Thyroid final

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Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.

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Thyroid final

  1. 1. HYPOTHYROIDISM-MANIFESTATIONS & MANAGEMENT Dr. Sachin Verma MD, FICM, FCCS, ICFC Fellowship in Intensive Care Medicine Infection Control Fellows Course Consultant Internal Medicine and Critical Care Web:- http://www.medicinedoctorinchandigarh.com Mob:- +91-7508677495
  2. 2. T3, T4 (-) Hypothalamus TRH (+) Pituitary T3, T4 (-) TSH (+) Thyroid
  3. 3. Hyperthyroidism Hypothyroidism
  4. 4. Patients of Thyroid Disorders Present As With Goiter Hypothyroid Without Goiter With Goiter Hyperthyroid Without Goiter Euthyroid With Goiter03/19/13 4
  5. 5. Hypothyroidism CausesWith Goiter Without Goiter Hashimoto’s Thyroiditis  Hashimoto’s Thyroiditis I2 deficiency goiter  Post ablative(radioactive I 2) Drug induced goiter  After thyroidectomy (Li, Amiodarone, PAS,  Congenital hypothyroidism ethionamide, Rifampicin)  Secondary hypothyroidism Due to goitrogens (Sheehan syndrome) Riedel’s thyroiditis
  6. 6. HYPOTHYROIDISMIODINE DEFICENCY is the most common cause of hypothyroidism worldwide.In Iodine sufficient areas, Autoimmune disease (HASHIMOTO’S THYROIDITIS) is most common.
  7. 7. HYPOTHYROIDISM Common presentation Symptoms Signs Dry & coarse skin- 76%  Ankle reflex absent- 77% Cold intolerance – 64%  Bradycardia - 58% Puffiness of face- 60%  Somnolence Sweating- 54%  Diastolic hypertension Wt gain-54%  Depression Paresthesia - 52 %  Anemia Constipation- 50%  Menorrhagia Aches & pains non specific  Infertility
  8. 8. HYPOTHYROIDISM Uncommon Presentations.  Hoarseness of voice  Deafness  Ascites  Pericardial & pleural effusion  Carpel tunnel syndrome  Impotence  Galactorrhoea & Amenorrhoea  Cardiac failure  Psychosis03/19/13 8
  9. 9. Thyroid • Thyroid Disease Can Brain Have Widespread Effects • Depression • Decreased Concentration Liver • General Lack of Interest • Increased LDL Cholesterol • Elevated Triglycerides Heart • Decreased Heart RateIntestines • Increased/Decreased• Constipation Blood Pressure• Decreased GI • Decreased Cardiac Activity Output KidneysReproductiveSystem • Decreased Function• Decreased Fertility • Fluid Retention and• Menstrual Abnormalities Edema• May Harm Development of Infant
  10. 10. Hashimoto’s Thyroiditis IN USAAbove 50 years Female – 10% HypothyroidAbove 60 years Male – 10% HypothyroidIn India prevalence rate of Hypothyroid is quite highbut data is not available.
  11. 11. Hashimoto’s Thyroiditis  Commonest cause of hypothyroidism  Most of the patients never develop goitre  Symptoms develop very gradually So difficult to Diagnose!03/19/13 11
  12. 12. Hashimoto’s Thyroiditis Painless Goiter/ No Goiter Investigations T3↓ T4 ↓ TSH↑ High titers of TPO ab. (almost 100%) Treatment Life long Thyroxin03/19/13 12
  13. 13. Viral ThyroiditisPainful Goiter (Usually small) , fever , sorethroatNatural History: Hyperthyroid 2 – 3 months Hypothyroid 2-6 months Euthyroid03/19/13 Few Patients may remain Hypothyroid Life Long 13
  14. 14. Viral Thyroiditis: TreatmentPain - Aspirin (600mg 4-6hrly) / NSAIDSSteroids – 40- 60 mg/ day according to severityHyperthyroid – PropranololHypothyroid – May require Thyroxin(50-100µgm)Euthyroid – After 6 months – 1 year No Drug Required 03/19/13 14
  15. 15. POST-PARTUM THYROIDITIS Post-partum thyroiditis (PPT) is an autoimmune, painless inflammation of the thyroid gland that occurs within a year in 5% to 10% of all pregnancies.22/1/05 2
  16. 16. Etiology and Pathogenesis Microchimerism: (Fetal cells in maternal blood) The presence of residual fetal cells which get attached to the maternal thyroid gland during pregnancy, induces autoimmune reactions as maternal immunosuppression is lost after delivery.22/1/05 8
  17. 17. Post Partum Thyroiditis Natural History: Hyperthyroid 2 - 3 months Hypothyroid 2 - 6 months Euthyroid  25% of Postpartum Thyroiditis Patients will develop Hypothyroidism after 5-10 years of delivery03/19/13 17
  18. 18. Atypical Presentations of Postpartum Thyroiditis  A Thyrotoxic phase followed by a return to normal thyroid function  A Hypothyroid phase alone22/1/05 13
  19. 19. Initial tests for diagnosis of Thyroid Dysfunction Primary Test TSH Additional Test Free T4
  20. 20. TSH raised (>3.5-5.5 according to the lab) Free T4 decreased Total T4 decreased .03/19/13 20
  21. 21. Hypothyroidism: Initial Diagnosis Free T3 May be normal in 25% cases of early hypothyroidism
  22. 22. Thyroid Ultrasound Relatively unimportant test Sensitive tool to ascertain size and number of thyroid nodules. Important tool in the follow up of a thyroid nodule if it is not to be operated03/19/13 22
  23. 23. Thyroid Scan WILL SHOW UPTAKE UPTAKE NORMAL UPTAKE 03/19/13 23
  24. 24. Thyroid Scan UPTAKE WITH GOITRE ( cold) Thyroiditis, Thyroid carcinoma DO FNAC03/19/13 24
  25. 25. Thyroid Scan UPTAKE WITH GOITRE (hot) Graves’ Disease03/19/13 25
  26. 26. Thyroid Scan NORMAL UPTAKE WITH GOITRE Colloid Goitre, Puberty Goitre, Adenoma DO FNAC03/19/13 26
  27. 27. COMMON THYROID AUTOANTIBODIES* ANTIGEN ANTIBODY TSH receptor TSHRAb (TSH Receptor Antibody) Thyroglobulin TgAbThyroid Peroxidase TPO Ab * Williams’ textbook of Endocrinology: 10th edition; chapter, 10 pg 36
  28. 28. GROUP TPO Ab General Population 8-10% Graves Disease 50-80% Autoimmune Thyroiditis 90-100% Relatives of Patients 40-50% Pregnant Women 14%22/1/05 6 * Williams’ textbook of Endocrinology: chapter, 10 pg 361
  29. 29. Treatment Of HypothyroidismDose of Levothyroxine depends on the degree of Hypothyroidism, Age & General health condition of the patientUsually daily replacement dose is 1.6µgm/Kg body weightStart with Low Dose
  30. 30. Treatment Of Hypothyroidism If Dose Missed, What To Do???One Dose Missed Take Two TabletsTwo Dose Missed Take Three TabletsThree Dose Missed Take Regular Dose
  31. 31. Treatment Of HypothyroidismWHEN SHOULD I TAKE IT ?? EMPTY STOMACH 30 mins BEFORE CALORIC MEAL
  32. 32. Follow up of a case of Hypothyroidism Serum TSH levels should be measured after 6-8 weeks of therapy and dosages should be adjusted accordingly Target TSH levels should be between 1-2 mU/l Once a stable TSH is achieved, it should be estimated every year03/19/13 32
  33. 33. Follow up of a case of Hypothyroidism Patient on Thyroxine TSH NORMAL WHAT SHOULD I DO?? Most of these patients are Hashimoto’s thyroiditis . They will require life long treatment Donot stop the drug Continue Thyroxine03/19/13 33
  34. 34. INTERPRETATION OF THYROID FUNCTION TESTS03/19/13 34
  35. 35. Situation 1 TSH Free T3 Free T4 Normal Normal Normal03/19/13 35
  36. 36. Diagnosis Normal Euthyroid03/19/13 36
  37. 37. Situation 2 TSH Free T3 Free T4 Normal High Normal /Decreased03/19/13 37
  38. 38. Diagnosis SubClinical / Early Hypothyroidism03/19/13 38
  39. 39. Situation 3 TSH Free T3 Free T4 Increased Decreased Decreased03/19/13 39
  40. 40. Diagnosis Hypothyroidism03/19/13 40
  41. 41. Situation 4 TSH Free T3 Free T4 Low High High03/19/13 41
  42. 42. Diagnosis Hyperthyroidism03/19/13 42
  43. 43. Situation 5 TSH Free T3 Free T4 Low Low or Normal Low03/19/13 43
  44. 44. Diagnosis Secondary Hypothyroidism Or Sheehan’s Syndrome03/19/13 44
  45. 45. SHEEHAN’S SYNDROME Female Excessive blood loss during delivery No lactation amenorrhoea Weakness,lethargic, anemia Depigmentation of areola, Shiny skin Loss of pubic & axillary hair Low B.P.
  46. 46. SHEEHAN’S SYNDROMETreatment Hormone replacement therapy including glucocorticoid (prednisone 5+2.5 mg/d), Thyroxine (75-150µgm/d)If lady wants periods- estrogen & progesterone preparations can be given.GOAL To maintain T4 level in the upper half of rangeTSH CANNOT BE USED TO MONITOR THERAPY
  47. 47. Hypothyroid And pregnancyDuring pregnancy requirement of thyroxin increases by 25-50µg/d during pregnancyEven on mild Thyroxin hormone deficiency there are chances of low IQ and developmental delay of the child
  48. 48. Hypothyroid And pregnancyThyroid Hormone exists in two forms : Free (Active) & Bound (with thyroxine binding globuline).In Pregnancy increased Estrogen, increases TBG which in turn increases Total T4 & T3 levelHowever Free T4, Free T4 REMAINS NORMAL.SO Free T4 should be used in the treatment and follow up during pregnancy & not total T4
  49. 49. Hypothyroidism In ElderlyIn Patients Above 60 Rule Out Coronary Artery DiseaseIf Coronary Artery Disease Present Or Suspected: Start Thyroxine With Low Dose And Then Increase The Dose Gradually Otherwise Angina May Precipitate.
  50. 50. Myxedema ComaPrecipitating factors : Infection, trauma, stroke, cardiovascular, hemorrhage drug overdose, diureticsSigns and Symptoms : Usually older age presenting as :  Mental confusion, hypothermia, bradycardia, ↓ Na, ↓ glucose, ↑ CO2, ↓ WBC, ↓ Hct, ↑ CPK ↓ EKG voltage 50
  51. 51. Myxedema ComaTreatment ICU transfer, IV levothyroxine 500 µg bolus followed by 50-100µg/d (same dose can be given through NG tube), antibiotics,ventilation, hydrocortisone IV, passive warming, careful volume management As T4 to T3 conversion is impaired so leothyronine is recommended but has a potential to provoke arrythmias.
  52. 52. Myxedema Madness.When being crazy is not in your head BUT IN THYROIDDelirium With Auditory Hallucinations &Paranoid DelusionsTakes The Form Of Psycotic Depression Or PurePsycosis.No Cognitive ImpairementTreatment- Thyroxine
  53. 53. Thank You
  54. 54. Sick Euthyroid SyndromeAny acute, severe illness can cause abnormalities of circulating TSH or Thyroid hormone levels in the absence of underlying Thyroid disease.Major cause - Release of cytokine IL-6Most common pattern ---- LOW T3 SNDROME---- in total & unbound T3 levels with normal T4 & TSH T4 T3 rT3 De iodination
  55. 55. Sick Euthyroid Syndrome LOW T4 SYNDROME ----1. Very sick patient may exhibit a dramatic fall in Total T3 & T42. Poor prognosis In Acute Liver disease initially Total T3 & T4 levels due to TBG release; these levels become subnormal as the disease progress Renal disease is often accompanied by low T3 levels In early stages of HIV T3 & T4 levels rises,. T3 levels falls with progression to AIDS , but TSH remains normal
  56. 56. Sick Euthyroid Syndrome Diagnosis is supported by History of thyroid disease Previous thyroid function testsHistory of Drugs that may affect thyroid hormonesMeasurement of rT3 together with FT3 , FT4 and TSHONLY RESOLUTION OF TESTS WITH CLINICAL RECOVERY CAN ESTABLISH THIS DISORDER

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