of Goiter
(Diffuse) Graves
Toxic MNG
Grade IV Toxic MNG
Huge Toxic MNG Huge Toxic MNG

Ocular Manifestations
 1. Primary (Autoimmune) manifestations:
(a) Proptosis, Exophthalmos

(b) Ophthalmoplegia
Sympathetic manifestations
 (a) Lid Lag

 (b) Lid Retraction causing a ‘Stare’
Thyroid Ophthalmopathy
Proptosis Lid lag

Secondary (Mechanical) complications
 (a) Optic nerve Compression – Mild proptosis,
blurring of vision, Marcuss -gun pupil

(b) Exposure keratitis
(c) Chemosis, periorbital oedema , Glaucoma
Ophthalmopathy in Graves
Periorbital edema and chemosis

Ophthalmopathy in Graves
Occular muscle palsy

Severe Exophthalmia
Thyroid Dermopathy
Pink and skin coloured papules, plaques on the shin

Graves with Acropathy
Graves Goiter Acropathy

Thyroid Acropathy
Clubbing and Osteoarthropathy

Non specific changes
1. Hyperglycemia, Glycosuria
2. Osteoporosis and hypercalcemia
3. ↓ LDL and Total Cholesterols
4. Atrial fibrillation, LVH, ↑ LV EF
5. Hyper dynamic circulatory state
6. High output heart failure
7. H/o excess Iodine, amiodarone, contrast dyes
Treatment Options
1. Symptom relief medications
2. Anti Thyroid Drugs – ATD
 Methimazole, Carbimazole
 Propylthiouracil (PTU)
3. Radio Active Iodine treatment – RAI Rx.
4. Thyroidectomy – Subtotal or Total
5. NSAIDs and Corticosteroids – for SAT
Symptom Relief
1. Rehydration is the first step

2. β – blockers to decrease the sympathetic excess
 Propranalol, Atenelol, Metoprolol
3. Rate limiting CCBs if β – blockers contraindicated
4. Treatment of CHF, Arrhythmias
5. Calcium supplementation
6. Lugol solution for ↓ vascularity of the gland
Duration of Treatment
 Reduction of thyroid hormones takes 2-8 weeks
 Check TSH and FT4 every 4 to 6 weeks
 In Graves, many go into remission after 12-18 months
 In such pts ATD may be discontinued and followed up
 40% experience recurrence in 1 yr. Re treat for 3 yrs.
 Treatment is not life long. Graves seldom needs surgery
 MNG and Toxic Adenoma will not get cured by ATD.
 For them ATD is not the best. Treat with RAI.
Radio Active Iodine (RAI Rx.)
 In women who are not pregnant
 In cases of Toxic MNG and TSA
 Graves disease not remitting with ATD
 RAI Rx is the best treatment of hyperthyroidism in adults
 The effect is less rapid than ATD or Thyroidectomy
 It is effective, safe, and does not require hospitalization.
 Given orally as a single dose in a capsule or liquid form.
 Very few adverse effects as no other tissue absorbs RAI
Radio Active Iodine (RAI Rx.)
 I123 is used for Nuclear Scintigraphy (Dx.)
 I131 is given for RAI Rx. (6 to 8 milliCuries)
 Goal is to make the patient hypothyroid

 No effects such as Thyroid Ca or other malignancies
 Never given for children and pregnant/ lactating women
 Not recommended with patients of severe Ophthalmopathy
 Not advisable in chronic smokers
Clinical Anatomy of Thyroid
73
Clinical Exam of Thyroid
74
75
76
Thyromegaly
77
Thyroid Function Tests
1. TSH
2. Free T4
3. Free T3
4. Anti-Thyroid Antibodies
5. Nuclear Scintigraphy
6. FNAC of nodule
78
The Nine Square Game
To evaluate our Thyroid patient
As per the AACE and ITS Guidelines
79
What tests should I order ?
As per the Guidelines of the AACE and ATA, ITS

1. TSH alone if Hypothyroidism is suspected
2. TSH and Free T4 only if Hyperthyroidism is
suspected or for routine evaluation
3. Free T3 if T3 toxicosis is suspected
4. For follow-up of treatment only TSH
5. Don’t order for Total T4 or Total T3
6. Never order RIU in pregnancy or lactation
80
BASIC THYROID EVALUATION
FREE THYROXINE or FT4
HIGH
NORMAL
LOW
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH

81
HIGH
NORMAL
EUTHYROID
LOW
LOW NORMAL HIGH

82
HIGH
NORMAL
PRIMARY
LOW
HYPOTHYROID
LOW NORMAL HIGH

83
HIGH
PRIMARY
HYPERTHYROID
NORMAL
LOW
LOW NORMAL HIGH

84
HIGH
SECONDARY
HYPERTHYROID
NORMAL
LOW
LOW NORMAL HIGH

85
HIGH
NORMAL
SUB-CLINICAL
HYPERTHYROID
LOW
LOW NORMAL HIGH

86
HIGH
NORMAL
SECONDARY
LOW
HYPOTHYROID
LOW NORMAL HIGH

87
HIGH
NORMAL
SUB-CLINICAL
HYPOTHYROID
LOW
LOW NORMAL HIGH

88
HIGH
NORMAL
LOW
NON THYROID
ILLNESS or NTI
LOW NORMAL HIGH

89
HIGH
NTI or Pt.
on ELTROXIN
NORMAL
LOW
LOW NORMAL HIGH

90
HIGH
PRIMARY NTI or Pt. SECONDARY
HYPERTHYROID on ELTROXIN HYPERTHYROID
NORMAL
SUB-CLINICAL SUB-CLINICAL
HYPERTHYROID EUTHYROID HYPOTHYROID
SECONDARY NON THYROID PRIMARY

LOW
HYPOTHYROID ILLNESS - NTI HYPOTHYROID
LOW NORMAL HIGH

91
HIGH
NORMAL
EUTHYROID
LOW
LOW NORMAL HIGH

92
HIGH
NORMAL
PRIMARY
LOW
HYPOTHYROID
LOW NORMAL HIGH

93
HIGH
NORMAL
SECONDARY
LOW
HYPOTHYROID
LOW NORMAL HIGH

94
HIGH
SECONDARY
HYPERTHYROID
NORMAL
LOW
LOW NORMAL HIGH

95
HIGH
NORMAL
SUB-CLINICAL
HYPERTHYROID
LOW
LOW NORMAL HIGH

96
HIGH
NORMAL
SUB-CLINICAL
HYPOTHYROID
LOW
LOW NORMAL HIGH

97
HIGH
NORMAL
LOW
NON THYROID
ILLNESS or NTI
LOW NORMAL HIGH

98
HIGH
NTI or Pt.
on ELTROXIN
NORMAL
LOW
LOW NORMAL HIGH

99
HIGH
PRIMARY NTI or Pt. SECONDARY
HYPERTHYROID on ELTROXIN HYPERTHYROID
NORMAL
SUB-CLINICAL SUB-CLINICAL
HYPERTHYROID EUTHYROID HYPOTHYROID
SECONDARY NON THYROID PRIMARY

LOW
HYPOTHYROID ILLNESS - NTI HYPOTHYROID
LOW NORMAL HIGH

100
THYROID HORMONES
TEST REFERENCE RANGE
TSH Normal Range 0.3 - 4.0 mU/L

Free T4 Normal Range 0.7-2.1 ng/dL
TSH upper limit will soon be revised to 2.5 mU/L
101
Thyroid Antibodies
 Anti Microsomal (TM ) Antibodies
 Anti Thyroglobulin (TG) Antibodies
 Anti Thyroxine Per Oxidase (TPO) Ab.
 Anti Thyroxine antibodies
 Thyroid Stimulating (TSA) Antibodies
 High titres TPO Ab in Hashimotos & Reidle’s thyroiditis
 Anti thyroxine Ab in peripheral resistance to Thyroxine
 TSA (TSI) in Graves’ Hyperthyroidism
102
Nucleotide Scintigraphy
 I 123 and TC 99m Radio Nucleotide Scintigraphy

 This test is not at all required in hypothyroidism
 This is only to confirm a hyper functioning thyroid or
 To assess whether a nodule is ‘hot’ or ‘cold’
 Never order for this test for hypothyroidism
 Similar is the case with FNAC – in hypothyroid goiter
 If TSH is high and FT4 is low there is no role for FNAC
103
We need to apply the current knowledge
104

Thyroid Disorders

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Thyroid Disorders

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THYROID

1. 5% of the general population are Sub-clinically

 Goitre (not in all cases), Hoarseness of voice

 Non-pitting oedema (myxoedema)

 Puffiness of eyes and face

 Delayed relaxation of Tendon Reflexes

 Slow hoarse speech and slow movements

 Thinning of lateral 1/3 of eye brows

 Bradycardia, pericardial effusion

Skin , Hair and Subcutaneous Tissues

Massive Pericardial Effusion in

Clearing of Pericardial Effusion with

Reappearance of Pericardial Effusion

 Goal : Normalize TSH level regardless of

 Treatment : Once daily dosing with

 Monitor TSH levels at 6 to 8 weeks, after

 Age (in elderly start with half dose)

 Feels better in 2 – 3 weeks

 A clinical condition resulting from increased

1. Plummer’s Disease – Toxic MNG

 Treatment is NSAIDs and Corticosteroids

1. Goitre: In majority of cases, Systolic bruit may be heard

 a) Loss of weight in spite of increased appetite

Huge Toxic MNG Diffuse Graves Thyroid

Huge Toxic MNG Huge Toxic MNG

 1. Primary (Autoimmune) manifestations:

(a) Proptosis, Exophthalmos

 (a) Lid Lag

Proptosis Lid lag

 (a) Optic nerve Compression – Mild proptosis,

blurring of vision, Marcuss -gun pupil

Periorbital edema and chemosis

Occular muscle palsy

Pink and skin coloured papules, plaques on the shin

Graves Goiter Acropathy

Clubbing and Osteoarthropathy

1. Rehydration is the first step

 I131 is given for RAI Rx. (6 to 8 milliCuries)

 Goal is to make the patient hypothyroid

To evaluate our Thyroid patient

As per the AACE and ITS Guidelines

As per the Guidelines of the AACE and ATA, ITS

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

SECONDARY NON THYROID PRIMARY