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Hypothyroidism final
 

Hypothyroidism final

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    Hypothyroidism final Hypothyroidism final Presentation Transcript

    • Hypothyroidism ESIC – PGIMSR, MGM Hospital, Mumbai Presenter: DR.UTKARSH DESHMUKH DNB General Medicine Index: 1.Case of Hypothyroidism 2.Discussion of Hypothyroidism 3.Subclinical Hypothyroidism 4.Myxedema Coma
    • History • A 50 year female patient Mrs. Pramilabai Residing at Mumbai was working as maid came to our hospital with complaints of  Generalized tiredness, cold intolerance, decrease appetite since 18 months.  Constipation & Somnolence since 12 months.  Hoarseness of voice & forgetfulness, since 6 months.  Difficulty in walking & getting up from squatting position since 6 months.  Since last 3 months swelling over face & feet. CASE
    • History • No H/o headache , vomiting or altered sensorium, seizures. • With exception of H/O deafness no other H/S/O other cranial nerve involvement. • No H/S/O sensory, autonomic or cerebellar involvement. • No H/S/O cardiac, respiratory, renal involvement. CASE
    • History • Past History: • History of similar complaints 3 years back & taken treatment but she was noncompliant. ( Details of Treatment Not available) • No H/O any other major illness. • Personal History: • Mixed diet, constipation & somnolence was present. • Obstetric & Gynecology • One son 25 year old • Attained menopause 5 years back. • Family History: • No history of similar complaints in family members CASE
    • Examination General Examination • Patient was conscious, oriented. • BMI 21 kg / m2 (No weight loss, Despite of loss of Appetite) • Afebrile • Pulse: 58/min regular (Sinus bradycardia) • BP: 136/94 mm Hg (Diastolic Hypertension) • RR: 16/min pallor:- present • Face: • Perorbital swelling with baggy eyelids. • Expressionless face with rough & dry skin of face. CASE
    • Examination General Examination cont…. • Thyroid examination was normal • No Icterus, cyanosis, clubbing, lymphadenopathy. • JVP not raised, Non- pitting pedal edema present. • Skin all over body: thick & dry. • Examination of spine & skull normal. CASE
    • Examination Systemic Examination [CNS] • Higher function : - • Conscious, oriented. • Speech slow, sluggish & hoarseness of voice. • Memory impaired. • Cranial Nerves : - Conductive deafness (VIII) • Motor examination:- • Nutrition – Normal • Tone – hypotonia • Power – Grade IV/V around hip joint bilaterally Rest WNL • Co-ordination – Normal • No abnormal movements CASE
    • Examination Systemic Examination [CNS]cont…. • Sensory examination : - Normal • Reflexes • Superficial reflexes:- Normal • Deep tendon Reflexes: - Hung up reflexes-- specially ankle, bicep, triceps • Cerebellar, autonomic examination normal • Gait : normal but slow CASE
    • Examination Systemic examination [CVS] • Sinus bradycardia and diastolic hypertension, rest WNL Systemic examination RS & Per-abdomen WNL CASE
    • Patient • Slow speech , expressionless face. • Here Watch for movements of the hand rather the muscle CASE VID-20130813-WA0000.mp4
    • Investigations • Hemogram • Hb – 10 gm/dl, WBC 8000/mm3 , platelets 322,000 • Peripheral smear – Normocytic normochromic • Thyroid function test • TSH – 110 µ U/ml (Normal 0.3-4.3) • T4 – 0.5 µg/dl (Normal 5.5-11.5) • T3 - 20 ng/dl (Normal 75-135) • BUN – 15 mg/dl, Sr. creatinine 0.7 mg/dl • LFT – normal ECG – Sinus bradycardia Anterior wall ischemia. • X-ray chest – WNL CASE
    • Treatment Tab. Thyroxine 50 µ gm TSH – 75 µ U/ml Thyroxine increased to100 µg/dl TSH – 35 µ U/ml Thyroxin increased to 150 (OPD visit TSH 3 µ U/ml) After 1 weeks After 2 weeks CASE
    • Treatment Other Treatment Statins Antinatianginal sos Antiplatelet Antihypertensive
    • Discussion Hypothyroidism DICUSSION
    • Introduction • Definition: - “ It is a deficiency in thyroid hormone secretion by thyroid gland, resulting in state of circulating level of thyroid hormone and reduced action at the cellular level”. • Etiology: Primary hypothyroidism ( 99 %) Autoimmune Thyroiditis (Hashimoto`s Thyroiditis) Iodine deficiency. Iatrogenic : Surgery, I131 . Drugs : Iodine Excess, lithium, antithyroid drugs. Congenital hypothyroidism & Infiltrative disorders. DICUSSION
    • Introduction (cont….) Secondary hypothyroidism  Hypopituitarism • Tumor • Surgery / irradiation • Infiltrative disorders • Sheehan`s syndrome Hypothalamic diseases (Tertiary Hypothyroidism): - Tumor, trauma, infiltrative disorders Isolated TSH deficiency DICUSSION
    • Introduction (cont…) Transient Hypothyroidism  Silent Thyroiditis , including postpartum thyroiditis  Sub-acute thyroiditis  Withdrawal of thyroxin therapy  After surgery or I131 DICUSSION
    • Statistics Epidemiology : - • Prevalence - 0.1 to 2% • 5 – 8 times more common in women. • More common in adult women with small body size at birth & during childhood. • Prevalence is also increased in elderly patients. • The Framingham study: Above 65 yrs of age hypothyroidism women 5.9% Men 2.4% DICUSSION
    • Statistics (cont…) India • In population-based study in Cochin on 971 adult • Prevalence of hypothyroidism – 3.9% • Subclinical hypothyroidism – 9.4% • Studies from Mumbai • Congenital hypothyroidism:- 1 out of 2640 neonate compared to 1 out of 3800 world wide. • Population based study : 800 children with thyroid diseases 79% had hypothyroidism. DICUSSION
    • Clinical Features  GENERAL • Lethargy, Somnolence • Weight gain, Goiter • Cold Intolerance  CARDIOVASCULAR • Bradycardia, Angina • CHF, Pericardial Effusion Hyperlipidemia. DICUSSION  NEUROMUSCULAR • Aches and pains • Muscle stiffness • Carpel tunnel syndrome • Deafness, Hoarseness • Cerebellar ataxia • Delayed DTR Myotonia (pseudomytonia) • Depression, Psychosis
    • Clinical Features  HAEMATOLOGICAL • Normocytic / normchromic Anemia • Iron def. Anemia.  REPRODUCTIVE SYSTEM • Infertility, Amenorrhea Menorrhagia • Impotence.  GASTRO- INTESTINAL • Constipation, Ileus, • Ascites.  Dermatological • Dry flaky skin and hair • Myxoedema, malar flushes • Vitiligo Carotenimia Alopecia DICUSSION
    • Algorithm for Hypothyroidism Measure TSH Elevated TSH Measure FT4 Normal Low Sub-clinical hypo TPO + TPO - T4 repl Annual FU Primary hypothyroid TPO + TPO - Hashimoto Others Normal TSH TPO: Thyroid Peroxidise FU: Follow Up Next Slide
    • Algorithm for Hypothyroidism Measure TSH Elevated TSH Normal TSH Considering Pituitary No Yes No tests Measure FT4 Low Normal No tests Evaluate Pituitary Sick Euthyroid Drugs effect
    • Treatment • Goal : Normalize TSH level (Generally in Lower Half of reference value) • Treatment : Once daily dosing with Levothyroxine sodium (1.6µg/kg/day) this comes to 100 - 150 mcg per day • Timing:- single dose empty stomach. • Monitor TSH levels at 6 to 8 weeks, after initiation of therapy or dosage change DICUSSION
    • How to Start ? • Available Tab: – 25, 50 and 100 mcg tablets. • Starting dose  Healthy patients at 1.6µg/kg/day. (Usually 100 – 150 µg/day) Healthy patients Elderly < 50 µg/day. Dose ↑ by 25 µg, if needed, at 6 to 8 weeks intervals. For patients with heart disease - 12.5 to 25 µg/day and DICUSSION
    • SUBCLINICAL HYPOTHYROIDISM DICUSSION
    • Subclinical Hypothyroidism  Definition: - “Biochemical evidence of thyroid hormone deficiency in patients who have few or no apparent clinical features of hypothyroidism”.  Prevalence: - World wide 1- 10%  Sex: - Highest rate in females > 75 yrs. DICUSSION
    • Subclinical Hypothyroidism (cont…) Causes Inadequate treatment of overt hypothyroidism. Transient elevation of TSH: Systemic illness Rare Causes  Heterophil antibody  TSH producing pituitary tumor  Thyroid hormone resistance Laboratory errors. DICUSSION
    • Subclinical Hypothyroidism (cont…) Risk Factors  Women, > 60 yrs.  Autoimmune disease: • Diabetes Mellitus type I • Rheumatoid arthritis • Autoimmune thyroid disorder  Post-partum thyroiditis / Sub-acute thyroiditis.  Prior H/O hyperthyroidism following: surgery or RAI – 131 therapy.  Head / neck Radiotherapy.  Drugs: - Lithium, Amiodarone, Iodine. DICUSSION
    • Subclinical Hypothyroidism (cont…) EFFECTS OF SH ON BODY Associated with elevated cholesterol. Altered endothelial function & carotid intimal thickness. Associated with increased risk of CHD. Impaired mood & cognition. DICUSSION
    • Subclinical Hypothyroidism (cont…) Diagnosis Asymptomatic. Diagnosed during routine thyroid function test. Subclinical Hypothyroidism • Mild: - TSH < 10 mU/L Common • More severe: - 10 – 20 mU/L. DICUSSION
    • High TSH TSH > 10 mU/L TSH 5-10 mU/L For > 3 months L levothyroxine TPO Antibody & Other Positive Negative No Treatment & Follow up Yearly
    • High TSH TSH > 10 mU/L TSH 5-10 mU/L For > 3 months L levothyroxine TPO Antibody & Other Positive Negative No Treatment & Follow up Yearly Other: -Increased lipids, young age, pregnancy, anovulation.
    • Subclinical Hypothyroidism (cont…) MANAGEMENT Target of the treatment TSH: - 0.5 – 3.0 mU/L. Levothyroxine: - 25 – 50 µg / Day.
    • Subclinical Hypothyroidism (cont…) BENEFITS OF TREATMENT  Improve cardiac function.  Improve mood and cognition.  Improve symptoms.  Prophylaxis against progression.  Help to decrease size of goiter.  Improve lipid status.  Improve quality of life.
    • MYXEDEMA COMA DICUSSION
    • Myxedema Coma Definition: - “It is serious form of thyroid hormone deficiency associated with altered mental status, hypothermia, Bradycardia high mortality rate around 50%. Precipitating factors : • Infection (Pneumonia), Sepsis. • CVS: - Congestive Cardiac Failure, MI • CNS: - Cerebrovascular Accidents • GIT : - GIT bleeding • Cessation of thyroxin therapy • Drug : - Sedatives, Antidepressants, diuretics. DICUSSION
    • Exposure to cold Hypoventilation Hypoxia Hypercapnia Myxedema Hypoglycemia Dilutional Hyponatremia Infection Pathogenesis
    • Myxedema Coma (cont…)  Clinical Features & Investigations • Mental confusion, hypothermia, bradycardia. • ↓ Na, ↓ glucose, ↑ CO2, • ↓ WBC, ↓ Hematocrit, ↑ CPK • ↓ EKG voltage, myxedema. DICUSSION
    • Treatment Hormone replacement Supportive Treatment Treatment of precipitating Factors DICUSSION
    • Myxedema Coma (cont…) Treatment :- Admission in ICU Hormone replacement Inj. Levothyroxine (T4 ) 500 µgm IV Follwed by 50-100 µgm for several days Can also be given nasogastric tube in same dose Inj. Levothyronine (T3 ) 10 -20 µgm ( Excess dose Provoke arrhythmia) DICUSSION
    • Myxedema Coma (cont…) Supportive Treatment  Oxygen (Ventilation, if necessary)  External warming (If Temperature < 30º C) oSpace blankets  Inj. Hydrocortisone 50 mg IV 6 hrly. Treatment of precipitating Factors  Broad spectrum antibiotics  Hypertonic saline  Glucose Avoid sedatives DICUSSION
    • References 1. Desai PM. Disorders of the Thyroid Gland in India. Indian J Pediatr. 1997;64:11–20. [PubMed ] 2. Jameson AL, Weetman AP. Disorders of Thyroid gland. In: Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, Loscalzo, editors.Harrison`s Principles of Internal Medicine.18th ed.USA.The McGraw-Hill Companies, Inc;2009. DICUSSION
    • References 3. Sawin C, Castelli W, et al. The aging thyroid. Thyroid deficiency in the Framingham Study. Arch Intern Med. 1985;145(8): 1386-8. 4. Bajaj S, Singh SK.Hypothyroidism.In:Bajaj S, et al,editors Manual of Clinical Endocrinology 1st ed. India.Endocrine Society Of India Osmania General Hospital,Inc.2012 DICUSSION
    • Take Home Massage Hypothyroidism is common disease which is more common in women It is one of the condition which can be very well controlled with single dose tablet So patient must be screened by doing TSH & FT4to rule out Hypothyroidism & Subclinical Hypothyroidism Compliance is very important Treatment for lifelong in case of hypothyroidism. DICUSSION