GROUP

C2
Physiology Laboratory
Small Group Discussion
Output

March 16, 2016

[HYPOTHYROIDISM/
HYPERTHYROIDISM]
By: ASUBARIO, Olufunmilola Omonike; BALADAD, Alvin Bryan; DE JESUS, Chrislou; GURUNG, Man
Bahadur; KALANGEG, Kristie; MAHALEE, Naphitcharak; MONTHATHONG, Thanapol; PANLASIGUI,
Rikkimae Maria; SAMSON, Chino Paolo; SOLONIO, Natalie Keith; VALDEZ, Gregorio
 HYPOTHYROIDISM/ HYPERTHYROIDISM
HYPOTHYROIDISM

Introduction
Hypothyroidism is a condition in which the body lacks sufficient thyroid hormone.
Since the main purpose of thyroid hormone is to "run the body's metabolism," it is
understandable that people with this condition will have symptoms associated with a
slow metabolism. The estimates vary, but approximately 10 million Americans have this
common medical condition. In fact, as many as 10% of women may have some degree
of thyroid hormone deficiency.

Causes
 The immune system attacking the thyroid gland
 Viral infections (common cold) or other respiratory infections
 Pregnancy (often called postpartum thyroiditis)
 Certain medicines, such as lithium and amiodarone
 Congenital (birth) defects
 Radiation treatments to the neck or brain to treat different cancers
 Radioactive iodine used to treat an overactive thyroid gland
 Surgical removal of part or all of the thyroid gland
 Shehaan Syndrome, a condition that may occur in a woman who bleeds severely
during pregnancy or childbirth and causes the destruction of the pituitary gland
 Pituitary tumor or pituitary surgery

Diagnosis
 Blood tests are also ordered to measure your thyroid hormones TSH and T4.
 You may also have tests to check:
 Cholesterol levels
 Complete blood count (CBC)
 Liver enzymes
 Prolactin
 Sodium

Signs and Symptoms

Early symptoms:

 Hard stools or constipation

 Increased sensitivity to cold temperature
 Heavier and irregular menstrual periods
 Joint or Muscle pain
Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 1
  Paleness or dry skin
 Thin, brittle hairs or fingernails
 Weakness
 Weight gain

Late symptoms:

 Decreased taste and smell

 Hoarseness
 Puffy face, hands, and feet
 Slow speech
 Thickening of the skin
 Thinning of eyebrows

Possible Complications

o Myxedema coma, the most severe form of hypothyroidism, is rare. It occurs when
thyroid hormone levels get very low. It can be caused by an infection, illness,
exposure to cold, or certain medicines in people with untreated hypothyroidism. It is
a medical emergency that must be treated in the hospital. Some patients may need
oxygen, breathing assistance (ventilator), fluid replacement, and intensive-care
nursing.

Symptoms and signs of myxedema coma include:

 Below normal temperature

 Decreased breathing
 Low blood pressure
 Low blood sugar
 Unresponsiveness
 Inappropriate or uncharacteristic moods

o Infertility, miscarriage, giving birth to a baby with birth defects

o Heart disease because of higher levels of LDL ("bad") cholesterol
o Heart failure

Treatment
Treatment is aimed at replacing the thyroid hormone you are lacking.

 Levothyroxine is the most commonly used medicine- most people with an

underactive thyroid will need to take this medicine for life.

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 2

 HYPERTHYROIDISM

Introduction

Hyperthyroidism is a condition in which the thyroid gland is overactive and makes

excessive amounts of thyroid hormone. The thyroid gland is an organ located in the
front of your neck and releases hormones that control your metabolism (the way your
body uses energy), breathing, heart rate, nervous system, weight, body temperature,
and many other functions in the body. When the thyroid gland is overactive
(hyperthyroidism) the body’s processes speed up and you may experience
nervousness, anxiety, rapid heartbeat, hand tremor, excessive sweating, weight loss,
and sleep problems, among other symptoms.

Epidemiology and Etiology

 In Europe, thyrotoxicosis affects around 1 in 2,000 people annually.

 Graves' disease is the most common cause of thyrotoxicosis, accounting for
around 75% of cases. Graves' disease is a rare disease in children, accounting
for 1-5% of all patients with Graves' disease. In adults, this disease affects
approximately 2% of women and 0.2% of men.
 Thyrotoxicosis due to toxic nodular goitre is more common in people aged over
60 years.
 Thyroiditis, in which destruction of thyroid cells causes release of thyroid
hormones into the circulation, is implicated in about 10% of thyrotoxicosis cases.
 Other causes include exogenous thyroid hormone excess, drug-induced
hyperthyroidism, TSH-secreting pituitary adenomas and pituitary resistance to
thyroid hormones.
 Thyrotoxicosis is still under-diagnosed however - it has been shown that in
people older than 65 years, undiagnosed hyperthyroidism occurs in 0.3% of
people and around 2% of people aged over 65 years have subclinical
hyperthyroidism.

Signs and Symptoms

Symptoms Signs
 Weight loss despite an  Palmar erythema.
increased appetite.  Sweaty and warm palms.

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 3

  Weight gain.  Fine tremor.
 Increased or decreased  Tachycardia - may be atrial
appetite. fibrillation and/or heart failure
 Irritability. (common in the elderly).
 Weakness and fatigue.  Hair thinning or diffuse
 Diarrhoea ± steatorrhoea. alopecia.
 Sweating.  Urticaria, pruritus.
 Tremor.  Brisk reflexes.
 Mental illness: may range from  Goitre.
anxiety to psychosis.  Proximal myopathy (muscle
 Heat intolerance. weakness ± wasting).
 Loss of libido.  Gynaecomastia.
 Oligomenorrhoea or  Lid lag (may be present in any
amenorrhoea. cause of hyperthyroidism).

NB: although these symptoms may be present, the symptoms and signs can be variable
and in some patients they are very mild.

Thyrotoxic periodic paralysis is a serious complication characterised by muscle

paralysis and hypokalaemia due to a massive intracellular shift of potassium. An annual
incidence of up to 2% has been reported in Asian people with thyrotoxicosis.

Thyrotoxic crisis or storm

 Patients may rarely present with thyrotoxic crisis or storm in either previously
undiagnosed or ineffectively treated cases.
 A thyroid storm is a rare condition affecting 1-2% of patients with
hyperthyroidism.
 The typical symptoms of thyroid storm are hyperthermia and mental disturbance,
along with thyrotoxic symptoms.
 Thyroid storm is associated with precipitating events, such as the withdrawal of
an anti-thyroid drug, radio-iodine therapy, infection and surgery.
 Management is with intravenous fluids, beta-blockers, anti-thyroid drugs and
steroids.
 It is also important to look for the presence of Addison's disease in these
patients.
 It has 20-30% mortality due to arrhythmias and hypothermia.

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 4

Causes of Hyperthyroidism

CAUSE PATHOPHYSIOLOGY GLAND SIZE* NODULARITY TENDERNESS

Toxic adenoma Autonomos Decreased Single Nontender

hormone nodule
production

Toxic multinodular Autonomous Increased Multiple Tender

goiter hormone nodules
production

Subacute Leakage of Increased None Tender

thyroiditis hormone
from gland

Lymphocytic Leakage of Moderately None Nontender

thyroiditis, hormone increased
postpartum from gland
thyroiditis,
medication-
induced thyroiditis

Graves’ disease Increased Increased None Nontender

(thyroid- glandular
stimulating stimulation
antibody) (substance
causing
stimulation)

Iodine-induced ncreased Increased Multiple Nontender

hyperfunctioning glandular nodules
of thyroid gland stimulation or no
(iodide ingestion, (substance nodules
radiographic causing
contrast, stimulation)
amiodarone
[Cordarone])

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 5

CAUSE PATHOPHYSIOLOGY GLAND SIZE* NODULARITY TENDERNESS

Functioning pituitary Increased Increased None Nontender

adenoma (thyroid- glandular
stimulating stimulation
hormone); (substance
trophoplastic tumors causing
(human chorionic stimulation)
gonadotropin)

Factitial Factitial Decreased None Nontender

hyperthyroidism hyperthyroidism

Struma ovarii; Extraglandular Decreased None Nontender

metastatic thyroid production
cancer

 Grave’s Disease

Graves’ disease is the most common cause of hyperthyroidism, accounting for 60 to 80

percent of all cases.8 It is an autoimmune disease caused by an antibody, active against
the thyroid-stimulating hormone (TSH) receptor, which stimulates the gland to
synthesize and secrete excess thyroid hormone. It can be familial and associated with
other autoimmune diseases. An infiltrative ophthalmopathy accompanies Graves’
disease in about 50 percent of patients.9

 Toxic multinodular goiter

Toxic multinodular goiter causes 5 percent of the cases of hyperthyroidism in the United
States and can be 10 times more common in iodine-deficient areas. It typically occurs in
patients older than 40 years with a long-standing goiter, and has a more insidious onset
than Graves’ disease.

 Toxic adenoma
Toxic adenomas are autonomously functioning nodules that are found most commonly
in younger patients and in iodine-deficient areas.

 Thyroiditis

Subacute

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 6

 Subacute thyroiditis produces an abrupt onset of thyrotoxic symptoms as hormone
leaks from an inflamed gland. It often follows a viral illness. Symptoms usually resolve
within eight months. This condition can be recurrent in some patients.

 Lymphocytic and Postpartum

Lymphocytic thyroiditis and postpartum (subacute lymphocytic) thyroiditis are
transient inflammatory causes of hyperthyroidism that, in the acute stage, may be
clinically indistinguishable from Graves’ disease. Postpartum thyroiditis can occur in up
to 5 to 10 percent of women in the first three to six months after delivery. A transient
hypothyroidism often occurs before resolution.

Treatment-Induced Hyperthyriodism

 Iodine-induced
Iodine-induced hyperthyroidism can occur after intake of excess iodine in the diet,
exposure to radiographic contrast media, or medications. Excess iodine increases the
synthesis and release of thyroid hormone in iodine-deficient patients and in older
patients with preexisting multinodular goiters.5

 Amiodarone-induced
Amiodarone- (Cordarone-) induced hyperthyroidism can be found in up to 12 percent of
treated patients, especially those in iodine-deficient areas, and occurs by two
mechanisms. Because amiodarone contains 37 percent iodine, type I is an iodine-
induced hyperthyroidism (see above). Amiodarone is the most common source of iodine
excess in the United States. Type II is a thyroiditis that occurs in patients with normal
thyroid glands. Medications such as interferon and interleukin-2 (aldesleukin) also can
cause type II.5

 Thyroid hormone-induced
Factitial hyperthyroidism is caused by the intentional or accidental ingestion of excess
amounts of thyroid hormone. Some patients may take thyroid preparations to achieve
weight loss.

 Tumors

Rare causes of hyperthyroidism include metastatic thyroid cancer, ovarian tumors that
produce thyroid hormone (struma ovarii), trophoblastic tumors that produce human
chorionic gonadotrophin and activate highly sensitive TSH receptors, and TSH-
secreting pituitary tumors

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 7

PATHOPHYSIOLOGY

Diagnosis
 A thyroid-stimulating hormone (TSH) test, which is a blood test that measures your
levels of TSH. If your TSH level is low, your doctor will want to do more tests.
 Thyroid hormone tests, which areblood tests to measure your levels of two types
of thyroid hormones, called T3 and T4. If your thyroidhormone levels are high, you
have hyperthyroidism.
*After you are diagnosed with hyperthyroidism, your doctor may also want to do:
 An antithyroid antibody test to see if you have the kind of antibodies that attack
thyroid tissue. This test can help diagnose Graves' disease and
autoimmune thyroiditis.
 A radioactive thyroid scan and radioactive iodine uptake tests, which
use radiation and a special camera to find out the cause of your hyperthyroidism.
 If you have Graves' ophthalmopathy, your doctor may also do anultrasound, an MRI,
or a CT scan to look more closely at your eyes.

*Early detection

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 8

It is not clear whether people who do not have any risk factors and who do not have any
symptoms of hyperthyroidism need to be tested regularly for thyroid problems. The
American Thyroid Association recommends that adults, particularly women, be
screened for thyroid problems every 5 years, beginning at age 35.
Treatment and Management

MECHANISM CONTRAINDICATIONS
TREATMENT INDICATIONS
OF ACTION AND COMPLICATIONS

Beta blockers Inhibit Prompt control Use with caution in

adrenergic of symptoms; older patients and
effects treatment of in patients with
choice for pre-existing heart
thyroiditis; first- disease, chronic
line therapy obstructive
before surgery, pulmonary
radioactive disease, or
iodine, and asthma
antithyroid
drugs; short-
term therapy in
pregnancy

Iodides Block the Rapid Paradoxical

conversion decrease in increases in
of T4 to thyroid hormone release
T3 and hormone with prolonged
inhibit levels; use; common side
hormone preoperatively effects of
release when other sialadenitis,
medications conjunctivitis, or
are ineffective acneform rash;
or interferes with the
contraindicated response to
; during radioactive iodine;
pregnancy prolongs the time
when to achieve
antithyroid euthyroidism with
drugs are not antithyroid drugs
tolerated; with
antithyroid

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 9

 MECHANISM CONTRAINDICATIONS
TREATMENT INDICATIONS
OF ACTION AND COMPLICATIONS

drugs to treat
amiodarone-
(Cordarone-)
induced
hyperthyroidis
m

Antithyroid Interferes Long-term High relapse rate;

drugs with the treatment of relapse more likely
(methimazole organificatio Graves’ in smokers,
[Tapazole] n of iodine; disease patients with large
and PTU) PTU can (preferred first- goiters, and
block line treatment patients with
peripheral in Europe, positive thyroid-
conversion Japan, and stimulating
of T4 toT3 in Australia); PTU antibody levels at
large doses is treatment of end of therapy;
choice in major side effects
patients who include
are pregnant polyarthritis (1 to 2
and those with percent),
severe Graves’ agranulocytosis
disease; (0.1 to 0.5
preferred percent); PTU can
treatment by cause elevated
many liver enzymes (30
endocrinologist percent), and
s for children immunoallergic
and for adults hepatitis (0.1 to
who refuse 0.2 percent);
radioactive methimazole can
iodine; cause rare
pretreatment of cholestasis and
older and rare congenital
cardiac abnormalities;
patients before minor side effects
radioactive (less than 5
iodine or percent) include
surgery; both rash, fever,

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 10

 MECHANISM CONTRAINDICATIONS
TREATMENT INDICATIONS
OF ACTION AND COMPLICATIONS

medications gastrointestinal
considered effects, and
safe for use arthralgia
while
breastfeeding

Radioactive Concentrate High cure rates Delayed control of

iodine s in the with singledose symptoms;
thyroid gland treatment (80 posttreatment
and destroys percent); hypothyroidism in
thyroid tissue treatment of majority of patients
choice for with Graves’
Graves’ disease regardless
disease in the of dosage (82
United States, percent after 25
multinodular years);
goiter, toxic contraindicated in
nodules in patients who are
patients older pregnant or
than 40 years, breastfeeding; can
and relapses cause transient
from antithyroid neck soreness,
drugs flushing, and
decreased taste;
radiation thyroiditis
in 1 percent of
patients; may
exacerbate
Graves’
ophthalmopathy;
may require
pretreatment with
antithyroid drugs
in older or cardiac
patients

Surgery Reduces Treatment of Risk of

(subtotal thyroid mass choice for hypothyroidism
thyroidectomy patients who (25 percent) or

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 11

 MECHANISM CONTRAINDICATIONS
TREATMENT INDICATIONS
OF ACTION AND COMPLICATIONS

) are pregnant hyperthyroid

and children relapse (8
who have had percent);
major adverse temporary or
reactions to permanent
antithyroid hypoparathyroidis
drugs, toxic m orlaryngeal
nodules in paralysis (less
patients than 1 percent);
younger than higher morbidity
40 years, and and cost than
large goiters radioactive iodine;
with requires patient to
compressive be euthyroid
symptoms; can preoperatively with
be used for antithyroid drugs
patients who or iodides to avoid
are thyrotoxic crisis
noncompliant,
refuse
radioactive
iodine, or fail
antithyroid
drugs, and in
patients with
severe disease
who could not
tolerate
recurrence;
may be done
for cosmetic
reasons

NEW POSSIBILITIES
Newer treatment options under investigation include endoscopic subtotal
thyroidectomy, embolization of the thyroid arteries, plasmapheresis, and percutaneous
ethanol injection of toxic thyroid nodules. Autotransplantation of cryopreserved thyroid
tissue may become a treatment option for postoperative hypothyroidism. Nutritional
supplementation with L-carnitine has been shown to have a beneficial effect on the

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 12

symptoms of hyperthyroidism, andL-carnitine may help prevent bone demineralization
caused by the disease.

Prognosis

The prognosis for a patient with hyperthyroidism is good with appropriate

treatment. Even with aggressive treatment, some manifestations of the disease may be
irreversible, including ocular, cardiac, and psychologic complications. Patients treated
for hyperthyroidism have an increased all-cause mortality risk, as well as increased risk
of mortality from thyroid, cardiovascular and cerebrovascular diseases, and hip
fractures.Morbidity can be attributed to the same causes, and patients should be
screened and treated for osteoporosis and atherosclerotic risk factors. Patients who
have been treated previously for hyperthyroidism have an increased incidence of
obesity and insulin resistance.The effect of hyperthyroidism on endothelial function may
be an independent risk factor for thromboembolism.

References:
1. Guyton, AC; Hall, JE: Textbook of Medical Physiology, 11th edition. Elsevier Inc. 2006.

2. Koeppen, BM; Stanton, BA: Berne and Levy Physiology, 6 th edition. Elsevier Inc.
2010.

3. en.wikipedia.org

4. http://patient.info/doctor/hyperthyroidism

5. https://en.wikipedia.org/wiki/Hyperthyroidism#Signs_and_symptoms

6. https://www.google.com.ph/search?q=hyperthyroidism+pathophysiology+diagram

7. http://www.aafp.org/afp/2005/0815/p623.html

Physiology Laboratory Small Group Discussion Output |Hypothyroidism/Hyperthyroidism 13