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HYPOTHYROIDISM
Dr Prabhat Agarwal
Asst Prof, P.G. Dept of Medicine,
S.N.M.C.Agra
Hypothyroidism
Introduction
 Reduced production of thyroid hormone
is the central feature
 It is the second most common endocrine
disorder (after diabetes mellitus) is USA
 It is more common in females
 F:M ratio is approx 10:1
 Rates of hypothyroidism increase
dramatically with age
Risk Factors
 More common in individuals who have a
family history of thyroid disorders
 Hypothyroidism and thyroid cancers are
more common in individuals who have
had irradiation of their neck in childhood
 However, most cases occur in individuals
with no risk factors
Hypothyroidism
Causes
PRIMARY HYPOTHYROIDISM-
 Thyroiditis
o Hashimoto’s throiditis (Chronic
lymphocytic)
o De Quervain’s thyroiditis (Subacute
granulomatous)
o Silent/Painless thyroiditis (Subacute
lymphocytic)
o Reidel’s thyroiditis (Subacute fibrocytic)
 Iatrogenic causes
o Radioactive iodine treatment of Grave’s ds
o Thyroidectomy
SECONDARY HYPOTHYROIDISM-
 Pituitary surgery
 Intracranial radiation
 Congenital panhypopituitarism
 Infiltrative diseases like sarcoidosis, amyloidosis,
hemochromatosis
OTHERS-
 Drugs like lithium, interferon, amiodarone
 Iodine deficiency
PRIMARYV/S SECONDARY
HYPOTHYROIDISM
PRIMARY SECONDARY
SKIN Thick and without wrinkles Thin with fine wrinkles
HAIR Coarse Fine
MENSES Menorrhagia Amenorrhea
SECONDARY
SEXUAL
CHARACTERS
Normal Poor
HEART SIZE May be enlarged Small
GOITRE May be present Absent
SOFT TISSUE
EDEMA
Marked Absent
BLOOD
PRESSURE
Normal or High Low
CHOLESTEROL Increased Normal
TSH High Low
PRIMARY SECONDARY
PLASMA CORTISOL Normal Low
TRH STIMULATION
TEST
Exaggerated Response No response
THYROID AUTO
ANTIBODIES
May be present Absent
TO DIAGNOSE PRIMARY AND SECONDARY
HYPOTHYROIDISM CLINICALLY, ONE SHOULD ALWAYS
EXAMINETHE SKIN, HAIR, SECONDARY SEXUAL
CHARACTERISTICS AND SOFT TISSUE EDEMA
Hashimoto’s Thyroiditis
 Most common cause of goitrous
hypothyroidism in iodine sufficient parts of the
world
 Characterized by thyroidal lymphocytic
infiltration with germinal centre formation,
follicular damage or destruction with fibrosis
 Goitre develops gradually and is firm in
consistency
 Presence of anti TPO and anti thyroglobulin
antibodies favours the diagnosis
 History of other auto immune disorders like
rheumatoid arthritis, pernicious anemia,
diabetes mellitus should be ascertained
Hypothyroidism
Clinical Features
 Largely due to the reduced metabolic rate
and deposition of glycosaminoglycans
(GAG) in different body compartments
 Myxoedema refers to the boggy
appearance of the skin and subcutaneous
tissues in the patients with severe
hypothyroid state
 Skin is pale and cool, reduction in sweat
and sebaceous secretions causing dryness
and coarseness
 GAG deposition in the larynx and
pharynx leads to hoarseness of voice
 Cardiovascular involvement causes
decreased cardiac output, narrowing of
pulse pressure and increased systemic
vascular resistance causing diastolic
hypertension. Pericardial effusion may
occur
 Modest weight gain despite reduced
appetite and constipation due to reduced
gut peristalsis
 In adult women, decreased libido, failure
of ovulation, polymenorrhoea,
menorrhagia and decreased fertility may
be seen
 In men, decreased libido, oligospermia and
impotence may result
 These are though to result because of
hyperprolactinemia as prolactin is also
underTRH control
 A child with congenital hypothyroidism is
sluggish and may present with prolonged
physiological jaundice, meconeum ileus,
umbilical hernia, feeding difficulties, dry
scaly skin and a large tongue
 Cretinism: severe hypothyroidism of
infancy
 X Ray Pelvis will reveal dysgenesis of
the femoral capital epiphysis, which is
pathognomonic of hypothyroidism in
infancy and childhood
Signs and Symptoms
 SYMPTOMS
Lethargy
Weight gain
Constipation
Slowed mentation, forgetfulness
Depression
Hair loss
Dry skin
Easy bruising
Menstrual abnormalities
Neck enlargement/ Goitre
 SIGNS-
Goiter
Low blood pressure and slow pulse
Hair thinning or loss
Dry skin
Confusion
Depressed affect
Non pitting edema
Hung up reflexes
DIAGNOSIS
 Based on the finding of a low free
thyroxine (T4) level, usually with an
elevation in the TSH levels
 For patients with hypothyroidism due to
pituitary dysfunction (secondary
hypothyroidism), both fT4 and TSH are
low
 There is no role of thyroid scans or
iodine uptake testing in patients with
hypothyroidism
TREATMENT
 Thyroxine replacement
The usual dose required to achieve full
replacement is between 100-150 ug/day
For patients with known heart disease or who are
at risk of it, doses are started at 25-50 ug with
increases of 25 ug every 4-6 weeks guided by
TSH levels
Young patients who are otherwise normal can be
started at doses of 100 ug/day
Patients with aTSH<=10.0 do not usually
require any therapy
MONITORING
 In general, once a patient receives a full
replacement dose of T4 (usually between
100-150 ug/day) and has aTSH
consistently in the normal range, there is
little likelihood that their thyroid
requirement will change over time
 There is no evidence to show the need of
re testing to ensure patients are
euthyroid in such a sub group of patients
 BecauseT4 andT3 are highly protein bound,
any condition where a patient’s serum
protein status changes, prompt testing is
advocated
 This includes conditions that lower serum
protein levels such as liver disease,
nephrotic syndrome or malnutrition or
increase them like pregnancy or estrogen
therapy
 Patients with subclinical
hypothyroidism (mildly elevatedTSH
and a normalT4) also benefit from their
annual testing of fT4 levels.
Approximately 10% of such patients
progress to hypothyroidism within 3 yrs
of diagnosis.Thereby annual testing is
advocated.
COMPLICATIONS
 Most complications are associated with
under or over treatment
 Inadequately treated subjects are at a higher
risk of cardiac disease
 Over treatment increases the risk of atrial
fibrillation and osteoporosis
 Hashimoto’s thyroiditis is associated with
other auto immune diseases like Addison’s
disease, pernicious anemia, vitiligo.They are
also at a higher risk for the future
development of lymphoma
De Quervain’s Thyroiditis
 Also known as sub acute/ viral/ granulomatous giant
cell thyroiditis
 Most likely viral in origin
 Presents with neck pain, which may radiate to the neck
or mandible
 Hoarseness, dysphagia and signs of thyrotoxicosis may
be present
 Thyroid gland is tender and firm
 Histopathologically a well developed follicular lesion
that comprises a central core of colloid and
surrounded multi nucleate giant cells is characteristic
 ESR is high and RAIU is low
 Nearly always self limiting
Post Partum Thyroiditis
 It is the occurrence of thyrotoxicosis,
hypothyroidism or thyrotoxicosis followed
by hypothyroidism in the 1st post partum
year, in women without overt thyroid
disease before pregnancy
 Occurs in 8-10% women post partum
 Upto 30% are anti TPO antibody positive
 Painless and self limiting
 Likely to recur in subsequent pregnancies
 Increased risk of developing permanent
primary hypothyroidism in future
Reidel’s Thyroiditis
 Characterized by the fibrosis of the thyroid
and adjacent structures
 Occurs in middle aged women
 Stony hard, immobile goitre resulting in
pressure symptoms due to the compression of
the trachea, oesophagus and the recurrent
laryngeal nerve
 One third patients have hypothyroidism
 Surgical removal is indicated when pressure
symptoms are present
 Glucocorticoids have beens used for
treatment because of the their anti
inflammatory effect
Myxoedema Coma
 Ultimate stage of severe long standing
untreated hypothyroidism
 Often precipitated by stroke, infection,
myocardial infraction, sedative drugs or
exposure to cold
 Treatment is started on the basis of clinical
suspicion. Initially the precipitating condition
needs to be identified and treated, and general
suppostive measures instituted
 Clinical features include altered sensorium
(coma), subnormal temperature, bradycardia,
hypotension and features of severe myxoedema
 Mortality of this condition is related to the
severity of hypothermia
 Throxine 500 ug is given iv stat followed by
100 ug iv daily (given through nasogastric tube
if intravenous formulation is not available)
 Glucocorticoid replacement with iv
hydrocortisone (5-10 mg/hour) should also be
given
 External heating should not be done as it
causes cutaneous vasodilatation, which
increases the strain on the heart
 Despite aggressive management, mortality
approaches 50%
 Euthyroid Sick Syndrome: in severely ill
patients during acute physiological stress,
the patients may have mildly elevatedTSH
levels and do not require thyroid
replacement.The levels settle within a few
weeks of recovery and may sometimes be
difficult to distinguish from pre existing or
new onset hypothyroidism.
REVISION
MCQs
Q1: the best marker to diagnose
thyroid related disorder is:
A. T3
B. T4
C. TSH
D. Thyroglobulin
Q2: the lab investigation of a patient
shows decreasedT3,T4 and TSH. It
cannot be?
A. Primary hypothyroidism
B. Panhypopituitarism
C. Liver Disease
D. None
Q3: the most common cause of
thyroiditis is?
A. Reidel’s thyroiditis
B. Hashimoto’s thyroiditis
C. Subacute thyroiditis
D. Viral thyroiditis
Q4: all of the following are true of
de Quervain’s thyroiditis except?
A. Pain
B. Increased ESR
C. Increased radio active iodine uptake
D. Fever
Q5: Hurthle cells are seen in?
A. Agranulomatous thyroiditis
B. Hashimoto’s thyroiditis
C. Papillary carcinoma thyroid
D. Thyroglossal cyst
Q6: Hung up ankle jerk is seen in?
A. Hypothyroidism
B. Hyperthyroidism
C. Diabetes Mellitus
D. Acromegaly
Q7:All of the following are painless
conditions except?
A. Hashimoto’s thyroiditis
B. De Quervain’s thyroiditis
C. Reidel’s thyroiditis
D. Post partum thyroiditis
Q8:All of the following are features
of hypothyroidism except?
A. Sinus bradycardia
B. Diastolic hypertension
C. Systolic hypertension
D. Pericardial effusion
Q9:All of the following are features
of primary hypothyroidism except?
A. Menorrhagia
B. Goitre
C. increasedTSH
D. Poor secondary sexual characters
THANKYOU!!

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Hypothyroidism

  • 1. HYPOTHYROIDISM Dr Prabhat Agarwal Asst Prof, P.G. Dept of Medicine, S.N.M.C.Agra
  • 3. Introduction  Reduced production of thyroid hormone is the central feature  It is the second most common endocrine disorder (after diabetes mellitus) is USA  It is more common in females  F:M ratio is approx 10:1  Rates of hypothyroidism increase dramatically with age
  • 4. Risk Factors  More common in individuals who have a family history of thyroid disorders  Hypothyroidism and thyroid cancers are more common in individuals who have had irradiation of their neck in childhood  However, most cases occur in individuals with no risk factors
  • 6. Causes PRIMARY HYPOTHYROIDISM-  Thyroiditis o Hashimoto’s throiditis (Chronic lymphocytic) o De Quervain’s thyroiditis (Subacute granulomatous) o Silent/Painless thyroiditis (Subacute lymphocytic) o Reidel’s thyroiditis (Subacute fibrocytic)
  • 7.  Iatrogenic causes o Radioactive iodine treatment of Grave’s ds o Thyroidectomy SECONDARY HYPOTHYROIDISM-  Pituitary surgery  Intracranial radiation  Congenital panhypopituitarism  Infiltrative diseases like sarcoidosis, amyloidosis, hemochromatosis OTHERS-  Drugs like lithium, interferon, amiodarone  Iodine deficiency
  • 8. PRIMARYV/S SECONDARY HYPOTHYROIDISM PRIMARY SECONDARY SKIN Thick and without wrinkles Thin with fine wrinkles HAIR Coarse Fine MENSES Menorrhagia Amenorrhea SECONDARY SEXUAL CHARACTERS Normal Poor HEART SIZE May be enlarged Small GOITRE May be present Absent SOFT TISSUE EDEMA Marked Absent BLOOD PRESSURE Normal or High Low CHOLESTEROL Increased Normal TSH High Low
  • 9. PRIMARY SECONDARY PLASMA CORTISOL Normal Low TRH STIMULATION TEST Exaggerated Response No response THYROID AUTO ANTIBODIES May be present Absent TO DIAGNOSE PRIMARY AND SECONDARY HYPOTHYROIDISM CLINICALLY, ONE SHOULD ALWAYS EXAMINETHE SKIN, HAIR, SECONDARY SEXUAL CHARACTERISTICS AND SOFT TISSUE EDEMA
  • 10. Hashimoto’s Thyroiditis  Most common cause of goitrous hypothyroidism in iodine sufficient parts of the world  Characterized by thyroidal lymphocytic infiltration with germinal centre formation, follicular damage or destruction with fibrosis  Goitre develops gradually and is firm in consistency  Presence of anti TPO and anti thyroglobulin antibodies favours the diagnosis  History of other auto immune disorders like rheumatoid arthritis, pernicious anemia, diabetes mellitus should be ascertained
  • 12. Clinical Features  Largely due to the reduced metabolic rate and deposition of glycosaminoglycans (GAG) in different body compartments  Myxoedema refers to the boggy appearance of the skin and subcutaneous tissues in the patients with severe hypothyroid state  Skin is pale and cool, reduction in sweat and sebaceous secretions causing dryness and coarseness
  • 13.  GAG deposition in the larynx and pharynx leads to hoarseness of voice  Cardiovascular involvement causes decreased cardiac output, narrowing of pulse pressure and increased systemic vascular resistance causing diastolic hypertension. Pericardial effusion may occur  Modest weight gain despite reduced appetite and constipation due to reduced gut peristalsis
  • 14.  In adult women, decreased libido, failure of ovulation, polymenorrhoea, menorrhagia and decreased fertility may be seen  In men, decreased libido, oligospermia and impotence may result  These are though to result because of hyperprolactinemia as prolactin is also underTRH control
  • 15.  A child with congenital hypothyroidism is sluggish and may present with prolonged physiological jaundice, meconeum ileus, umbilical hernia, feeding difficulties, dry scaly skin and a large tongue  Cretinism: severe hypothyroidism of infancy  X Ray Pelvis will reveal dysgenesis of the femoral capital epiphysis, which is pathognomonic of hypothyroidism in infancy and childhood
  • 16. Signs and Symptoms  SYMPTOMS Lethargy Weight gain Constipation Slowed mentation, forgetfulness Depression Hair loss Dry skin Easy bruising Menstrual abnormalities Neck enlargement/ Goitre
  • 17.  SIGNS- Goiter Low blood pressure and slow pulse Hair thinning or loss Dry skin Confusion Depressed affect Non pitting edema Hung up reflexes
  • 18. DIAGNOSIS  Based on the finding of a low free thyroxine (T4) level, usually with an elevation in the TSH levels  For patients with hypothyroidism due to pituitary dysfunction (secondary hypothyroidism), both fT4 and TSH are low  There is no role of thyroid scans or iodine uptake testing in patients with hypothyroidism
  • 19. TREATMENT  Thyroxine replacement The usual dose required to achieve full replacement is between 100-150 ug/day For patients with known heart disease or who are at risk of it, doses are started at 25-50 ug with increases of 25 ug every 4-6 weeks guided by TSH levels Young patients who are otherwise normal can be started at doses of 100 ug/day Patients with aTSH<=10.0 do not usually require any therapy
  • 20. MONITORING  In general, once a patient receives a full replacement dose of T4 (usually between 100-150 ug/day) and has aTSH consistently in the normal range, there is little likelihood that their thyroid requirement will change over time  There is no evidence to show the need of re testing to ensure patients are euthyroid in such a sub group of patients
  • 21.  BecauseT4 andT3 are highly protein bound, any condition where a patient’s serum protein status changes, prompt testing is advocated  This includes conditions that lower serum protein levels such as liver disease, nephrotic syndrome or malnutrition or increase them like pregnancy or estrogen therapy
  • 22.  Patients with subclinical hypothyroidism (mildly elevatedTSH and a normalT4) also benefit from their annual testing of fT4 levels. Approximately 10% of such patients progress to hypothyroidism within 3 yrs of diagnosis.Thereby annual testing is advocated.
  • 23. COMPLICATIONS  Most complications are associated with under or over treatment  Inadequately treated subjects are at a higher risk of cardiac disease  Over treatment increases the risk of atrial fibrillation and osteoporosis  Hashimoto’s thyroiditis is associated with other auto immune diseases like Addison’s disease, pernicious anemia, vitiligo.They are also at a higher risk for the future development of lymphoma
  • 24. De Quervain’s Thyroiditis  Also known as sub acute/ viral/ granulomatous giant cell thyroiditis  Most likely viral in origin  Presents with neck pain, which may radiate to the neck or mandible  Hoarseness, dysphagia and signs of thyrotoxicosis may be present  Thyroid gland is tender and firm  Histopathologically a well developed follicular lesion that comprises a central core of colloid and surrounded multi nucleate giant cells is characteristic  ESR is high and RAIU is low  Nearly always self limiting
  • 25. Post Partum Thyroiditis  It is the occurrence of thyrotoxicosis, hypothyroidism or thyrotoxicosis followed by hypothyroidism in the 1st post partum year, in women without overt thyroid disease before pregnancy  Occurs in 8-10% women post partum  Upto 30% are anti TPO antibody positive  Painless and self limiting  Likely to recur in subsequent pregnancies  Increased risk of developing permanent primary hypothyroidism in future
  • 26. Reidel’s Thyroiditis  Characterized by the fibrosis of the thyroid and adjacent structures  Occurs in middle aged women  Stony hard, immobile goitre resulting in pressure symptoms due to the compression of the trachea, oesophagus and the recurrent laryngeal nerve  One third patients have hypothyroidism  Surgical removal is indicated when pressure symptoms are present  Glucocorticoids have beens used for treatment because of the their anti inflammatory effect
  • 27. Myxoedema Coma  Ultimate stage of severe long standing untreated hypothyroidism  Often precipitated by stroke, infection, myocardial infraction, sedative drugs or exposure to cold  Treatment is started on the basis of clinical suspicion. Initially the precipitating condition needs to be identified and treated, and general suppostive measures instituted  Clinical features include altered sensorium (coma), subnormal temperature, bradycardia, hypotension and features of severe myxoedema
  • 28.  Mortality of this condition is related to the severity of hypothermia  Throxine 500 ug is given iv stat followed by 100 ug iv daily (given through nasogastric tube if intravenous formulation is not available)  Glucocorticoid replacement with iv hydrocortisone (5-10 mg/hour) should also be given  External heating should not be done as it causes cutaneous vasodilatation, which increases the strain on the heart  Despite aggressive management, mortality approaches 50%
  • 29.  Euthyroid Sick Syndrome: in severely ill patients during acute physiological stress, the patients may have mildly elevatedTSH levels and do not require thyroid replacement.The levels settle within a few weeks of recovery and may sometimes be difficult to distinguish from pre existing or new onset hypothyroidism.
  • 31. MCQs
  • 32. Q1: the best marker to diagnose thyroid related disorder is: A. T3 B. T4 C. TSH D. Thyroglobulin
  • 33. Q2: the lab investigation of a patient shows decreasedT3,T4 and TSH. It cannot be? A. Primary hypothyroidism B. Panhypopituitarism C. Liver Disease D. None
  • 34. Q3: the most common cause of thyroiditis is? A. Reidel’s thyroiditis B. Hashimoto’s thyroiditis C. Subacute thyroiditis D. Viral thyroiditis
  • 35. Q4: all of the following are true of de Quervain’s thyroiditis except? A. Pain B. Increased ESR C. Increased radio active iodine uptake D. Fever
  • 36. Q5: Hurthle cells are seen in? A. Agranulomatous thyroiditis B. Hashimoto’s thyroiditis C. Papillary carcinoma thyroid D. Thyroglossal cyst
  • 37. Q6: Hung up ankle jerk is seen in? A. Hypothyroidism B. Hyperthyroidism C. Diabetes Mellitus D. Acromegaly
  • 38. Q7:All of the following are painless conditions except? A. Hashimoto’s thyroiditis B. De Quervain’s thyroiditis C. Reidel’s thyroiditis D. Post partum thyroiditis
  • 39. Q8:All of the following are features of hypothyroidism except? A. Sinus bradycardia B. Diastolic hypertension C. Systolic hypertension D. Pericardial effusion
  • 40. Q9:All of the following are features of primary hypothyroidism except? A. Menorrhagia B. Goitre C. increasedTSH D. Poor secondary sexual characters