Hypothyroidism
ESIC – PGIMSR, MGM Hospital,
Mumbai
Presenter:
DR.UTKARSH DESHMUKH
DNB General Medicine
Index:
1.Case of Hy...
History
• A 50 year female patient Mrs. Pramilabai
Residing at Mumbai was working as maid
came to our hospital with compla...
History
• No H/o headache , vomiting or altered
sensorium, seizures.
• With exception of H/O deafness no other
H/S/O other...
History
• Past History:
• History of similar complaints 3 years back & taken
treatment but she was noncompliant. ( Details...
Examination
General Examination
• Patient was conscious, oriented.
• BMI 21 kg / m2
(No weight loss, Despite of loss of Ap...
Examination
General Examination cont….
• Thyroid examination was normal
• No Icterus, cyanosis, clubbing,
lymphadenopathy....
Examination
Systemic Examination [CNS]
• Higher function : -
• Conscious, oriented.
• Speech slow, sluggish & hoarseness o...
Examination
Systemic Examination [CNS]cont….
• Sensory examination : - Normal
• Reflexes
• Superficial reflexes:- Normal
•...
Examination
Systemic examination [CVS]
• Sinus bradycardia and diastolic hypertension, rest
WNL
Systemic examination RS & ...
Patient
• Slow speech , expressionless face.
• Here Watch for movements of the hand rather the
muscle
CASE
VID-20130813-WA...
Investigations
• Hemogram
• Hb – 10 gm/dl, WBC 8000/mm3
, platelets 322,000
• Peripheral smear – Normocytic normochromic
•...
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...
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 cir...
Introduction (cont….)
Secondary hypothyroidism
 Hypopituitarism
• Tumor
• Surgery / irradiation
• Infiltrative disorders...
Introduction (cont…)
Transient Hypothyroidism
 Silent Thyroiditis , including postpartum
thyroiditis
 Sub-acute thyroid...
Statistics
Epidemiology : -
• Prevalence - 0.1 to 2%
• 5 – 8 times more common in women.
• More common in adult women with...
Statistics (cont…)
India
• In population-based study in Cochin on 971
adult
• Prevalence of hypothyroidism – 3.9%
• Subcli...
Clinical Features
 GENERAL
• Lethargy,
Somnolence
• Weight gain, Goiter
• Cold Intolerance
 CARDIOVASCULAR
• Bradycardia...
Clinical Features
 HAEMATOLOGICAL
• Normocytic /
normchromic Anemia
• Iron def. Anemia.
 REPRODUCTIVE
SYSTEM
• Infertili...
Algorithm for Hypothyroidism
Measure TSH
Elevated TSH
Measure FT4
Normal Low
Sub-clinical hypo
TPO + TPO -
T4 repl Annual ...
Algorithm for Hypothyroidism
Measure TSH
Elevated TSH Normal TSH
Considering Pituitary
No Yes
No tests Measure FT4
Low Nor...
Treatment
• Goal : Normalize TSH level (Generally in
Lower Half of reference value)
• Treatment : Once daily dosing with
L...
How to Start ?
• Available Tab: – 25, 50 and 100 mcg tablets.
• Starting dose
 Healthy patients at 1.6µg/kg/day. (Usually...
SUBCLINICAL
HYPOTHYROIDISM
DICUSSION
Subclinical Hypothyroidism
 Definition: -
“Biochemical evidence of thyroid hormone
deficiency in patients who have few or...
Subclinical Hypothyroidism
(cont…)
Causes
Inadequate treatment of overt
hypothyroidism.
Transient elevation of TSH: Syst...
Subclinical Hypothyroidism
(cont…)
Risk Factors
 Women, > 60 yrs.
 Autoimmune disease:
• Diabetes Mellitus type I
• Rheu...
Subclinical Hypothyroidism
(cont…)
EFFECTS OF SH ON BODY
Associated with elevated cholesterol.
Altered endothelial funct...
Subclinical Hypothyroidism
(cont…)
Diagnosis
Asymptomatic.
Diagnosed during routine thyroid function test.
Subclinical ...
High TSH
TSH > 10 mU/L TSH 5-10 mU/L
For > 3 months
L levothyroxine TPO Antibody & Other
Positive Negative
No Treatment &
...
High TSH
TSH > 10 mU/L TSH 5-10 mU/L
For > 3 months
L levothyroxine TPO Antibody & Other
Positive Negative
No Treatment &
...
Subclinical Hypothyroidism
(cont…)
MANAGEMENT
Target of the treatment
TSH: - 0.5 – 3.0 mU/L.
Levothyroxine: - 25 – 50 µg...
Subclinical Hypothyroidism
(cont…)
BENEFITS OF TREATMENT
 Improve cardiac function.
 Improve mood and cognition.
 Impro...
MYXEDEMA
COMA
DICUSSION
Myxedema Coma
Definition: - “It is serious form of thyroid
hormone deficiency associated with altered
mental status, hypo...
Exposure to cold
Hypoventilation
Hypoxia Hypercapnia
Myxedema
Hypoglycemia
Dilutional Hyponatremia
Infection
Pathogenesis
Myxedema Coma (cont…)
 Clinical Features & Investigations
• Mental confusion, hypothermia, bradycardia.
• ↓ Na, ↓ glucose...
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 ...
Myxedema Coma (cont…)
Supportive Treatment
 Oxygen (Ventilation, if necessary)
 External warming (If Temperature < 30º ...
References
1. Desai PM. Disorders of the Thyroid Gland in
India. Indian J Pediatr. 1997;64:11–20. [PubMed
]
2. Jameson AL,...
References
3. Sawin C, Castelli W, et al. The aging thyroid.
Thyroid deficiency in the Framingham Study.
Arch Intern Med. ...
Take Home Massage
Hypothyroidism is common disease which is
more common in women
It is one of the condition which can be...
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Hypothyroidism final

  1. 1. 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
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. Examination Systemic examination [CVS] • Sinus bradycardia and diastolic hypertension, rest WNL Systemic examination RS & Per-abdomen WNL CASE
  10. 10. Patient • Slow speech , expressionless face. • Here Watch for movements of the hand rather the muscle CASE VID-20130813-WA0000.mp4
  11. 11. 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
  12. 12. 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
  13. 13. Treatment Other Treatment Statins Antinatianginal sos Antiplatelet Antihypertensive
  14. 14. Discussion Hypothyroidism DICUSSION
  15. 15. 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
  16. 16. 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
  17. 17. Introduction (cont…) Transient Hypothyroidism  Silent Thyroiditis , including postpartum thyroiditis  Sub-acute thyroiditis  Withdrawal of thyroxin therapy  After surgery or I131 DICUSSION
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. SUBCLINICAL HYPOTHYROIDISM DICUSSION
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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.
  34. 34. Subclinical Hypothyroidism (cont…) MANAGEMENT Target of the treatment TSH: - 0.5 – 3.0 mU/L. Levothyroxine: - 25 – 50 µg / Day.
  35. 35. 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.
  36. 36. MYXEDEMA COMA DICUSSION
  37. 37. 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
  38. 38. Exposure to cold Hypoventilation Hypoxia Hypercapnia Myxedema Hypoglycemia Dilutional Hyponatremia Infection Pathogenesis
  39. 39. Myxedema Coma (cont…)  Clinical Features & Investigations • Mental confusion, hypothermia, bradycardia. • ↓ Na, ↓ glucose, ↑ CO2, • ↓ WBC, ↓ Hematocrit, ↑ CPK • ↓ EKG voltage, myxedema. DICUSSION
  40. 40. Treatment Hormone replacement Supportive Treatment Treatment of precipitating Factors DICUSSION
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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

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