Hypothyroidism

HYPOTHYROIDISM
Etiology
Primary
Hashimoto thyroiditis, Radio active iodine therapy for Graves disease, Subtotal thyroidectomy, Subacute thyroiditis, Iodide deficiency


Secondary
Pituitary adenoma, pan hypopituitarism
Tertiary
Hypothalamic disfunction (rare)
Clinical finding
Incidence : Various causes depending
geographic & enviromental factors
Hashimoto thyroiditis the most
common cause of hypothyroidism
Newborn infants (Cretinism)
Fatigue, coldness, weight gain, constipation,
menstrual irregularities, muscle cramps
Physical findings:
-Cool,rough, dry skin, puffy face and hands,
hoarse voice, slow reflexes
-Cardiovascular sign : bradycardia, diminished
CO, low voltage QRS, cardiac enlargement
-Pulmonary function : Respiratory failure
-intestinal paralysis: slowed , chronic
constipation, ileus
-Renal function : Decresed GFR, renal
impairement
-Anemia, Severe muscle cramp, parestesias,
muscle weaknes
-CNS symptoms: fatigue, inability to
concentrate

Complication
Myxedema coma end stage of
untreated hypothyroidism, cause by
radiotherapy in Graves Disease
Myxedema & Heart disease CAD
Hypothyroidism Neuropsychiatric
disease depression, confuse,
paranoid, manic

Treatment Hypothyroidism
Levothyroxine (T4), not liothyronine (T3) because rapid absorption, short half life, transient effect. Dosis T4, 1X in the morning to avoid
insomnia 0.05 mg-0.2 mg/d
Mixedema coma ICU, intubation & mechanical ventilation, Treat infection, heart failure, IV drips with caution, levothyroxin IV .


Thyroiditis

Definition
Thyroiditis heterogenous group of inflamatory disorders the
thyroid gland
Etiologies range from autoimmune to infectious origins
Clinical course Acute, subacute, or chronic. Can be euthyroid,
transient phase thyrotoxicosis and / or hypothyroidism. Painless
or painfull

Classification of thyroiditis
I. Autoimmune thyroiditis
Chronic autoimune thyroiditis
o Hashimotos thyroiditis
o Atrophic thyroiditis
o Focal thyroiditis
o Juvenile thyroiditis
o Silent thyroiditis / Postpartum thyroiditis
II. Subacute thyroiditis
III. Acute suppurative thyroiditis
IV. Riedels thyroiditis



Type synonim
Hashimotos thyroiditis Chronic lymphocytic thyroiditis
Chronic autoimmune
Thyroiditis goiter Lymphadenoid
Painless postpartum thyroiditis Postpartum thyroiditis
Painless sporadic thyroiditis Subacute lymphocytic
thyroiditis
Silent sporadic thyroiditis
Painfull subacute thyroiditis -Subacute lymphocytic
thyroiditis
-Subacute thyroiditis
* de Quervains thyroiditis
* Giant-cell thyroiditis
-Subacute granulomatous
thyroidits
-Pseudogranulomatous
thyroiditis

Terminology for Thyroiditis.
Type Synonym
Suppurative thyroiditis Infectious thyroiditis
Acute suppurative thyroiditis
Pyogenic thyroiditis
Bacterial thyroiditis
Drug-induced thyroiditis
(amiodarone,lithium,
interferon alpha,
interleukin-2)



Riedels thyroiditis Fibrous thyroiditis

Hashimoto thyroiditis
Hashimotos thyroiditis
Etiology & pathogenesis
HT is immunologic disorder which lymphocytes become sensitized to thyroidal antigens and autoantibodies are performed.
Thyroid antibodies in HT are:
1. Thyroglobulin antibody (Tg Ab)
2. Thyroid peroxidase antibody (TPO Ab) = ( Microsomal antibody)
3. TSH Receptor blocking antibody ( TSH - R Ab block)

Symptom & Signs
*HT usually presents with goiter , euthyroid or
mild hypothyroidism.
*Sex distribution : F/M 4:1
*Painless & patients may be anware of the
goiter
Laboratory findings
T4 N/ low, TSH will be elevated. RAIU may
be high, normal or low
Tg Ab & TPO Ab positif
Fine needle aspiration biopsy large
infiltration lymphocytes Hurttle cells

Diagnostic procedures
Test of thyroid autoimmunity:
TPOAb 95% + in HT & 90% Atrophic
thyroiditis
TgAb less frequently +
Diagnostic specificity of thyroid
antibody tests is not absolute.
Test for thyroid function TSH, fT4
RAIU : normal, low or high.
USG : diffusely reduced echogenecity
FNAB not necessary,excep. rapidly enlarging
goiter







Treatment
Goiter small & asymptomatic not require therapy
Levo-thyroxine is given over hypothyroidism to supress TSH & decreased serum thyroid antibody. Levo-thyroxine in euthyroid, still
controversial
Corticosteroids : regression pain, reduction in size of the goiter, thyroid antibody, not recommended in benign disease.
Surgery indicated pain, cosmetic, or pressure symptoms after levothyroxine and corticosteroid therapy.


Riedels thyroiditis
Rare 1,06/100.000, middle age or elderly women
Etiology unknown (autoimmune process or primary fibrotic
disorder)
Characterized fibrosis replaces normal thyroid
parenchyma,1/3 cases multifocal fibrosclerosis
Thyroid fibrosis (stony hard,woody), painless, progressive
anterior neck mass,
Generalized fibrosing (1/3 patients), pressure symptoms
laryngeal nerve paralysis or hypoparathyroidism (rare)
Usually euthyroidism, hypothyroidism (30%)
Laboratorium : non spesific
USG/CT-Scan inconclusive
Difinitive diagnosis open Biopsy
treatment:
Corticosteroids medical treatment of choice
Tamoxipen, methotrexate inhibitor fibroblast proliferation (
early stages)
Levothyroxine hypothyroidism
Surgical care diagnosis, relieving tracheal compression
Mortality asphyxia (6-10%), extrathyroidal fibrotic lesions may
complicate the prognosis