Thyroid Disorders

Thyroid Regulation

HYPOTHALAMUS - TRH

ANT. PITUITARY - TSH

TSH -R
THYROID T4 and T3

PLASMA T4 + FT4
PLASMA T3 + FT3

TISSUES FT4 to FT3

Thyroid Hormones

THEY ARE NOT ESSENTIAL FOR LIFE, BUT

ARE EXTREMELY HELPFUL
THYROID GLAND DISORDERS

 THYROID HORMONE EFFECTS:

 Affects every single cell in the body

 Modulates:

 Oxygen consumption

 Growth rate

 Maturation and cell differentiation

Thyroid Gland Disorders

 Overproduction of thyroid hormones

 Underproduction of thyroid hormones

 Thyroid nodules

 Thyroiditis

 Thyroid neoplasms
Hyperthyroidism
Thyroid Gland Disorders
 TSH High usually means Hypothyroidism

 Rare causes:
 TSH-secreting pituitary tumor
 Thyroid hormone resistance
 Assay artifact

 TSH low usually indicates Thyrotoxicosis

 Other causes
 First trimester of pregnancy
 After treatment of hyperthyroidism
 Some medications (Steroids-dopamine)
 Thyroid Gland Disorders

 THYROTOXICOSIS:
 is defined as the state of thyroid hormone excesss

 HYPERTHYROIDISM:
 is the result of excessive thyroid gland function
Abnormalities of Thyroid Hormones

 Thyrotoxicosis
 Primary
 Secondary
 Without Hyperthyroidism
 Exogenous or factitious

 Hypothyroidism
 Primary
 Secondary
 Peripheral
Causes of Thyrotoxicosis

Primary Hyperthyroidism
 Grave´s disease
 Toxic Multinodular Goiter

 Toxic adenoma

 Functioning thyroid carcinoma metastases

 Struma ovarii

 Drugs: Iodine excess

Causes of Thyrotoxicosis

 Thyrotoxicosis without hyperthyroidism

 Subacute thyroiditis
 Silent thyroiditis
 Other causes of thyroid destruction:
 Amiodarone, radiation, infarction of an adenoma
 Exogenous/Factitia

 Secondary Hyperthyroidism
 TSH-secreting pituitary adenoma
 Thyroid hormone resistance syndrome
 Chorionic Gonadotropin-secreting tumor
 Gestational thyrotoxicosis
Thyrotoxicosis

 Symptoms:  Signs:
 Hyperactivity  Tachycardia
 Irritability  Atrial fibrillation
 Dysphoria  Tremor
 Heat intolerance &  Goiter
sweating
 Palpitations  Warm, moist skin
 Fatigue & weakness  Muscle weakness,
 Weight loss with increased myopathy
appetite  Lid retraction or lag
 Diarrhea  Gynecomastia
 Polyuria  Exophtalmus
 Sexual dysfunction  Pretibial myxedema
Manifestations of Thyrotoxicosis
Differential Diagnosis

 Panic attacks

 Psychosis

 Mania

 Pheochromocytoma

 Hypoglycemia

 Occult malignancy
Treatment
 Reducing thyroid hormone synthesis:
 Antithyroid drugs (Methimazole, Propylthyouracil)
 Radioiodine (131I)
 Subtotal thyroidectomy

 Reducing Thyroid hormone effects:

 Propranolol
 Glucocorticoids
 Benzodiazepines

 Reducing peripheral conversion of T4 to T3

 Propylthyouracil
 Glucocorticoids
 Iodide (Large oral or IV dosage) (Wolf-Chaikoff effect)
Treatment: Special Considerations
 Thyrotoxic crisis or Thyroid storm:
 It´s a life-threatening exacerbation of thyrotoxicosis,
acompanied by fever, delirium, seizures, coma, vomiting,
diarrhea, jaundice.
 Mortality rate reachs 30% even with treatment
 It´s usually precipitated by acute illness, such as:
 Stroke, infection,trauma, diabetic ketoacidosis, surgery,

radioiodine treatment

 Propylthyouracil IV or Nasogastric tube

 Radioiodine (131I)
 Propranolol
 Glucocorticoids
 Benzodiazepines
 Iodide (Large oral or IV dosage) (Wolf-Chaikoff effect)
HYPOTHYROIDISM
 Definition
 A deficiency of thyroid hormones, which in turn results in a
generalized slowing down of metabolic processes.

 In infants and children => marked slowing of growth and

development, with serious permanent consequences including
mental retardation.

 In adulthood => a generalized slowing down of the organism,

with the clinical picture of myxedema.
 Causes of Hypothyroidism

 Primary
 Congenital
 Acquired
 Transient
 Secondary
 Pituitary
 Hypothalamic
Hypothyroidism

 Symptoms:  Signs:
 Bradycardia
 Tiredness  Dry coarse skin
 Weakness  Puffy face, hands and
 Dry skin feet
 Diffuse alopecia
 Sexual dysfunction
 Peripheral edema
 Hair loss  Delayed tendon reflex
 Difficulty relaxation
 Carpal tunel syndrome
concentrating  Serous cavity effusions.
Hypothyroidism
Special Considerations
 Myxedema coma
 Reduced level of consciousness, seizures
 Hypotension/shock
 Hypothermia
 Hyponatremia

 Usually in elderly hypothyroid pts.

 Usually precipitated by intercurrent illnesses that impairs

ventilation

 It´s an Emergency with a high mortality rate

 Treatment: Lyotironine(T3) or T4, Hydrocortisone, external

warming, IV fluids
Many Causes, One Treatment

 Goal : Normalize TSH level regardless of cause of hypothyroidism

 Treatment : Once daily dosing with Levothyroxine sodium (1.6

µg/kg/day)

 Monitor TSH levels at 6 to 8 weeks, after initiation of therapy or dosage

change
Treatment: Special Considerations

 Elderly patients

 Coronary Artery Disease

 Poor adrenal gland reserve

 Childrens

 Pregnancy

 Emergency surgery (Non thyroid related)

Goiter and Thyroid Cancer
Definitions

Goiter is a diffuse or nodular enlargement of the

thyroid gland resulting from excessive replication of
benign thyroid epithelial cells.

A thyroid nodule is a discrete lesion

within the thyroid gland that is palpably
and/or ultrasonog- raphically distinct
from the surrounding thyroid
parenchyma
Etiology of Nontoxic Goiter

 Iodine deficiency
 Goitrogen in the diet
 Hashimoto's thyroiditis
 Subacute thyroiditis
 Inherited defect in thyroidal enzymes necessary for
T 4 and T 3 biosynthesis
 Generalized resistance to thyroid hormone (rare)
 Neoplasm, benign or malignant
Multinodular Goiter
Clinical Issues

 Hyperthyroidism

 Suspicion of malignancy

 Compressive/obstructive symptoms

 Cosmetic concerns
MULTINODULAR GOITER
Presentation

 Asymptomatic
 Neck mass discovered by patient or physician
 Abnormal CXR
 Symptomatic
 Pressure symptoms
 Hoarseness
 Thyrotoxicosis
NODULAR GOITER
Suspicious Nodule or Goiter
 High suspicion
 Family history of medullary thyroid carcinoma
 Rapid tumor growth
 A nodule that is very firm or hard
 Fixation of the nodule to the adjacent structures
 Paralysis of the vocal cord
 Regional lymphadenopathy
 Distant metastasis
 Moderate suspicion
 Age of either<20 or >70 years
 Male sex
 History of head and neck irradiation
 A nodule >4 cm in diameter or partially cystic
 Symptoms of compression, including dysphagia, dysphonia,
hoarseness, dyspnea, and cough
Ultrasound
 Ultrasonographic Cancer Risk Factors for a
Thyroid Nodule
 hypoechogenicity,
 microcalcifications,
 irregular margins,
 increased nodular flow visualized by Doppler,
 the evidence of invasion or regional lymphadenopathy
Multinodular Goiter : Evaluation

 TSH
 FT4, T3
 Radionuclide Scan / RAIU
 US
 CT Scan (without contrast)
 FNA biopsy
Multinodular Goiter
Fine Needle Aspiration Evaluation

 Biopsy all accessible nodule(s)

 Biopsy suspicious nodule(s) cold on scan;

firm by palpation; growing in size

 Results less reliable in large goiters

 Most common diagnosis is “colloid nodule”

Fine Needle Aspiration Evaluation
FNA results
 Malignant- pt needs to have surgical management

 Benign- observation with interval ultrasounds and

clinical examinations

 Indeterminate- radioisotope scan- perform

suppression scan and if cold proceed to surgical
management- if hot nodule consider observation

 Non diagnostic- repeat FNA or U/S guided FNA

Thyroid Cancers
Benign Neoplasms of the Thyroid

Thyroid adenoma is a benign neoplastic growth

contained within a capsule.

Hurtle cell adenoma

Thyroid Cancer

 Papillary (mixed papillary and follicular) 75%

 Follicular carcinoma 16%

 Medullary carcinoma 5%

 Undifferentiated carcinomas 3%

 Miscellaneous (lymphoma, fibrosarcoma, 1%

squamous cell carcinoma, malignant
hemangioendothelioma, teratomas, and metastatic
carcinomas)
Papillary Carcinoma

 very slowly grow and remain confined to the thyroid

gland and local lymph nodes for many years.

 In older patients, more aggressive and invade locally

into muscles and trachea.

 in later stages, they can spread to the lung.

 Death is usually due to local disease, with invasion of

deep tissues in the neck less commonly, death may
be due to extensive pulmonary metastases..
Follicular Carcinoma

 is characterized by the presence of small follicles,

colloid formation is poor.

 capsular or vascular invasion.

 more aggressive and local invasion of lymph nodes or

by blood vessel invasion with distant metastases to
bone or lung.

 often retain the ability to concentrate radioactive iodine,

to form thyroglobulin, and, rarely, to synthesize T3 and
T4.
Follicular Carcinoma

 rare ''functioning thyroid cancer'' is almost always a

follicular carcinoma.

 more likely to respond to radioactive iodine therapy.

 In untreated patients, death is due to local extension or

to distant bloodstream metastasis with extensive
involvement of bone, lungs, and viscera.
Medullary Carcinoma
 a disease of the C cells (parafollicular cells) derived

 calcitonin, histamin, prostaglandins, serotonin, other peptides

 more aggressive , but not undifferentiated thyroid cancer.

 locally into lymph nodes and into surrounding muscle and

trachea.

 lymphatics and blood vessels and metastasize to lungs and

viscera.

 Calcitonin and CEA clinically useful markers for diagnosis and

follow-up.
Medullary Carcinoma

 About 80% are sporadic

 the remainder are familial. four familial patterns:
 without associated endocrine disease (FMTC);
 MEN 2a medullary carcinoma, pheochromocytoma, and
hyperparathyroidism;
 MEN 2B, medullary carcinoma, pheochromocytoma,
and multiple mucosal neuromas;
 MEN 3 : with cutaneous lichen amyloidosis, a pruritic
skin lesion located on the upper back.
Undifferentiated (Anaplastic) Carcinoma

 small cell, giant cell, and spindle cell carcinomas.

 usually occur in older patients with a long history of

goiter in whom the gland suddenly -over weeks or
months- begins to enlarge and produce pressure
symptoms, dysphagia, or vocal cord paralysis.

 Death from massive local extension usually occurs

within 6-36 months These tumors are very resistant to
therapy .
Lymphoma
 only type of rapidly growing thyroid cancer that is
responsive to therapy

 as part of a generalized lymphoma or may be primary

in the thyroid gland.

 occasionally with long-standing Hashimoto's thyroiditis

 characterized by lymphocyte invasion of thyroid

follicles and blood vessel walls, which helps to
differentiate thyroid lymphoma from chronic thyroiditis.

 If there is no systemic involvement, the tumor may

respond dramatically to radiation therapy
Cancer metastatic to the thyroid

 Cancers of the breast and kidney, bronchogenic

carcinoma, and malignant melanoma.

 The primary site of involvement is usually obvious,

 Occasionally , the diagnosis is made by needle biopsy

or open biopsy of a rapidly enlarging cold thyroid
nodule.

 The prognosis is that of the primary tumor,

Management of Thyroid Cancer
Papillary and Follicular Carcinoma:
 Low-risk group under age 45 with primary lesions under 1 cm
and no evidence of intra- or extraglandular spread.

 For these patients, lobectomy is adequate therapy

 All other patients high-risk, and for these total thyroidectomy

and-if there is evidence of lymphatic spread -a modified neck
dissection are indicated.

 Prophylactic neck dissection is not necessary.

 For the high-risk group, postoperative radioiodine ablation

Management of Thyroid Cancer
 Follow-up at intervals of 6-12 months should include
careful examination of the neck for recurrent masses.

 If a lump is noted, needle biopsy is indicated to confirm

or rule out cancer.

 Serum TSH should be checked

 Serum Tg should be < 1 ng/ml .

Thyroiditis
Definition

Infectious or autoimmune inflammatory

diseases of thyroid gland

 Classification

• Hashimoto thyroiditis
• Subacute granulomatous thyroiditis
• Infectious thyroiditis
• Radiation & Trauma induced thyroiditis
• Subacute Lymphocytic thyroiditis
• Postpartum thyroiditis
• Drug induced thyroiditis
• Riedel’s thyroiditis
 HASHIMOTO’s THYROIDITIS
Chronic Lymphocytic Thyroiditis

• Is the most prevalent form of thyroid autoimmune disease

(3-4 % of popul.) and most common cause of hypothyroidism

• Is characterized by gradual thyroid failure, goitre or both
• Is more common in middle age
• Clusters in families
• May be associated with other autoimmune

disorders

Dr. Hakaru Hashimoto

 Subacute Granulomatous
(de Quervain’s) Thyroiditis

• Most frequent cause of thyroid pain and tenderness

• Postviral inflammatory process

(Coxsackievirus, mumps, measles, adenovirus, other)

• Strongly associated with HLA-B35, most common in

40-50 years old women

• Transient thyroiditis (thyrotoxic for 2-6 wks)

 Clinical Presentation

• Previous viral infection (in 1-3 weeks)

• Pain over thyroid,upper neck, jaw,
throat,ears
• Hoarseness,dysphagia
• Fever, palpitation, nervousness,
lassitude
• Tender, enlarged, firm and often
nodular
Treatment of DeQuervain’s Thyroiditis

 A nonsteroidal antiinflammatory drug

 Aspirin: 2.4-3.6 g in divided doses
 Naproxen: 1.0-1.5 g in divided doses
 Prednisone : 30-40 mg qd
 A beta blocker
 Propranolol : 40-120 mg
 Atenolol : 25-50 mg
Infectious Thyroiditis

 Acute (with abscess formation)

 Gram-positive or negative organisms (via blood
or a fistula from the piriform sinus adjacent to the
larynx)
 Chronic
 Mycobacterial
 Fungal
 Pneumocystis
Infectious Thyroiditis

 Acute
 Usually unilateral neck pain and tenderness
 Fever, chills, a unilateral neck mass (fluctuant)
 USG, FNAB, drainage and antibiotics
 Chronic
 Bilateral, less prominent neck pain
 Some patients have hypothyroidism
 FNAB
Radiation and Trauma-Induced Thyroiditis

 Radiation Thyroiditis
 Radioiodine treatment of Graves disease
 Develops 5-10 days later and is mild

 Trauma-induced Thyroiditis
 Palpation, thyroid biopsy, surgery, car seat belt
Subacute Lymphocytic Thyroiditis
(Painless, Silent, Lymphocytic)

 A variant form of Hashimoto’s thyroiditis

 Associated with HLA-DR3
 Postulated initiating factors :
 Excess iodine intake
 Various cytokines
Treatment of Subacute
Lymphocytic Thyroiditis

 Most patients need no treatment

 Symptomatic treatment during the hyperthyroid
phase : propranolol or atenolol
 T4 ( 50-100 µg daily) given for 8-12 wks,
discontinued and reevaluated 4-6 wks later
Postpartum Thyroiditis

• Occurs in 3-16% of pregnancies (25 % in T1DM)

• Is seen within 1 year after parturition
• Is likely to recur after subsequent pregnancies
• Thyrotoxicosis is mild and transient
• Antithyroid antibodies are elevated
• RAIU is low
• Slightly increased ESR
Presentation of Postpartum Thyroiditis

 Transient hyperthyroidism (2-8 wks) followed by

hypothyroidism (2-8 wks) and then recovery 20-
30 %

 Transient hyperthyroidism alone 20-40 %

 Transient hypothyroidism alone 40-50 %

Drug-Induced Thyroiditis

 Interferon-alpha thyroiditis

 Interleukin-2 thyroiditis

 Amiodarone
Riedel’s Thyroditis

 Is a fibrotic process associated with a mononuclear cell

inflammation that extends beyond the thyroid into soft
tissue

 Can involve the parathyroids, the recurrent laryngeal

nerve, trachea, mediastinum, ant. chest wall

 Fibrosclerosis may involve the retroperitoneal space,

mediastinum, retroorbital space, the biliary tract
Treatment of Riedel’s Thyroiditis

 Thyroxine
 Surgery
 Glucocorticoids
 Tamoxifen
 Methylprednisone pulse therapy + azathioprine or
penicillamine