Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
2CASES…………!!!!!!!!1)A 38 yr /old lady with generalised paresthesias,pain indiff.joints,generalised weakness, occasional vo...
THINKTHYROIDVAGUE SYMPTOMSMULTIPLE SYMPTOMSOLD AGEPOSTPARTUM PERIODCOLD /HEAT INTOLERANCEDIMENTIAFORGETFULNESSMILD ANEMIAM...
HYPOTHYROIDISM&MYXEDEMA CRISISDr.Sajid NomaniMEM (PGT)Peerless Hospital & B.K.Roy Research CenterKolkata
Goals of Discussion…..• THYROID -quick review• HYPOTHYROIDISMDefinitionClinical symptomsTreatment• MYXEDEMA CRISIS
The Thyroid Gland…….Vercelloni 1711: “a bag of worms ” whose eggspass into the esophagus for digestive purposesParry 1825:...
Introduction……• Largest endocrine gland• 20 grams in adult• Each lobe• 2-2.5cm in width and thickness• 4cm in height• Isth...
Introduction……• Two principal hormones.• Thyroxine (T4 ) and triiodothyronine (T3).• Required for homeostasis of all cells...
In the Thyroid Gland……5 steps in the hormonogenesis1. Trapping of inorganic Iodine from dietary Iodides2. Activation of Io...
The negative feedback…..
Thyroid gland normally releases 100-125 mcg of thyroxine (T4) daily and small amountsof T3Tri Iodo Thyronine – T310% is fr...
Normal……..• TSH :0.5-5.0 mIU/ L……….(Soon -TSH---2.5)• T4 (T) :4.5 - 12.5 µg/dl(F) :0.8 - 1.8 ng/LT4 is 99.9% protein bound...
Thyroid Function Tests• TSH• Free T4• Free T3• Anti-Thyroid Antibodies• Nuclear Scintigraphy• FNAC of nodule
What tests should I order ?As per the Guidelines of the AACE and ATA, ITS• TSH alone if Hypothyroidism is suspected• TSH a...
HypothyroidismThe Underactive Thyroid
Introduction….• This is the most common pathological hormone deficiency• Results in a slowing down of metabolic processes....
How common is it in India???....• Hypothyroidism :INDIA : 3.9% [Usha menon,A.G.Unnikrishnan,ijem july 2011]WORLDWIDE :2 %•...
Introduction…..• Classification:Time of onset: Congenital or acquiredSeverity: Clinical or subclinicalSite of dysfunction:...
Interpration…..!!!!!!!!!!LOWNORMALHIGHLOW NORMAL HIGHFREETHYROXINEorFT4THYROID STIMULATING HORMONE - TSHPRIMARYHYPOTHYROID...
Sign & symptoms…..Everything from the brain to the skin is affected by thehormone made by the thyroid gland.Hypothyroidism...
Sign & symptoms…..• Depends on degree of hormone deficiency(overt, subclinical)• Depends on speed of development of hormon...
General• Lethargy, Somnalence• Weight gain, Goitre• Cold IntolerenceCardiovascular• Bradycardia, Angina• CHF, Pericardial ...
Clinical Signs of Hypothyroidism Coarse Hair; Dry cool and pale skin Goitre (not in all cases), Hoarseness of voice Non...
Management……GOAL---keep TSH ,half of upper ref .range.L-Thyroxine 1.6mcg/kg/day in otherwise healthypatientsin patients ...
coming back…to our case 11)A 38 yr /old lady with generalised paresthesias,pain indiff.joints,generalised weakness ,& low ...
Additional Info generated….• Family H/O hypothyroidism• Delivered 6 mo. back & Brest feeding• Taking Iron & Calcium tabs.•...
• Started---75mcg /day empty stomach• Called back after 6 weeks.Pt. reports good compliance TSH—20 u/l↑ Doses—100mcgCalled...
HIGH DOSES REQUIRMENT OF LEVOTHYROXINE• MALABSORPTION• Celiac disease• Small bowel surgery• MEDICATION• Estrogen• Amaidron...
High doses requirment of lEVOTHYROXINE MALABSORPTION /↑EXCRETION OF T4Gastrointestinal disorders,Impaired acid secretionC...
What to do???• Space out thyroxine from other offending drugs.• Can be converted in night doses.• No adjustment for Renal ...
Maternal Hypothyroidism• AACE recommendations• Carry out TSH assay routinely before pregnancy or during thefirst trimester...
Do you need to treat Subclinical hypothyroidism• 5-8% indivisual have SCH.• 4.3 % progressed to overt hypothyroidism• Trea...
In the emerge ncy roomMYXEDEMA CRISISLife-threatening severe hypothyroidism• 80% -100 % mortality rate• Reduced to 15-20% ...
MYXEDEMA CRISIS A rare clinical state of insidious onset, in anindividual with pre-existing hypothyroidism End-stage of ...
Our 2nd patient65 yoF with confusion brought in by police, Unable to answer questions95F HR 50 BP 95/75 RR 20 02 85%EKG: l...
Myxedema Coma: Clinical• OFTEN ELDERLY (but not always!!)• History of hypothyroidism• Levothyroxine replacement, thyroid c...
Myxedema Coma: Risk factor• Cold weather• Elderly women• Undiagnosed or under treated hypothyroidism• Precipitating event
Myxedema Coma: Precipitants• Discontinued thyroid hormone replacement• CVA or MI• Infection (UTI, URI)• Hemorrhage• Narcot...
Myxedema Coma :FindingsDecrease mental status – from baselineHypothermia/ Hypoglycemia/ HyponatremiaBradycardiaHypoven...
Myxedema Coma :Findings CardiacBradycardia / hypotensionCHFCardiomegalyPericardial effusionLow voltage EKG
Myxedema Coma :Findings NeckThyroidectomy scarGoiter (uncommon) DermatologicDry, scaly, yellow skinLoss of lateral 3...
Myxedema Coma :Findings
Diagnosis• Diagnosis is clinical• Thyroid panel reflects chronic state
Myxedema Coma: Workup• Basic lab tests and radiology• FT4, TSH• CBC (anemia), electrolytes (hyponatremic),• renal function...
Managment Supportive careABCsRewarming Treat precipitating causes
Treatment ::Myxedema Coma Rewarming : 0.5celcius/h.,passive rewarming Thyroid hormoneLevothyroxine (T4) @4mcg/kg300 - 5...
RECOMENDATION• The American Thyroid Association recommends screening atage 35 years and every 5 years thereafter, with clo...
HYPOTHYROIDISM.& MYXEDEMA CRISIS
HYPOTHYROIDISM.& MYXEDEMA CRISIS
HYPOTHYROIDISM.& MYXEDEMA CRISIS
HYPOTHYROIDISM.& MYXEDEMA CRISIS
HYPOTHYROIDISM.& MYXEDEMA CRISIS
Upcoming SlideShare
Loading in …5
×

HYPOTHYROIDISM.& MYXEDEMA CRISIS

9,922 views

Published on

Published in: Health & Medicine
  • Be the first to comment

HYPOTHYROIDISM.& MYXEDEMA CRISIS

  1. 1. 2CASES…………!!!!!!!!1)A 38 yr /old lady with generalised paresthesias,pain indiff.joints,generalised weakness, occasional vomiting;cough, she developed symptoms of tremor, irritability ,& shefeels cold even in normal day.Seen by PCP & investigated:CBC-@ Normal,except than Hb-9.5gm/dl,uric acid-7.2mg/dl (N-≤6) ;CPK- 300,2) 65 yoF with confusion brought in by police, Unable to answerquestions95F HR 50 BP 90/70 RR 20 02 85%EKG: low voltage, sinus bradycardia
  2. 2. THINKTHYROIDVAGUE SYMPTOMSMULTIPLE SYMPTOMSOLD AGEPOSTPARTUM PERIODCOLD /HEAT INTOLERANCEDIMENTIAFORGETFULNESSMILD ANEMIAMILD HYPERURICEMIAALTERED LIPID PROFILEELEVT.CPK
  3. 3. HYPOTHYROIDISM&MYXEDEMA CRISISDr.Sajid NomaniMEM (PGT)Peerless Hospital & B.K.Roy Research CenterKolkata
  4. 4. Goals of Discussion…..• THYROID -quick review• HYPOTHYROIDISMDefinitionClinical symptomsTreatment• MYXEDEMA CRISIS
  5. 5. The Thyroid Gland…….Vercelloni 1711: “a bag of worms ” whose eggspass into the esophagus for digestive purposesParry 1825: “a vascular shunt to cushion thebrain from sudden increases in blood flow
  6. 6. Introduction……• Largest endocrine gland• 20 grams in adult• Each lobe• 2-2.5cm in width and thickness• 4cm in height• Isthmus• 0.5cm thick• 2cm height and width
  7. 7. Introduction……• Two principal hormones.• Thyroxine (T4 ) and triiodothyronine (T3).• Required for homeostasis of all cells.• Influence cell differentiation, growth, and metabolism• Considered the major metabolic hormones becausethey target virtually every tissue
  8. 8. In the Thyroid Gland……5 steps in the hormonogenesis1. Trapping of inorganic Iodine from dietary Iodides2. Activation of Iodine to high valance I23. Incorporation of I2 into Tyrosine of Thyroid Globulin4. Coupling of formed MIT and DIT to form T4 & T35. Proteolysis of Thyroglobulin to release T4 & T3
  9. 9. The negative feedback…..
  10. 10. Thyroid gland normally releases 100-125 mcg of thyroxine (T4) daily and small amountsof T3Tri Iodo Thyronine – T310% is from thyroid gland90% derived from conversion of T4 to T3half life 6 hours99.5% protein bound to TBG, TPA, TATetra Iodo Thyronine – T4Is exclusively from thyroid glandhalf life 7 days99.9% protein bound to TBG, TPA, TAFrom the thyroid gland- 80% of hormone secreted is T4- 20% of hormone secreted is T3POTENCY—T3:T4=4:1
  11. 11. Normal……..• TSH :0.5-5.0 mIU/ L……….(Soon -TSH---2.5)• T4 (T) :4.5 - 12.5 µg/dl(F) :0.8 - 1.8 ng/LT4 is 99.9% protein bound to TBG, TPA, TA• T3 (T) :80 -200 ng/dl( F) :2.3- 4.2 pg/mlT3 is 99.5% protein bound to TBG, TPA, TABound hormones are inactive – should not be measuredOnly Free T4 and Free T3 are metabolically active
  12. 12. Thyroid Function Tests• TSH• Free T4• Free T3• Anti-Thyroid Antibodies• Nuclear Scintigraphy• FNAC of nodule
  13. 13. What tests should I order ?As per the Guidelines of the AACE and ATA, ITS• TSH alone if Hypothyroidism is suspected• TSH and Free T4 only if Hyperthyroidism suspected• Free T3 if T3 toxicosis is suspected• For follow-up of treatment only TSH• Don’t order for Total T4 or Total T3• Never order RIU in pregnancy or lactation
  14. 14. HypothyroidismThe Underactive Thyroid
  15. 15. Introduction….• This is the most common pathological hormone deficiency• Results in a slowing down of metabolic processes.• Prevalence 2-3% in the general population• Mean age at diagnosis is mid-40s• Male: Female 1:20
  16. 16. How common is it in India???....• Hypothyroidism :INDIA : 3.9% [Usha menon,A.G.Unnikrishnan,ijem july 2011]WORLDWIDE :2 %• Congenital hypothyroidism:INDIA: 1:2640WORLDWIDE :1 :3800 (vaidya & Pearce,2008)• Subclinical :9.4%M:F=6.2% :11.6%
  17. 17. Introduction…..• Classification:Time of onset: Congenital or acquiredSeverity: Clinical or subclinicalSite of dysfunction: Primary or secondary/tertiary
  18. 18. Interpration…..!!!!!!!!!!LOWNORMALHIGHLOW NORMAL HIGHFREETHYROXINEorFT4THYROID STIMULATING HORMONE - TSHPRIMARYHYPOTHYROIDSECONDARYHYPOTHYROIDSUB-CLINICALHYPOTHYROIDSECONDARYHYPERTHYROIDEUTHYROIDNON THYROIDILLNESS - NTISUB-CLINICALHYPERTHYROIDPRIMARYHYPERTHYROIDNTI or Pt.on ELTROXIN
  19. 19. Sign & symptoms…..Everything from the brain to the skin is affected by thehormone made by the thyroid gland.Hypothyroidism "It slows you down,It makes youlethargic and fatigued Your hair becomes brittle,and your skin becomes dry. You become cold mucheasier than the average person.
  20. 20. Sign & symptoms…..• Depends on degree of hormone deficiency(overt, subclinical)• Depends on speed of development of hormonedeficiency (gradual, better tolerated)
  21. 21. General• Lethargy, Somnalence• Weight gain, Goitre• Cold IntolerenceCardiovascular• Bradycardia, Angina• CHF, Pericardial Effusion• HyperlipIdemia, XanthelsmaHaematological• Iron def. Anaemia,• Normo cytic /chromic AnaemiaReproductive system• Infertility, Menorrhagia• Impotence, Inc. ProlactinNeuromuscular• Aches and pains• Muscle stiffness• Carpel tunnel syndrome• Deafness, Hoarseness• Cerebellar ataxia• Delayed DTR, Myotonia• Depression, PsychosisGastro-intestinal• Constipation, Ileus, AscitesDermatological• Dry flaky skin and hair• Myxoedema, Malar flushes• Vitiligo, Carotenimia, AlopeciaSign&symptoms…..
  22. 22. Clinical Signs of Hypothyroidism Coarse Hair; Dry cool and pale skin Goitre (not in all cases), Hoarseness of voice Non-pitting oedema (myxoedema) Puffiness of eyes and face Delayed relaxation of DTR Slow hoarse speech and slow movements Thinning of lateral 1/3 of eye brows Bradycardia, pericardial effusion
  23. 23. Management……GOAL---keep TSH ,half of upper ref .range.L-Thyroxine 1.6mcg/kg/day in otherwise healthypatientsin patients age>60 or if CAD present, 0.5-1.0mcg/day and slowly increaseT3-controversialrecheck levels in 6 weeks
  24. 24. coming back…to our case 11)A 38 yr /old lady with generalised paresthesias,pain indiff.joints,generalised weakness ,& low mood. cold intolerance,occasional vomiting; coughWHAT FURTHER TO LOOK…..• History• CO-EXISTING FACTORS• Comorbidities• Age• Severity of hypothyroidism• Coexisting drugs
  25. 25. Additional Info generated….• Family H/O hypothyroidism• Delivered 6 mo. back & Brest feeding• Taking Iron & Calcium tabs.• O/P—Small firm goiter• TSH—30 U/ml• FT4--- 0.4ng/ml• FURTHER TESTING ????DIAGNOSISPrimary HypothyroidismPostpartum ThyroiditisAnti TPO antibody(thy.peroxidase)Anti Tg(thyroglobulin)antibodyUSGFNAC
  26. 26. • Started---75mcg /day empty stomach• Called back after 6 weeks.Pt. reports good compliance TSH—20 u/l↑ Doses—100mcgCalled back after 6 weekTSH---15u/l ???……NOT CONTROLLEDWHAT ARE CAUSES FOR HIGH DOSES REQUIRMENT???IS THYROXINE TREATMENT DURING BREASTFEED SAFE TOBABY???
  27. 27. HIGH DOSES REQUIRMENT OF LEVOTHYROXINE• MALABSORPTION• Celiac disease• Small bowel surgery• MEDICATION• Estrogen• Amaidrone• Lithium prepration• Ferrous sulfate• Calcium• PPI• Carbamazepine• Phenytoin• Lovastatin• Bulk laxative• Magnesium prepration• Alumunium hydroxide
  28. 28. High doses requirment of lEVOTHYROXINE MALABSORPTION /↑EXCRETION OF T4Gastrointestinal disorders,Impaired acid secretionCeliac diseaseSmall bowel surgery MEDICATIONIncrease catabolism of T4:RifampinCarbamazepinePhenytoinPhenobarbitolDrugs interfere T4absorption:Cholestyramineorcolestipol,SucralfateFerrous sulfate,Calcium CarbonateAluminum hydroxide gels,SertralineRaloxifene, Omeprazole
  29. 29. What to do???• Space out thyroxine from other offending drugs.• Can be converted in night doses.• No adjustment for Renal / Hepatic diseases.• Safe in Breastfeeding.Our patientSpacing done between medicationCont.same doses; TSH reduced to—2.8Called backed after 3 month for evaluation; TSH—0.1REVERSIBLE HYPOTHYROIDISM20%Autoimmune found to be reversibleSpontaneous disappearance of blocking agent
  30. 30. Maternal Hypothyroidism• AACE recommendations• Carry out TSH assay routinely before pregnancy or during thefirst trimester to rule out thyroid disorder• Avoid complications by administering thyroid hormonereplacement therapy• Both mild as well as overt hypothyroidism are managed byadministering levothyroxine therapy which can be safelyadministered during pregnancy• Assess TSH levels every 6 weeks .• Increase the dose of thyroid hormone in pregnant women withmoderate to severe hypothyroidism
  31. 31. Do you need to treat Subclinical hypothyroidism• 5-8% indivisual have SCH.• 4.3 % progressed to overt hypothyroidism• Treat at all ages if:• Consider treatment, if:2012 European Thyroid AssociationPublished by S. Karger AG, BaselTSH >10.0 mU/lPregnancy (or pre-pregnancy)Age <65 yearsSymptoms or signs of hypothyroidismHigh vascular risk IHD/DM/DL/SMOKER]Positive thyroid peroxidase antibodiesGoitre
  32. 32. In the emerge ncy roomMYXEDEMA CRISISLife-threatening severe hypothyroidism• 80% -100 % mortality rate• Reduced to 15-20% with aggressively managment
  33. 33. MYXEDEMA CRISIS A rare clinical state of insidious onset, in anindividual with pre-existing hypothyroidism End-stage of untreated hypothyroidism. Precipitated by intercurrent illness such as infection,stroke or CNS depressants
  34. 34. Our 2nd patient65 yoF with confusion brought in by police, Unable to answer questions95F HR 50 BP 95/75 RR 20 02 85%EKG: low voltage, sinus bradycardia…CT-WNL, Chest Xray---Pleural effusion• Found wandering in the street• Unable to answer questions• Skin is coarse and waxy• Tranverse surgical scar on neck• Generalized weakness and prolonged DTR
  35. 35. Myxedema Coma: Clinical• OFTEN ELDERLY (but not always!!)• History of hypothyroidism• Levothyroxine replacement, thyroid cancer,• surgery, RAIA• Physical exam• Comatose or decreased mental status• Hypothyroid signs: Cool/dry skin, delayed reflexes,• lid lag, thin hair, hypothermia, ileus, effusionsMyxedema (not always easy to detect)
  36. 36. Myxedema Coma: Risk factor• Cold weather• Elderly women• Undiagnosed or under treated hypothyroidism• Precipitating event
  37. 37. Myxedema Coma: Precipitants• Discontinued thyroid hormone replacement• CVA or MI• Infection (UTI, URI)• Hemorrhage• Narcotics, diarrhea, comorbid illness
  38. 38. Myxedema Coma :FindingsDecrease mental status – from baselineHypothermia/ Hypoglycemia/ HyponatremiaBradycardiaHypoventillationPeri-orbital edemaNon-pitting EdemaDelayed Tendon Reflex
  39. 39. Myxedema Coma :Findings CardiacBradycardia / hypotensionCHFCardiomegalyPericardial effusionLow voltage EKG
  40. 40. Myxedema Coma :Findings NeckThyroidectomy scarGoiter (uncommon) DermatologicDry, scaly, yellow skinLoss of lateral 3rd of eyebrowsNon-pitting waxy edema of face / extremities
  41. 41. Myxedema Coma :Findings
  42. 42. Diagnosis• Diagnosis is clinical• Thyroid panel reflects chronic state
  43. 43. Myxedema Coma: Workup• Basic lab tests and radiology• FT4, TSH• CBC (anemia), electrolytes (hyponatremic),• renal function (increased Cr)• EKG (bradycardia), CXR (effusions)• Evaluate for pituitary disorders• Cortisol, cosyntropin stimulation test• FSH, LH
  44. 44. Managment Supportive careABCsRewarming Treat precipitating causes
  45. 45. Treatment ::Myxedema Coma Rewarming : 0.5celcius/h.,passive rewarming Thyroid hormoneLevothyroxine (T4) @4mcg/kg300 - 500mcg IV Hydrocortisone 100mg IV q8possible unrecognized adrenal or pituitary insufficiency Antibiotics & other supports
  46. 46. RECOMENDATION• The American Thyroid Association recommends screening atage 35 years and every 5 years thereafter, with closer attentionto patients who are at high risk (eg, pregnant women, women>60 y, patients with type 1 diabetes or other autoimmunedisease, patients with history of neck irradiation).• The American College of Physicians recommends screening allwomen older than 50 years who have one or more clinicalfeatures of disease.• The American Association of Clinical Endocrinologistsrecommends TSH measurements of all women of childbearingage before pregnancy or during the first trimester.• The US Preventive Task Force concludes that the evidence isinsufficient to recommend for or against routine screening forthyroid disease in adults (Grade I recommendation).

×