Thyroid Thyroid disordersdisorders By Dr. Osman BukhariBy Dr. Osman Bukhari

Synthesis & release of thyroid Synthesis & release of thyroid hormoneshormones

11 - -TrappingTrapping of iodine in z gland of iodine in z gland 22 - -OrganificationOrganification of iodine by of iodine by

peroxidaseperoxidase 33-- CouplingCoupling of mono & diiodotyrosine to of mono & diiodotyrosine to

form T4 & T3form T4 & T3 44 - -ReleaseRelease of T4 & T3 of T4 & T3

* * Thyroid secretes mostly T4 & very Thyroid secretes mostly T4 & very little T4, but 90% of circulating T3 little T4, but 90% of circulating T3 ( most active hormone) is derived ( most active hormone) is derived from peripheral deiodination of T4 to from peripheral deiodination of T4 to T3 in z liver, kidney & musclesT3 in z liver, kidney & muscles..

* * Over 99% of circulating hormones are bound Over 99% of circulating hormones are bound to TBG, thyroid binding preaMlb. & albumin. to TBG, thyroid binding preaMlb. & albumin. Only free hormone enter cells binding to Only free hormone enter cells binding to specific nuclear receptors for tissue actionspecific nuclear receptors for tissue action..

Hypothalamic- Pituitary- Thyroid Hypothalamic- Pituitary- Thyroid axisaxis-: -:

11--TRH stimulates release of TSHTRH stimulates release of TSH

22--TSH stimulates TSH receptors to increase TSH stimulates TSH receptors to increase synthesis & release of stored T3 & T4 synthesis & release of stored T3 & T4 increasing their level in z plasmaincreasing their level in z plasma

33 - -T3 & T4 feed back on z pituitary and T3 & T4 feed back on z pituitary and hypothalamus to reduce synthesis of TRH & hypothalamus to reduce synthesis of TRH & TSHTSH

HyperthyroidismHyperthyroidism This refers to z clinical manifestations This refers to z clinical manifestations

with increased serum levels of T3 & T4with increased serum levels of T3 & T4..

CausesCauses-: -: 11 - -Graves, diseaseGraves, disease+++ +++

- - A.I disease characterized by increased A.I disease characterized by increased secretion & release of thyroid secretion & release of thyroid hormoneshormones

- - Associated with vascular goitre & may Associated with vascular goitre & may be accompanied by infiltrative be accompanied by infiltrative ophthalmopathy & less commonly ophthalmopathy & less commonly dermopathy & acroachydermopathy & acroachy

- - F : M = 9:1, 20 -40 yearsF : M = 9:1, 20 -40 years - - Pathogenesis is due to TSH receptor Pathogenesis is due to TSH receptor

antibodies that bind to TSH-R in z antibodies that bind to TSH-R in z gland and stimulate hyperfunction. gland and stimulate hyperfunction. TSH-R Ab are present in 80 % of pat. TSH-R Ab are present in 80 % of pat. TPO & thyroglobulin Abs are TPO & thyroglobulin Abs are increased in most patsincreased in most pats..

- - Pats with Graves disease are at Pats with Graves disease are at increased risk of developing other A.I increased risk of developing other A.I diseasesdiseases..

- - The natural history is that of The natural history is that of remission and relapses. Many pats remission and relapses. Many pats eventually Hypothyroideventually Hypothyroid

22 - -Toxic adenomas or nodulesToxic adenomas or nodules: :

a- Toxic multinodular goitrea- Toxic multinodular goitre

b- Toxic solitary nodule or adenoma b- Toxic solitary nodule or adenoma (Plumer,s disease)(Plumer,s disease)

* * they are not accompanied by they are not accompanied by ophthalmopathy or dermopathy (due to ophthalmopathy or dermopathy (due to glycosaminoglycan & lymphocytic glycosaminoglycan & lymphocytic infiltration. Thyroid Abs are not usually infiltration. Thyroid Abs are not usually present in z plasmapresent in z plasma..

33 - -Sub acute thyroiditisSub acute thyroiditis (de Quervain,s (de Quervain,s thyroiditis) : there are general symptom of thyroiditis) : there are general symptom of inflammation, neck pain, thyroid tenderness, inflammation, neck pain, thyroid tenderness, high ESR and initial transient hyperthy. Is high ESR and initial transient hyperthy. Is followed by transient hypothrfollowed by transient hypothr..

44 - -Iodine induced hyperthyroidismIodine induced hyperthyroidism (Jodbasedow disease)_ occur in MNG (Jodbasedow disease)_ occur in MNG after large doses of iodine e.g. after large doses of iodine e.g. dietary iodine supplements, contrast dietary iodine supplements, contrast & drugs like amiodarone& drugs like amiodarone

55 - -Thyrotoxicosis factitiaThyrotoxicosis factitia - from - from ingestion of exogenous thyroxiningestion of exogenous thyroxin..

66 - -Strom ovarii-ovarian dermoid & Strom ovarii-ovarian dermoid & teratomas secreting thyroid teratomas secreting thyroid hormones autonomously from z hormones autonomously from z contained thyroid tissuecontained thyroid tissue

77 - -Hashimotos,s thyroiditisHashimotos,s thyroiditis – causes – causes transient hyperthyroidismtransient hyperthyroidism

88 - -Pregnancy & trophpoblastic Pregnancy & trophpoblastic tumourstumours – postpartum thyroiditis – postpartum thyroiditis causing transient hyperthy. Due to causing transient hyperthy. Due to release of stored hormones following release of stored hormones following damage to z thyroid by TPO Abs. damage to z thyroid by TPO Abs. Very high levels of hCG stimulate Very high levels of hCG stimulate TSH-R in early preg, molar preg, TSH-R in early preg, molar preg, chorioCa & testicular malignchorioCa & testicular malign..

99 - -Metastatic functional thyroid CaMetastatic functional thyroid Ca.. 1010 - -Post-irradiationPost-irradiation

1111 - -TSH secreting pituitary tumoursTSH secreting pituitary tumours..

*** *** Over 90 % of cases of hyperthy. Over 90 % of cases of hyperthy. are caused by Graves, toxic MNG & are caused by Graves, toxic MNG & toxic solitary nodulestoxic solitary nodules..

Clinical manifestationsClinical manifestations of hyperthyroidism:of hyperthyroidism: symptoms symptoms -:-:

- - VariableVariable- - fatigability -irritability - restlessnessfatigability -irritability - restlessness

- - nervousness - anxiety - palpitationnervousness - anxiety - palpitation - - heat intolerance - diarrhea - Wt lossheat intolerance - diarrhea - Wt loss

- - proximal muscle weakness - tremorsproximal muscle weakness - tremors - - sweating - menstrual irregularitiessweating - menstrual irregularities

- - goitre - hypokaemic periodic goitre - hypokaemic periodic paralysisparalysis

- - painful eyes, increased lacrimation, painful eyes, increased lacrimation, exoph photophobia, blurred vision & exoph photophobia, blurred vision & diplopiadiplopia

SignsSigns-:-: - - goitre with a bruit -hyperkinesisgoitre with a bruit -hyperkinesis

- - fine finger tremor of out-stretched fine finger tremor of out-stretched handshands

- - warm sweaty hands - palmer erythemawarm sweaty hands - palmer erythema

- - sinus tachycardia with full pulse or AFsinus tachycardia with full pulse or AF

- - systolic HT- HF - proximal myopathysystolic HT- HF - proximal myopathy

- - lid retraction & lid laglid retraction & lid lag

- - proptosis, exophthalmus keratitisproptosis, exophthalmus keratitis

- - periorbital & conjunctival edemaperiorbital & conjunctival edema

- - ophhalmoplegiaophhalmoplegia

- - pretibial myxedema( in 3% of Graves)pretibial myxedema( in 3% of Graves) - - thyroid acropachy: clubbing & swollen thyroid acropachy: clubbing & swollen

fingers from periosteal new bone fingers from periosteal new bone formationformation

- - onychlysisonychlysis- - brisk reflexesbrisk reflexes

- - gynaecomastiagynaecomastia****Ophthalmopathy is clinically apparent Ophthalmopathy is clinically apparent

in 20-40 % of Graves & usually consist in 20-40 % of Graves & usually consist of chemosis, conjunctivitis & mild of chemosis, conjunctivitis & mild proptosisproptosis..More severe case occur in 5-10% & have More severe case occur in 5-10% & have exophthalmus & diplopiaexophthalmus & diplopia..

** ** The eye sighs, pretibial myxoedema The eye sighs, pretibial myxoedema and thyroid acropachy occur only in and thyroid acropachy occur only in Graves diseaseGraves disease

** ** Elderly pats frequently present with Elderly pats frequently present with AF, tachycardia and/or HF with only AF, tachycardia and/or HF with only few other signsfew other signs

** ** Children frequently present with Children frequently present with excessive growth rate, behavioral excessive growth rate, behavioral problems & may show Wt gainproblems & may show Wt gain

Complications of Complications of hyperthyroidismhyperthyroidism::

- - AF & HFAF & HF

- - OsteoporosisOsteoporosis

- - Hypercalcemia & nephrocalcinosisHypercalcemia & nephrocalcinosis

- - Hypokalaemic periodic paralysis Hypokalaemic periodic paralysis induced by exercise or heavy CHO induced by exercise or heavy CHO ingestioningestion

- - Sexual problems in malesSexual problems in males

Diff. Diag. of hyperthyroidismDiff. Diag. of hyperthyroidism:: - - AnxietyAnxiety

- - PhaeochromocytomaPhaeochromocytoma

- - Cardiac with AF refractory o TRCardiac with AF refractory o TR

- - Other causes of ophthalmoplegia Other causes of ophthalmoplegia and exophthalmosand exophthalmos

Diag of hyperthyroidismDiag of hyperthyroidism - - Clinical suspicion confirmed byClinical suspicion confirmed by::

- - Suppressed serum TSH except in Suppressed serum TSH except in 2dry hyperthyroidism2dry hyperthyroidism

- - Raised serum T4, free T4 or T3 & T3Raised serum T4, free T4 or T3 & T3

- - TSH-R abs, TPO & thyroglobulin Abs TSH-R abs, TPO & thyroglobulin Abs are present in most casesare present in most cases

- - Radio-iodine uptakeRadio-iodine uptake

- - ImagingImaging

Treatment of hyperthyroidismTreatment of hyperthyroidism 11 - -Antithyroid drugsAntithyroid drugs

22 - -RadioiodineRadioiodine

33 - -SurgerySurgery

Antithyroid drugsAntithyroid drugs ( ( Thiourea drugsThiourea drugs) )

They inhibit z formation of thyroid They inhibit z formation of thyroid hormones. Generally used for young hormones. Generally used for young adults, mild hyperthy, small goitres adults, mild hyperthy, small goitres and preparing pats for surgery & and preparing pats for surgery & radioactive iodine therapyradioactive iodine therapy

11 - -CarbimazoleCarbimazole & z active metabolite & z active metabolite methimazolemethimazole– Also have mild – Also have mild immunosuppressive activity. immunosuppressive activity. - Initial dose 40-60mg divided or - Initial dose 40-60mg divided or singlesingle

- - SE- rash, nausea, vomiting, SE- rash, nausea, vomiting, arthralgiaarthralgia , ,

jaundice & agranulocytosis ( o.1%)jaundice & agranulocytosis ( o.1%)

- - It crosses z placentaIt crosses z placenta

22 - -PropylthiouracilPropylthiouracil

- - Dose 100-200mg 8-hourlyDose 100-200mg 8-hourly

- - additionally blocks conversion of T4 to additionally blocks conversion of T4 to T3T3

- - SE—rash, nausea, vomiting & agranuloSE—rash, nausea, vomiting & agranulo

Beta blockersBeta blockers

- - PropranololPropranolol

- - Dose –40-8mg 8-houlyDose –40-8mg 8-houly

- - Avoid in bronchial asthma & use withAvoid in bronchial asthma & use with

care in HFcare in HF

- - Decrease conversion of T4 to T3Decrease conversion of T4 to T3

Treatment regimensTreatment regimens 11 - -Gradual dose titrationGradual dose titration

- - Start with z high doseStart with z high dose

- - Review after 4-6 Ws & reduce doseReview after 4-6 Ws & reduce dose

depending on clinical state & T4 & T3depending on clinical state & T4 & T3

levelslevels

- - Stop BB when clinically & biochemStop BB when clinically & biochem

euthyroideuthyroid

- - Review after2-3Ms & reduce Review after2-3Ms & reduce carbimazcarbimaz

if controlledif controlled

- - Reduce dose gradually to 5mg overReduce dose gradually to 5mg over

66 - -24Ms if z disease remained24Ms if z disease remained

controlledcontrolled

- - When euthyroid on 5mg dailyWhen euthyroid on 5mg daily

discontinue carbimazolediscontinue carbimazole

* * Propylthiouracil is used in a similar wayPropylthiouracil is used in a similar way..

22 - -Block & replace regimenBlock & replace regimen

- - Full doses of antithyroid drugs are givenFull doses of antithyroid drugs are given

e.g. carbimazole 40mg to suppress thee.g. carbimazole 40mg to suppress the

thyroid completely while replacingthyroid completely while replacing

thyroxin 100 mcg daily once z pat is thyroxin 100 mcg daily once z pat is euthyroid & continued for 18Mseuthyroid & continued for 18Ms

- - This regimen avoids over or under TRThis regimen avoids over or under TR and offers z immunosuppressive and offers z immunosuppressive

effecteffect of carbimazoleof carbimazole

- - It is CI in pregnancy as T4 crossesIt is CI in pregnancy as T4 crosses placenta less well than carbimazoleplacenta less well than carbimazole ** **About 50% relapse after a course of About 50% relapse after a course of

antithyroid TR & long term therapy, antithyroid TR & long term therapy, surgery or R/I therapy is considered. surgery or R/I therapy is considered. Those with large single or MNG are Those with large single or MNG are unlikely to remit after a courseunlikely to remit after a course..

Surgery– subtotal thyroidectomySurgery– subtotal thyroidectomy Surgery is considered for large goitres Surgery is considered for large goitres

unlikely to remit after med TR, pressure unlikely to remit after med TR, pressure symptoms, preg women uncontrolled symptoms, preg women uncontrolled with low doses of Thiourea, poor with low doses of Thiourea, poor compliance with drugs, persistent dug compliance with drugs, persistent dug SE & recurrent hyperthy after drugsSE & recurrent hyperthy after drugs

- - Pat rendered euthyroid or Ipodate Pat rendered euthyroid or Ipodate preoperativelypreoperatively

- - Thyroid vascularity is reduced Thyroid vascularity is reduced preoperatively by Ipodate or Lugols preoperatively by Ipodate or Lugols iodine solution to reduce thyroid crisisiodine solution to reduce thyroid crisis

- - Complications of surgery include Complications of surgery include postoperative bleeding &tracheal postoperative bleeding &tracheal compression, recurrent laryngeal compression, recurrent laryngeal nerve palsy, hypocalcemia, hypothy nerve palsy, hypocalcemia, hypothy & recurrent hyperthy& recurrent hyperthy..

Radioactive iodineRadioactive iodine - - Now commonly being after child Now commonly being after child

bearing agebearing age

- - CI during pregnancy & while breast CI during pregnancy & while breast feedingfeeding

- - Dose 200-500Dose 200-500

- - pat rendered euthyroid pat rendered euthyroid preoperatively and stop drugs 4 days preoperatively and stop drugs 4 days beforebefore

- - Early neck pain, transient hyperthy, Early neck pain, transient hyperthy, progressive incidence of hypothy, progressive incidence of hypothy, worsening of ophthal, ?carcinogenesisworsening of ophthal, ?carcinogenesis..

Hyperthy in pregnancy & neonatal Hyperthy in pregnancy & neonatal lifelife

- - Maternal hyperthy is uncommon during Maternal hyperthy is uncommon during pregnancy, mild & usually due to pregnancy, mild & usually due to GravesGraves

- - TSH-R Abs cross z placenta & stim fetal TSH-R Abs cross z placenta & stim fetal thyroid, carbimazole also crosses thyroid, carbimazole also crosses placenta but T4 poorly & so block & placenta but T4 poorly & so block & replace regim is CIreplace regim is CI

- - Use smallest necessary dose of drugs Use smallest necessary dose of drugs and breast feeding while on usual doses and breast feeding while on usual doses is safeis safe..

- - If high doses are needed surgery can be If high doses are needed surgery can be performed, best in z 2performed, best in z 2ndnd trimester trimester . .

- - A child borne to a mother with A child borne to a mother with Graves may be borne with hyperthy Graves may be borne with hyperthy even if she is treated because ABS even if she is treated because ABS may still be present. The fetus may still be present. The fetus should be monitored monthly with should be monitored monthly with pulse & hormonespulse & hormones

Thyroid crisis or stormThyroid crisis or storm - - Rare, mortality 10%Rare, mortality 10%,,

- - present with rapid deterioration of present with rapid deterioration of hyperthy with hyperpyrexia, extreme hyperthy with hyperpyrexia, extreme restlessness, tachycardia, hypotension, restlessness, tachycardia, hypotension, delirium & comdelirium & com

- - precipitated by stress, infection or precipitated by stress, infection or trauma in a pat inadequately treated or trauma in a pat inadequately treated or surgery in unprepared pat or R/I surgery in unprepared pat or R/I therapytherapy

- - Diag is clinicalDiag is clinical

- - TR include Propranolol, hydrocortisoneTR include Propranolol, hydrocortisone , ,

Na iodide orally, Ipodate (inhibit Na iodide orally, Ipodate (inhibit release of hormones & conversion of release of hormones & conversion of T4 to T3), IV fluids, lowering temp & T4 to T3), IV fluids, lowering temp & high doses of Thioureashigh doses of Thioureas..

HypothyroidismHypothyroidism Syndrome that results from deficiency of Syndrome that results from deficiency of

thyroid hormones. F : M =15 : 1thyroid hormones. F : M =15 : 1 It may be primary or secondary to It may be primary or secondary to

hypothalamic-pituitary diseasehypothalamic-pituitary disease..

Primary hypothyPrimary hypothy:: 11 - -AutoimmuneAutoimmune

- - Atrophic thyroiditisAtrophic thyroiditis - - Hashimoto,s thyroiditisHashimoto,s thyroiditis

- - Postpartum thyroiditisPostpartum thyroiditis

** ** Associated AI diseasesAssociated AI diseases

22 - -Post-surgeryPost-surgery

33 - -Post-irradiationPost-irradiation ( R/A iodine or ( R/A iodine or external neck irradiation)external neck irradiation)

** **11 , ,22 & & 33 account for more than 90% account for more than 90% of causesof causes..

44 - -Defects of hormone synthesisDefects of hormone synthesis

- - Iodine deficiencyIodine deficiency

- - Dyshormonogenesis due to Dyshormonogenesis due to genetic defects in hormone synth genetic defects in hormone synth e.g. Pendred,s syndrome (hypothy + e.g. Pendred,s syndrome (hypothy + sensorineural deafnesssensorineural deafness

- - Anti thyroid drugsAnti thyroid drugs - - Other drugs e.g. amiodarone, lithium Other drugs e.g. amiodarone, lithium

( inhibit release of thyroid hormones ), ( inhibit release of thyroid hormones ), interferoninterferon

55 - -Post sub acute thyroiditisPost sub acute thyroiditis 66 - -InfiltrationInfiltration e.g. tumours, sarcoidosis e.g. tumours, sarcoidosis

77 - -Food goitrogensFood goitrogens e.g. cassavas e.g. cassavas 88 - -peripheral resistant to thyroidperipheral resistant to thyroid

hormoneshormones 99 - -CongenitalCongenital e.g. agenesis e.g. agenesis..

Secondary hypothySecondary hypothy 11--HypopituitarismHypopituitarism

22 - -Isolated TSH deficiencyIsolated TSH deficiency

** **Goitre is absent in atrophicGoitre is absent in atrophic

thyroiditis, irradiation, after total thyroiditis, irradiation, after total thyroidectomy & in 2ry hypothythyroidectomy & in 2ry hypothy

Clinical featuresClinical features::- - Hypothy causes S & S referable to all Hypothy causes S & S referable to all

and diagn may be missed if not and diagn may be missed if not positively considered. Myxoedema positively considered. Myxoedema refers to accumulation of refers to accumulation of mucopolysaccharides, hyaluronic mucopolysaccharides, hyaluronic acid & chondroitin SO4 in S/C tissuesacid & chondroitin SO4 in S/C tissues..

- - The classic picture of slow, dry- The classic picture of slow, dry- haired, thick- skinned, deep voiced haired, thick- skinned, deep voiced pat with Wt gain, cold intolerance, pat with Wt gain, cold intolerance, bradycardia & constipation makes z bradycardia & constipation makes z diagn easy, but milder cases are diff diagn easy, but milder cases are diff to diagn clinicallyto diagn clinically..

SymptomsSymptoms:: - - Tiredness & malaise - Wt Tiredness & malaise - Wt

gain/anorexiagain/anorexia

- - Cold intolerance - Poor memoryCold intolerance - Poor memory

- - Depression - Poor libidoDepression - Poor libido

- - Goitre - dry brittle hairGoitre - dry brittle hair

- - Dry coarse skin - ConstipationDry coarse skin - Constipation

- - Arthralgia, myalgia, muscle weakness Arthralgia, myalgia, muscle weakness and stiffness - Menorrhagia, and stiffness - Menorrhagia, oligomenorrhoea or amenorrhoea in oligomenorrhoea or amenorrhoea in females. - deafnessfemales. - deafness

- - Psychosis - ComaPsychosis - Coma

SignsSigns:: - - Mental slowness - Poverty of Mental slowness - Poverty of

movementmovement - - Ataxia - deafness - psychosisAtaxia - deafness - psychosis

- - Dry thin hair - Loss of lateral eyebrowDry thin hair - Loss of lateral eyebrow - - Hypertension - Hypothermia - HFHypertension - Hypothermia - HF - - Bradycardia - Pericardial effusionBradycardia - Pericardial effusion - - Ascites & pleural eff—rare - PallorAscites & pleural eff—rare - Pallor

- - Cold peripheries - Hard pitting edemaCold peripheries - Hard pitting edema - - Carpal tunnel syndrome - deep voiceCarpal tunnel syndrome - deep voice

- - Periorbital edema - dry carotinemic skinPeriorbital edema - dry carotinemic skin - - Goitre - OverWt - AnemiaGoitre - OverWt - Anemia

- - Proximal myopathy - MyotoniaProximal myopathy - Myotonia

- - Slow relaxing reflexesSlow relaxing reflexes

- - Slow growth velocity, poor school Slow growth velocity, poor school performance & arrest of pubertal performance & arrest of pubertal development in children with development in children with hypothyhypothy

-Hypothy should be excluded in all Hypothy should be excluded in all pats with menstrual disturbances, pats with menstrual disturbances, infertility and hyperprolactinaemiainfertility and hyperprolactinaemia

- - - Hypothy in elderly is diff to Hypothy in elderly is diff to differentiate from normal agingdifferentiate from normal aging

InvestigationsInvestigations:: - - High serum TSH confirm z diagn of pry High serum TSH confirm z diagn of pry

hypothy - very sensitivehypothy - very sensitive

- - Low total or free T4 confirms hypothy state Low total or free T4 confirms hypothy state as TSH is low or normal in 2ry hypothyas TSH is low or normal in 2ry hypothy

- - High thyroid Abs (TPO & Thyroglobulin)High thyroid Abs (TPO & Thyroglobulin)

- - AnemiaAnemia

- - HypercholestrolaemiaHypercholestrolaemia

- - Organ specific AbsOrgan specific Abs

- - HyponatraemiaHyponatraemia

- - ECG-S. bradycardia, low voltage, Tw inv & ECG-S. bradycardia, low voltage, Tw inv & JwJw

Complications of hypothyroidismComplications of hypothyroidism:: - - CAD & HFCAD & HF

- - Increased susceptibility to infectionIncreased susceptibility to infection

- - Organic psychosisOrganic psychosis

- - Infertility—MiscarriageInfertility—Miscarriage

- - Adrenal crisis may be precipitated byAdrenal crisis may be precipitated by

thyroid therapythyroid therapy

- - Myxedema coma: Most often seen in Myxedema coma: Most often seen in elderly women leading to severe elderly women leading to severe hypothermia, hypovent, hypoxia, hypothermia, hypovent, hypoxia, hyponatr, hypoten and hypercapnia. hyponatr, hypoten and hypercapnia. Convulsions & CNS signs, confusion & Convulsions & CNS signs, confusion & comacoma

It is precipitated by an underlying It is precipitated by an underlying infection, illness & cold exposure. infection, illness & cold exposure.

Mortality is 50Mortality is 50% %

Diff diagn:Diff diagn: Hypothy should be considered in Hypothy should be considered in unexplained asthenia, menstrual unexplained asthenia, menstrual disturbance, constipation, Wt gain, disturbance, constipation, Wt gain, hyperlipidaemia, anemia, refractory hyperlipidaemia, anemia, refractory HF, ascites & psychosisHF, ascites & psychosis

- -

Treatment of hypothyroidismTreatment of hypothyroidism - - T4 is z drug of choice for replacementT4 is z drug of choice for replacement

- - In young fit pats start with 100mcg/dIn young fit pats start with 100mcg/d

- - In small, old or frail start with 50mcg/dIn small, old or frail start with 50mcg/d

- - In IHD with severe hypothy start In IHD with severe hypothy start carefully with 25mcg/dcarefully with 25mcg/d

- - Increase dose by 25-50 every 1-3W till Increase dose by 25-50 every 1-3W till pat is euthyroidpat is euthyroid

- - Adequacy of TR is assessed clinically Adequacy of TR is assessed clinically and by TSH & T4and by TSH & T4

- - Maintenance dose is 100-150 mcg/d Maintenance dose is 100-150 mcg/d with annual TFTwith annual TFT..

- - Clinical improvement do not begin Clinical improvement do not begin before 2W & resolution of symptoms before 2W & resolution of symptoms may take 6Mmay take 6M

- - TR is life longTR is life long - - Myxedema coma –ICUMyxedema coma –ICU

- - 400mcg IV start, then 1oomcg 400mcg IV start, then 1oomcg dailydaily

- - Rewarm pat graduallyRewarm pat gradually - - Hydrocortisone 100mg 8 hourlyHydrocortisone 100mg 8 hourly

- - Glucose to prevent hypoglycemiaGlucose to prevent hypoglycemia

- - Intubate & O2 if hypovent. Or Intubate & O2 if hypovent. Or hypercaphypercap..

Screening for hypothyScreening for hypothy:: Routine screening of newborn to Routine screening of newborn to

detect high TSH as an indicator of detect high TSH as an indicator of Pry hypothy is efficient & cost-Pry hypothy is efficient & cost-effective to prevent cretinism if T4 is effective to prevent cretinism if T4 is started earlystarted early..

A 30 y lady presented to her GP with A 30 y lady presented to her GP with increasedincreased irritability & anxietyirritability & anxiety which has which has been noticed by her husband & colleagues been noticed by her husband & colleagues at work over z last 3/12. She lost Wt. at work over z last 3/12. She lost Wt. despite good appetite & has increased despite good appetite & has increased frequency of bowel movements. She feels frequency of bowel movements. She feels extremely tired, sweats profusely & can extremely tired, sweats profusely & can not tolerate hot weathernot tolerate hot weather..

No PH of sig medical problemNo PH of sig medical problem Her parents are diabetic, a sister had Her parents are diabetic, a sister had

thyroid dis and an elderly sister suffers thyroid dis and an elderly sister suffers from chronic anemiafrom chronic anemia..

O/E: she appears agitated & tremulous. Her O/E: she appears agitated & tremulous. Her eyes appear prominent, pulse 104/min & eyes appear prominent, pulse 104/min & regular, BP 150/70regular, BP 150/70

Systemic examSystemic exam. Was normal. Was normal..

CBC, urine exam. & blood urea-E were CBC, urine exam. & blood urea-E were normalnormal

11 - -What is z most likely diagnWhat is z most likely diagn??

22 - -Mention additional 3 symptom & signsMention additional 3 symptom & signs ? ?

33 - -How would neck exam. helps you to How would neck exam. helps you to reach a diagnreach a diagn??

44 - -Tow investigations to confirm z diagnTow investigations to confirm z diagn??

55 - -Mention a serological investigation to Mention a serological investigation to reveal the nature of z underlying disreveal the nature of z underlying dis??

66 - -One diff. diagnOne diff. diagn??

77 - -How would you manage this patientHow would you manage this patient ? ?