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Thyroid
Thyroid

Tarek Mahdy

Ass Professor of Endocrine And Bariatric Surgery Mansoura Faculty Of Medicine Mansoura - Egypt

TheThe ThyroidThyroid GlandGland

The The Thyroid Thyroid Gland Gland NamedNamed afterafter thethe thyroidthyroid cartilagecartilage (Greek: (Greek:

NamedNamed afterafter thethe thyroidthyroid cartilagecartilage

(Greek:(Greek: ShieldShield--shaped)shaped)

Gland NamedNamed afterafter thethe thyroidthyroid cartilagecartilage (Greek: (Greek: Shield Shield - - shaped) shaped)

TheThe ThyroidThyroid GlandGland

The The Thyroid Thyroid Gland Gland VercelloniVercelloni 1711:1711: “ “ a a bag bag of of

VercelloniVercelloni 1711:1711: aa bagbag ofof wormswormswhosewhose eggseggs

passpass intointo thethe esophagusesophagus forfor digestivedigestive purposespurposes

ParryParry 1825:1825: aa vascularvascular shuntshunttoto cushioncushion thethe

brainbrain fromfrom suddensudden increasesincreases inin bloodblood flowflow

h i o n t h e t h e brain brain from from sudden sudden

ThyroidThyroid EmbryologyEmbryology

Thyroid Thyroid Embryology Embryology MedialMedial portionportion ofof thyroidthyroid glandgland ArisesArises

MedialMedial portionportion ofof thyroidthyroid glandgland ArisesArises fromefrome thethe endodermalendodermal tissuetissue ofof thethe basebase ofof tonguetongue posteriorlyposteriorly,, thethe foramenforamen cecumcecum -- lacklack ofof migrationmigration resultsresults inin aa retrolingualretrolingual massmass AttachedAttached toto tonguetongue byby thethe thyroglossalthyroglossal ductduct -- lacklack ofof atrophyatrophy afterafter thyroidthyroid descentdescent resultsresults inin midlinemidline cyscystt formationformation ((thyroglossalthyroglossal ductduct cyst)cyst) DescentDescent occursoccurs aboutabout fifthfifth weekweek ofof fetalfetal lifelife -- remnantsremnants maymay persistpersist alongalong tracktrack ofof descentdescent

persistpersist alongalong tracktrack ofof descentdescent LateralLateral lobeslobes ofof thyroidthyroid glandgland

LateralLateral lobeslobes ofof thyroidthyroid glandgland DerivedDerived fromfrom aa portionportion ofof ultimobranchialultimobranchial body,body, partpart ofof thethe fifthfifth branchialbranchial pouchpouch fromfrom whichwhich CC cellscells areare alsoalso derivedderived ((calcitonincalcitonin ssecretingecreting cellscells))

Lingual Thyroid (failure of descent)

Verification that lingual mass is thyroid by its ability to trap I 123

lingual mass is thyroid by its ability to trap I 1 2 3 Lingual thyroid Chin
lingual mass is thyroid by its ability to trap I 1 2 3 Lingual thyroid Chin

Lingual thyroid Chin marker

its ability to trap I 1 2 3 Lingual thyroid Chin marker Significance: May be only

Significance: May be only thyroid tissue in body (~70% of time), removal resulting in hypothyroidism; treatment consists of TSH suppression to shrink size

Anatomy, physiology and pathology of the thyroid gland
Anatomy, physiology and pathology of the thyroid gland
Anatomy, physiology and pathology of the thyroid gland
Anatomy, physiology and pathology of the thyroid gland

Anatomy, physiology and pathology of the thyroid gland

Anatomy, physiology and pathology of the thyroid gland
Anatomy
Anatomy
Anatomy

ThyroidThyroid AnatomyAnatomy

Thyroid Thyroid Anatomy Anatomy In some people a third “pyramidal lobe” exists, ascending from the isthmus

In some people a third “pyramidal lobe” exists, ascending from the isthmus towards hyoid bone

Brownish-red and soft during life Usually weighs about 25- 30g (larger in women) Surrounded by a thin, fibrous capsule of connective tissue External to this is a “false capsule” formed by pretracheal fascia

Right and left lobes United by a narrow isthmus, which extends across the trachea anterior to second and third tracheal cartilages

Position and relations Clasps anterior and lateral surface of pharynx, larynx, oesophagus and trachea “like
Position and relations Clasps anterior and lateral surface of pharynx, larynx, oesophagus and trachea “like
Position and relations Clasps anterior and lateral surface of pharynx, larynx, oesophagus and trachea “like
Position and relations Clasps anterior and lateral surface of pharynx, larynx, oesophagus and trachea “like

Position and relations

Position and relations Clasps anterior and lateral surface of pharynx, larynx, oesophagus and trachea “like a
Position and relations Clasps anterior and lateral surface of pharynx, larynx, oesophagus and trachea “like a

Clasps anterior and lateral surface of pharynx, larynx, oesophagus and trachea “like a shield” Lies deep to sternothyroid and sternohyoid muscles Parathyroid glands usually lie between posterior border of thyroid gland and its sheath (usually 2 on each side of the thyroid), often just lateral to anastomosis between vessel joining superior and inferior thyroid arteries Internal jugular vein and common carotid artery lie postero-lateral to thyroid

Position and relations Recurrent laryngeal nerve is an important structure lying between trachea and thyroid
Position and relations Recurrent laryngeal nerve is an important structure lying between trachea and thyroid
Position and relations Recurrent laryngeal nerve is an important structure lying between trachea and thyroid
Position and relations Recurrent laryngeal nerve is an important structure lying between trachea and thyroid

Position and relations

Position and relations Recurrent laryngeal nerve is an important structure lying between trachea and thyroid –
Position and relations Recurrent laryngeal nerve is an important structure lying between trachea and thyroid –

Recurrent laryngeal nerve is an important structure lying between trachea and thyroid

– may be injured during thyroid surgery ipsilateral VC paralysis, hoarse voice

Each lobe

– pear-shaped and ~5cm long

– extends inferiorly on each side of trachea (and oesophagus), often to level of 6 th tracheal cartilage

Attached to arch of cricoid cartilage and to oblique line of thyroid cartilage

– moves up and down with swallowing and oscillates during speaking

Arterial supply highly vascular main supply from superior and inferior thyroid arteries – lie between
Arterial supply highly vascular main supply from superior and inferior thyroid arteries – lie between
Arterial supply highly vascular main supply from superior and inferior thyroid arteries – lie between

Arterial supply

Arterial supply highly vascular main supply from superior and inferior thyroid arteries – lie between capsule
Arterial supply highly vascular main supply from superior and inferior thyroid arteries – lie between capsule
Arterial supply highly vascular main supply from superior and inferior thyroid arteries – lie between capsule

highly vascular main supply from superior and inferior thyroid arteries

– lie between capsule and pretracheal fascia (false capsule)

all thyroid arteries anastomose with one another on and in the substance of the thyroid, but little anastomosis across the median plane (except for branches of superior thyroid artery)

Arterial supply superior thyroid artery – first branch of ECA – descends to superior pole
Arterial supply superior thyroid artery – first branch of ECA – descends to superior pole
Arterial supply superior thyroid artery – first branch of ECA – descends to superior pole

Arterial supply

Arterial supply superior thyroid artery – first branch of ECA – descends to superior pole of
Arterial supply superior thyroid artery – first branch of ECA – descends to superior pole of
Arterial supply superior thyroid artery – first branch of ECA – descends to superior pole of

superior thyroid artery

– first branch of ECA

– descends to superior pole of gland, pierces pretracheal fascia then divides into 2-3 branches

inferior thyroid artery

– branch of thyro-cervical trunk

– runs superomedially posterior to carotid sheath

– reaches posterior aspect of gland

– divides into several branches which pierce pretracheal fascia to supply inferior pole of thyroid gland

– intimate relationship with recurrent laryngeal nerve

– in ~10% of people the thyroid ima artery arises from aorta, brachiocephalic trunk or ICA, ascends anterior to trachea to supply the isthmus

Venous drainage usually 3 pairs of veins drain venous plexus on anterior surface of thyroid
Venous drainage usually 3 pairs of veins drain venous plexus on anterior surface of thyroid
Venous drainage usually 3 pairs of veins drain venous plexus on anterior surface of thyroid

Venous drainage

Venous drainage usually 3 pairs of veins drain venous plexus on anterior surface of thyroid –
Venous drainage usually 3 pairs of veins drain venous plexus on anterior surface of thyroid –
Venous drainage usually 3 pairs of veins drain venous plexus on anterior surface of thyroid –

usually 3 pairs of veins drain venous plexus on anterior surface of thyroid

– superior thyroid veins drain superior poles

– middle thyroid veins drain lateral parts

• superior and middle thyroid veins empty into internal jugular veins

– inferior thyroid veins drain inferior poles

• empty into brachio-cephalic veins

• often unite to form a single vein that drains into one or other brachio-cephalic vein

Lymphatic drainage lymphatics run in the interlobular connective tissue, often around arteries communicate with a
Lymphatic drainage lymphatics run in the interlobular connective tissue, often around arteries communicate with a
Lymphatic drainage lymphatics run in the interlobular connective tissue, often around arteries communicate with a

Lymphatic drainage

Lymphatic drainage lymphatics run in the interlobular connective tissue, often around arteries communicate with a
Lymphatic drainage lymphatics run in the interlobular connective tissue, often around arteries communicate with a

lymphatics run in the interlobular connective tissue, often around arteries communicate with a capsular network of lymph vessels pass to prelaryngeal LN’s pretracheal and paratracheal LN’s lateral lymphatic vessels along superior thyroid veins pass to deep cervical LN’s some drainage directly into brachio-cephalic LN’s or directly into thoracic duct

Lymph nodes of the neck

Lymph nodes of the neck
Innervation nerves derived from superior, middle and inferior cervical sympathetic ganglia – reach thyroid through
Innervation nerves derived from superior, middle and inferior cervical sympathetic ganglia – reach thyroid through
Innervation nerves derived from superior, middle and inferior cervical sympathetic ganglia – reach thyroid through

Innervation

Innervation nerves derived from superior, middle and inferior cervical sympathetic ganglia – reach thyroid through
Innervation nerves derived from superior, middle and inferior cervical sympathetic ganglia – reach thyroid through
Innervation nerves derived from superior, middle and inferior cervical sympathetic ganglia – reach thyroid through

nerves derived from superior, middle and inferior cervical sympathetic ganglia

– reach thyroid through cardiac and laryngeal branches of vagus nerve which accompany arterial supply

postganglionic fibres and vasomotor – indirect action on thyroid by regulating blood vessels

HistologyHistology

Histology Histology

The thyroid gland is composed of 2 lobes connected by an isthmus.

It is surrounded by a dense irregular collagenous connective tissue capsule, in which (posteriorly) the parathyroid glands are embedded.

The thyroid gland is subdivided by capsular septa into lobules containing follicles.

These septa also serve as conduits for blood vessels, lymphatic vessels, & nerves

lobules containing follicles . These septa also serve as conduits for blood vessels, lymphatic vessels, &
Thyroid Follicles
Thyroid Follicles
Thyroid Follicles Thyroid follicles are spherical structures filled with colloid , a viscous gel consisting mostly

Thyroid follicles are spherical structures filled with colloid, a viscous gel consisting mostly of iodinated thyroglobulin.

Thyroid follicles are enveloped by a layer of epithelial cells, called follicular cells, which in turn are surrounded by parafollicular cells. These 2 parenchymal cell types rest on a basal lamina, which separates them from the abundant network of fenestrated capillaries in the connective tissue.

Function. Thyroid follciles synthesize & store thyroid hormones.

Follicular Cells
Follicular Cells

Follicular cells are normally cuboida l in shape but become columnar when stimulated & squamous when inactive. cuboidal in shape but become columnar when stimulated & squamous when inactive.

Follicular cells contain many small apical vesicles , involved in transport & release of thyroglobulin & into the colloid. apical vesicles, involved in transport & release of thyroglobulin & into the colloid.

Follicles: the Functional Units of the Thyroid Gland

Follicles: the Functional Units of the Thyroid Gland Follicles Are the Sites Where Key Thyroid Elements

Follicles Are the Sites Where Key Thyroid Elements Function:

• Thyroglobulin (Tg)

• Tyrosine

• Iodine

• Thyroxine (T 4 )

• Triiodotyrosine (T 3 )

Follicular Cells
Follicular Cells
Follicular Cells Synthesis & release of the thyroid hormones throxine ( T 4 ) & triiodothyronine

Synthesis & release of the thyroid hormones throxine (T 4 ) & triiodothyronine (T 3 )

Thyroglobulin is synthesized like other secretory proteins.

Circulating iodide is actively transported into the cytosol, where a thyroid peroxidase oxidizes it & iodinates tyrosine residues on the thyroglobulin molecule; iodination occurs mostly at the apical plasma membrane.

A rearrangement of the iodinated tyrosine residues of thyroglobulin in the colloid produces the iodothyronines T 4 & T 3 .

Follicular Cells
Follicular Cells

Binding of thyroid-stimulating hormone to receptors on the basal surface stimulates follicular cells to become columnar & to form apical pseudopods, which engulf colloid by endocytosis.

After the colloid droplets fuse with lysosomes, controlled hydrolysis of iodinated thyroglobulin liberates T 3 & T 4 into the cytosol.

These hormones move basally & are released basally into the bloodstream & lymphatic vessels.

basally into the bloodstream & lymphatic vessels. These processes are promoted by TSH , which binds

These processes are promoted by TSH, which binds to G-protein-linked receptors on the basal surface of follicular cells.

Parafollicular Cells
Parafollicular Cells
Parafollicular Cells Parafollicular cells are also called clear ( C ) cells because they stain less

Parafollicular cells are also called clear (C) cells because they stain less intensely than thyroid follicular cells.

They synthesize & release calcitonin, a polypeptide hormone, in response to high blood calcium levels.

cells. They synthesize & release calcitonin , a polypeptide hormone, in response to high blood calcium
cells. They synthesize & release calcitonin , a polypeptide hormone, in response to high blood calcium
Thyroid Physiology

Thyroid

Physiology

The Thyroid Produces and Secretes 2 Metabolic Hormones

Two principal hormones

Thyroxine (T 4 ) and triiodothyronine (T 3 )

Required for homeostasis of all cells

Influence cell differentiation, growth, and metabolism

Considered the major metabolic hormones because they target virtually every tissue

TRHTRH

ProducedProduced byby HypothalamusHypothalamus ReleaseRelease isis pulsatilepulsatile,, circadiancircadian DownregulatedDownregulated byby TT 33 TravelsTravels throughthrough portalportal venousvenous systemsystem toto adenohypophysisadenohypophysis StimulatesStimulates TSHTSH formationformation

Thyroid-Stimulating Hormone (TSH)

Upregulated by TRH

Downregulated by T4, T3

Travels through portal venous system to cavernous sinus, body.

Stimulates several processes

Iodine uptake

Colloid endocytosis

Growth of thyroid gland

Produced by Adenohypophysis Thyrotrophs

Hypothalamic-Pituitary-Thyroid Axis Negative Feedback Mechanism

Hypothalamic-Pituitary-Thyroid Axis Negative Feedback Mechanism

Biosynthesis of T 4 and T 3

The process includes

Dietary iodine (I) ingestion

Active transport and uptake of iodide (I - ) by thyroid gland

Oxidation of I - and iodination of thyroglobulin (Tg) tyrosine residues

Coupling of iodotyrosine residues (MIT and DIT) to form T 4 and T 3

Proteolysis of Tg with release of T 4 and T 3 into the circulation

Iodine Sources

Available through certain foods (eg, seafood, bread, dairy products), iodized salt, or dietary supplements, as a trace mineral

The recommended minimum intake is 150 µg/day

Active Transport and I - Uptake by the Thyroid

Dietary iodine reaches the circulation as iodide anion (I - )

The thyroid gland transports I - to the sites of hormone synthesis

I - accumulation in the thyroid is an active transport process that is stimulated by TSH

Oxidation of I - and Iodination of Thyroglobulin (Tg) Tyrosyl Residues

I - must be oxidized to be able to iodinate tyrosyl residues of Tg

Iodination of the tyrosyl residues then forms monoiodotyrosine (MIT) and diiodotyrosine (DIT), which are then coupled to form either T 3 or T 4

Both reactions are catalyzed by TPO

Thyroperoxidase (TPO)

TPO catalyzes the oxidation steps involved in I - activation, iodination of Tg tyrosyl residues, and coupling of iodotyrosyl residues

TPO has binding sites for I - and tyrosine

TPO uses H 2 O 2 as the oxidant to activate I - to hypoiodate (OI - ), the iodinating species

Proteolysis of Tg With Release of T 4 and T 3

T 4 and T 3 are synthesized and stored within the Tg molecule

Proteolysis is an essential step for releasing the hormones

To liberate T 4 and T 3 , Tg is resorbed into the follicular cells in the form of colloid droplets, which fuse with lysosomes to form phagolysosomes

Tg is then hydrolyzed to T 4 and T 3 , which are then secreted into the circulation

Conversion of T 4 to T 3 in Peripheral Tissues

Production of T 4 and T 3

T 4 is the primary secretory product of the thyroid gland, which is the only source of T 4

The thyroid secretes approximately 70-90 µg of T 4 per day

T 3 is derived from 2 processes

The total daily production rate of T 3 is about 15-30 µg

About 80% of circulating T 3 comes from deiodination of T 4 in peripheral tissues

About 20% comes from direct thyroid secretion

T 4 : A Prohormone for T 3

T 4 is biologically inactive in target tissues until converted to T 3

Activation occurs with 5' iodination of the outer ring of T 4

T 3 then becomes the biologically active hormone responsible for the majority of thyroid hormone effects

Sites of T 4 Conversion

The liver is the major extrathyroidal T 4 conversion site for production of T 3

Some T 4 to T 3 conversion also occurs in the kidney and other tissues

T 4 Disposition

Normal disposition of T 4

About 41% is converted to T 3

38% is converted to reverse T 3 (rT 3 ), which is metabolically inactive

21% is metabolized via other pathways, such as conjugation in the liver and excretion in the bile

Normal circulating concentrations

T 4 4.5-11 µg/dL

T 3 60-180 ng/dL (~100-fold less than T 4 )

Hormonal Transport

Carriers for Circulating Thyroid Hormones

More than 99% of circulating T 4 and T 3 is bound to plasma carrier proteins

Thyroxine-binding globulin (TBG), binds about 75%

Transthyretin (TTR), also called thyroxine-binding prealbumin (TBPA), binds about 10%-15%

Albumin binds about 7%

High-density lipoproteins (HDL), binds about 3%

Carrier proteins can be affected by physiologic changes, drugs, and disease

Free Hormone Concept

Only unbound (free) hormone has metabolic activity and physiologic effects

Free hormone is a tiny percentage of total hormone in plasma (about 0.03% T 4 ; 0.3% T 3 )

Total hormone concentration

Normally is kept proportional to the concentration of carrier proteins

Is kept appropriate to maintain a constant free hormone level

Changes in TBG Concentration Determine Binding and Influence T 4 and T 3 Levels

Increased TBG

Total serum T 4 and T 3 levels increase

Free T 4 (FT 4 ), and free T 3 (FT 3 ) concentrations remain unchanged

Decreased TBG

Total serum T 4 and T 3 levels decrease

FT 4 and FT 3 levels remain unchanged

Drugs and Conditions That Increase Serum T 4 and T 3 Levels by Increasing TBG

Drugs that increase TBG

Oral contraceptives and other sources of estrogen

Methadone

Clofibrate

5-Fluorouracil

Heroin

Tamoxifen

Conditions that increase TBG

Pregnancy

Infectious/chronic active hepatitis

HIV infection

Biliary cirrhosis

Acute intermittent porphyria

Genetic factors

Drugs and Conditions That Decrease Serum T 4 and T 3 by Decreasing TBG Levels or Binding of Hormone to TBG

Drugs that decrease serum T 4 and T 3

Glucocorticoids

Androgens

L-Asparaginase

Salicylates

Mefenamic acid

Antiseizure medications, eg, phenytoin, carbama- zepine

Furosemide

Conditions that decrease serum T 4 and T 3

Genetic factors

Acute and chronic illness

WolffWolff--ChaikoffChaikoff EffectEffect

IncreasingIncreasing dosesdoses ofof II -- increaseincrease hormonehormone synthesissynthesis initiallyinitially HigherHigher dosesdoses causecause cessationcessation ofof hormonehormone formation.formation. ThisThis effecteffect isis counteredcountered byby thethe IodideIodide leakleak fromfrom normalnormal thyroidthyroid tissue.tissue. PatientsPatients withwith autoimmuneautoimmune thyroiditisthyroiditis maymay failfail toto adaptadapt andand becomebecome hypohypothyroid.thyroid.

thyroiditisthyroiditis maymay failfail toto adaptadapt andand becomebecome hypohypo thyroid.thyroid.

JodJod--BasedowBasedow EffectEffect

OppositeOpposite ofof thethe WolffWolff--ChaikoffChaikoff effecteffect

ExcessiveExcessive iodineiodine loadsloads induceinduce hyperhyperthyroidismthyroidism

ObservedObserved inin hyperthyroidhyperthyroid diseasedisease processesprocesses

GravesGravesdiseasedisease ToxicToxic multinodularmultinodular goitergoiter

ToxicToxic adenomaadenoma

ThisThis effecteffect maymay leadlead toto symptomaticsymptomatic thyrotoxicosisthyrotoxicosis inin patientspatients whowho receivereceive largelarge iodineiodine dosesdoses fromfrom

DietaryDietary changechangess

ContrastContrast administrationadministration

IodineIodine containingcontaining medicationmedication ((AmiodaroneAmiodarone))

PerchloratePerchlorate

ClOClO 44 -- ionion inhibitsinhibits thethe NaNa ++ // II -- transporttransport protein.protein. NormalNormal individualsindividuals showshow nono leakleak ofof II 123123 afterafter ClOClO 44 duedue toto organificationorganification ofof II -- toto MITMIT // DITDIT PatientsPatients withwith organificationorganification defectsdefects showshow lossloss ofof RAIU.RAIU. UsedUsed inin diagnosisdiagnosis ofof PendredPendred syndromesyndrome

--

showshow lossloss ofof RAIU.RAIU. UsedUsed inin diagnosisdiagnosis ofof PendredPendred syndromesyndrome --

Thyroid Hormone Action

Thyroid Hormone Plays a Major Role in Growth and Development

Thyroid hormone initiates or sustains differentiation and growth

Stimulates formation of proteins, which exert trophic effects on tissues

Is essential for normal brain development

Essential for childhood growth

Untreated congenital hypothyroidism or chronic hypothyroidism during childhood can result in incomplete development and mental retardation

Thyroid Hormones and the Central Nervous System (CNS)

Thyroid hormones are essential for neural development and maturation and function of the CNS

Decreased thyroid hormone concentrations may lead to alterations in cognitive function

Patients with hypothyroidism may develop impairment of attention, slowed motor function, and poor memory

Thyroid-replacement therapy may improve cognitive function when hypothyroidism is present

Thyroid Hormone Influences Cardiovascular Hemodynamics

Thyroid hormone Mediated Thermogenesis (Peripheral Tissues)

hormone Mediated Thermogenesis (Peripheral Tissues) Release Metabolic Endproducts Local Vasodilitation

Release Metabolic Endproducts

(Peripheral Tissues) Release Metabolic Endproducts Local Vasodilitation Decreased Elevated Blood Volume T 3

Local

Vasodilitation

Decreased
Decreased

Elevated Blood Volume

Local Vasodilitation Decreased Elevated Blood Volume T 3 Increased Cardiac Output Cardiac Chronotropy and

T 3

Local Vasodilitation Decreased Elevated Blood Volume T 3 Increased Cardiac Output Cardiac Chronotropy and Inotropy
Local Vasodilitation Decreased Elevated Blood Volume T 3 Increased Cardiac Output Cardiac Chronotropy and Inotropy

Increased Cardiac Output

Elevated Blood Volume T 3 Increased Cardiac Output Cardiac Chronotropy and Inotropy Systemic Vascular

Cardiac Chronotropy and Inotropy

Increased Cardiac Output Cardiac Chronotropy and Inotropy Systemic Vascular Resistance Decreased Diastolic Blood

Systemic

Vascular

Resistance

Decreased Diastolic Blood Pressure

Laragh JH, et al. Endocrine Mechanisms in Hypertension. Vol. 2. New York, NY: Raven Press;1989.

Thyroid Hormone Influences the Female Reproductive System

Normal thyroid hormone function is important for reproductive function

Hypothyroidism may be associated with menstrual disorders, infertility, risk of miscarriage, and other complications of pregnancy

Doufas AG, et al. Ann N Y Acad Sci. 2000;900:65-76. Glinoer D. Trends Endocrinol Metab. 1998; 9:403-411. Glinoer D. Endocr Rev. 1997;18:404-433.

Thyroid Hormone is Critical for Normal Bone Growth and Development

T 3 is an important regulator of skeletal maturation at the growth plate

T 3 regulates the expression of factors and other contributors to linear growth directly in the growth plate

T 3 also may participate in osteoblast differentiation and proliferation, and chondrocyte maturation leading to bone ossification

Thyroid Hormone Regulates Mitochondrial Activity

T 3 is considered the major regulator of mitochondrial activity

A potent T 3 -dependent transcription factor of the mitochondrial genome induces early stimulation of transcription and increases transcription factor (TFA) expression

T 3 stimulates oxygen consumption by the mitochondria

Thyroid Hormones Stimulate Metabolic Activities in Most Tissues

Thyroid hormones (specifically T 3 ) regulate rate of overall body metabolism

T 3 increases basal metabolic rate

Calorigenic effects

T 3 increases oxygen consumption by most peripheral tissues

Increases body heat production

Metabolic Effects of T 3

Stimulates lipolysis and release of free fatty acids and glycerol

Induces expression of lipogenic enzymes

Effects cholesterol metabolism

Stimulates metabolism of cholesterol to bile acids

Facilitates rapid removal of LDL from plasma

Generally stimulates all aspects of carbohydrate metabolism and the pathway for protein degradation

EvaluationEvaluation OfOf ThyroidThyroid

Evalu ation Evalu ation Of Of T hyroid T hyroid

HistoryHistory

AgeAge GenderGender ExposureExposure toto RadiationRadiation Signs/symptomsSigns/symptoms ofof hyperhyper-- // hypohypo-- thyroidismthyroidism RapidRapid changechange inin sizesize

WithWith painpain maymay indicateindicate hemorrhagehemorrhage intointo nodulenodule WithoutWithout painpain maymay bebe badbad signsign

HistoryHistory

GardnerGardner SyndromeSyndrome (familial(familial adenomatousadenomatous polyposispolyposis))

AssociationAssociation foundfound withwith thyroidthyroid caca MostlyMostly inin youngyoung womenwomen (94%)(94%) (RR(RR 160)160) ThyroidThyroid caca precededpreceded dxdx ofof GarnersGarners 30%30% ofof timetime

CowdenCowden SyndromeSyndrome

MucocutaneousMucocutaneous hamartomashamartomas,, keratoses,fibrocystickeratoses,fibrocystic breastbreast changeschanges && GIGI polypspolyps FoundFound toto havehave associationassociation withwith thyroidthyroid caca (8/26(8/26 patientspatients inin oneone series)series)

HistoryHistory

FamilialFamilial h/oh/o medullarymedullary thyroidthyroid carcinomacarcinoma

FamilialFamilial MTCMTC vsvs MENMEN IIII

FamilyFamily hxhx ofof otherother thyroidthyroid caca H/oH/o HashimotoHashimoto’’ss thyroiditisthyroiditis (lymphoma)(lymphoma)

HistoryHistory

HistoryHistory elementselements suggestivesuggestive ofof malignancy:malignancy:

ProgressiveProgressive enlargementenlargement HoarsenessHoarseness DysphagiaDysphagia DyspneaDyspnea HighHigh--riskrisk ((famfam hxhx,, radiation)radiation)

NotNot veryvery sensitivesensitive // specificspecific

DDisordersisorders ooff tthehe TThyroidhyroid GlandGland

PhysicalPhysical ExaminationExamination ofof thethe ThyroidThyroid GlandGland

InspectionInspection GlassGlass ofof watewaterr forfor swallowingswallowing

PalpationPalpation AnteriorlyAnteriorly FromFrom behindbehind

EachEach lobelobe meameasuressures :: vertverticalical dimensiondimension horizontalhorizontal dimensiondimension –– 11 cmcm

: : vert vertical ical dimension dimension horizontalhorizontal dimensiondimension –– 11 cmcm –– 22 cmcm

–– 22 cmcm

ThyroidThyroid PalpationPalpation

TextureTexture –– softsoft // firmfirm // hardhard

TextureTexture –– softsoft // firmfirm // hardhard SurfaceSurface –– smoothsmooth // seedyseedy //

SurfaceSurface –– smoothsmooth // seedyseedy // lumpylumpy

ShapeShape

–– diffusediffuse // nodularnodular

PresencePresence ofof regionalregional adenopathyadenopathy

PhysicalPhysical

CompleteComplete HeadHead && NeckNeck examexam VocalVocal cordcord mobilitymobility (?Strobe)(?Strobe) PalpationPalpation thyroidthyroid CervicalCervical lymphadenopathylymphadenopathy OphthalmopathyOphthalmopathy

PhysicalPhysical

PhysicalPhysical findingsfindings suggestivesuggestive ofof malignancy:malignancy:

FixationFixation AdenopathyAdenopathy FixedFixed cordcord IndurationInduration StridorStridor

NotNot veryvery sensitivesensitive // specificspecific

GravesGraves OphthalmopathyOphthalmopathy

Graves Graves Ophthalmopathy Ophthalmopathy

NeckNeck BruisingBruising

Neck Neck Bruising Bruising SuggestsSuggests hemorrhagehemorrhage intointo nodulenodule

SuggestsSuggests hemorrhagehemorrhage intointo nodulenodule

LingualLingual ThyroidThyroid

Lingual Lingual Thyroid Thyroid

WorkupWorkup

SerumSerum TestingTesting

TSHTSH –– firstfirst--lineline serumserum testtest

IdentifiesIdentifies subclinicalsubclinical thyrotoxicosisthyrotoxicosis

T4,T4, T3T3 CalciumCalcium ThyroglobulinThyroglobulin

PostPost--treatmenttreatment goodgood toto detectdetect recurrencerecurrence

CalcitoninCalcitonin –– onlyonly inin casescases ofof medullarymedullary AntibodiesAntibodies –– HashimotoHashimoto’’ss RETRET protoproto--oncogeneoncogene

GraphGraph
GraphGraph

ImagingImaging

PlainPlain FilmsFilms

NotNot routinelyroutinely orderedordered MayMay show:show:

TrachealTracheal deviationdeviation PulmonaryPulmonary metastasismetastasis CalcificationsCalcifications (suggests(suggests papillarypapillary oror medullary)medullary)

TrachealTracheal DeviationDeviation

Tracheal Tracheal Deviation Deviation

ThyroidThyroid ultrasoundultrasound

Thyroid Thyroid ultrasound ultrasound

ThyroidThyroid ultrasoundultrasound

Thyroid Thyroid ultrasound ultrasound

UltrasonographyUltrasonography

ThyroidThyroid vs.vs. nonnon--thyroidthyroid

GoodGood screenscreen forfor thyroidthyroid presencepresence inin childrenchildren

CysticCystic vs.vs. solidsolid LocalizationLocalization forfor FNAFNA oror injectioninjection SerialSerial examexam ofof nodulenodule sizesize

22--33 mmmm lowerlower endend ofof resolutionresolution

MayMay distinguishdistinguish solitarysolitary nodulenodule fromfrom multinodularmultinodular goitergoiter

DominantDominant nodulenodule risksrisks nono differentdifferent

UltrasonographyUltrasonography

FindingsFindings suggestivesuggestive ofof malignancy:malignancy:

PresencePresence ofof halohalo IrregularIrregular borderborder PresencePresence ofof cysticcystic componentscomponents PresencePresence ofof calcificationscalcifications HeterogeneousHeterogeneous echoecho patternpattern ExtrathyroidalExtrathyroidal extensionextension

NoNo findingsfindings areare definitivedefinitive

NuclearNuclear MedicineMedicine

ConceptConcept UsesUses

MetabolicMetabolic studiesstudies ImagingImaging

IodineIodine isis takentaken upup byby glandgland andand organifiedorganified TechnetiumTechnetium trappedtrapped butbut notnot organifiedorganified UsuallyUsually onlyonly forfor papillarypapillary andand follicularfollicular RectilinearRectilinear scannerscanner (historical(historical interest)interest) vs.vs. scintillationscintillation cameracamera

NuclearNuclear MedicineMedicine

Nuclear Nuclear Medicine Medicine
Nuclear Nuclear Medicine Medicine

RectilinearRectilinear ScanScan

ProvidedProvided lifelife-- sizesize imagesimages NotNot commoncommon todaytoday

Rectilinear Rectilinear Scan Scan ProvidedProvided lifelife -- sizesize imagesimages NotNot commoncommon todaytoday

NuclearNuclear MedicineMedicine

Radioisotopes:Radioisotopes:

II--131131 II--123123 II--125125 TcTc--99m99m ThalliumThallium--201201 GalliumGallium 6767

NuclearNuclear MedicineMedicine

TechnetiumTechnetium 99m99m

MostMost commonlycommonly usedused isotopeisotope (some(some authors)authors) 99m:99m: ““mm”” refersrefers toto metastablemetastable nuclidenuclide

DecayDecay productproduct ofof MolybdenumMolybdenum--9999 LongLong halfhalf--lifelife beforebefore decayingdecaying intointo TcTc--9999

AdministeredAdministered asas pertechnatepertechnate (TcO4(TcO4 -- )) ImagesImages cancan bebe obtainedobtained quicklyquickly

““OneOne--StopStop”” evaluationevaluation

HotHot nodulesnodules needneed f/uf/u IodineIodine scanscan

DiscordantDiscordant nodulesnodules higherhigher riskrisk ofof malignancymalignancy

NuclearNuclear MedicineMedicine

IodineIodine

127127 –– onlyonly stablestable isotopeisotope ofof iodineiodine 123123 –– cyclotroncyclotron productproduct

HalfHalf--lliiffee 13.313.3 hrhr Expensive,Expensive, limitedlimited availabilityavailability LowLow radiationradiation--exposureexposure toto patientpatient

131131 –– fissionfission productproduct

HalfHalf--lifelife 88 dadaysys Cheap,Cheap, widelywidely availableavailable BetterBetter forfor metsmets (diagnostic(diagnostic andand therapeutic)therapeutic) (high(high radiationradiation exposure)exposure)

125125 –– nono longerlonger usedused

LongLong halfhalf--lifelife (60(60 days);days); highhigh radiationradiation exposureexposure witwithh poorpoor visualizationvisualization

RadioactiveRadioactive iodineiodine uptakeuptake andand scanscan

RadioRadio labeledlabeled IodineIodine (I(I--123)123) isis givengiven toto thethe patientpatient whichwhich isis activelyactively trappedtrapped andand concentratedconcentrated byby thethe thyroidthyroid gland.gland. ItIt cancan assess:assess:

FunctionFunction UptakeUptake MorphologyMorphology ScanScan

RadioactiveRadioactive iodineiodine uptakeuptake

Uptake:Uptake:

--MeasurementsMeasurements ofof %% ofof thethe administeredadministered dosedose localizinglocalizing toto thethe glandgland atat aa fixedfixed time.time. --ReflectsReflects glandgland function.function. --NormalNormal 2424 hourhour uptakeuptake isis ~10~10 toto 30%.30%.

Tc Tc - - 99m 99m versus versus I I - - 123 123

TcTc--99m99m versusversus II--123123

RadioactiveRadioactive iodineiodine scanscan

Radioactive Radioactive iodine iodine “ “ scan scan ” ”
Radioactive Radioactive iodine iodine “ “ scan scan ” ”

CombiningCombining uptakeuptakeandand scanscan

AnyAny nodulesnodules cancan bebe HotHot,, WarmWarm,, oror ColdColddependingdepending onon thethe intensityintensity ofof thethe uptake.uptake.

HotHot NoduleNodule

Hot Hot Nodule Nodule

ColdCold nodulenodule

Cold Cold nodule nodule

MultinodularMultinodular GoiterGoiter

Multinodular Multinodular Goiter Goiter

RadioactiveRadioactive iodineiodine uptakeuptake andand scanscan

HotHotnodulesnodules (autonomously(autonomously functioningfunctioning thyroidthyroid nodules)nodules) areare usuallyusually notnot malignant,malignant, forfor practicalpractical purposes.purposes. ColdColdnodulesnodules (( eithereither hypofunctioninghypofunctioning oror nonfunctioning)nonfunctioning) cancan bebe malignantmalignant inin approximatelyapproximately 55--8%8% ofof cases.cases.

NuclearNuclear MedicineMedicine

ThalliumThallium--201201

Expensive,Expensive, rolerole poorlypoorly defineddefined CanCan detectdetect (but(but notnot treat)treat) metsmets NotNot trappedtrapped oror organifiedorganified –– mechanismmechanism unclearunclear

PotassiumPotassium analogueanalogue

PotentialPotential advantages:advantages:

NotNot necessarynecessary toto bebe offoff thyroidthyroid replacementreplacement PatientsPatients withwith largelarge bodybody iodineiodine poolpool (ex:(ex: recentrecent CTCT withwith contrast)contrast) oror hypofunctioninghypofunctioning glandgland CanCan sometimessometimes imageimage medullarymedullary

NuclearNuclear MedicineMedicine

GalliumGallium--6767

GenerallyGenerally lightslights upup inflammationinflammation

HashimotoHashimoto’’ss

UsesUses inin thyroidthyroid imagingimaging limitedlimited

AnaplasticAnaplastic LymphomaLymphoma

NuclearNuclear MedicineMedicine

OtherOther imagingimaging agentsagents

TcTc--99m99m sestamibisestamibi TcTc--99m99m pentavalentpentavalent DMSADMSA RadioiodinatedRadioiodinated MIBGMIBG

DevelopedDeveloped forfor medullarymedullary (APUD(APUD derivative)derivative)

RadiolabeledRadiolabeled monoclonalmonoclonal antibodiesantibodies

NuclearNuclear MedicineMedicine

HurthleHurthle--cellcell neoplasmsneoplasms

BetterBetter imagedimaged withwith TechnetiumTechnetium sestamibisestamibi

ConcentratesConcentrates inin mitochondiramitochondira

PoorlyPoorly imagedimaged withwith iodineiodine

OtherOther ImagingImaging ModalitiesModalities

CTCT

KeepKeep inin mindmind iodineiodine inin contrastcontrast

MRIMRI

PETPET

NotNot firstfirst--line,line, butbut maymay bebe adjunctiveadjunctive

MRIMRI

MRI MRI

FineFine NeedleNeedle AspirationAspiration (FNA)(FNA)

Fine Fine Needle Needle Aspiration Aspiration (FNA) (FNA)

USUS GuidedGuided FNAFNA

US US Guided Guided FNA FNA

FineFine--NeedleNeedle AspirationAspiration BiopsyBiopsy

Technique:Technique:

2525--gaugegauge needleneedle MultipleMultiple passespasses IdeallyIdeally fromfrom peripheryperiphery ofof lesionlesion ReaspirateReaspirate afterafter fluidfluid drawndrawn ImmediatelyImmediately smearedsmeared andand fixedfixed PapanicolaouPapanicolaou stainstain commoncommon

FineFine--needleneedle aspirationaspiration (FNA)(FNA) biopsybiopsy

Fine Fine - - needle needle aspiration aspiration (FNA) (FNA) biopsy biopsy Source: Thyroid Disease Manager

Source: Thyroid Disease Manager

FNAFNA biopsybiopsy

FNA FNA biopsy biopsy Source: Thyroid Disease Manager

Source: Thyroid Disease Manager

FNAFNA biopsybiopsy

FNA FNA biopsy biopsy Source: Thyroid Disease Manager

Source: Thyroid Disease Manager

FNAFNA resultsresults

InadequateInadequate specimenspecimen AdequateAdequate specimenspecimen BenignBenign MalignantMalignant SuspiciousSuspicious

FineFine--NeedleNeedle AspirationAspiration BiopsyBiopsy

EmergedEmerged inin 1970s1970s –– hashas becomebecome standardstandard firstfirst--lineline testtest forfor diagnosisdiagnosis ConceptConcept ResultsResults comparablecomparable toto largelarge--needleneedle biopsy,biopsy, lessless complicationscomplications Safe,Safe, efficacious,efficacious, costcost--effectiveeffective AllowAllow preoppreop diagnosisdiagnosis andand thereforetherefore planningplanning SomeSome useuse forfor sclerosingsclerosing nodulesnodules

FineFine--NeedleNeedle AspirationAspiration BiopsyBiopsy

Problems:Problems:

SamplingSampling errorerror

SmallSmall (<1(<1 cm)cm) LargeLarge (>4(>4 cm)cm)

HashimotoHashimoto’’ss versusversus lymphomalymphoma FollicularFollicular neoplasmsneoplasms FluidFluid--onlyonly cystscysts SomewhatSomewhat dependentdependent onon skillskill ofof cytopathologistcytopathologist

FNAFNA ofof PapillaryPapillary CaCa

NG:NG:

nuclearnuclear groovesgrooves IC:IC:

intranucleaintranuclea rr inclusionsinclusions

Papillary Ca Ca NG:NG: nuclearnuclear groovesgrooves IC:IC: intranucleaintranuclea rr inclusionsinclusions
ThyroidThyroid
ThyroidThyroid

TarekTarek MahdyMahdy

AssAss ProfessorProfessor ofof EndocrineEndocrine AndAnd BariBariatricatric SurgerySurgery MansouraMansoura FacultyFaculty OfOf MedicineMedicine MansouraMansoura -- EgyptEgypt

DisordersDisorders ofof thethe ThyroidThyroid GlandGland

AbnormalAbnormal thyroidthyroid functionfunction

HypothyroidismHypothyroidism HyperthyroidismHyperthyroidism

ThyroidThyroid enlargementenlargement

StructuralStructural ThyroidThyroid DiseaseDisease ¬¬

AbnormalAbnormal thyroidthyroid functionfunction

HypothyroidismHypothyroidism

HyperthyroidismHyperthyroidism

HypothyroidismHypothyroidism

HypothyroidismHypothyroidism isis aa disorderdisorder withwith multiplemultiple causescauses inin whichwhich thethe thyroidthyroid failsfails toto secretesecrete anan adequateadequate amountamount ofof thyroidthyroid hormonehormone

TheThe mostmost commoncommon thyroidthyroid disorderdisorder

UsuallyUsually causedcaused byby primaryprimary thyroidthyroid glandgland failurefailure

AlsoAlso maymay resultresult fromfrom diminisheddiminished stimulationstimulation ofof thethe thyroidthyroid glandgland byby TSHTSH

HyperthyroidismHyperthyroidism

HyperthyroidismHyperthyroidism refersrefers toto excessexcess synthesissynthesis andand secretionsecretion ofof thyroidthyroid hormoneshormones byby thethe thyroidthyroid gland,gland, whichwhich resultsresults inin acceleratedaccelerated metabolismmetabolism inin peripheralperipheral tissuestissues

TypicalTypical ThyroidThyroid HormoneHormone LevelsLevels inin ThyroidThyroid DiseaseDisease

 

TSHTSH

TT 44

TT 33

HypothyroidismHypothyroidism

HighHigh

LowLow

LowLow

HyperthyroidismHyperthyroidism

LowLow

HighHigh

HighHigh

ClinicalClinical FeaturesFeatures ofof HypothyroidismHypothyroidism

Features Features of of Hypothyroidism Hypothyroidism Tiredness Forgetfulness/Slower Thinking Puffy Eyes Enlarged

Tiredness

Forgetfulness/Slower Thinking

Puffy Eyes

Enlarged Thyroid (Goiter)

Thinking Puffy Eyes Enlarged Thyroid (Goiter) Moodiness/ Irritability Depression Inability to Concentrate

Moodiness/ Irritability

Depression

Inability to Concentrate

Hoarseness/ Deepening of Voice

Persistent Dry or Sore Throat

Thinning Hair/Hair Loss

Difficulty Swallowing

Loss of Body Hair

Dry, Patchy Skin

Slower Heartbeat

Menstrual Irregularities/ Heavy Period

Infertility

Weight Gain Cold Intolerance

Elevated Cholesterol

Family History of Thyroid Disease or Diabetes

Constipation

Muscle Weakness/ Cramps

HypothyroidismHypothyroidism

Hypothyroidism Hypothyroidism

HypothyroidHypothyroid FaceFace

Notice the apathetic facies, bilateral ptosis, and absent eyebrows

Hypothyroid Hypothyroid Face Face Notice the apathetic facies, bilateral ptosis, and absent eyebrows

Faces of Clinical Hypothyroidism

Faces of Clinical Hypothyroidism

HypothyroidismHypothyroidism

ClinicalClinical

PresentationsPresentations

EasyEasy fatigabilityfatigability

ColdnessColdness WeightWeight gaingain ConstipationConstipation MenstrualMenstrual irregularitiesirregularities MuscleMuscle crumpscrumps HairHair lossloss

Difficulty Difficulty concentrating concentrating

ClinicalClinical FindingsFindings

SkinSkin –– cool,cool, rough,rough, drydry yellowishyellowish colorcolor ((carotenemiacarotenemia)) FaceFace –– puffypuffy VoiceVoice –– hoarsehoarse ReflexesReflexes –– slowslow BradycardiaBradycardia PeripheralPeripheral nonpittingnonpitting

edema edema

HypothyroidismHypothyroidism

CVSCVS ::

ImpairedImpaired muscularmuscular contractioncontraction

EKGEKG -- bradycardiabradycardia,, lowlow voltagevoltage ofof QRSQRS complexescomplexes andand PP andand TT waveswaves

QRSQRS complexescomplexes andand PP andand TT waveswaves EchoEcho -- cardiaccardiac enlargement,enlargement,
QRSQRS complexescomplexes andand PP andand TT waveswaves EchoEcho -- cardiaccardiac enlargement,enlargement,

EchoEcho -- cardiaccardiac enlargement,enlargement, pericardialpericardial effusioneffusion

HypothyroidismHypothyroidism

PulmonaryPulmonary functionfunction ::

RespirationsRespirations –– shallowshallow andand slowslow ImpairedImpaired ventilatoryventilatory responseresponse toto hypercapniahypercapnia

AnemiaAnemia ::

ImpairedImpaired HbHb synthesissynthesis IronIron andand folatefolate deficiencydeficiency PerniciousPernicious anemiaanemia

RenalRenal functionfunction ::

DecreasedDecreased GFRGFR ImpairedImpaired abilityability toto excreteexcrete waterwater loadload

HypothyroidismHypothyroidism

NeuromuscularNeuromuscular systemsystem ::

MuscleMuscle crumpscrumps andand weaknessweakness ParesthesiasParesthesias CarpalCarpal tunneltunnel syndromesyndrome

CNSCNS symptomssymptoms ::

LethargyLethargy InabilityInability toto concentrateconcentrate DepressionDepression

HypothyroidismHypothyroidism

DiagnosticDiagnostic StudiesStudies ThyroidThyroid functionfunction teststests

TSH,TSH, fTfT4,4, TTTT33

ThyroidThyroid autoantibodiesautoantibodies

AntiAnti TPO,TPO, AntiAnti TgTg

UUltrasonographyltrasonography

EnlargedEnlarged thyroidthyroid glandgland withwith aa diffuselydiffusely hypoechogenichypoechogenic patternpattern

OtherOther LaboratoryLaboratory StudiesStudies:: ElevatedElevated cholesterolcholesterol

andand TG,TG, elevatedelevated CPKCPK

anemia,anemia,

CausesCauses ofof HypothyroidismHypothyroidism

PrimaryPrimary (fT(fT 44 ;; TSHTSH ))

AutoimmuneAutoimmune (Hashimoto(Hashimoto’’s)s) thyroiditisthyroiditis

Iatrogenic:Iatrogenic: 131131 II treatment,treatment, ionizingionizing externalexternal irradiation,irradiation,

susubbttotalotal oror totaltotal thyroidectomythyroidectomy

Drugs:Drugs:

InterleukinInterleukin--22

AmiodaroneAmiodarone,, Lithium,Lithium, InterferonInterferon--αα,,

Congenital:Congenital: absentabsent oror ectopicectopic thyroidthyroid gland,gland, dyshormonogenesisdyshormonogenesis,, TSHTSH--RR mutationmutation

IodineIodine deficiencydeficiency

InfiltrativeInfiltrative disorders:disorders: amyloidosisamyloidosis,, sarcoidosissarcoidosis,, hemochromatosishemochromatosis,, scleroderma,scleroderma,

ccyystinosisstinosis

CausesCauses ofof HypothyroidismHypothyroidism

CentralCentral -- HypothalamicHypothalamic--pituitarypituitary dysfunctiondysfunction (fT(fT 44 ;; TSHTSH N/N/))

TumorsTumors PituitaryPituitary surgerysurgery oror irradiationirradiation InfiltrativeInfiltrative disordersdisorders TraumaTrauma GeneticGenetic formsforms ofof CPHDCPHD oror isolatedisolated TSHTSH deficiencydeficiency

TransientTransient (fT(fT 44 N/N///;; TSHTSH /N//N/))

SilentSilent thyroiditisthyroiditis includingincluding postpost--partumpartum thyroiditisthyroiditis

AutoimmuneAutoimmune (Hashimoto(Hashimotos)s) ThyroiditisThyroiditis

PrevalencePrevalence

5%5% -- 15%15% ofof womenwomen

1%1% --

5%5% ofof menmen

SexSex ratioratio (F:M)(F:M) -- 88--9:19:1 DiagnosticDiagnostic criteriacriteria

PositivePositive testtest forfor thyroidthyroid autoantibodiesautoantibodies PresencePresence ofof lymphocyticlymphocytic infiltrationinfiltration ofof thyroidthyroid GoiterGoiter ThyroidThyroid functions:functions: 50%50%--75%75% -- euthyroideuthyroid 25%25%--50%50% -- subclinucalsubclinucal

hypothyroidismhypothyroidism

5%5%--10%10% -- overtovert hypothyroidismhypothyroidism

AAutoimmuneutoimmune ((HashimiotoHashimiotoss)) ThyroiditisThyroiditis

AssociationsAssociations withwith otherother diseasesdiseases

IDDMIDDM (Insulin(Insulin dependentdependent diabetesdiabetes mellitus)mellitus)

AutoimmuneAutoimmune polyendocrinpolyendocrinopathyopathy diseasesdiseases

TypeType 1:1: momocococutanecutaneoouuss candcandidiidiaadisdis,, hypoparathyroidismhypoparathyroidism,, AddisonAddison’’ss diseasedisease,, alalopecia,opecia, primprimaryary hypogonadismhypogonadism ……

TypeType 2:2: AddisonAddison’’ss diseasedisease,, thyroiditithyroiditiss,, IDDMIDDM ……

PerniciousPernicious anemianemiaa AddisonAddison‘‘ss diseasedisease MyastheniaMyasthenia gravisgravis VitVitiligoiligo CeliacCeliac disediseasease

TurnerTurner syndromesyndrome (50%)(50%) DownDown synsynddromerome (20%)(20%) KlienfelterKlienfelter syndromesyndrome

HashimotoHashimotoss

(Chronic,(Chronic, LymphocyticLymphocytic))

MostMost commoncommon causecause ofof hypothyroidismhypothyroidism UsuallyUsually nonnon--tendertender andand asymptomaticasymptomatic BossalatedBossalated

UsuallyUsually nonnon -- tendertender andand asymptomaticasymptomatic BossalatedBossalated

AntibodiesAntibodies inin HashimotoHashimotoss

AntimicrosomalAntimicrosomal abysabys

AgainstAgainst peroxidaseperoxidase

AntithyroglobulinAntithyroglobulin abysabys

AgainstAgainst thyroglobulinthyroglobulin

AutoantibodiesAutoantibodies againstagainst TSHTSH receptorreceptor

NetNet effecteffect isis preventprevent TSHTSH stimulationstimulation ofof glandgland

HashimotoHashimotoss ThyroiditisThyroiditis

TreatmentTreatment

’ ’ s s Thyroiditis Thyroiditis Treatment Treatment LevothyroxineLevothyroxine ifif hypothyroidhypothyroid

LevothyroxineLevothyroxine ifif hypothyroidhypothyroid TriiodothyronineTriiodothyronine (for(for myxedemamyxedema coma)coma) ThyroidThyroid suppressionsuppression ((levothyroxinelevothyroxine)) toto decreasedecrease goitergoiter sizesize SurgerySurgery forfor compressioncompression oror painpain oror suspicioussuspicious ofof malignantmalignant

GrossGross andand MicroscopicMicroscopic PathologyPathology ofof ChronicChronic ThyroiditisThyroiditis

Gross Gross and and Microscopic Microscopic Pathology Pathology of of Chronic Chronic Thyroiditis Thyroiditis
Gross Gross and and Microscopic Microscopic Pathology Pathology of of Chronic Chronic Thyroiditis Thyroiditis

SubacuteSubacute ThyroiditisThyroiditis

DeQuervainDeQuervainss,, GranulomatousGranulomatous

MostMost commoncommon causecause ofof painfulpainful

thyroiditisthyroiditis OftenOften followsfollows aa URIURI

FNAFNA maymay revealreveal multinuleatedmultinuleated

giantgiant cellscells oror granulomatousgranulomatous change.change. CourseCourse

PainPain andand thyrotoxicthyrotoxicosisosis (3(3--66 weeks)weeks) AsymptomaticAsymptomatic euthyroidismeuthyroidism HypothyroidHypothyroid periodperiod (weeks(weeks toto months)months) RecoveryRecovery (complete(complete inin 9595%% afterafter 44--66 months)months)

(weeks(weeks toto months)months) RecoveryRecovery (complete(complete inin 9595%% afterafter 44 -- 66 months)months)
(weeks(weeks toto months)months) RecoveryRecovery (complete(complete inin 9595%% afterafter 44 -- 66 months)months)
(weeks(weeks toto months)months) RecoveryRecovery (complete(complete inin 9595%% afterafter 44 -- 66 months)months)
(weeks(weeks toto months)months) RecoveryRecovery (complete(complete inin 9595%% afterafter 44 -- 66 months)months)

SubacuteSubacute ThyroiditisThyroiditis

DiagnosisDiagnosis

ElevaElevatteded ESRESR AnemiaAnemia ((normochromicnormochromic,, normocyticnormocytic)) LowLow TSH,TSH, ElevatedElevated T4T4 >> T3,T3, LowLow antianti--TPO/TPO/TgbTgb LowLow RAIRAI uptakeuptake (same(same asas silentsilent thyroiditisthyroiditis))

TreatmentTreatment

NSAIDNSAID’’ss andand salicylsalicylatesates OralOral steroidssteroids inin severesevere casescases BetaBeta blblockersockers forfor symptomssymptoms ofof hyperthyroihyperthyroiddism,ism, IopaIopanoicnoic acidacid forfor severesevere symptomssymptoms PTUPTU notnot indicatedindicated sincesince excessexcess hohormonermone resultsresults fromfrom leakleak insteadinstead ofof hyperfunctionhyperfunction SymptomsSymptoms cancan recurrecur requiringrequiring repeatrepeat treatmenttreatment GravesGraves’’ diseasdiseasee mmaayy occasionalloccasionallyy ddeevelopvelop asas aa llaatete sequellaesequellae

HistopathologyHistopathology ofof SubacuteSubacute ThyroiditisThyroiditis

Histopathology Histopathology of of Subacute Subacute Thyroiditis Thyroiditis

SilentSilent ThyroiditisThyroiditis

SilentSilent thyroiditisthyroiditis isis termedtermed painlesspainless SubacuteSubacute ThyroiditisThyroiditis ClinicalClinical

HyperthyroidHyperthyroid symptomssymptoms atat presentationpresentation ProgressionProgression toto euthyroidismeuthyroidism followedfollowed byby hypothyroidismhypothyroidism forfor upup toto 11 year.year. HypothyroidismHypothyroidism generallygenerally resolvesresolves

DiagnosisDiagnosis