THYROID DISODERS

BY :
NSUBUGA IVAN
NANDELENGA MERCY
MWALIM MARYM OMAR
MUGISHA RUTH
SUPERVISED BY :
DR LAGORO CHARLES, CONSULTANT INTERNAL MEDICINE (M.MED)
 Thyroid Gland
• two lobed mass in the anterior neck btn cricoid cartilage and suprasternal notch

• on either sides of the larynx and trachea connected by isthmus

• produces 2 related hormones - thyroxine(T4) and

triiodothyronine(T3)

• acts through receptors α and β playing a critical role in cell differentiation

and organogenesis(intrauteral), maintain thermogenic and metabolic
homeostasis-Adults
Thyroid axis/hypothalamopituitary-thyroid axis
 Explanation

• Hypothalamic TRH stimulates the anterior pituitary production of TSH

which in turn stimulates thyroid hormone synthesis and secretion.
• thyroid hormones via negative feedback prodominately through
thyroid hormone receptorβ2(TRβ2) inhibits TRH and TSH
production.
NOTE: set point in the axis is established by TSH, TRH is the
major postive regulator of TSH synthesis and secretion, thyroid
hormones are the dominant regulator of TSH production
 continua....
• TSH is released in a pulsatile manner,

• exhibits diurnal rythm with highest levels at night

• has a plasma t1/2 of 50mins

• can be measured using immunoradiometric assays

Thyroid hormone sythensis and
metabolism
 Thyroid function in pregnancy
Five factors alter thyroid function in preg:
1. transiet increase in hcg during the 1st trimester, this weakly
stimulates the TSH-R
2. estrogen-induced rise in TBG during the first trimester which
remains sustained during preg
3. alteration in immune system leading to the onset, exacerbation, or
ameliotion of an underlying autoimmune thyroid disease
 continua....
4. increased thyroid hormone metabolism by the placenta
5. increased urinary iodide excretion

NOTE: women with a precarious iodine intake (<50mcg) are at risk of

goitre during pregnacy or giving birth to an infant with a goitre and
hypothyroidism
 Physical examination
Inspection
signs and features of abnormal thyroid function (extrathyroidal features
of opthalmopathy and demopathy)
neck masses, distended veins, movt on swallowing
Palpation
slighty flexed neck
locate the cricoid cartilage and then the isthmus and followed laterally
to locate either lobe
NOTE: size, consistency, nodularity, tenderness or fixation, pulsation
 INTERPRETATION OF TFT’S
TSH T4 T3
Primary High low low
hypothyroisism

Secondary low low low

hypothyroidism
Primary Low high high
hyperthyroidism
Secondary high high high
hyperthyroidism
High risk groups for thyroid dysfunction
• Pts with atrial fibrillation
• Pts with hyperlipidemia (4-14%have hypothyroidsm)
• DM on annual review
• Women with type 1 DM during 1st and post delivery (3-fold rise in
incidence of postpartum thyroid dysfunction)
• Pts on amiodarone or lithium (6 monthly)
• Pts with Down's or Turner's syndrome or Addison's disease (yearly)
 HYPOTHYROIDISM
• iodine deficiency remains the most common cause

• incase of iodine sufficiency then- autoimmune disease( Hashimoto’s

thyroiditis) and iatrogenic causes (txt of hyperthyroidism)
Causes of hypothyroidism
 Congenital hypothyroidism
• occurs in about 1 in 4000 newborns
• may be transiet esp if mother has TSH-R blocking antibodies, or has
recieved antithyroid drugs
• permanet occurs in majority of cases
• neonatal hypothyroidism is due to : thyroid gland dysgenesis in 80-
85%, inborn errors of thyroid hormone synthesis 10-15%, TSH-R
antibody mediated in 5%
 clinical manifestations
• may appear normal at birth
• prolonged jaundice
• feeding problems
• hypotonia
• enlarged tongue
• delayed bone maturation
• umbilical hernia
• neurological damage
• cardiac manifestations(x4)
 Diagnosis and treatment
• measurement of TSH or T4 levels in heel-prick blood samples.

• when positive T4 is instituted at a dose of 10-15ug/kgper day dose

adjustment with close monitoring of TSH levels
 HYPOTHYROIDISM
Causes
• Primary- diseases of thyroid

• Secondary- diseased of hypothalamo-pituitary axis

 PRIMARY HYPOTHYROIDISM
Autoimmune atrophic hypothyroidism
• Commonest cause
• Thyroid microsomal auto antibodies, lymphoid infiltration and atrophy
• F>M, assoc other autoimmune(AI) diseases
Hashimoto’s thyroiditis
• AI thyroiditis, atrophic changes with later regeneration leading to goitre
formation.
• May have an initial toxic phase.
Postpartum thyroiditisusually transient
Iodine deficiency endemic goitre
Dyshormonogenesis- rare congenital condition
coma, goitre, puffy eyes, depression , large tongue
MACROGLOSSIA
 DIAGNOSIS
• History and examination
• Serum TSH –
• Low total or free T4
• Thyroid autoantibodies
• FBC- usually normochromic/normocytic. May be macrocytic(assoc.
pernicious anaemia) or microcytic (if menorrhagia)
• Cholesterol- may be raised
 TREATMENT

Replacement therapy with T4 for life

• Starting dose depends on severity and age and fitness of person

• Avoid starting high dose in elderly(risk of AF) or those with known

ischaemic heart disease ( may precipitate angina)
• Titrate according to clinical response and TSH level

• Clinical improvement may take 2 weeks and total resolution up to

6 months
• Dose may need increasing in pregnancy
 Clinical hypothyroidism
• no residual thyroid function
• daily replacement dose of levothyroxine usually 1.6 ug/kg body
weight (typically 100-150ug) taken atleast 30 min before breakfast.
• incase of Graves’ disease txt, there is often underlying autonomous
function hence lower replacement doses (typically 75-125ug/d)
• adult pts under 60years old without evidence of heart disease
(starting dose 50-100ug)
• adjust dose basing on TSH levels
 Subclinical hypothyroidism
• Biochemical evidence of thyroid hormone deficiency in pts who have
few or no apparent clinical features of hypothyroidism.
• no universally accepted recommendations
• levothyroxine incase of female pt who wishes to get preg or when TSH
levels are above 10mIU/L
• trial txt if suggestive symptoms of hypothyriodism, positive TPO
antibodies or any evidence of heart disease
• confirm 3month persitent elevation of TSH before intiating txt
(levothyroxine 25-50ug/d) goal is normalizing TSH
 Special txt considerations
• levothyroxine replacement is associated with pseudotumor cerebri in
children
• pregnant women
• elderly pts require 20% less dose than young adults
 MYXOEDEMA COMA
• Rare
• Most common in elderly
• Present with confusion, ( ＊ seizures) leading to coma
• Hypothermia(upto 23ºC), hypoventilation, hypoglycaemia and hyponatraemia
• Assoc with high mortality- up to 50%
• precipitated by factors that impair respiration: drugs(sedatives, anesthetics,
antidepressants), pneumonia, congestive heart failure, myocardia infarction, GIT
bleeding, cerebrovascular accidents

MANAGEMENT-
• oral/iv thyroxine(iv levothyroxine single bolus 200-400ug loading dose, daily oral
dose of 1.6ug/kg/d-reduced by 25% if given iv) gradually increase dose,
rewarming(only if temp<30ºC), rehydration, hydrocortisone iv 50mg 6hrly,
liothyronine iv/oral (intial dose 5-20ug then 2.5-10ug 8hrly, lower dose for those
at CVS risk-arrhythmias)
 HYPERTHYROIDISM
Defn: hyperthyroidism is a state of excessive thyroid function while
hyrotoxicosis is a state of thyroid hormone excess
• Common- 2-5% all females.

• M:F= 1:5

• Most common in those aged 20-40 years

• Nearly always primary (due to thyroid disease)

 CAUSES OF HYPERTHYROIDISM
 Graves’ disease
 Commonest
 AI process- TSH Receptor antibodies (TRAB’s)
 Assoc other AI disease

 Toxic solitary adenoma

 Toxic multinodular goitre

 De Quervain’s thyroiditis- transient, probably viral origin, thyroid

tenderness and systemic symptoms

 Post partum thyroiditis

 CLINICAL FEATURES
• GIT
wght loss inspite increase in appetite
diarrhea due to increased activity of ganglionic level
• CVS
palpitations
shortness of breath at rest/minimal extertion
angina
irregular heart rate
cardiac failure in elderly
 continua...
• Neuromuscular system
undue fatigue and muscle weakness
tremor-fine resting tremors(diffuse irritability of grey matter)
• Skeletal system
increase in linear growth in children
• Genitourinary system
oligo-/amenorrhoea
occasional urinary frequency
 continua...
• Intergumentary
Hair loss, gynacomastia
pruritus
palmar erythema
• Psychiatry
irritability
nervousness
insomnia
 continua...
• Sympathetic overactivity
dyspnoea, palpitations, tiredness,
heat intolerance, sweating, nervousness
increased appetite, increased catabolism-decreased weight
increased creatinine(myopathy)
 SPECIFIC FEATURES OF GRAVES’ DISEASE

• Thyroid acropachy

• Pretibial myxoedema

• Graves’ eye signs

• Periorbital oedema
• Proptosis
• Opthalmoplegia
• Optic nerve compression
PRETIBIAL MYXOEDEMA
THYROID ACROPATHY
 DIAGNOSIS
• History and examination

• Serum TSH-

• Raised serum T3/T4

• Microsomal and thyroglobulin antibodies usually positive in Graves’

• Anti TSH receptor antibodies

 TREATMENT OPTIONS
• 3 main options
• Medical- antithyroid drugs

• Radio iodine

• Surgery
 ANTITHYROID DRUGS
• Carbimazole / Methimazole (10-20mg 8hrly/12hrly)
• Rash, nausea and vomiting, agranulocytosis(0.1%), jaundice
• Both inhibit formation of thyroid hormones
• CBZ- has mild immunosupressive action
• Propythiouracil(100-200mg 6-8hrly)
• Rash, N+V, aplastic anaemia
• PTU- inhibits peripheral conversion of T4-T3
• Gradually reduce dose after 6-12 months once TSH normal
• 50% will relapse over next 2 years
 AGRANULOCYTOSIS
•Risk of 1 in 1000

•Usually within 3 months of starting treatment

•Warn to seek medical attention if develop unexplained fever or sore

throat

•If toxicity develops on CBZ switch to PTU and vice versa

 RADIOACTIVE IODINE
• Iodine –131 given as a stat dose
• Accumulates in thyroid and destroys gland by local irradiation
• Takes several months to be fully effective
• Must be rendered euthyroid before starting treatment
• Contraindicated in children, whilst breast feeding or in pregnancy
• May cause immediate transient worsening of hypthyroidism
• May worsen thyroid eye disease
• Often become hypothyroid in next 20 years
 SURGERY- SUBTOTAL THYROIDECTOMY
• Must be rendered euthyroid first to prevent thyroid storm
• Stop antithyroid drugs 14 days pre op and give potassium iodide to
reduce vascularity of gland
• Indications-
• Patient choice
• Large goitre- poorly respond to antithyroid meds
• Drug intolerance/contraindication
• Poor compliance
• Recurrent hyperthyroidism after drugs
 SURGICAL COMPLICATIONS
• Early post op bleeding
• Laryngeal nerve palsy
• Transient hypocalcamia (parathyroid)
• Recurrent hyperthyroidism –1-3%
• Hypothyroidism- common
 THYROID CRISIS
• Rare
• Mortality 10%
• Rapid deterioration with hyperpyrexia, tachycardia/AF, extreme
restlessness and dehydration
• Often precipitated by stress, infection or surgery/RA iodine in an
unprepared patient.
• Rx- propranolol(20-40mg 6hrly), potassium iodide, antithyroid drugs
and steroids (suppress many of manifestations of hyperthyroidism)
GRAVES’ EYE DISEASE
LID RETRACTION
PROPTOSIS
 STAGING OF EYE DISEASE
Grade 0 N o signs or symptoms
Grade 1 O nly signs(lid retraction/lag), no symptoms
Grade 2 S oft tissue involvement
Grade 3 P roptosis (>22mm)
Grade 4 E xtraocular muscle involvement(diplopia)
Grade 5 C orneal ulceration
Grade 6 S ight loss with optic nerve involvement
＊ EUGOGO system by european group on Graves’ orbirtopathy
 TREATMENT OF EYE DISEASE
• Mild
• Methylcellulose eye drops
• Sleep with bed head elevated
• Diuretics

• Moderate
• steroids

• Severe
• Irradiation of the orbits
• Lateral tarsorraphy
• Surgical decompression
 THE END
Reference
Harrison textbook of internal medicine 20th edition

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