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HYPOTHYROIDISM
UNIT 1
DR AFR AABEDE
REGISTRAR
ANATOMY/EMBRYOLOGY
TG consist of bilateral lobes
that extend from the side of the
thyroid cartilage down on both
sides to the 6th tracheal ring
It also extend anterioly to the
isthmus overlying the 2nd and 3rd
rings of trachea.
The thyroids develops from a
bud which pushes out from the
floor of the pharynx and then
descends to it’s definitive
position in the neck
INTRODUCTION
• Hypothyroidism results from
deficient production of thyroid
hormone or a defect in thyroidal
hormonal receptor activity
• It can be congenital or acquired
• Congenital form can be further
subdivided into:
Primary (aplasia or hypoplasia
of TG)
Secondary (TSH deficiency)
Tertiary (TRH deficiency)
Embryology contd
The fetal thyroids bilobed shape
is recognizable by the seventh
wk GA.
By 12th wk GA the fetus
depends on it’s own pituitary –
thyroid axis for synthesis and
secretion of throid hormone
normal mature feedback
develops by 3rd month post
natal life.
physiology
-1% familial
Physical examinations
Signs relating to hypothyroidism:
*hypothermia
*large fontanelle’s (esp PF)
*wide cranial sutures
*coarse facial features
*macroglossia
*delayed DTR
*distended abdomen
*umbilical hernia
CLINICAL FEATURES
Physical examinations
Signs of possible goitre
Helpful tricks for examination:
*inspect base of tongue for an
ectopic gland
*while supporting the posterior
neck and occiput,allow the
infant’s head to hang back over
the parent’s arm or examination
table.
ACQUIRED
HYPOTHYROIDISM
Hypothyroidism that occurs after the
neonatal period
Genetics
* genetic predisposition-CLT pts
*30-40% have familial hx
*50% of 1st degree relatives have
thyroid antibodies
*autoimmune thyroiditis(schmidt)-
stronger HLA linkage
*genetic syndromes have a higher
incidence of autoimmune thyroiditis
Aetiology: myriad
*auto-immune destruction by:
-chronic lymphocytic
thyroiditis(Hashimoto)
commonest in non endemic
areas
-autoimmune polyendocrine
syndrome(scmidt)
*iodine deficiency disorders commonest in endemic
regions
*iatrogenic:
-antithyroid drugs(
-iodides
-irradiation
-subtotal thyroidectomy eg for thyroitoxicosis
*hypothalamic/pituitary lesions
*large heamangioma of the liver
*infectious:-postviral subacute thyroiditis
-associated with congenital infections
like rubella and toxoplasmosis
*environmental
-goitrogen ingestion like
iodide,expectorants and
thioureas
*metabolic- cytinosis and
histocytosis X
*congenital- late onset congenital
large ectopic gland
*genetic syndromes-
Downs,Turners
Epidemiology
*may develop at any age
*CLT prevalence correlates with
iodine intake directly
proportionately
*occurs`more frequently in
chilren with type 1 DM
Clinical Features of
acquired hypothroidism
Linear growth failure
Declining school performance
Timing of hypothyroid related
symptoms:
*early hypo+ asymptomatic
*symptoms indicates chronicity and
thus mean progression from
compensated to uncompensated
hypoth.
Any thyroid enlargement,its duration
and tenderness: may present with
Past medical hx factors assoc with
hypothyroid:
*genetic syndromes
*radiation exposure
*medication
*history of DM
Familial hx of hypo/hyperthyroidism
*any hx of such or other auto
immune endocrinopathies-increased
risk of autoimmune thyroiditis
Physical examination
Short stature/fall-off on growth curve
Increased upper segment/lower segment
ratio
+ goitre with its xtics(clues 2
cause+marker 4 ff-up)
*consistency
*symmetry
*nodularity
*signs of inflammation
Myxedema(water retention)-not limited to
subcut tissue. May lead to CCF,pleural
effusion and coma
Muscle hypertrophy+muscle weakness
Pale,cool,dry caroteinemic skin
Tanner staging of sexual
development (both delayed and
precocious puberty can be
seen)
Galactorrhea is a possible
finding
INVESTIGATIONS CONG.
HYPO
NN screening program (filter card)
*methods vary from one developed
world to the other most screen for T4
then do the TSH for those with the
lowest 10th per centile of that day’
value.
Abnormal results leads to immediate
examination and confirmatory tests.
Serum T4 and TSH give the
confirmation.
* TSH= sensitive indicator of 10 hypo
NN hypothyroid index
False positives
*blood specimens obtained
before 48hrs of life may have
elevated TSH due to the normal
post-natal surge
*TBG def: total T4 is low but TSH
is normal.(x linked0
INVESTIGATIONS FOR ACQ
HYPOTHYROIDISM
Same as for congenital forms essentially low T4 and
elevated TSH
If TSH is normal or low, hypopituitarism or
hypothalamic lesion may be suspected
Free T4 =MOST sensitive marker for the above
In children older than 2yr of age serum cholesterol
is usually elevated.
Skeletal maturation is markedly delayed
Presence of circulating antibody(antithyroglobulin
and antimicrosomal) implies an autoimmune basis
Head MRI for suspected 20 or 30 hypo,pit or
hypothalamic lesion.
False positive test for
acquired hypothyroidism
Thyroid binding globulin
deficiency =low total T4 but
normal free T4 and TSH
Peripheral resistance to thyroid
hormone =normal/high total T4
Euthyroid sick syndrome=low T4
and T3;norma/low TSH;
increased shunting to reverse
T3
TREATMENT
L-throxine 10-15ug/kg/day. Titrate to
keep T4 in the upper range of normal
(CH)
2-5ug/kg/day po once daily(AH)
titrate to maitain normal TFTs
Treatment is for life
No restrictioons on diet but soya
formulas and iron containing drugs
may interfere with absorption of L-
throxine
FOLLOW-UP
Whenever starting medication or adjusting
dose,check T4 and TSH 4-6 wks later to assess the
adequacy of the new dose
When to expect improvement:
*CH-parents may note increase in
activity,improvement in feeding and increase in
urination and bowel movement soon after.
*AH-catch up growth,other signs and symptoms
resolve at a variable rate
* Goitre in CLT may not regress with treatment.
Signs to watch out for
Poor growth and low T4 and
elevated TSH suggest poor
compliance and undertreatment
COMPLICATIONS
Congenital hypothyroidism
If untreated-severe
MR(cretinism)
Poor motor development
Poor growth
Acquired hypothyroidism If
untreated
Impaired linear growth
Myxedema coma
Encephalopathy
PROGNOSIS
Congenital hypothyroidism
*Excellent if treatment is started within the
1st 4 ks of life (not usually the case here)
*level of T4 at birth is an important indicator
of long time sequalae.
Acquired hypothyroidism
*If patients are compliants prognosis is
excellent.
*in those whom treatment has been
delayed catch up growth may not fully
normalise height to predicted values
• IS THERE A PLACE FOR
NEONATAL
HYPOTHYROID
SCREENING PROTOCOL
IN NIGERIA??
THANK
YOU
• FAQs
• Comparison of Downs syndrome and
Hypothyroidism
• Comparison of Beckwitt and
Hypothyroidism
• Causes of Hypotonia in infancy
• Causes of neonatal constipation
• Neonatal screening program in
developing world