Professional Documents
Culture Documents
Introduction
Autoimmunity-Concept
Environmental factors affecting thyroid
Description
Smoking
Micronutrients
Iodine
Selenium
Thiocynate
Drugs
Amiodarone
Lithium
Interferon alpha
TKI
Infections
Radiation
Pollutants
Summary
INTRODUCTION
Environmental factors triggers thyroid
autoimmunity (TAI) in genetically susceptible
individuals.
TAI autoimmunity and dysfunction can present
with hypothyroidism or hyperthyroidism.
Background incidence of thyroid autoimmunity in
India.
Hypothyroidism
Overthypothyroidism3.9%
SubclinicalhypothyroidismM/F11.4/6.2%
53%SCHhave+TPOAb
Hyperthyroidism
Overt-1.3%
Subclinical hyperthyroidism1.6
AUTOIMMUNITY MODEL
AUTOIMMUNITY-MOLECULAR
SMOKING
Graves disease
Increases the risk of Graves disease occurrence (Hagg et
al).
Decreases the chance of remission of hyperthyroidism .
Smoking alters natural history of GO
More frequent,
More severe
Less responsive to medical treatment
Hashimoto thyroiditis
Negative association with TPOAb and TgAb.
Negative association with hypothyroidism
? Protective effect
MICRONUTRIENTS
S M A L L M O L E C U L E , B I G I M PA C T
Environment
Goiter was more common in
Smoker
Women with high parity
Goiter was less common in
Alcoholism
OCP user
Aalborg
SEX
Copenhagen
Low TSH
11.1%
7.2
%
8.3%
4.0%
Increased TSH
8.2%
2.1
9.1%
2.7%
SOURCES OF IODINE
Iodine-containing drugs
Cough syrups-Iodine containing
Povidone-Iodine, used for topical disinfection.
Seaweed preparations containing up to 2 mg iodine per
gram in protein-bound form available
Contrast agents for conventional radiography or
computer tomography.
Erythrosine (food additive E127) containing 57% iodine
and used, for example, to improve the colour of canned
cherries or of candies.
Iodised salt; (over-iodised by inadvertence).
Frequency of positive Tab was much higher in HT-US than in non-HT-US (59/87, 67.8% vs 233/1208, 19.3%, P< .
0001)
TgAb (45/87, 51.7% vs 179/1208,14.8%, P<.0001)
TPOAb (55/87, 63.2% vs 149/1208, 12.3%, "2 " 158.3, P <0001)
In HT-US subjects, serum levels of TgAb were also significantly higher in IS-users than
in IS-nonusers (median, IQR: 108 U/mL, 8501 U/mL vs 0 U/mL, 053 U/mL; P " .02)
Serum levels of levels of TPOAb were not significantly different between the two
groups (161 U/mL, 0588 U/mL, vs 0 U/mL, 0434 U/mL)
SELENIUM
Ningshan
Ziyang
AMIODARONE
Amiodarone
benzofuran derivative
two iodine atoms per molecule
37% iodine by weight
WolffChaikoff effect
JodBasedow effect
AMIODARONE INDUCED
HYPOTHYROIDISM
Prevalence-1020% (Short term), 5-10% (1 year)
more frequent in iodine-sufficient areas.
Incidence ratio (W:M)- 1.5:1.
Thyroid autoantibodies increase likelihood of
developing AIH.
OR X 14 (F/+Tab).
Symptoms of hypothyroidism (Classical plus)
Torsades de pointes
Acute kidney injury (Reversal with LT4 supplement)
AMIODARONE INDUCED
THYROTOXICOSIS
Prevalence=5-10%.
The M:F incidence ratio is 3:1.
The time of onset of AIT is less predictable.
When to suspect?
Reappearance or exacerbation of the under lying cardiac
disorder after amiodarone treatment.
Deranged warfarin sensitivity.
Feature
Type 1 AIT
Type 2 AIT
Yes
No
Thyroid antibody
Yes
Usually no
Pathogenesis
Iodine induced
hyperthyroidism
Thyroiditis
Histopathology
Follicular hyperplasia
Thyroid USG
CFDS
Increased vascularity
Decreased vascularity
Thyroidal RAIU
Increased/Low/Decreased
Decreased (<1%)
MIBI
Thyroid retention
Decreased/Absent
Spontaneous remission
No
Possible (20%)
Thionamides
(KClo4)
Glucocorticoids
Subsequent hypothyroidism
Unlikely
Possible
Likely
No
40 to 60 mg/day
of prednisolone
for 1 to 3 month
Alters the T3 to TR
binding
Alters TR to DNA binding
Alters ITDI (decrease 2,
increase 3)
GOITER
Goiter occur in 5-30% of subjects
More common in female
Diffuse>Nodular
More common with longer duration of treatment
More common with prior antibodies
50% to 70% with USG (so USG recommended)
Levothyroxine is recommended
Very large goiter
Cosmetic/compressive
TSH >10 mu/L
INTERFERON
Thyroid dysfunction can be found in the 25 to
40% of the patients.
Can be divided into
Autoimmune
Graves disease
Hashimoto thyroiditis
Asymptomatic disease
Non autoimmune
Destructive thyroiditis
Non autoimmune hypothyroidism
TYROSI
NE
KINASE
INHIBIT
ORS
TOXIC
EFFECT
OF
TARGET
ED
THERAP
Y
INFECTIONS
INFECTIONS
HEPATITIS C
The frequency of abnormally high
levels of antithyroid antibodies in
HCV-positive patients varies from
8% to 48%.
Spectrum of thyroid dysfunction
Thyroiditis
Hyperthyroidism
Thyroid cancer
Am J Med.2004;117
RADIATION
I N V I S I B L E E N E R GY , V I S I B L E E F F E C T S
Lancet;1998
POLLUTANTS
POLLUTANTS
Symbols:AandBsignificantdifferencesbetweengroupswithAandthosewithBwithinthesame
area(thelevelofsignificanceindicatedinthetext).
CorDp<0.01orp<0.001,respectively,betweengroupswithCorDinpollutedareaandgroups
withappropriatenumberinbackgroundpollutionarea.
Chemosphere;2007
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