Thyroid disorder

Mardin mazhar
Shanga ismail
Hawnaz hamasalh
Hwda mhamad

Introduction of thyrod
gland

Second largest endocrine gland in body,Small

butterfly shaped gland located at base of neck
below the sternocleidomastoid muscles
Thyroid is controlled by the hypothalmus
and pituitary
Weighs 18-60gms in adults,Histologically it is
made up of follicular and parafollicular cells.

thyrod gland

folicular cell

function

Stimulates & maintains metabolic processes

Produces thyroid hormones T3-triiodothyronine
and T4-thyroxine
These hormones regulate metabolism & affect
the growth and function of other systems in the
body

Secretes calcitonin to lower serum calcium

levels
Parathyroid gland secretes PTH to raise serum
calcium levels

Function cont..

Metabolic stimulants of:

Neural and skeletal development

Oxygen consumption at rest
Stimulating bone turnover by increasing formation
and resorption
Promoting chronitropic and ionotropic effects
Increasing number of catecholamine receptors in
heart
Increasing production of RBC
Altering the metabolism of carbs, fats, and protein

Hormones: T3 & T4

T3 (Triiodothyronine) & T4
(Tetraiodothyronine
Stored in Follicles (round sacs) in the thyroid
filled with thyroglobulin, a thyroid protein.

Dietary iodine enters follicles where they are

stored as T3 and T4

T4 is converted to T3 by peripheral organs such

as kidney, liver, and spleen
T3 is 10x more active than T 4
Only 20% of total T3 is secreted by thyroid

Hormones: T4

T4-thyroxine contains 4 iodine atoms

It is a slow-acting pre-hormone
T4 takes 4 days to peak in blood
Half-life 7 days

Overall effects take 6 weeks

T3 is the active and faster-acting hormone
The immediate effects of T3 last 1-2 days
Half-life 1.5 days

T3 and T4 structure

Iodine

Dietary Iodide is removed from the

bloodstream by means of an active pump
The pump can concentrate iodide in the
follicular sacs at 350x greater than the blood
concentration
Oxidation of iodide by thyroid peroxidase
converts iodide iodine
Peripheral de-iodination of T4 to T3 is regulated
by many factors including health, nutritional
status, and other hormones

Hormones- TSH

TSH
TSH is a pituitary hormone
Controlled by TRH-thyrotropin releasing hormone
from hypothalamus
Functions to stimulate thyroid hormone
production

May enlarge thyroid (goiter) when under producing

Labs:

High TSH indicates low thyroid hormone= hypo

Low TSH indicates high thyroid hormone = hyper

Hormones-Calcitonin & PTH

Produced by thyroid to regulate serum calcium

levels
Calcitonin stimulates movement of calcium
into bone
Parathyroid hormone (PTH) opposite effect of
calcitonin

Negative Feedback
System
TRH

TSH

T3 & T4

Thyroid

The disruption
of any of these
mechanisms
can cause
abnormal
levels of T3
and T4 leading
to thyroid
disease

Hypothyroidism

Primary Hypothyroidism

Disease of the thyroid gland

Secondary Hypothyroidism
Hypothalamic-pituitary diseases
(reduced TSH)

Causes of Hypothyroidism

PRIMARY
Congenital
Agenesis
Ectopic thyroid remnants

Defects of hormone synthesis

Iodine deficiency
Dyshormonogenesis
Antithyroid drugs
Other drugs (e.g. lithium, amiodarone,
interferon)

Causes of Hypothyroidism

Autoimmune
Atrophic thyroiditis
Hashimoto's thyroiditis
Postpartum thyroiditis

Infective
Post-subacute thyroiditis

Causes of
Hypothyroidism

Iatrogenic

Radioactive iodine therapy

External neck irradiation
post-surgery

Infiltration

amyloidosis, sarcoidosis, hemochromatosis,

scleroderma


SECONDARY
Hypopituitarism: tumors, pituitary surgery or
irradiation, infiltrative disorders, Sheehan's
syndrome, trauma, genetic forms of combined
pituitary hormone deficiencies
Isolated TSH deficiency or inactivity
Hypothalamic disease: tumors, trauma,
infiltrative disorders, idiopathic

Risk factor

Although anyone can develop hypothyroidism, you're at an

increased risk if you:
Are a woman older than age 60
Have an autoimmune disease
Have a close relative, such as a parent or grandparent, with an
autoimmune disease
Have been treated with radioactive iodine or anti-thyroid
medications
Received radiation to your neck or upper chest
Have had thyroid surgery (partial thyroidectomy)
Have been pregnant or delivered a baby within the past six
months

signs and symptom

Fatigue
Increased sensitivity to cold
Constipation
Dry skin
Unexplained weight gain
Puffy face
Hoarseness
Muscle weakness
Elevated blood cholesterol level
Muscle aches, tenderness and stiffness
Pain, stiffness or swelling in your joints
Heavier than normal or irregular menstrual periods
Thinning hair
Slowed heart rate
Depression
Impaired memory

diagnosis

Diagnosis of hypothyroidism is based on your

symptoms and the results of blood tests that
measure the level of TSH and sometimes the
level of the thyroid hormone thyroxine. A low
level of thyroxine and high level of TSH
indicate an underactive thyroid. That's
because your pituitary produces more TSH in
an effort to stimulate your thyroid gland into
producing more thyroid hormone.

Treatment

Replacement therapy with

levothyroxine (thyroxine, i.e. T4) is
given for life.
In the young and fit, 100 - 150 g daily is
suitable.
thyroid function tests after at least 2 months on
a steady dose
the aim is to restore T4 and TSH to well within
the normal range
An annual thyroid function test is recommended
.


Excessive amounts of the hormone can cause
side effects, such as:
Increased appetite
Insomnia
Heart palpitations
Shakiness

Complication

Goiter.Constant stimulation of your thyroid to release

more hormones may cause the gland to become larger
a condition known as a goiter.
Heart problems.Hypothyroidism may also be
associated with an increased risk of heart disease,
primarily because high levels of low-density lipoprotein
(LDL) cholesterol the "bad" cholesterol can occur in
people with an underactive thyroid.
Mental health issues.Depression may occur early in
hypothyroidism and may become more severe over time.
Hypothyroidism can also cause slowed mental
functioning.

Peripheral neuropathy.Long-term uncontrolled hypothyroidism can

cause damage to your peripheral nerves the nerves that carry
information from your brain and spinal cord to the rest of your body,
Myxedema.This rare, life-threatening condition is the result of longterm, undiagnosed hypothyroidism. Its signs and symptoms include
intense cold intolerance and drowsiness followed by profound lethargy
and unconsciousness.
Infertility.Low levels of thyroid hormone can interfere with ovulation,
which impairs fertility.
Birth defects.Babies born to women with untreated thyroid disease
may have a higher risk of birth defects than may babies born to
healthy mothers. These children are also more prone to serious
intellectual and developmental problems. Infants with untreated
hypothyroidism present at birth are at risk of serious problems with
both physical and mental development.

Hyperthyrodism

Hyperthyroidism - result of excessive thyroid

function
major etiologies of thyrotoxicosis are
hyperthyroidism caused by Graves' disease,
toxic MNG, and toxic adenomas

Causes of
hyperthyroidism

Common
Graves' disease (autoimmune)
Toxic multinodular goitre
Solitary toxic nodule/adenoma

Reasons for too

much thyroxine (T4)

Graves' disease.Graves' disease, an autoimmune disorder

in which antibodies produced by your immune system
stimulate your thyroid to produce too much T-4, is the most
common cause of hyperthyroidism.
Hyperfunctioning thyroid nodules (toxic adenoma,
toxic multinodular goiter, Plummer's disease).This
form of hyperthyroidism occurs when one or more adenomas
of your thyroid produce too much T-4. An adenoma is a part
of the gland that has walled itself off from the rest of the
gland, forming noncancerous (benign) lumps that may cause
an enlargement of the thyroid. Not all adenomas produce
excess T-4, and doctors aren't sure what causes some to
begin producing too much hormone.

Cont

Thyroiditis.Sometimes your thyroid gland

can become inflamed for unknown reasons.
The inflammation can cause excess thyroid
hormone stored in the gland to leak into your
bloodstream. One rare type of thyroiditis,
known as subacute thyroiditis, causes pain in
the thyroid gland. Other types are painless
and may sometimes occur after pregnancy
(postpartum thyroiditis).

Hyperthyrodism

Clinical features: due to

Hypermetabolic state
Overactivity of sympathetic nervous system

Symptoms

Palpitation
Weight loss

Increased
appetite
Irritability
Tremor
Goiter
Restlessness
Stiffness
Muscle weakness
Breathlessness

Heat intolerance
Excessive

sweating
Itching
Thirst
Vomiting
Diarrhoea
Oligomenorrhoea
Loss of libido

Signs

Tremor
Irritability
Psychosis
Tachycardia or atrial fibrillation
Warm peripheries
Systolic hypertension
Cardiac failure
Lid lag
Proximal myopathy
Proximal muscle wasting
Onycholysis
Palmar erythema

diagnosis

Medical history and physical exam.During

the exam your doctor may try to detect a slight
tremor in your fingers when they're extended,
overactive reflexes, eye changes and warm,
moist skin. Your doctor will also examine your
thyroid gland as you swallow.
Blood tests.A diagnosis can be confirmed with
blood tests that measure the levels of thyroxine
and TSH in your blood. High levels of thyroxine
and low or nonexistent amounts of TSH indicate
an overactive thyroid.

If blood tests indicate hyperthyroidism,

your doctor may recommend one of the
following tests to help determine why
your thyroid is overactive:

Radioactive iodine uptake test.For this test, you

take a small, oral dose of radioactive iodine
(radioiodine). Over time, the iodine collects in your
thyroid gland because your thyroid uses iodine to
manufacture hormones. You'll be checked after two,
six or 24 hours and sometimes after all three time
periods to determine how much iodine your thyroid
gland has absorbed.
A high uptake of radioiodine indicates your thyroid gland
is producing too much thyroxine. The most likely cause
is either Graves' disease or hyperfunctioning nodules.


Thyroid scan.During this test, you'll have a
radioactive isotope injected into the vein on the
inside of your elbow or sometimes into a vein in your
hand. You then lie on a table with your head
stretched backward while a special camera produces
an image of your thyroid on a computer screen.
The time needed for the procedure may vary,
depending on how long it takes the isotope to reach
your thyroid gland. You may have some neck
discomfort with this test, and you'll be exposed to a
small amount of radiation.

Treatment

Antithyroid drugs:
1. Carbimazole.
2. Propylthiouracil.
These drugs inhibit the formation of thyroid hormones
common side effects - rash, urticaria, fever,
and arthralgia
Rare but major side effects include hepatitis;
an SLE-like syndrome; and, most important,
agranulocytosis

Treatment

Radioactive iodine
RAI accumulates in the thyroid and destroys the
gland by local radiation.

It takes several months to be fully effective.

Surgery:
subtotal thyroidectomy
Only in patient who have previously been
rendered euthyroid.

Goiter

Goiter refers to an enlarged thyroid gland

Biosynthetic defects, iodine deficiency,
autoimmune disease, and nodular diseases
can each lead to goiter
diffuse nontoxic goiter - diffuse enlargement
of the thyroid occurs in the absence of nodules
and hyperthyroidism
Worldwide, diffuse goiter is most commonly
caused by iodine deficiency and is termed
endemic goiter

Congenital Thyroid
Diseases

Agenesis /Aplasia
Hypoplasia
Accessory or aberrant thyroid glands
Thyroglossal duct cyst

Thyroglossal Duct Cyst

A thyroglossal duct cyst is a neck mass or lump

that develops from cells and tissues remaining after
the formation of the thyroid gland during embryonic
development.
Children
Failure of regression
Neck, medial
Squamous or columnar lining
often appears after an upper respiratory infection
when it enlarges and becomes painful.
Complications: inflammation,

Case with
hypothyrodism

History: A 50 year old housewife complains of progressive

weight gain of 20 pounds in 1 year, fatigue, postural
dizziness, loss of memory, slow speech, deepening of her
voice, dry skin, constipation, and cold intolerance.
Physical examination: Vital signs include a temperature
96.8oF, pulse 58/minute and regular, BP 110/60. She is
moderately obese and speaks slowly and has a puffy face,
with pale, cool, dry, and thick skin. The thyroid gland is not
palpable. The deep tendon reflex time is delayed.
Laboratory studies: CBC and differential WBC are normal.
The serum T4 concentration is 3.8 ug/dl (N=4.5-12.5), the
serum TSH is 1 uU/ml (N=0.2-3.5), and the serum cholesterol
is 255 mg/dl (N<200)

Case with
hyperthyrodism

History: A 35 year old nurse complained of nervousness, mood

swings, weakness, and palpitations with exertion for the past 6
months. Recently, she noticed excessive sweating and wanted to
sleep with fewer blankets than her husband. She used oral
contraceptives and her menstrual periods were regular.
Physical examination: Pulse was 92/minute and BP was 130/60.
She appeared anxious, with a smooth, warm, and moist skin, a
fine tremor, a bounding cardiac apical impulse, and she couldn't
rise from a deep knee bend without aid. Her thyroid was diffusely
enlarged, soft, mobile, without nodularity and there was no
lymphadenopathy. Her eyes were not prominent (proptotic) and
she had no focal skin thickening.
Laboratory studies: Serum T4=15.6 ug/dl and serum T3=210
ng/dl.

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