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Thyroid gland disorders hyper and hypo0110017 (2)
1.
2. Thyroid gland is located in the neck, anterior to the
trachea
Produces: T4 & T3 (active hormone)
The thyroid gland facilitates normal growth and
maturation by maintaining a level of metabolism in the
tissues that is optimal for their normal function.
4. The gland is affects:
1.Growth and maturation
2.Metabolism
3.Cardiovascular system
4.Autonomic nervous system
5. Brain : growth & development of nervous system
Bone&tissue growth : linear growth & maturation
of bones
CVS : increased contractility,heart rate &cardiac
output
GUT : increased absorption of nutrients, increased
motility
Liver : increased gluconeogenesis&glycogenolysis
6. Adipose tissue : increased lipolysis
Muscle : increased protein catabolism in skeletal
muscle
Kidney : increased erythropoietin synthesis
Respiration : increased central stimulation of
respiration
Energy metabolism : increased BMR, increased
oxygen consumption, increased heat production
stimulation of Na-K-ATP ase
7. DIVIDED INTO:
A. THYROTOXICOSIS (Hyperthyroidism)
Overproduction of thyroid hormones
B. HYPOTHYROIDISM (Gland destruction)
Underproduction of thyroid hormones
C. NEOPLASTIC PROCESSES
1. Benign
2. Malignant
8.
9. Causes of Thyrotoxicosis:
Primary Hyperthyroidism :
• Grave´s disease
F>M, age 20-40.
IgG auto antibodies bind TSH receptors
T3 & T4 leads to gland hyper function.
• Toxic Multinodular Goiter ( plummer’s
disease ) : too much T3& T4 .
• Toxic adenoma
• Functioning thyroid carcinoma
• Activating mutation of TSH receptor
• Drugs: Iodine excess, Amiodarone
10.
11. Treatment:
1.Reducing thyroid hormone synthesis:
Antithyroid drugs (Methimazole, Propyl-thyo-uracil)
Mech: they prevent the thyroid gland from producing excess amounts of
hormones.
Radioiodine (131I) (avoid contact with small children and pregnany
women)
Mech: Taken by mouth, radioactive iodine is absorbed by your
thyroid gland, where it causes the gland to shrink and symptoms
to subside but thyroxine needs to be replaced.
2.Surgical:
Subtotal/total thyroidectomy
Orbital decompression if thyroid eye disease causing
compression of optic nerve
12. 3.Reducing Thyroid hormone effects:
Propranolol
Glucocorticoids
Benzodiazepines
4.Reducing peripheral conversion of T4 to
T3 :
Propylthyouracil
Glucocorticoids
Iodide (Large oral or IV dosage) (Wolf-Chaikoff
effect)
21. Deep tendon reflex (or Woltman sign):
A stretch reflex, when the stretch is created by
a blow upon a muscle tendon.
It is seen in about 75% of patients with
hypothyroidism
Normal time for relaxationis 240–320 ms.
Delays in relaxation time in patients with
hypothyroidism appears to be proportional to
the level of thyroid-hormone deficiency
22. Occurs when there is a severe defect in thyroid hormone
synthesis
◦ Is a chronic inflammatory autoimmune disease
characterized by destruction of the thyroid gland by
autoantibodies against thyroglobulin, thyroperoxidase,
and other thyroid tissue components
◦ Will often have significantly elevated anti-TPO ab
23. Non Pharmacological :
◦ Lifestyle - smoking cessation, weight loss
Pharmacological:
◦ levothyroxine sodium products requires individualized patient
dosing.
◦ Levothyroxine acts like the endogenous thyroid hormone
thyroxine (T4, a tetra-iodinated tyrosine derivative). In the liver
and kidney, T4 is converted to T3, the active metabolite
◦ Clinical and biochemical evaluations at 6 to 8week intervals until
the serum TSH concentration is normalized
Surgical
◦ thyroidectomy if compression of local structures
25. 25
Primary Hypothyroidism
Treatment Algorithm
TSH >3.0 IU/mL TSH <0.5 IU/mL
Initial Levothyroxine Dose
Increase
Levothyroxine
Dose by
12.5 to 25 g/d
Repeat TSH Test
6-8 Weeks
TSH 0.5- 2.0 IU/mL
Symptoms Resolved
Measure TSH at 6
Months, Then Annually
or
When Symptomatic
Continue Dose Decrease
Levothyroxine
Dose by
12.5 to 25 g/d
26.
27. Z.A. is a 56 year old housewife came to the endocrinologist
complaining of progressive weight gain of about 20 pounds
(9.07 kg) in 1 year, fatigue and slight memory loss. She had
slow speech, dry skin and stated that she always had
constipation and cold extremities.
Physical examination showed body temperature of 36.2oC,
pulse 60/minute and BP 100/70. She is obese with BMI 33.
Her face was puffy and had pale, cool, dry and thick skin.
The thyroid gland is slightly enlarged, firm, not nodular,
mobile, and not tender. The deep tendon reflex time is
delayed.
28. Laboratory analysis showed serum total T4 concentration 3.8
µg/dL, serum TSH 23.0 U/mL, and the serum total
cholesterol 7.5 mmol/L.
29. Normal range of the hormones in adult's serum:
T4 (Thyroxine) Free: 0.8 - 2.8 ng/dl
T4 (Thyroxine) Total: 5 - 12 µg/dl
T3 (Triiodothyronine) Free: 2.3- 4.2 pg/ml
T3 (Triiodothyronine) Total: 120 -190 ng/dl
Thyroid-Stimulating Hormone (TSH): 0.5 - 5.0 mU/ml
Thyroglobulin: 3-5 µg/dl
TRH :5-60 ng/L
Thyroxine binding globulin :1-2 mg/dl
Total cholesterol: 3-5.5 mmol/l
30. 1.What is the most likely diagnosis in Z.A. case ?
Explain why.
Hypothyrodism
weight gain ,fatigue ,slight memory loss
slow speech,dry skin,constipation ,cold extremities.
Low body temperature of 36.2oC, low pulse 60/minute and
slightly hypotensive 100/70
Puffy pale face ,cool, dry and thick skin. The thyroid gland
is slightly enlarged
tendon reflex time is delayed.
Decreased T4 concentration, increased TSH and serum total
cholesterol.
31. 2.What are the most likely causes ?
Iodine deficiency
Hasimoto’s thyroiditis
Thyroidectomy
Radiation therapy
Drugs-lithium,antithyroid drugs and PAS
Absent or ectopic thyroid gland
Dyshormonogenesis
TSH receptor mutation
32. 3.How can Mrs. Z.A. case be managed ?
In general, hypothyroidism can be adequately treated
with a constant daily dose of levothyroxine (LT4).
Clinical & Biochemical evaluations at 6 to 8 weeks
intervals until serum TSH Conc is normalized .
33. 4.Mention the mechanism of action of L-
thyroxin ?
T4 and T3 bind to thyroid receptor proteins in the cell
nucleus and cause metabolic effects through the
control of DNA transcription and protein synthesis .
34. 5.What are the precautions for the replacement
therapy by L-thyroxin?
When initiating levothyroxine therapy, serum TSH
should be measured to monitor for adequate
replacement. TSH can take up to 4 months to normalize
It is recommended that the TSH is measured 6–8 weeks
after initiation of, or a change in levothyroxine dose.
Once the patient is on a stable dose of levothyroxine,
annual monitoring of TSH is recommended.
35. 6.What are the expected side effects for L-
thyroxine?
Allergy
Leg cramps, muscle weakness,
Headache,
Feeling nervous or irritable,
Diarrhea,
Mild hair loss,
Tachycardia .
36. The endocrinologist prescribed Mrs. Z.A. Eltroxin®
and scheduled her to return for checkup after one
month. A week later, Mrs. Z.A. was brought to the
emergency unit by her daughter. She had palor,
dyspnae, lethargic and impaired awareness. On
examination her pulse was 50 beats per min. Her
daughter declared that her mother fell into this case
after her last dose of propranolol.
37. 7.What is the most likely cause of Mrs. Z.A.
bradycardia? Discuss.
Due to short duration , the drug didn’t cause it’s full
effect .
Propranolol is a non selective beta-blocker which is
known to have negative chronotropic effect and
negative ionotropic effect. in combination with
hypothyroidism caused her symptoms .
38. After a week, Mrs. Z.A. returned to the
outpatient clinic for the regular check, her
pulse was normal but she complained of
having the primary symptoms again. Lab
tests showed serum total T4 concentration
3.1 µg/dL, serum TSH 22.0 U/mL, and the
serum cholesterol 160 mg/dl. Mrs Z.A.
admitted that she is on cholestyramine
therapy.
39. 8.How can you rationalize the remission of the
primary symptoms?
cholestyramine as been shown to interfere with the
absorption of ingested thyroid hormone.
40. 9.What measures do you suggest to manage the
remission of the primary symptoms?
Interference with thyroid hormone absorption by
cholestyramine can be minimized by allowing a time
interval of at least four hours between the ingestion of
the two agents .
41. 10.What non-pharmacological treatment do you
recommend to lower the total serum cholesterol level?
Diet (include green vegetables, fruits, avocado, fish
oil, almond, and nuts.)
Exercise
42.
43. RH is a 35 year old nurse complained of nervousness,
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 had maintained a normal weight of 120 pounds but
was eating twice as much as she did 1 year ago.
44. Physical examination: Pulse was 92/minute and BP
was 130/80. She appeared anxious, with a smooth,
warm, and moist skin, a fine tremor, a bounding
cardiac apical impulse, a pulmonic flow murmur, and
she couldn't rise from a deep knee bend without aid.
Her thyroid contained 3 nodules, 2 on the right and one
on the left with a total gland size of 60 grams (3 times
normal size), all nodules being of firm consistency 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=250 ng/dl
45. Normal range of the hormones in adult's serum:
T4 (Thyroxine) Free: 0.8 - 2.8 ng/dl
T4 (Thyroxine) Total: 4.5 - 11.5 µg/dl
T3 (Triiodothyronine) Free: 2.3- 4.2 pg/ml
T3 (Triiodothyronine) Total: 75 -200 ng/dl
Thyroid-Stimulating Hormone (TSH): 0.3 - 5.0 U/ml
Total cholesterol: 3-5.5 mmol/l
46. 1. What is likely diagnosis for this patient ? Are
additional diagnostic tests necessary to define the level
of thyroid function and if so which one(s)?
Hyperthyroid.
Yes, TSH
47. 2. What are the symptoms that made you
consider that diagnosis?
Weakness, palpitations with exertion , excessive
sweating , not gaining weight although eating twice the
amount as a year ago.
Pulse was 92/minute , BP was 130/60, anxious, a fine
tremor.
