TIROID

TiROTOKSIKOSIS
(HIPERTIROIDISM)
 TIROTOKSIKOSIS &
HIPERTIROIDISM
.
.TIROTOKSIKOSIS: keadaan hormon tiroid
berlebihan yang disebabkan oleh overproduksi
kelenjar tiroid, atau di luar kelenjar tiroid,
kebocoarn/hilangnya simpanan kelenjar tiroid

HYPERTHYROIDISM: keadaan hormon tiroid

berlebihan yang disebabkan oleh overproduksi
kelenjar tiroid
PEMERIKSAAN KELENJAR TIROID
DAN SEKITARNYA
 Serum TSHs & FT4
TSH , FT4 tirotoksikosis
TSH , FT4 normal :
T3 tirotoksikosis (FT3 )
Tirotoksikosis Subklinik
Penyakit Non tiroid
TSH normal, FT4 :
TSH-secreting adenoma
Pituitary resistance to thyroid hormon
Generalized resistance to thyroid hormon
TSH normal, FT4 normal normal
Algoritma Diagnosis
Hipertiroidisme
Tersangka
Tersangka HIPERTIROIDISME
HIPERTIROIDISME

Ukur
Ukur Kadar
Kadar TSH
TSH dan
dan FT
FT44

TSH
TSH :: nn TSH :
TSH TSH :
TSH TSH :: nn //
TSH
FT
FT44 :n
:n FT
FT44 : n FT44 :
FT FT44 :
FT

Bukan
Bukan
Ukur
Ukur FT33 TSH
TSH secreting-
secreting-
Hipertiroidisme
Hipertiroidisme pituitary
pituitary adenoma
adenoma
Thyroid
Thyroid hormone-
hormone-
Hipertiroidisme
Hipertiroidisme resistance
resistance syndrome
syndrome
TSH
TSH FT
FT44
 Hipertiroidisme
Hipertiroidisme
Ukur FT33 TSH
TSH FT
FT44

TSH , FT4 N,, FT33 : N TSH ,, FT4 N, FT33

T33 Toksikosis Hipertiroidisme

Hipertiroidisme
Hipertiroidisme Subklinik
Evolving
Evolving Graves
Graves disease Penyakit Graves
Struma
Struma Nodosa
Nodosa Toksik
Toksik Struma
Struma Nodosa
Nodosa Toksik
Toksik (Multi/adenoma)
(Multi/adenoma)
Terapi
Terapi Tiroksin
Tiroksin Berlebihan
Berlebihan Tiroiditis
Tiroiditis
Nonthyroidal
Nonthyroidal illness
illness Hipertiroidisme
Hipertiroidisme Iatrogenik/Faktisius
Hipertiroidisme
Hipertiroidisme Gestasional
Karsinoma
Karsinoma Tiroid
Tiroid
Struma
Struma Ovarii
Ovarii
Chorionic
Chorionic gonadotropin
gonadotropin secreting
secreting Tumor
Tumor
Familial
Familial nonautoimmune
nonautoimmune hyperthyroidism
hyperthyroidism
and
and Albrights
Albrights syndrome
 Klasifikasi Tirotoksikosis
A. Hiperfungsi tiroid (hipertiroid)
1. Produksi TSH >>
2. Abnormal stimulator tiroid
a. Penyakit Grave (> 90%)
b. Tumor trophoblastik
3. Autonomi tiroid intrinsik
a. Adenoma hiperfungsi
b. Struma multinoduler toksik
 Klasifikasi
B. Tidak berhubungan dengan hiperfungsi tiroid
1.Gangguan simpanan hormon
a. Tiroiditis subakut
b. Tiroiditis kronik dengan tirotoksikosis transien
2. Sumber hormon ekstratiroid
c. Tirotoksiosis faktitia
d. Hamburger Toxicosis
e. Jaringan tiroid
(1)Struma ovarii
(2)Functioning follicular ca.
 Manifestation of Thyrotoxicosis
Symptoms Signs
- Nervousness - Hyperactivity
- Fatigue - Tachycardia/arrythmia
- Weakness - Systolic hypertension
- Increased perspiration - Warm, moist, smooth
- Heat intolerance skin
- Hyperactivity - Stare and eyelid
- Tremor retraction
- Increase apetite - Tremor
- Palpitation - Hyperreflexia
- Weight loss - Muscle weakness
- Menstrual disturbance
 PENYAKIT GRAVE
(Parrys disease / Basedows disease)

3 Manifestasi mayor :
1. Hipertiroid + struma difus
2. Opthalmopati
3. Dermopati
Acropachy
 PENYAKIT GRAVE
PREVALESI
- Dapat pada semua umur,
umumnya dekade tiga & empat
- Rasio wanita : pria = 7 : 1
- Faktor genetik : frekuensi
HLA-B8 and DRw3 kaukasian
HLA-Bw36 Jepang
HLA-Bw46 Cina
Penyakit tiroid - autoimun
Graves disease
Hashimotos disease
Primary myxedema
 Graves Disease
1.Gene
1.Gene
Antigen
Antigen specific
specific 2.Environ
2.Environ TSH
(thyroid
(thyroid gland
gland TSH
responsive)
responsive) ment
ment Receptor
Receptor
TT suppressor
suppressor
TSH
B
B Iodide
Iodide hipofisis
cAMP
cAMP
TSH
TSH
Receptor
Receptor
Antibody
Antibody
(TSHRab)
(TSHRab)

T
T33
T
T44
Thyroid
Thyroid growth
growth
Vascularity
Vascularity
T
T helper
helper
 PENYAKIT GRAVE
PATOGENESIS
- Hipertiroid gangguan mekanisme homeostasisi
yang mengontrol sekresi
- Gangguan berasal : thyroid stimulating
immunoglobulin (TSI) - limphosit (IgG).
- Antibodi melawan reseptor TSH (TRAb)
TSAb: thyroid stimulating antibody,bind&stimulate TSH receptor
TBII: thyrotrophin binding inhibitory immunoglobulin, inhibition of TSH
to its receptor
TSBAb: thyroid stimulatingblocking antibody,which blocks the action of
TSH by binding to TSH receptor
Ikatan dengan reseptor TSH berefek :

1. Stimulasi
2. Tidak ada efek
3. Kadang berlawanan
Respon: hyper,eu/hipotiroid
Diagnosis Penyakit Graves
Anamnesis dan Pemeriksaan Jasmani
Pemeriksaan laboratorium
TSH S
FT4
T3 T3 Toksikosis

Sidik tiroid
Kadang diperlukan kalau ragu atau
ada ketidak-cocokan
Tiroiditis: uptake rendah
USG Kurang ada manfaat
BAJAH Tidak biasa dilakukan (hanya kalau
disertai nodul dingin)
 GRAVES DISEASE

THYROID
- Diffuse toxic goiter, less symetric.
- Thrills and bruits are important but often
absent.
- Thrills (palpable) and bruits (audible) sign of
turbulence associated with an increased rate of
flow through turtuos vessel.
 GRAVES DISEASE

OCULAR SIGNS & SYMPTOMS

- Wide palpebral aperture (Dalrymples sign)
- Lid lag (von Graefes sign)
- Staring or frigthened expressions
- Infrequent blinking (Stellwags sign)
- Absence of farehead wringkling on upward
(Joffroys sign)
- Inability to keep converged (Mobius sign)
 OCULAR SIGNS & SYMPTOMS

- Diplopia
- Swelling of orbital contents and puffiness of
the lids
- Chemosis, corneal injection/ulceration
- Exophthalmus
- Decreased visual acuity, retinal
edema/hemorrhages, optic nerve damage
 GRAVES DISEASE
CARDIAC MANIFESTATION
- Tachycardia
- Atrial fibrillation
- LVH and strain on ECG
- Premature atrial/ventricular contractions
- Congestive heart failure
- Angina with/without coronary artery disease
- Myocardial infarction
- Resistance to some drug effects (digoxin)
- Residual cardiomegaly
Systolic BP Diastolic BP
Pulse pressure 50-80 mmHg
 DIAGNOSIS

Signs and symptoms

Laboratory :
Increased value of FT3, FT4
Decreased value of TSH
Increased value of RAIU
(hyperfunction)
Pengelolaan
Obat Anti Tiroid
Terapi Bedah
Radiasi
 Anti Thyroid Drug
Thionamides :
Propylthiouracil (PTU)
Methimazole (MMI) &Carbimazole
Inorganic Iodide
Potassium Perchlorate
Lithium Carbonate
-adrenergic Antagonist Drugs
Keberhasilan Pengelolaan
Sembuh 40-60 %
Kambuh 40-60 %
Tindakan Bedah
Komplikasi pembedahan
Radioterapi
Hipotiroidisme
Obat Terus ?
Efek samping obat
 Toxic Nodular Goiter

- A proportion of patients with non toxic nodular

thyroid glands develop thyrotoxicosis;

- Directly correlates to the goiters duration;
- Thyrotoxicosis
develops insidiously;
- Diagnosis by scintifigraphy hyper functioning/ toxic
nodular will concentrate the radionuclide;
- Treatment: thyroidectomy or I radioctive
 ALGORITME DIAGNOSTIK NODUL TIROID
NODUL TIROID
TSHs, T4 (FT4)
TOKSIK NON TOKSIK
(tidak dibicarakan)
BAJAH

CURIGA GANAS GANAS TIDAK

JINAK ADEKUAT

KJ KG Dif
Baik Ulang
Ulang Bajah
Bajah
Operasi Dif
Sidik Buruk
GANAS JINAK
Tak
Hot/ Cold BerDif
Warm

Terapi Supresi
Catatan : -------- bila tidak ada fasilitas sidik tiroid
: KJ (Klinis Jinak), KG (Klinis Ganas)
 SUBACUTE THYROIDITIS

An excess of preformed hormone

leaks from the gland owing to
the presence of inflammatory disease.
New hormone formation decrease
because of TSH increase.
Self-limited often followed by transient
of thyroid hormone insufficiency.
HIPOTIROID
Tanda dan gejala hipotiroid
Penyebab hipotiroid
Levotiroksin
Pilihan pertama
Dapat dipakai untuk Tx koma miksedema
Aman untuk ibu hamil
Dosis awal : 50-100 mcg PO 1 x/hari
dinaikkan 25-50 mcg/3-4mgg s/d eutiroid dan
kadar TSH normal
Dosis rumatan : 100-200 mcg PO 1/hr
Lansia/Kardiovaskuler : dosis awal 25-50 mcg
PO 1x/hr, dosis dinaikkan 25 mcg/4mgg s/d
eutiroid dengan TSH normal
KEGAWATANDARURAT
Krisis Tiroid
Myxedema coma
 KRISIS TIROID
Faktor risiko :
1. Hipertiroidisme yang tidak diobati
2. Pengobatan kurang memadai : tindakan
bedah, infeksi, tiroidektomi, serangan
kardiovaskuler, toksemia hamil, KAD, HHS,
hipoglikemia induksi insulin, penghentian
terapi anti tiroid, pemberian terapi yodium
radioaktif.
Penyakit Grave/struma multi noduler toksik
Kriteria diagnostik krisis tiroid
Manajemen krisis tiroid
 KOMA MIKSEDEMA
Miksedema : penebalan, edema non
pitting pada jaringan lunak hipotiroid
Wanita usia lanjut, infeksi, obat, paparan
lingkungan (paparan udara dingin),
keadaan terkait metabolik.
Tanda & gejala : riwayat hipotiroid lama,
hipotermi berat (<270C), bradikardi, gagal
nafas, penurunan kesadaran
 Perawatan pra-rumah sakit
Perawatan Instalasi Darurat Medis
1. Resusitasi awal : intavena
2. Monitoring jantung & terapi O2 indikasi
3. Ventilasi mekanik : penurunan respirasi
4. Evaluasi penyebab penurunan kesadaran :
glukosa darah, oksimetri
5. Dugaan klinis : hormon tiroid intravena
6. Obati faktor pencetus
7. Hipotensi membaik dengan kristaloid
8. Hipotermi : selimut/pemanasan
9. Hindari : sedatif, narkotik, anestetik
Konsultasi : rawat intensif
Terapi utama : hormon tiroid
1. Intavena : hati hati pada PJK
Monitor detak jantung, hentikan bila aritmia
a. Levothyroxine : bolus awal 200-500 mkg
IV/via NG, ruwatan 100-200 mkg/hari IV / via
NG
b.Liothyronine (lebih cepat) : bolus 50 mkg IV
pelan dilanjutkan 25 mkg IV/ 8jam sam pai
membaik, kemudian 25 mkg/ 12 jam atau 5-
20 mkg IV pelan/4-12 jam (umumnya 12 jam)
2. Oral : kasus ringan
Mulai dosis kecil dinaikkan pelan pelan
 Penyebab :
1. Autoimun : Grave, tiroiditis kronik, tiroiditis
subakut, tiroiditis post partum
2. Induksi obat : defisiensi, farmakologik
( medikasi media kontras) struma nodusa,
amiodaron
3. Infeksi : tiroditid supurativ, tiroiditis paska
infeksi viral
4. Idiopatik : struma multinoduler toksik
5. Iatrogenik : tirotoksikosis faktitia
6. Malignitas : adenoma toksik, hiperfungsi nodul
tunggal