I

,.

/CA

,f

ll

lrl

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.fadcrrhe ,LL odlr/<

7+nMr 2
l

'l:,
1l
,i3

ii.
:(r
,

,Casescenario: SWELLTNG tN FRONT OF THE'NECK

ii\

:.:

i,t

::

i,l i:

ILA Endoeririe mbdule: Sweiling in front of the, n$ck.

I

l,

li
i

"ir ;a
;,i i
.,i,::

Scenario:
I

Puan Gopi, aged 40, prAsented fouryears ago w,ith a swelling in front of the nec[<which Brraduplly incrcased in size. She ngticed that she hidlost vi;Jjght despite a gooo appetite u,.la fuc.l! *o.ri"a and 'lecided to see her family doctor. on further cfuestioning, she addeclthat she irad palpitations, excessive sweating and trerror. The doctor prespribed some oral medication and after tating the :'

medication, her symptorns improved. She is still on the same medication but at a reduced dose.
't,'

Learning objectives:
,r

'l

E Embryology, gross anatolny and histological fgatures of thyroid gland. E Physiology of thyroid hormone secretion.
E Biosynthesis of

thyroid hc,rmones

:'
E Pathophysiology of hyperthyroidism.
E]

Cliiiical features of lnvestigations

hyperthyroidism :
and radiological

El

- biochemical

E Principles of management of hyperthyroidism

medical and surgical

",ll Antiihyroid drugs

El Pyidhosocial intervention
,11i

!.i!l j

r ll t, tt'

i
::

:].f
:'
i

'-"tl
I

t t!' ti.. '

I

..
:l:.

i
:.

ll
I

;:..:t ' .t -. j

jl
j

i!.. :l

:,1

t,

irl
j

i
1

i$
irl
,i

tl'

,i i rr

i;

i",.

i.l ri

Gross Anaior'rr)' of

Tfhya"oii'rtr G{anc{

(Dr. Soe Lr,vin)

Locaticn:
.lla

In liont of larynx

ancl trachea.

rts: I-obes (right ancl 1eft) Apex: extenc'ls as far as the cbliclue line on lamina o1'thyroid cartilage Llase : iies at the level ol4tl' or 5tl'tracheal flng.
Isthrnus

Lies in

lront'it )nd, 3r'd ancl 4'l'tracheal rings.

:

l'-yranriclal lob'.' Often pr:eseitt.

Plojects r-rprvarcl from isthmLrs (Lrsually to the left of rnedian plane).

comflton cnroiid a&.ry

Relations (of lobes): Anterolatelaily (lronr deep to sr'rperficial): _ St"nloUlyroicl, Sterpohyoicl, Omohyoicl and SteLnocIe iclomastoid mu:cles'

Trachea EsoPha:gus

lnteriial iungular vein

Comnton carotid

:Vagus nerve

Trar;ezius ntuscle

Posterolateral Iy:

Cryotid ,tr.ath (containing common ca1olid altel'y, intemal jugular vcin and vagus trerve)'

M:'diall,v

Lirlyrrx, llachea, plrarynx, esoplragLrs, cxtel.nal l'aryngeal nerve, Lecurrent laryngeal nerve (in the gloove betlveen trachea ancl esophagus), ,r
supEridr thyrojd

aGly

supe.rcr tirvroid vetn

iiterne I jug0lar v6io pyrrnrldal lohs thy.old

lob th)aold

rniddls thyroid vsin

irferior thyroid adert inferior.hyrold veins

recarfent Iaryn8eal ne(,e

brnchio.ephallc voin

Isthmus

e*t-riorty - 2nu, 3'u, aucl .l'h Iracheal

A

rings.
.

nterioriy: Stelnothyrn icl, Sternohyoitl, Anterior j Lrgulrr veins.

Trachea
Thyrtoid

Esophagus lnternal jungula'vein

ernocleldomastoid mu Carotid sheath

Cornmon ce:c:.'c vagus nerys

e'a'.

Trapezius muscle

Blood supply Arterial suppl)z

i.

Superior thyroid arterY: a branch ofexternal carotid, descends to upper pole, the pretracheal external laiyngeal nerre is irnrnecli.ately behind the arteiy as it pierces gland' fascia and approaches the Llpper pole of thyroid irrjury to in thyroideciomy ligation of the'artery shoulcl be close to the pole to avoid

the nerve)

ii.

Inferior thyroid artery: - arises from thYrocervical trunk of subclavian, ascends l,ehind the gland to the levelthe of cricoids cartilage tlien turns nredially and clownwarcl to the posterior border of

iii.

giand. it divides outside the pretracheal fascia into branches rwhich pii--rce thc fascia ttetween
:

separately (recurrent laryngealnerye crosses either in fiont, behind or Dasses it tralches ,therefore ligation of the adery should be lvi:Il lateral to the glancl).

'Ihyroidea
-.

:-r

individuat;from-$rae+iioeephali+-+rude" ach-oJ-aorta -ol'r1gh! common carotid aitery and enters the lowerpart of isthmus'
ulo

ima:
of

5upE.i6f

'Fli
f:rteenrl
laryn3.crf ncrtu

thTr*d artcry

il_::i

Vrlit: ncr"c
Recu trenc

liyrrr d
3-frr'd

lrrTngral ncrvo

Iiierlor
rhyloid artery
lEch(:il_

i. ii. iii.

LettoL, , LllrLiir, ge:

i.lrperior thyroicl vein Nlicldle thyroid vein I ifbrior t,hyroicl vein

clrains into internal j Ltguiar vein. clrains into internal jugLLlar. clrains into lefl br:achiocephalic vein.

inltrior thyroid veins of the two sicies anastomose \.vitlt another in fi'ont of trachea).

lnf,

lh'/r*id

rt

I'lidLl le

lhyroid v

lubrlil'riofl

I - :.-ri :i: i +;;'"iili:'

A. lilyrioirlro ima

lnl. jugulor

In[, thtlr)1d

vv

$rochiorap|rlit tr,

i,

brorhiocupJnli< v

Lunpiiatic

cl r:ai n

E ts

age:

rnainly drains irlto deep cervical nodes'

a few

to paratraiheal nodes'

which is not ar,herent Thyroid gland is invested in a sheath d-erlved. from pretracheal {ascia except biween the isthmus ancl2"d, 3-'d& 4th' tracheal rings" the It is attached above to the hyoid bone and obli{ue line of the thyroid cartiiage and therei'cre thyroid gland followsthe movements of larynxiin srvallowing

ll,.

Development of ThYroid Gland

(Dr. 5oe Lwin)
3'd week

(IUL)

Origin: r -nd r;, o_ zrh n Thyroid gland is derived fro.m the Endoclermal thickening l,etween l".ancl 2"",'i" &' 4"' ol the ;ioor of pharyngeal arches (between Tuberculum impar anrl Copula) in the midline

. ' . E n F d

pharynx. iiito 1he unti":rlying Endociermal thickening becomes a cliverticuliim which grows inferiorly mesenchyme and forms the fhyroglossal duct. a The cluct elongates anci its djstal end irecomes bilobed and the proximai patl becrrmes solid cord. the The bilobed terminal srvellings expand as a result of epithe'tial proliferatic;n lo hrm thyroid gland.

-th }veeK /

Thyroicl giand reaches its finalposition, Solict corcL between tlie thyroid glancl and'the tongue disappe; rs,
-of

---

- ----r-_-+jte-of-origin-o+hyrogJossal-duct--orrthe dorsUn
'Foratnen Cecum'

le'igue remails lis a

p_iL

called

stage the thyroici gland consists of solid ma..,; ot- cells but later tl-:e mass brokens up into pt"t.s and eords by invading lhe vassular mc:.enchmaitissue Finally the plates and cords become srnall clusters of cells.

In the early

i.

:.r ,i
,:l:

.'t

, l i

l"

u-:n!rnl!r

' '

riiaiu iir iiie terricr oiuleir ceii ciusier anci rirLrs foiiicles are formecl. PalalollicLrlar C cells (ivhich produce calcitonin) at'e derivecl lrom IJltirnobranchial body. Fibr'ous capSule ancl connective tissLre aie derivecl fi'orn thc sirrrounding rnesenchyme.
acai.iit-r

{'oliirici slfiits to

lilr{jlr.
lltrilrlr;ri,...
,tJlr:.i

Develoirmental anonralies of thyroid giand

A gen es is

F a E s * s

Commonest cause of cretinism.

Tncomplete desccnt

At any point betr,veen the base of tongr-re aiicl trachea. Lingualthyroicl is most common among the incomplete desce,tt anomalies.

Ectopic th)lroi cl tissLre Occasionally found in the thorax in relation to trachea, bronchus or evell the esophagus.

Persistent thyroglossal ducl

Usually appears irr chitclhoocl or yotrng ndtrlts. Thyroglossal cyst - ' A?Vtii" remnant of thyroglossal clr-rct,that rnay lie at any lroint aloug the ttriglat'rrv pathr,r'ay of the thyroicl gland. - Always itt ot' near thc midlirrc of tlre neck. - 50% are close to or iust inf-erior to body o( hyoid bone.
ThyLogiossal

Usualiy afler rupture ol'a cyst, but may be present at bifil

fls[ula

.;'
.

Derivatives of Pharyngcal Arches, Pouchcs alrd Clefts

Idctoderm of the Clefts
I

'ntl Erttirrcrine
Derivatives

Glantls

External auditory meatus

Remnants of 2nd,3'd & 4th

ard

91,t" Ilassall

corpuscle of thymr"rs gland

Pouches
1rt
2n,t

Derivat
Tubotympanic recess; Midd
Palatine tonsil

Auditoly rube

rrd
(+

Thymus;

Inf'e r:ior

parathyroi

Superior parnthyroid gland

Parafollicular (C) cell of th1 i'oid gland Ultimobranchial bocly tt Thyloid gla.nd is der:ived fi'om the Endodennal thickening between l an.-l pharyngeal arches (between TLrberculLim irnpar and Copula) in the midline
pharyn x.

8z

4'h

of

f{istology of' T}eyrorc{ G}and

(A/P Dr. San San Tliwin)

Figr:r'c 1. Note the line collagenous seltta (S) that arise flonr the fibro-elastic connective tissue c:ipsrrle oIthe tltyroicl gland extencling into the glar-rcl arrd also conveying blood vessels, lyrnph:ttics tr.rcl nerves.

Figuru, 2. Note the thyroicl lbllicles lined by follicLrlar cells which are simpie cuboidal cells.
9

|?

Thyroid l'ollicles are fillecl with a glycoprotein complex calletl thyroglobulit,, also ltnown
as colloicl, wl-rich stores the thyroid hoLmones (T3 and Ta).

ln actively secreting glancls, follicles

cr-rboidal

witlr very litt,e amottltt of colloid or coltttnnar. Tlfgl$LlYpg-q'cells are the firlli cells are relalively tall
are ,small

ancl the
s

which are sintple cuboidal in type.

o o

When less active, the follicies aLe distendecl witli stored colloid and the lining ceils appear fl attened (tow cuboidal). The functional uirits of tlie thyroicl glancl are the tliyroid follicies, lined by a single l;ryer of (1't type of cells) cuboidal epithelial cells or follicular cells bounded b;'' a basement
membrane.

The follicies contain a homogenous p-L1kish mass of colloid material.

Figure

3. Note the 'C' cells or Ciear cells shown by arows.

2nd

tvpe of cellq:

Parafoliicular cells or C -cells are founcl singly or in smal1 clumos in the interloilicular spaces, These cells are 2 to 3 times larger thari follicular cells" *ThEserells @secrsts calcJtqnb *vhiehlowers-the$lsed ealcium le:reL

Clinical correlation:

Iodine deficiency goiter. Cretinism in hypothyroid childLen. Hyperthyroidism is common in Graves? disease.
10

FKSVSKffiLffiGV

*ir$lyslology

{Dr"

Mah Kli}

The Tlryroid Produces and Secretes 2 lVletabolic Hormones

Thyroxirre (T. ) and triioclothyronine

Req,-11rg6

(T3)

for homeostasis of all cells

Influence cell differentiation, growth, and metabolism

Considered the major metabolic horrnones because they target virtually

every tissue
T.l

is biologically inactive in target tissues until converted to

T3

Actirration occLirs with 5' iodination of the outer ring of

T3

Ta

then becomes the biologically active horrrorre resporrsible for the majority of thyroid hormone elfects

lhc liver is the nrajor extrathyroicialTa conversion sile for procluction

Sorner T.,to T3 conversion also occurs in

of Tj

the kidney and othertissues

bound to plasma carrier proteins

t/lore than 99% of circulating

Ta ancl T3 is

Thyroxine-binding globulin (TBG), binds about 75%

Transthyretin (TTR), a'so callecl thyroxine-bihding prealbumin (TBPA), binds about I0%-1-S% Albunlin binds about
r'%

Fligh-ciensity lipoproteins (HDL), binds about 3%

Carriei'proteins can be affected by physiologic changes, drr.rgs, and disease

Thyroid-Stimulating Hormone

{TSH}

.
"

Regirl;rtes thyroicl horrnone production, secretiorr, ancl growtlr

ls regulated by the negative feedbacl< action of Ta and
T3

Hypotha lam ic-Pitr-rita ry-Thyroid Axis

Negative Feedback Mechanism

'i-;t-e--al

e;d

<otorie

sigrnals

.wF*4@>

S.i-inrul.cle

\ ," (
'*i Pil'uilcry

"e//@lnhibir
ru +u
-r.g'l{.-.dn>d<\q
,-t:

odinotiori

T"+.:--:**
i
rl

'-r3

Biosynthesis of

T+

and

T3

Deiodinose .<!*:*"+*

Bqsol membrsne

The process

includes
I

. " "

Dietary iodine (l) ingestion Active transport ancl uptake of iodide (l-i by thyroid

gland
I

oxidation of l- and iodination of thyroglobulin (Tg) tyrosine residues

Coup.lling of iodotyrosine residues (MlT and DIT) to form

Ta

ancl T3

Proteolysis of Tg witlr release of

Ta

and

T3

into the circulation

Thyroid Hormone .&ction

Thyroid Hormone Actions Which lncrease Oxygen Consurnption

" '

lncrease mitochonclrial Size,Number and Key Enzymes lncrease Plasma inenrbrane Na-l( ATPase Activity Increase Futile Thern,ogettic Energy Cycles
Dccrease Superoxide Dintulase Activity

Thyroi,.1 l-lorm,.rne Plays a lVlajor Role in Growth and Developrnent

'lhyroid hormone initiates or sustains differentiation and growth

Stimr-rlates foi'mation of proteins, which exert trophic effects on tissues ls essential for nortnal brain development

Essential for childhood growth

Untreated congenital hypolhyroidism or cltronic hypothyroidism during childhood can resuit in incornplete deveiopnlent and mental retardation

Thyroitl Flormr;nes anclthe Central Nervous System

(CNS)

Thyro;ci hormones are essentialfor neui-al developrnent and rnatitration and function of the
CNS

"

Decre..secl thyroid lrormone concentrations may lead to alterations in cognitive function

Effects Jf Thyroicl Hormones Un Tlre CardiovascLtiar System lncrea:;e heart rate

increase force of cardiac contractions
I

ncrea-se stroke volume

lncrease Cardiac oLttput Up-regulate catecholamine receptors

Effects Of Thyroid Flormones On The Respiratory System

"

lncrease resting respiratory rate

lncrease minute ventilation

' '

lncrease ventilatory response to hypercaprria and hypoxia

Thyroid Hormone lnfluences the Female Reproductive System

Normal thyroid hormone function is important for reproductive function

Effects Of The Thyroid Hormones ln Growth And Tissue Deveiopment

lncrease growth and maturation of bone

' "
,

lncrease tooth development and eruption lncrease growth and maturation of epidermis,hair foliicles and nails lncrease rate and force of skeletal muscle contraction tissue lnhibits synthesis and increases degradation of mucopolysaccharides in subcutaneor-is

Metabolic Effects of

T3

. '

stimulates lipolysis ancl release of free fatty acids and glycerol

lnduces expression of lipogenic enzymes,,'ii' Effects cholesterol meta bolism Stinrulates metabolism of cholesterol to bile acids
.11

Faciliiates rapid removal of

LDL

from

plasma

'r

protein Generally stimulates all aspects of carbohydrate metabolism and the pathway for rl
degrad atio n

Signs and Syrnptoms of Hyperthyroidism

lvlental Disturbances/ lrrita bilityDifficrilty sleeping

Bulging Eyes/Unblinking Stare Vision Change

t',t'il '//

/i,

_
Pa
Ta

Persistent Dry or Sore Throat

bitficulty Swallowing lpitations

chyaa rd ia

Inlarged l.hyroid (Goiter)

Menstrua I I rregr-rlarities Lighi Perjod
Fr

"/' ,*\

Weight

Loss or Gain

Heat Intolerirnce
lncreasecl Sweating

equent Bowel Movements Warm, IVloist

Palms

,/

SLrdden Paralysis

I n este r lv,1i scr rr ia ge/ Excess,ve Vomiting in pregnancy

f ir)L-Tri

Family History of Thyroid Disease

or Diibetes

Graves Disease

" Autoirlntunedisorder
Production of TSH receptor autoantibodies Stimulate thyroid hormone overproduction
Charactei-ized by tire presence of B- and T-iymphocytes in thyroid tissue
TSH receptor activation

TlryroglobLrlin and thyroid peroxidase antibodies

sodium/ioclide cotransporter
Auto a ntige
ns

(N

lS)

activity

en ha ncecl (increased RAI)

l-lypothyro
Ca

iclisn-r

uses:

congenital agenesis or itypoplastic

a

utoim nrune (Hashirncto's thyroiditis)

odine rieficiency with; oitre

iodine excess

l*

ffigffiffFtrffiMg$T-ffiV

the necl< Tutor's Guide {3ioe hemistryi

ILA: Swelling in
'1'hyroiri

gliincl lrrocluces two principal horrrtorres --tltyroxiire (T.1) ancltriioclothyronine (T3), and also secrets calcitonin, a lrormone concernecl with calciunt ltorneostasis. l-: is about 4 times more active
T,,

than

ln lts biological functiols, and is l-0 tirnes more active in binding to the receptors. About B0%

ofTnis,ori,.rertedtoT3onenteringtoperipheraltissr"tes.Someamountof rT3withnegligible bioiogilal activity is also prodirced.l-3 &T4 require iodine for bioactivity, arrd are synthesized as part of a vei'v iar"ge molecule, ihyroglobLrlin which is stored in intracelluiar colloids. Thyroid hormones act by binC :rg to cvtosolic receptors very similar to steroid hormone receptors.
ln the einbryo, thyroicl horrnole is necessary for trermal clevelr:pment. l'"iypothyroidisrn in the

embryo is resporrsible for cretinism, which is characterized by rnultiple congenitaldefects and mental ietarciation.

il'r,l{

/}i \ tto-1i s ii

\r'

/,1 Ii
Thyru:r,:i

ii

c-(/ ,t )l-r

F.r /\i

\:

Frlir,ll

la

lt
[Iil

\l

H0ri ,l

\\i

II
Iril,rrlollry: he[31

tE

ilU-1\ l

/'\

!-r't.il
t

I1

V 7
Rwrnr

iiiilj

Ta

and

T1

Srrnthesis and rElease

cf thvroid hormones
wlTtsr r-_oL LorD

FOr-r_lc;LJl_af r sPAcE

@e
IflY.r.-QrQ qF=!

L,_

l'. t\I

/=-R\sc.o,'ddry rsu,FJ

'" -" ""

'\\

--\

\\

'-:C'l
Dutotttnrttott^

,u."*"",*

L;lsqlll5l

NrT rI DrT

I u"o-tv','
I

Thyroglobulin {TCb) is an iodinated ciinteric glycosylatecl protein produ' cd by and used :ntirel"' within the thyroid gland, lt is the. llrccutsor of T3 .Q-14. CllO accounts fot B-10% and iodir le aboiit. 0.2 -IVoof its wcight. lt consisls ollboLtt 5000 aniir,'.1 lrticlr. with 11-5 tyro: 'ne residue, eacil of rruhich is a potential site of ioclination. About 70%of iodide exisis in MIT & DlT, r hile 30% is in T3 & 1'0. Il
sufficient iocline strllply,
Ta:-1,

ratio is 7:1-.
-f3

E Ta in Tgb is synthesized in the basal porti0n ol'cell ancl nroves to the lLtmen, cts as a storage irf the colloid. After stimulation by TSH, colloicls reeirlei'thc cell and phag, iysosome activiiY incrc rses. Acid proteases & peptidases hytlrolyze Tgb into amiiro .rcids inclucling 1 . & Ta, which arc therr
discharged.

Bioloeical functions of thvroid horntlnesi

a) b) c)
ej)
e)

Stimulate the mctabolic activities ancj increases Promote prote in synthesis like steroicl

O7 cofisLu-rl

ption it, trost of lhe bo,ly tissu :s'

hort.i'roners.

Promotes intestinal absorption of glucose, irrcreasc gluconeogene:,ts, and glycogerrrlysis. Stimulate lipid turnover & ul,ilization.
Regulate water and electrolyte metabolisnl

Goiten abnqrmal,increase in size of thyroicl gland. S,inple enclemic goit

':t-

is due to riocliire, rlefic

:nC!
Lre

Hyperthyroicli*nr (Thyrotoxicosis): associated with o'rerproduction of tl,yroicl hormotle':. li carr

diagnosed [:v scannin6 or by cstimatir:n of
T3, T.r

Li

TSI-1

irr

the plasnra,

Hypothyroidisrn: impairment in lhe iunction of thyroid gland.

Cretinism: in chiJdren; lVlyxtiealctita: in adults.

Thvroid functioq assessmn! Measuremenl of BMR reflects thyroid activity. The estinration of PBI is .mployed to ass :ss thy,oid function. The normal PBI concentration is 3-B prg/100 nrl. ln recentyears, the concentration of ffa, concentratio ns a re:
Free T3 Free T4
To

&T5l-lare nreasured by Rl/': or ELl5A. The noi"mal se rum

-:. 80.:220

nT/dl

: 0.8-2.a ng/dl

Total T4
TSH

: 5-12 pLg/cll
i

: <10 piU/dl

Radioactive iodine uptake ancl scanning of thyroid glarnd are also used iirr diagnosis.

I i

i.

;lt

u,r

p h ys i cl I o

gy o-f hyp i : rt I ny rr: i cl i s rr

(by Dr.lhan Than tltwe)

Hypertl ivroicli srn (Thyrotoxicor.is)

Deiinii.l,;n: ilyrterlhyroiclisnrisaclinical synclronreresuitirrgfromtheeffectonthetissueso{excessive : cirr.uleiting tlryroicl hormones: l'3 and 14 leadingto an increased metabolic rate. rr Normal leves oi tlryroid hormones irr adult br7 ELISA melhod are: o TSH=0.2-3-3.8 micro U/ml and

o
Ca

T4=5.1-l-3,5 mi':ro U/nrl,

Grave's diseasc: Diffrrse Toxic Goitre (85%)
-lo;<ic

uses;

o , o -

ulti-rro'iular goitre Funclioning to; ic adenomas

M

Utilommon causes:

o ThYroiditis o Exogenousadnrittistration r-, locline inclucecl c Malignancies.lthyroid carcinoma'2'struma

ovarii

giystern:c i:,:a-il:,.es of Thyrcrtoxj,osis. l'ite features il.i 'i ille se{:rl only in 6rave's disease.
r\nr:rly

.*--------"'-"*,--'

flei]hl lcri

LIenorrn.:ti,a

--

{t
l,(
t

OslaflDr)(c:'

i ----- - - Y-

tt

til

Prelrb'al

nlyxoedefiu '

Grave's Disease: pathophysiology

. e

An autoirnmune disease (>g5%)

Due to the presence of circulating autoariiibodies ol lgG

iss

which minric the 36li

)11

TSH - LATS ( long acting thyroid stimtrlatirig imrnunoglobu ,n)

$"ffi!lUI;\TT NC

[.tTe-r\$l'J Ij{) Dl]i$

nvcr,

cliseas+)

l)ituit:rry glrncl

/ ji'cdb:rtt { c.rntr,:l /
|

I I

r'w
1 i
/

ao$

//1'5ll
-+*

Nesrtive

\ \

\ \

\ \

/,'StimLdat [-1 ., \, hormorr

.

/ :'. i'

.1T:

l.l,

\\it \'----i
ary !*t

\Yntrlcej

\i

\.1

^
l^;

6A

ri6l ni @ {r& s ' oascfl Es

6& o

Rcgrrlltcd pn,rtluctitln oI thr.toid honnr)nes

nrcgtrlatcLl r-rverpri.,;cluction nf thvroirl horrrronss

The Pathogenesis Of Graves Disease

,Arli\,ilB1

3-s.lli

GRA\iES DISEASL,

&

ss

rsr.r$ * / \ d

+F+
\/ I \-

ll'icFl'A:i E rl

a-jr Ll

fi rHD A DRel lERG,{g I'1ET-ABOLIC FATS

ltil

(.1 . lT)

Anlf,)odies slknulale

TSH. rrc*'tors

Suppress,: j TSH
High Te1..

Ererhlii|

irunui sd in,1

;r'lttt

Fing Jtemnl

E;{:U:Sf T"/.Tj

sciFFrassg;rriH

Fig"2-3

:l

i,

Organ Changes in Grave's Disease

G

ross:

, ' u

Dif lusely

enlar;ed thyroicl glancl, 30gms

Cut surface: firm ancl rneaty in appearance, vascular, sntooth, soft, capsule intact'
Craves'disqase is a common cause of

fryperthyroidism, an orrer-prodttction clf

tityro|i horntonc.
wlrlt,lt cituse5 cnlargenrent r:f the ll rytoicl ;trlrl ot.liet
5yr r I lrtol t'ls 5l.lcll as e.xotrrlttlialrnos, Ite-aL itito[e:t atlce arirJ ;rnr.ietY

fli:r'r

rt;ll

tl tyroicl

Irrlarrlecl tliyroid

iinl)\,r\1.
Microscr.rpic findings

ts -l

too many tall colLlmnar cells, crowded, lryperplasia, papillae encroach on colloid, colloid
and scallopecl, stronral llrrnphocytes and lymplroid follicies seen
Key

is thin

for microscopic identification* ln Hashimoto hurthle cells-

, ,l

':

.ln Graves papillae and scalloping

i': "..1 ' ),' .'

:i_,.'
r' .
.

:. .' . ,..;.,..'; ji: ,. ::1.; ..^ij, . r. ::. . '. - ,.., ,t .l; , :. i r; ].f ..,r. iij:i,j. ri;.i'. r':.ir'rlilr:.l'jj . ..:..
.

:"'1', : f

r''.
: .. .t . 'j l

,,..

:'j,: i..\ _.: i.,ii.":. ,,i -. y:1 ;. i/.1.;i.r:.

'

',ii,ddft ".t1?:r,i;

;iw
:l-tl';:...i;:
l.ti
.

Fhalrnnae ole

gy of thyroiel disorclers

A. Hyg,o'il-ryruidisi

ln general, the goal of thyroid replacement therapy is to replace endogenous thyroicl ltormone productioi"r, avoid iatrogenic thyrotoxicosis, and treat systemic complicationr; of severe hyoothyroidism.

Levoitryroxirie
l-evothvroxine is the treatr-nent of choice because it is well e"ibsorbed and has a half-lifr: cf 7 Cays which allows claily dosing and steady levels of T3 and T4 being reachecJ irr approximately fl weeks.ra The starting dose shoLrld take into consideration factors such as age, preexisiing coronary artery disease, and cardiac arrhythmias. A starting dose of 1.6 pg/kg/dey in healthy patients is recomirerrdecJ, birt in elder !y patients or those with r;rr cliac clisease, it would be pruclen:. io st;,rt at a dose oi 25 pg to 50pg once daii;r'.

Liothy rc irinc. Liothyrirrrirre il--triiodothryronine) is rarely used alone as thyroid hornrone repia*,nrent oecause it car, cause rapid increases in its concentration, which cot-rld be cietii,lental in eldi.-rly patients and ihose witlt cardiac disease, lt can be used ai:ng with levothyroxine when levothyroxine alone does not provide relief of symptcms.

Thyroiri extri:ct
Thyroici extract or rratural trryroicl hormone is pig thyroid glancl that has been driecl and crutshecl in porrrrder form. This is not a recommended thyroid hormone replacenrent becaLrse the amount of T4 and T3 can be variable and there can be an excess T3 in this preparation.

B. Flypr:rilryroid isrn Propylthio u i'acil Antithyroid medications sLrch as propylthioiiracil and methimazole act predonrinanllv b! interferinq with the organification of iodine, hence suppressing thyroid hormone levels. Because these agents block only the synthesis of nevrr thyroid horrnones, the siores of preexisting thyroid hormone within the thyroid glancl rnust be exhaListed filst before they cein be fully effective, which may take 3 to B weeks in patients with Gtaves' disease or toxic nodular goiter. Propyltlriouracil (pTU) is a ,-lerivative ol thiourea that inhibits extrathyroidal -l coirversir:ri of 'T'zl to 3 and is preferred for pregnant wornen wiih hyperthyroidism becausc it do,:s not cross tire placental barrier as readily as rnethimazole. lt is readily absorbed, r,ryith a serum half-life of I to 2 hours. lts duration of action is longer riran tl-ie half-life and shoLtld be dosed every 6 to eight hours. lts starting dosage is 10C nrg three tini':s daily, with a maintaining dose of 100 to 200 mg a
day.

Patients undergoing treatment with antitlryroid drugs should hi;ve their thyroid hormone ievels reassessed every 3 to 12 vrT6gks cluring dose iitr:rtioit to rnottitor for iatrogenic hypothyioiclisnr. Comrnon sii.lo cficcts iirclutcle ra.;hes, llrtti-ttLts, joint pains, ancl fever. Tl'rese can be treatecl sylllptomatically wtthottt discontinuing the rledicatiorr, but if :rrthralilia occul"s, it shoulcl ire discotttinttilcl because it can be a precLrrsor of a iltorr: :;lt'ir:tt:; polyarihriiis s"ndrot"l.lc. Agranulocytosis is the trost setious coirtplicatiorr arrd ffia! octrtr in ti 1 trl 0 " percent of patients being p;iverr anlith,vrolcl mcrlic;rticns.r0The rlsk is highr,:i i those taking propylthiouracil wiihin the firsi fcr,,i nonths of ther; rpy.
r

IV'lethimazole Meth!nrazole blocks the oxiclation of iocline in the thlrroid glanc ' lt is the cliurS' of choice in nonpregnant patie nts because oi'its etiiordable cost, iongei italf-lift , and lower risk of hematologic aclverse effects, it can h,e taken as a single claily dcse, improving patients'compliance to the meclicalion. The stariing dose is 15 io.30 mg daily, which can be given along with a bpta blocl<er. If the i atient beconits clinically ancl biochemically euthyroicl after one izear of merjicailiorr methimazole can be cliscontinr:ercl. ir,ol:rpse ntLry occLtr, ancl is ,1enerally seen within a yeat of discontinr-ting the medicatiorr. lf iltere is re l;tps,,',, antithyrcid iherapy carr be restarted ancj other options sirch as raciioactivi: iocJitre or sul:,,eily is

iiltal<e,

considerecl.

lodide
loclides biock the extrathyroidal corrversion ol T4 to T3 and inhibit rerlease cri thyroid lrormone. lt is prirrcipally Lrsed as acljLrncl.ive therapy br:lore emergei cy thyroicl sLlrgery, to recluce vascularity of the thyroid glanci !:efo'e si.irgery, atr,-l in failed therapy rrvith beta blockers.zr These are-. not used in the routine tt'eatilt:tr't of hyperlhyroidism because it tends to paracioxically incicase ;iotntone teie.tsc with clironic use.. Organrc iodicle radiographic contrast agents ruch as iopan ric acid or ipodate sodiunr ate rnore corrmr:nly uscrl than iirorgat:ic iodicies (eg. potassium iodide). lopanoic acicl causes rapicl and signilicant irihibition ol' peripheral conversion olTzl to T?r arrd qr;ickly ier-luces T3 levels. Potassium iodide (l-r-rgol solution) contaiirs 8 rng of iodicle perdrop, arnd i:, usecl ftlr the treatment of thyroid storm for 10 to 1zl clays ittiorto thyroiclectr,rtny. Beta=adrenerg ic recepto r bl cickei"s ol Beta blockers help to promptly alleviate lhe sympathomimetic ''nanifestalioir:: hyperlhyroidism (eg, palpilaiioirs, anxiety, lrenrors, and hcat i;,tolerance) regardless of its Lrnderlying caLrse. lrr paticnts with carciiac arrirythmras like:,int-is lachyeardia or atrial{ibi.iliation r,vit}r a rapid voiilrieular rcsponll) raic, beta blockers can fLlnction to conirol thc heart ratc. Propanolol, a nonselective bota blocl<er, is prnferred becilr.r:se nf its elirect ciferl on hyperirieta',olisttt and is inost comrnonly used, altiroirgh other beta blockeis can !re given.z: l)ropanolo; slr,o partially inhibits conversion of -f4 to T3 in the peripheral tissues.q Beta blockers may be the only treatmeirt requir--d in paiieirt:; rryith transient ii,rms of hyperthyrcidism, howerver, in patients witlr more sustained fclrr,rs of

hyper"thyrojclism (ie, Graves' clisease, toxic noduiar goiter), clefinitive treatment is necessa ry. Proparrolol close can start at 2O to 40 mg every B hours at-rci be increased progri.:ssively up to a lna.:liilutri darly close ol240 rng Lrntil sytlptonrs are conirollecl. Lbnger-acting beta blockers such as metoprolol and atenolol can also be used. ln caseswhere a short-acting parenteral agent ls needed, Esmolol can be aclninist..ted. Beta blcrcl<ers shoLrlcJ be Lrsed wrth caLrtion in patients with a histori.r of heart disease, cbstructive pulmonary disease, asthma, or Raynaud's phenomenotr.

5. Ranionctive iocCine theraPY Racjica,l6tive iodine caLlse: selective uptal<e ancl concetrtratiott in thyrocytes. Follorruirrg oral administration, it clestroys thyroid tisslte, thereby controiling -fhis is the treatnrent of choice for the rnajority of hypeilhyroiclism effeciiveiy. patie;is v,yitli Graves' clisease ancl toxic nodular goiier. Higlr dose radioactive ioclin*, theraly is recoirmenclecl irr elclerly patients, those with p,reexisting cardiac clisease, anr,l patients with toxic noclular golter or toxic adenomas. Its marin acir.erse effect is the clevelopmerrt of postablative hypothyroidism, which is nroi'e con-rrnonly seep irr patierrts with Graves' cii$ease. Lifelong monitoring of thyroici irorrrrone levels is irecessary because patienis develop tlris complication at a r.tte of lt% anpLrally. /irrotlrer side effeci is ihe transientworsening of hy'erthyroiciisnr during the first montlr of treatment due to radiation thyroiditis. Opthalmopaihy nray cleveiop or exacerbate in 15 percent r:f patients with Graves' in those who smol<e cigarettes. Lower dose radioactive clisease, "rp"iinlly can be used in those patierrts to redLtce the risk of iodine,: or preclnisone ophthalmopathy. Radioaciive iocline is contraindicated in pregnant or lactating women because it can readily cross tlre placenta barrrer and can be excreted into mill<. This can lead to an ablative effect to the infant's thyroici gland resuliing in hypothyroidism.

ilLHNKffiAT wwwffim'ffi ffiKJrffiffi

Tutorial Guide for Thyrotoxiccsis Syrnptcrns: Loss of weight wiiir good appetite
H..-.at

intolerance

Faisily

Pa!pitations

ii'

irritable, nelvous and anxious

':

increased catecholamine sensitivity Decreased cardiac a-adrenergic receptors lncreased numbers of $- adrenergic receptors in the heart.

Tremors
l-eiior rp u I cr LrE,uL

increased catecholamine sensitivity

"nd WeaktreSS

Passing loose

stools

lncreased gut motility

Difficulty ln gettinSi up from the toiiet seat after going to the toilet because of weakness of muscles - Proximal mYoPathY
Eye

s have become Prominent

Noticed a swelling iri front of my neck. (goitre) Menstrual history : cligomenorrhoea

Signs

Fine tremor
\,,ri

arm, sweaty palms

'

'itie pulse pressure

H'gh sleeoing pulse rate

T-rchyca
r"C

ia

A.rialfib'illatiott
,l

Tiiyrotoxic

ca

rcliomyopaihy-Congestive

ca

rdiac faiIure

Proximai l!mb girdle mYoPathY

Brisk re f le :es
Eye signs: Chemosis, exo[,hthalamLrs, lid lag. Licl

retraction, extra ocr:lar rnuscle weal<ness --

Gravds disease

Diffuse syn rretrical enlargement of the thyroici glancl Thyroid bruit

increased vascularity of

the thyroid glarid

Thyroid acropachy or clubbing - Graves disease

Onycholysis -separation of finger nails l'ronr their ilercis-tJraves disease
Pre

tibial myxoedema - thickening of skin ove r llre tibia without pitting -Grave-s

cliseasL

Causes of thyrotoxicosis derlyi n g aeti ology Dia g i-r ostic fea"ilr: r*s Conrrnon causes Graves' disease Thyroid siimulatirtg iirntunoglobulin (TSl) binds to and stiirulates the thyroid lncreased llryroid raclioactive iocJine uptal(e lvitir difluso Lii)t.r;(e or] scail, pr,lsiiir,rt: thyrope roxirlase antiboclies; raiserl seruin tliy1,3i6 stirirulatiirl, iittmtlnoglslriliir, dif"fuse goiire; oph'thalnropatlry ntay []o prt?$efi1.
Un

Toxic acl en oma Motroclot ta I a it to i ton tou :-,ly :;'.'cietin g be n ig n thyroid tumour Normal to iltcreased thyroicl ri,rdioarctive iocline LrlJtake wjtl'r ari I,rpta}<e irr th,.r nodule on scan; thyroperoxidase ai-rtibodies abse nt Toxic multirrodular goitre [4Lrltiple ironoclc',rral arrtonomor-tsly secretincJ benign thyroid tumours Normal to increasecl thyi'oid raclioactiire iocljrie r-tptal<e with ft cal areas of ircrear':ci and reduced uptake on scttrt, 1.l-iyrope roxiclaso antibodies a1",,;ent
Exogenor,rs thyroid hormone (thyrotoxicos is factitia) Excess exogenous thyroid hormorre L-ovr; to undeiectable thi.roid raciioacti,'e iod'ile uptake, iow serum thyropei"oxidase values.

Painless postpartum

Autoimmune lymphocytic infiiiration of tliyrc;cl urith release () stored thyro;d hormone Low to uncietectable thyroid radioactive iodine uptake; thyrc,reroxidase atriilrotji*,s present; occurs within six montlrs after preqnancy.

lymp hoclitic thyroid itis

Less cofmr"nen cau$e6 Painless sporadic thyroiclitis Arltoinrmune lyrlphocytic infiltri lioir of ihyroicl with release of stored thyroidhormone Low to undetectable thyroicl radioaclive iociirrc r-rptake;
preserrt -thyroper:oxicl ase antibocl ies

Subacute thyroiditis Thyroicl inflamrlation',,irilir release ol stc'red thyroid hr-'rmonr:; possibly viral Low to undetectable thyroid radioactive iodine uptal<e; low titre or absent thyroperoxiclase airtibociies. lodine induced hyperthyroidisrn Excess iodine l*ow to undetlctable thyroici radioactive iodine uplal(e.

DrLrg rnclr-rcec1 tlryrotoxicc sis(liihiurn, inierferon alfa)

lndur f ion oi thyroid autoirrmurrity (Gra',,es'disease) or inflarntnaiory thyroiditis lhyroid radioactive iodine r,iptal<e eleva'red in Graves' ciisease or low to undetectable in thyroiditis
Am iocl aro ne ind u cedthyrctoxicosis iodine inclr-rced hyperlhyroidisrn (type l) or

inflan'rnaiory thyroidiiis (type I l) Low to undetectable thyrcid radioactive.iodine uptake Rare ;)aLrss Thyroid stimulating hormrine(TSH) secreting pltuitary adenr rna PitLritrry aclcnoma llaised serum thyroid stimulating hormone and _-st-rbriirit willr raised peripheral serum thyroid hormones Gestational thyrotoxicosis Stimulation of thyroicl gland thyroid stimulaiing hormone receptors by hun-ran chorionic gonadotrophin Thyroici radioactive iodine uptake contraindicated in pregnancy. First tiir-ne ster,often in seiring of hyperemesis or miiltiple gestation. Molar pregnancy Stirntilat:on of thyroid gland thyroid stim r-r iating; h'rrmr:ne receptors by h uman chorion ic gonadotroph in Molar precjnancy
i

Strunra ovarii Cvariarr teratoma witlr dilferentiatiorr primarily into thyroid cells Low tc' undetectable thyrc,id radioactive iodine uptake (raised uptake of radioactive iodine irr pelvis)

Widelv rneiastatic furrctior,al follicular thyroid carcinoma Thyroic{ lrorn-rone productlort by iarge tumour masses"
Diflere,rtiated thyroid carc;noma witlt bt-ilky metastases; tLrrnour rac{ioactive iodinei,ptake visible on vrrhole-body scan
lnvesti.gations Eler.ratecl free Ta and /or T: and a suppressed TSFI confirnr the clinical diagnosis of thyrotoxicosis. Thyroicl stirnulating antiborly (TSH-i-eceptor antibody)is usually elevated in Graves disease.
Treatment moclalities
Medical
Su rge

ry

Radioaci;ve iodine

Medical : Antith'rroicl

rugs

Tl.ioca rbim id e drr:gs-Ca rbimazole, Propylthio uracil

Ptrease

refer to Pharrnacology Section

inhib ts periirheral Block thyroid hormone synthesis by inhibiting tlryroicl peroxidise. Propyii.hisLrracil
conversion

of T, toT3.

( ;-2 years) Medical therapy must be administerecJ for a prolongt:d i;criod of time

on cessation of medication, 40 to 50% remain iti retrtissiott

Those who relapse may Lrnclergo clefinitive sLlrsery or rarlioactive iodine theraprT.

severe agrarrul tcytosi'; Side effects: minor- rash, pruritus, arthralgiil, choestatic jaundice, more
(o.s%)

patients must be instructecl to ciiscontinue the i"nedir:ation and consult tlre physician if they cleve lop fever or sore lhroat because these symptoms m.rr7 irrdicarte agranulocytr:sis"

of B Patients are given B blockers usually propanolol unless tltere are contriindications to u:;e alion block,ers, during the acute phase of treatment tc ;rlie r,'i.rL,: symptorns dtt : to syrnpathetir'siinlu
like tachycardia, sweating etc. As the thyroid hormr.rttc lt'vels return
ta pe red
.

to iicrmal, the

B blocker is

Surgery g'ands artd Subtotal or total thyroidectomy is the treatment ol'choice for patients vvith very large obstructive symptoms, or nt ultinod ula r gla ncls.

preoperatively, patient receives 6 weel<s of treatrtreni: with antithyroicl '-irugs to ensure ihat th''-y are

euthyroidattimeofsurgery.2weeksbeforesurgery/,o|alsatUratedsoir:tionofpotassir-rnricdi.jeis administered daily to decrease the vascularity of the glzrnd'

permanent hypoparathyroidisrn and recurrent laryn-qgai nerve palsy oci ur llostoperai-i'r:ly irt ")'Yo of patients.
Radioactive iodine

"'lodine

is the

treatment of choice in most aduiis r,vith Graves' disease'

patients with severe thyrotoxicosis, very large glancis, or underlying he, rt disease shoulrJ be rendered euthyroid with antithyroid meclication before receiving radio;rctive iodine ber:ause t"lodine treatment can cause a release of preformed thyroid hormone nto the circulat;on urhich can precipitate carcliac arrhythmias ancl exacerbate symptoins of thyrr:toxlcosis ithrTroid crises)"

a period of 6 weeks ancl 2 months. Between IO%-?O% become hypothyioid within the fjrst yeai" of treatrnent, and thereatter hypothyroiclisrn occlr's ilt a rate of 3% to 5% per year. tJltime'ielv SC'.t/o to 80%

of patients become hyperthyroid.

Serum free Ta and TSH levels should be monitoi'e d and rcpiacementwiltr levothyroxine

insiituieclif

hypothyroidism occurs

ffiAffiHffiLffiGV

R.rcliological lnvestigations of

the

-{"hyroid

Gland

The lhi,roir-J {,1;inrj is a hc.rrntort,: prodLrcing irutterfly-slrapecl glarrd locatecj at the base of the neck. It lies autcliul io the thyloicl iincl cricoicl callillgcs u1'the llrlynx ancl the 1'irstthree tracheal ring^s.-ti,e 1-h'7rc;icl Glancl, which is composed of a riglrt lobe and a left lobe, produces and secretes thyroicl horrnolres into the blooilstreanr. Tlrese horrnones regulate body ternperature, heart rate, blood
pressLrre, energy level, growth r,ate and weigltt.

Plain xlays of rhe necl< are nrit perl'onnecl lor diagnosing Thyroid abnormalities
Sornetinres a rttrost'ernal goiler can

,;

be

srrspcctecl on plain

xrays leacling to futher evalr:ation.

{-ater:ii

;1nd -l.rnte!'iol" posteriol" vielvs

of flie

neci<"
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i

The xray:; sholv a large softtissLre density situated anteriorto the trachea. The traclrea is cl,:viated lo tlre rilrlrt.

There is calcific.rtion along

the iiiteral wall of the left thyrr:id gland

ULTRASOUND is the most corninon imaging moclality used to diagnose Thyroid diseases . Ultrasound uses sorrnd of very high frequeniiy to image organs .

"il l q!rEy rtur (1 ,,;./!-1. nrrrr, t,i<rriqDlrlail

rhyroiJ

hr

*n,.,;!;;jlrjiihlii4:
ae.'

tlrrJ

reflecte,:i bacl<

tultrasour-rci wave.s penetrate bocly tissues ,some signals are .'fi'rese signals are processecl ancl cornbined to generate an

irnage.

Ultrasound of norfiral Thyroid

..; ..r..i'1 , _:,t:
in

,";.
__

- -:: liirai!.

' ' 'rrt'i ',.t li':ri]:r+ri'.r:

,l '.rr::'},:'r'::1,:,

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jl:l '. "r'

Rt lobe of Thyroid

Left lobe

lf

i-lrr7r,'id

lht lnternal Jugular vein

lnternal carotid artery

j.

,,,.,

i.

., ..,-.-i;+.:"''jl." .t. ,... t,-jlr_ ."-t

i;

Ultrasound images are described as :Hypoechoic - lesion appears black Hyperechoic - lesion appears white lsoecl'roic - iesion is same eclrogenicity as the thyroicl parenchyma.
U/S can differentiate betweerr solicl aird cystic lesions.

Benign lesions have well defined margins ancl unifornr echo texture

Solid lesion

Cysti
IF!{-+-.- :l'.rFTll=

::t;j]
.:,fi,f-J

,;]
r:ll

:1.,'1;"i.

].1
,.1

A numberof ultrasound features suggest an increased likelihood that a gir'en thyroid nodule malignant and they include:

is

microcalcification imacrocalcifications, by contrasl, are common in benign nodules); irregular margins; "tallerthan wicle" morphology (inciicative of solid rathri than fliricl natLle nodule); internal vascularity; enlarged cervical ll,rnpir nocles on the same:;ide of the neck The mOre Of theSe {oer,rres f h:r coon rho nrnrg lii<ely it iS i.O hre nralignant

olt he

Central area of necrosis

lrreguiar rnargin

Likely to be malignant -- needs further evaluation

Lesion tallerthan wider,

tii., NIUbLtAR h/lEDlClNI SCAN Cafclnomas :'

is reserved for characterizing functioning nodules and for staging

.
[1-] a hot noclule

NormalThYroid nuclear medicine scan

Lesions iri Nuclear Meclicine irnages are described as

[2] cold nodule

areas of increasecl uptake'

area of no uPtake.

Computed tomography (CT) scannirrg is an e ffer:tive nretlrod flr detecting rei.ional

distant metastasis from thyroid cancer.

at,td

Right lobe of thyroicl

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-

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. t:i.:
1

:ra,1

,' : , , i+,r'ii;+jr",-,,. -.i;'or1 ,,' ,.,:...t,j : ;4.;11; .,,,;1 .,:,.-]t,r-i' 'tl : i:,:tt':r' ;iil';';i::; . t',,,t.'' '''. i' 'i t'1"'.-,"...1 ;" ' .,1 -..',,.i, ['-rr,,o'.. ,l '' '.t,_i ., ,, .,, ,I :ul f1;''1 ",''.,.'1,!.=-., 'i'i-' i.
.

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,"., .
.

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.;.

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'ij:.

i1#"'4-ry,*rr,.ili:',,1;, -., .",' u'. 1 l, B

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re-,]r-5{ir'i:a' .i;ri.l.rir': "t

"t.l:r:.:r;,

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l

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.rLi
1

1l ''1j ', .:

,rl.,trrilJi:l:ia;

dense mass

Coronal section of Thyroid gland

CT

Axial s' ction of Thyroid glanr,

images are described

as

Hypodense - darker I blacker than nornral Thyroid parenchyma Hyperdense * brighter than normalThyroid parenchynra lsodense - same dense as norrnai Thyroid pai'enchyma.

l'/lAGNir:Tie R[SONA|!CE lRllA'Gli\G of Thyroid gland

Atthe pl'esent time, magneti: resonance imaging (Mnl) has a limited role in characterizing of cervical lymph node thyroi0 nociules, although it appears to be effective itr the diagnosis
m

elastl

rs.

Coronal section of normai Th"rroid

Axial section

of

ThYroid

Lesion r,'rrith i ncre ased

MRI IMagnetic Resonance lmaging lncreased signals Decreased signal

the images are described

as

-Bright

lesion
.

Black lesion

ffPL.THB lL.T

(e

.ff

il ffi A f; -,',i,|;t,{

J*

S fl
j1'r

ll{-,[

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PL]I3I,{'C

HIiALTH ASPE,CTS OF TFi\'l1O}ID D{SEASES

Epitlenriology':
Clof ra! ()r'cr'', !clv:

Tlre 11,)st cortrnrorr thyloici rliselse which is o1'lrprtrusl iittpolt:rrrcc irr pLtblic lrealtlr is
hypothy,,roidism. It is because oi the ease in screening ancl treating them.Iodine Deficiency

I)isoldels (lDD) have ntultiirle ancl seriouts aclverse efl-ects inclr,rding cretinism, goitre,
irnpairc<-l cognitive fimctior-r. inrpailecl grolvtlt, jnJant Inortality,

I-ow Birth

'Weight,

and

stillbirths in a large ploportion of the r,vorlcl's population. The dcglec of impairment in iirnclion is relatecl to the sevelity of iodine deficiency. Even nrarginal degrees of iodine
cleficiency hiLve a r-neasurable impact on hutnan clevelopntent. fhere has been great progress

in prevention and treatment of IDD in the last ciecacle,

Stuclie:, clone by

Malia AncJcrsson et ai (2005)

as

publishetl in the BLrlletin o1'the Worlcl

r,vere

Iiealtlr Crganization showecl that the Global T'otal Goiter Prevalence (GTP)

at 15.8%.

Thyroici Diseases in Ivialaysia: Newborn screening began as t-ar back in 11991 as a congenital hypothyroicl screening

initiative (An-rar Singh

rtrte

201 0).

During the petiod of

199

i -1997 sirowed local birth prevalence

of 1 in 3l')0 lvith congenital hypothyloidism.

From 2)01-2009, 576 neonales r,r,ere confirned to have congenital hypothyloiclism. As hypothi'roiclism is easily trea,ied tluough sci'eenings, it has become the rnain concem jn
lvlalaysia.

Seiami, {i et al (2010)

clicl a rrationwicle cross-sectior-ral school-based survey was undertaken

iuuong chilcile 'r aged 8-10 ycar,s old to cleterrnine tlte 'current iodine cleficiency stzrlus jn thecountry. IJcter';nination of tu"inaly iocline (UI) ancl palpation of the thyroid glancl were carried ont among 18,A72 ancl 18,073 childlen respectively wliile iocljne test of the salt samples was
rlone using Ii-apicl Test Kits ancl tire ioclornetric methocl. The resLrlts sliowecl tliat based on \,\,/HO/ i/. e l!-)l)lllltllClrjr ciirii'ia, thc

nriionil iiicilinir UI was 1C() pigil

ovei'a11 netional prevalence

125riL,

T5iirpcrceniiic

(6'/, 166)l showing bolcicrline: aciequacy. The

of iocline cleficiency

disorclers

(IDD) with U1<l00 pg/L was 48.2')/oioSZ. Ci: 46'0, 50' l), higher among chiltlt'en

rioted residing in i'r-tral arcas thair in urbzrn areas. The highcst prevalence .rf UI<100 Prg/i- r'va-s among the aborigines
Hg. l, Degreo

[(814% (95% CI75.1, 86.4)'l'

oJ iodine

ol public heahh signi{icance

nuttition bascd on rnedian urirrary iodine

,,oi

l'. ,

\)"

,)u;/s
'i,

,l) ",ii ilc

:.

ij^6

i) \

(t
M \P$,P
lodinP d.'lr jf nry

(< l0

l(i,)
p4/lj

Mo16ritr indino d.ild,f,c/ [r;ld

i2k9

fl
El

]qlnt dttiitnr/ islF!',r lrg/ll

I

irrllnil
fihk

loLLl9',i

Fti)
1,1/l)

rfirdreir(hded l'yperdltroidirn i?O'L299 alvss!

hF.-il;1

RFI ol

rnns.q.rpd

Fs

(>lcl] fq,l)

\o drn

According to the above map, Malaysia is in the mild iodine deficiency range i'e. 50-99 microgram per litre as assessed tluough urinziry iodine

levels.

,i

A study

done by

M. Malauzy et a1 (1993) ou a total of 2,450

sriU.leilts

in ltelantan showcrl that

endemic goitre was highest in the inlancl areas and the coast (44.9'l ,) foiloi.vcd

bf

inlancl area

(35.9o/o)anclthe coastai arca(23.OVo).Some of the causes for ioclinir cleficiency in Maiaysia

inchide low iocline contentof soil and \,vater, inadecluate iodine conient in iocal fo,rds arrci low consumption ofmarine seafoocl. Stuclies reportecl in WHC br-rlletin showed iodine i, ilSl,'ffY lotv in hilly aieaS asin the I'Iimalzryas, the Alps iu Europe-ancl flre Andes of Soutt America' it
may cause the cijct to be cicficicnt in ioclinc and causing cnclcntic 8,ritre.

In

1994-96. the Minjstry of l lealtlr conducted a National

iDD surr'''y that involvc'lalinost

12,0O0 school children agecl 8-10 year-s. Based on the WFIO/ICC,IDD rcferertce,the stlri/ey

found a goitre 1;revalence ol

O.7o/o

in Sai'awak ,2.Z% in Peninsular Malaysiaand I 3% in ijabah

r,vas

(MOFI, 2003). The merlian urinary iodine level

66.0 ptgll inS:rbah, 82.2 p:,gl|in the

Penin':'rlr:rn ! 115.0 mg.ll ii; Sarawak. The over:rll iinplovecliodine

l-re

statr-rs

in Salawak could

irti. ii,,r'.:ci

:o rire distribution of ioclized sali atrclinstrllation of iodinators in the watel

su:pl'. .risch'rols and longhouses in lDD enclernicaleas a lew yeals priot'to the sr,rrvey (Foo

:t ai.. r 990). Based on the sllrvey reslilts forSabah,

impro.",ecl

a state-levcl prograrnme

tbr salt

iodization i,vas iaunchecl ancl fully implementeclby June 2000. fhe situation in Sabah has
zLs

rnonitoring of school chilclrenagecl 8-10 years in2002 fbunci the meclian urinary

iocline ievel at 240

ptgll

The slLrclies supportecl the hvpothesis that endemic goitre is also cleficient in the interior of the

countwesirecially in Kelantan, Sat'awak and Keclah. In the i,ear 2(){)[), the Malaysian Enclocrine
gr-riclelirie
zrnd

Metabolic Society had published the Practice

lor thyroicl

clisorclcr:s (The Malaysian Consensr-rs).

It covels the clinical management

of alttypes ol thyroicl rliseascs like thyroLoxicosis, hypothyloiclisrn (jocline

cleficiency/enriemic goitre) iLncl other goitres.

Refbrerice:

1. 2. 3. 4.
5. 6.

\\/orlel Heaith Orglnizatiou

N4alaysi2n Endocrine and Metabolic Society PubLication

ivled. J Malaysia Vol 48 No 1 March 1993 http://rvrarw.rnims.corrr/Mala-vsia/pubitopic/lvleclical%20Tribune/2011-0liCongenital

h)'pothyroidism sqreening

IDD hlewsletter FebrLrary 2010

lroo L(1, Zainab T, Goh SY, Letchulnanan GR, Nafikr"rdin M, Dolaisingam P &

l(halidl3AK (1990). lodization of village water supply in the control of endemic

iodinecletlciency in nual Salawak, Malaysia. Biomed Environ Sci 9:236-241.

Psychosocial aspect of thyroitl diseases

I{ypothyroidisrn
r,vho are previously undiagnosecl cases oi'tliyroicl illness present u.ith depression and/or cognitive cleficits, especially memory clisturban;e. They tend 1,-r be hLavv sei. often with gray hair, can be in their forties or older. The lethargy, iatigue ancl slo-,.ing oi ihought processes can be rnistaken for a depressive disorder.
Hyperthyro id isnr The patients can present with anxiety, sweating, trenror, racing thorrghtS, and hypr ractiviry. patients also present witli paranoid, manic or psychotic manifestati, rns.
511"1-t

Most

of the patients

'

Thyroicl cancer ightening and may have ps-,chological corSOQLrerlr.es that persist even once the cancer has been successfLrlly treated. once rreviously healthy inclividrrals are told tl-rat they have thyroicl cancer, it is qLrite conlllon to experir nce solre clegrce of parric and becotne fi'iglitened. J'his can last for clays to lr,eelis, and in some incliviclr-rals, it (lan tal(o years before regaining a for'rer se.se o[.o,'fi*i",r.. irr onc's heartrr. Goiter
The prominent nodltle in the neck can cause lorv self esteen-i because of cosmetic reason o.social stigma. No discrimination in carin-9 these patients is requiled to mirimiTe stigrnatizatior-r.

The cliagrrosis of cancer is frequently

(Compiled by Associate Piofessor Dr.lvlinn Soe)