Zahid qamar

INTRODUCTION
It is the functional or structural de arrangement in the synthesis of thyroid hormone It can result from a lack of a thyroid gland or from iodine-131 treatment, and can also be associated with increased stress. A 2011 study concluded that about 8% of women over 50 and men over 65 in the UK suffer from an under-active thyroid and that as many as 100,000 of these people could benefit from treatment they are currently not receiving.[1]

Hypothyroidism

1.8% of total population. Second only to DM as most common endocrine disorder. Incidence increases with age. More common in females. 2-3% of older women.

Etiology

PRIMARY HYPOTHYROIDISM Hoshimotos thyroiditis-most common Idiopathic hypothyroidism-probably old Hoshimotos Irradiation of thyroid Surgical removal Late stage invasive fibrous thyroiditis Iodine deficiency Drug therapy (Lithium, Interferon) Infiltrative Diseases: Sarcoidosis, Amyloidosis Scleroderma, Hemochromatosis

SECONDARY HYPOTHYROIDISM 5% of cases. Pituitary or hypothalmic neoplasm. Congenital hypopituitarism. Pituitary necrosis (Sheehans syndrome)

Tertiary hypothyroidism
Occurs in hypothalamus Results when the hypothalamus fails to produce sufficient thyrotropin-releasing hormone (TRH). TRH prompts the pituitary gland to produce thyroid-stimulating hormone (TSH). Hence may also be termed hypothalamic-pituitary-axis hypothyroidism. It accounts for less than 5% of hypothyroidism cases

Clinical Manifestations
Cretinism Myxedema

Cretinism
Hypothyroidism in infancy or early child hood. Endemic iodine deficiency areas of the world i.e himalya , waziristan & other hilly areas etc. it may be sporadic cretinism (hypothyroidism due to inborn errors of metabolism)

 Impaired development of CNS & skeletal system.

Severe mental retardation(Related to time at which thyroid deficiency occur in utero)
Maternal thyroid deficiency before the development of fetal thyroid gland leads to severe mental retardation.

Clinical features of cretinism

Short stature Coarse facial features Protruding tongue Umbilical hernia.

Myxedema (Gull disease)

Hypothyroidism occuring in older children and adults is called myxedema. CLINICAL FEATURES include Generalized apathy Mental sluggishness in early stages may lead to depression Individuals with myxedema are listless, cold intolerant , obese , have constipation & pericardial effusions.

Signs and Symptoms

Non-specific. May be confused with other conditions especially in postpartum depression and elderly. Maintain high index of suspicion. In older patients, hypothyroidism may be confused with Alzheimers and depression. Patient may end up getting treated for depression.

Common signs and symptoms S/S Weakness Skin changes Slow speech Eyelid edema Cold sensation Decreased sweating Cold skin Thick tongue Facial edema Coarse hair Skin pallor Forgetfulness Constipation

% pts affected 99 97 91 90 89 89 83 82 79 76 67 66 61

Diagnosis

In Primary Hypothyroidism Serum TSH is high. Free thyroid hormone are depressed. In Secondary Hypothyroidism Both TSH and free thyroid hormones are low.

Anti bodies in hypothyroidism

Anti bodies: Anti thyroid peroxidase [ anti microsomal] antibodies Anti thyroglobulin antibodies. Anti bodies against T3 and T4 in auto immune hypothyroid disease. In primary hypothyroidism; - up to 12 % pt do have anti gastric parietal cell antibodies. - these pts. Can develop pernicious anemia.

Generally Once diagnosis of primary hypothyroidism is made, additional imaging or serologic testing is unnecessary if gland is normal on exam. In secondary hypothyroidism, further testing with pituitary provocative testing and imaging to rule out microadenoma. In general, evidence of decreased levels of more than one pituitary hormone is indicative of a panhypopituitary problem.

Lab Values

TSH level
High

Free T4 level
Low

Free T3 level
Low

Likely Diagnosis

High (>10 U/mL Normal [{10mU/L]} High (6-1uU/mL Normal {6-10mU/L]) High

Normal

Primary Hypothyroidism Subclinical hypothyroidism with high risk for future development of overt hypothyroidism Subclinical hypothyroidism with low risk for future development of overt hypothyroidism Congenital absence of T4-T3 converting enzyme; amiodarone Cordarone) effect on T4-T3 conversion Peripheral thyroid hormone resistance Pituitary thyroid deficiency or recent withdrawal of thyroxine after excessive replacement therapy

Normal

High

Low

High Low

High Low

High Low