Thyroid Gland disorders

Thyroid Gland disordersThyroid Gland disorders

Omar Dhaimat, MD FACEOmar Dhaimat, MD FACE

Consultant EndocrinologistConsultant Endocrinologist

HMCHMC

DUBAI 2008DUBAI 2008

IntroductionIntroduction

Common disease.Common disease. Different types.Different types. Variable terminology.Variable terminology. Treatable disease.Treatable disease. Wide spectrum of presentation.Wide spectrum of presentation. All age groups.All age groups.


IntroductionIntroduction

Found by Leonardo da Vinci by 1500.Found by Leonardo da Vinci by 1500. Called the thyroid gland by Thomas Called the thyroid gland by Thomas

Wharton in 1656.Wharton in 1656. Courtois discovered Iodine about 1812.Courtois discovered Iodine about 1812. Kendall extracted thyroxine In 1920s.Kendall extracted thyroxine In 1920s. Kocher won a noble prize for work in thyroid Kocher won a noble prize for work in thyroid

disease.disease.









ThyroiditisThyroiditis


Autoimmune Thyroid DestructionAutoimmune Thyroid Destruction

3 mechanisms.3 mechanisms. A.A.Thyroid autoimmunity:Thyroid autoimmunity: Thyroid antibodies are directed against Thyroid antibodies are directed against

thyroid peroxidase and against thyroid peroxidase and against thyroglobulin.thyroglobulin.

Both cellular and humoral immunity.Both cellular and humoral immunity. B.B.Genetic susceptibilityGenetic susceptibility::



Association with HLA-DR3,4&5 has been Association with HLA-DR3,4&5 has been reported in patients with HT &PPT.reported in patients with HT &PPT.

CTLA-4 may be associated with familial HT.CTLA-4 may be associated with familial HT. Subacute thyroiditis had higher incidence in Subacute thyroiditis had higher incidence in

those with HLA-bw35.those with HLA-bw35.



C.C.Environmental factors:Environmental factors: Hypothyroidism in patients with HT develop Hypothyroidism in patients with HT develop

more in smokers.Also,PPH happens more more in smokers.Also,PPH happens more with smokers..with smokers..

Iodine insufficiency in diet may be protective Iodine insufficiency in diet may be protective against autoimmune thyroiditis.against autoimmune thyroiditis.


Clinical and Biochemical Clinical and Biochemical Changes in thyroiditisChanges in thyroiditis

A.ThyrotoxicosisA.Thyrotoxicosis:: In painless ST,PPH ,SAT;Inflammatory In painless ST,PPH ,SAT;Inflammatory

destruction of the thyroid may lead to destruction of the thyroid may lead to transient thyrotoxicosis as preformed thyroid transient thyrotoxicosis as preformed thyroid hormones are released from the damaged hormones are released from the damaged gland.gland.



As the stored are depleted ,there is often a As the stored are depleted ,there is often a progression through a period of euthyrodism progression through a period of euthyrodism to hypothyrodism.to hypothyrodism.

Tg will increase first,TSH will be suppressed Tg will increase first,TSH will be suppressed ,T3,T4 will be elevated.,T3,T4 will be elevated.

Symptoms are usually not severe.Symptoms are usually not severe.



B.B.Hypothyrodism:Hypothyrodism: Gradual depletion of stored thyroid Gradual depletion of stored thyroid

hormones.hormones. HT most common,but all other causes may HT most common,but all other causes may

progress to permanent hypothyroidism.progress to permanent hypothyroidism. TSH will rise,t3,t4 will be low.If they are TSH will rise,t3,t4 will be low.If they are

normal with high TSH ,this is called normal with high TSH ,this is called ‘subclinical hypothyroidism’.‘subclinical hypothyroidism’.


Hashimoto’s thyroiditisHashimoto’s thyroiditis

Most common cause.Most common cause. Most have goiter.Firm ,bumpy ,symmetric painless Most have goiter.Firm ,bumpy ,symmetric painless

.10% have atrophic thyroid gland..10% have atrophic thyroid gland. Hypothyroidism is the commonest presentation.Hypothyroidism is the commonest presentation. TPO are present in 90%,ATG in 20-50 %.TPO are present in 90%,ATG in 20-50 %. 24 hr RAI uptake is not helpful in dx.24 hr RAI uptake is not helpful in dx. Levothyroxine is the treatment of choice.Levothyroxine is the treatment of choice. Lymphoma is a very rare complication.Lymphoma is a very rare complication.





Painless Postpartum thyroditisPainless Postpartum thyroditis

10 % of women in USA may develop it 10 % of women in USA may develop it within first few months after delivery.within first few months after delivery.

Most common in women with high TPO Most common in women with high TPO levels during 1levels during 1stst trimester ,immediately after trimester ,immediately after therapy,have other autoimmune diseases therapy,have other autoimmune diseases like DM 1.like DM 1.

30 % will have the classic triphasic hormone 30 % will have the classic triphasic hormone pattern.pattern.



PPTPPT

70% chance of recurrence with subsequent 70% chance of recurrence with subsequent pregnancies.pregnancies.

Hypothyroidism may be treated if symptoms Hypothyroidism may be treated if symptoms are present for a period of time.are present for a period of time.

Antithyroid medications are contraindicated.Antithyroid medications are contraindicated. Beta blockers can be used if symptoms are Beta blockers can be used if symptoms are

severe.severe.


Painless Sporadic ThyroiditisPainless Sporadic Thyroiditis

Indistinguishable from PPT except by the relation Indistinguishable from PPT except by the relation of the later to pregnancy.of the later to pregnancy.

Account for 1% of cases with thyrotoxicosis.Account for 1% of cases with thyrotoxicosis. Small,non-tender,very firm,diffuse goiter is present Small,non-tender,very firm,diffuse goiter is present

in 50% of patients .in 50% of patients . Low or undetectable concentration of I123 at 24 Low or undetectable concentration of I123 at 24

hrs.hrs. Treatment,same as PPT.Treatment,same as PPT.


Painful Subacute ThyroiditisPainful Subacute Thyroiditis

Most common cause of thyroid pain.Most common cause of thyroid pain. Self-limited inflammatory disorder.Self-limited inflammatory disorder. Follows URTI,high incidence in summer,with Follows URTI,high incidence in summer,with

the peak of Enterovirus.the peak of Enterovirus. Clinical scenario:Clinical scenario:



Generalized Generalized myalgias,pharyngitis,low grade myalgias,pharyngitis,low grade fever and severe neck pain,swelling or both.fever and severe neck pain,swelling or both.

50% have symptoms of thyrotoxicosis.50% have symptoms of thyrotoxicosis. State of biochemical euthyroidism.State of biochemical euthyroidism. Hypothyroidism will last for 4-6 months.Hypothyroidism will last for 4-6 months.



5% will have residual hypothyroidism.5% will have residual hypothyroidism. Hall mark is Hall mark is ELEVATED ESR.ELEVATED ESR. Leukocyte count is normal or slightly Leukocyte count is normal or slightly

elevated.elevated. High T4,T3.(T4 ratio to t3<20).Undetectable High T4,T3.(T4 ratio to t3<20).Undetectable

TSH.TSH.



24-hour I(123) is low in the toxic phase .24-hour I(123) is low in the toxic phase . Treatment: symptomatic relief.Treatment: symptomatic relief. NSAIDS,ASA.NSAIDS,ASA. Glucocorticoids Glucocorticoids in more severe cases.in more severe cases. Beta-blockers.Beta-blockers.


Suppurative ThyroiditisSuppurative Thyroiditis

Bacterial infection,fungal,mycobacterial or Bacterial infection,fungal,mycobacterial or parasitic infection.parasitic infection.

Thyroid is resistant to infection Thyroid is resistant to infection (encapsulated,high iodide content,rich blood (encapsulated,high iodide content,rich blood supply and extensive lymphatic drainage).supply and extensive lymphatic drainage).

People at risk:1.Preexisting thyroid disease.People at risk:1.Preexisting thyroid disease.



2.Congenital anomalies(2.Congenital anomalies(pyriform sinus pyriform sinus fistulafistula most common source of infection in most common source of infection in children).children).

3.Immuno-suppressed,elderly.3.Immuno-suppressed,elderly. 4.AIDS (4.AIDS (pneumocystis carinii and others).pneumocystis carinii and others).



Presentation: ill with Presentation: ill with fever,dysphagia,dysphonia,anterior neck pain and fever,dysphagia,dysphonia,anterior neck pain and erythema and a tender thyroid mass.erythema and a tender thyroid mass.

Normal thyroid function test.Normal thyroid function test. High ESR,WBC.High ESR,WBC. FNA with gram’s staining and culture is the FNA with gram’s staining and culture is the

diagnostic test of choice.diagnostic test of choice. Therapy:Therapy: appropriate antibiotics and drainage of appropriate antibiotics and drainage of

any abscess.any abscess.


Riedel’s ThyroiditisRiedel’s Thyroiditis

Progressive fibrosis.Progressive fibrosis. Rare disease.Rare disease. High serum High serum thyroid antibody thyroid antibody in 67% of in 67% of

patients.patients. Rock- hard,fixed & painless goiter.Rock- hard,fixed & painless goiter.


Riedel’s ThyroiditisRiedel’s Thyroiditis

Tracheal,esophageal compression or Tracheal,esophageal compression or hypoparathyroidism.hypoparathyroidism.

Open biopsy is needed.Open biopsy is needed. Glucocorticoids,methotrexate and tamoxifen Glucocorticoids,methotrexate and tamoxifen

can be used.can be used. Surgery is the treatment of choice.Surgery is the treatment of choice.


Drug-induced thyroiditisDrug-induced thyroiditis

Amiodarone.Amiodarone. Lithium.Lithium. Interferon alpha .Interferon alpha . Interleukin 2.Interleukin 2.





HyperthyroidismHyperthyroidism

Graves’ disease is the most common cause Graves’ disease is the most common cause of hyperthyroidism.of hyperthyroidism.

Hyperthyroidism versus thyrotoxicosis.Hyperthyroidism versus thyrotoxicosis. Other causes: toxic multi-nodular Other causes: toxic multi-nodular

goiter,autonomous hyper-functioning goiter,autonomous hyper-functioning adenoma,Tsh-secreting pituitary adenoma.adenoma,Tsh-secreting pituitary adenoma.

S.A.T,lymphocytic thyroiditis.S.A.T,lymphocytic thyroiditis.



Other rare causes(Hydat.M,c.carc,Struma Other rare causes(Hydat.M,c.carc,Struma Ovarii,metastatic thyroid carcinoma.Ovarii,metastatic thyroid carcinoma.

Presentation:Presentation: Signs and symptoms:Signs and symptoms: 1.Nervous system.1.Nervous system. 2.Cardiac system.2.Cardiac system.



3.Musculoskeletal system.3.Musculoskeletal system. 4.GI system.4.GI system. 5.Eyes:5.Eyes: Lid lag,lid retraction,exophalmos,infiltrative Lid lag,lid retraction,exophalmos,infiltrative

ophthalmopathy.ophthalmopathy.






Skin manifestation:Skin manifestation: Warm,moist and velvety .Hot sweaty Warm,moist and velvety .Hot sweaty

hands,Onycholysis.Pretibial myxedema.hands,Onycholysis.Pretibial myxedema. Thyroid acropachy.Thyroid acropachy.






Metabolic system:Metabolic system: Weight loss,increase in appetite.Weight loss,increase in appetite. Apathetic hyperthyroidism?????Apathetic hyperthyroidism?????




TestsTests

TSH.TSH. Free t3,free t4.Free t3,free t4. TSI,antibodies.TSI,antibodies. Thyroid uptake of RA iodine.Thyroid uptake of RA iodine. Thyroid scan role.Thyroid scan role.









Thyroid Gland disorders

Documents

dubai 2008ppt70

thyroid disease

thyroid peroxidase

thyroid autoimmunity

thyroid antibodies

painless sporadic thyroid

atrophic thyroid gland

preformed thyroid hormones