This document presents a case study of a 34-year-old woman with hypothyroidism. Her symptoms include fatigue, blurred vision, vertigo, cold intolerance, menorrhagia, and constipation. On examination, she appears thin, pale, and has delayed reflexes. Laboratory tests show elevated TSH and low T3 and T4, confirming hypothyroidism. Ultrasound reveals an enlarged liver and thyroid nodule. The document then discusses hypothyroidism, its causes, clinical manifestations, diagnosis, and management, including the use of levothyroxine treatment and monitoring of TSH levels. It also covers special populations like pregnant women, the elderly, and cases of myxedema

1. Hypothyroidism
Moderator- Dr MANZOOR WANI
Department of Gastroenterology
BY DR DEVARJUN PANNU
1ST YEAR DNB MEDICINE, JLNM SRINAGAR

2. Case of Hypothyroidism
• History – Rafeequa 34 year old unmarried female complains of fatigue,
blurring of vision , vertigo, cold intolerance, menorrhagia , and constipation .
• Physical examination- Vital signs includes a temperature of 97 F , pulse of
64/ min and regular , BP – 90/60 mm of Hg . She is thin weighing 41.5 kg ,
small 4’7 inches speaks slowly with pale with pale , cool , dry skin . The
thyroid gland is not palpable . The deep tendon reflux is delayed .
• Laboratory studies - WBC - 5,500/ml , Hg – 11.3 g/dl ( Microcytic
Hypochromic ), Platelets-=1,14,000/ml . Serum TSH- 432 uIU/ ml , T3 -0.35
ng/ml , T4 - 5.66 ug/dl . ESR - 15 mm/ hour , serum cholesterol 201mg/dl.

3. Radiological Investigation
 USG Abdomen- Liver Hypertrophied left caudate lobe with
atrophied Right lobe heterogeneous echo pattern with modular
margins. Gall bladder
showing multiple calculi (largest12mm) . Kidney Bilateral
medullary nephrocalcinosis
 USG thyroid- Chronic thyroiditis with heterogeneous parenchyma
echo pattern with increased vascularity in Doppler . Left lobe
shows well encapsulated nodule 26*17*26 mm with volume 6.3 ml
with central cystic area 8*8mm . ? Follicular neoplasm ,
?Adenomatous nodule TIRADS Grade 3

4. X- ray

5. HYPOTHYROIDISM
•2nd MC endocrine disorder after Diabetes Mellitus
•MC cause of hypothyroidism worldwide - iodine
Deficiency
•MCC in iodine sufficient areas- Hashimoto's
Thyroiditis
•99% cases- Primary Hypothyroidism
•<1% cases- Secondary Hypothyroidism
•Easy to diagnose & gratifying to treat

6. Introduction
 Condition where there is a reduced production of thyroid
hormone. Categorized as primary and secondary on the basis
of its cause
 Primary Hypothyroidism occurs due to improper functioning
of the thyroid gland.
May be further classified as overt and subclinical
hypothyroidism. Affects approximately 5% of individuals with
elderly women being most commonly affected.
 Secondary Hypothyroidism occurs due to inadequate
stimulation of thyroid gland by thyroid stimulating hormone
(TSH). May be due to
congenital or acquired defects in the pituitary or hypothalamus.

7. Primary Hypothyroidism Etiology
 Thyroid dysfunction -
 Autoimmune thyroiditis (Hashimoto's thvroiditis)
 Congenital absence or defect in the thyroid tissue
 Thyroid removal by surgery
 Radio ablation by radio active iodine or irradiation
 Destruction of thyroid tissue caused by infiltrative
 disorders(amyloidosis,sarcoidosis)
 Impaired synthesis of thyroid hormone -
 lodine deficiency---MOST COMMON CAUSE
 Congenital enzymatic defects
 Drug-mediated: thionamides , amiodarone , lithium, aminoglutethimide, carbemazole

8. Secondary Hypothyroidism Etiology
Reduced secretion of TRH or TSH
• Hypothalamic disorders
1. Tumor (lymphoma, germinoma , glioma)
2. Infiltrative disorders (sarcoidosis, hemochromatosis, and histiocytosis)
• Hypopituitarism
1. Mass lesions
2. Pituitary surgery
3. Pituitary irradiation
4. Hemorrhagic apoplexy (Sheehan's syndrome)
5. Lymphocytic hypophysitis

9. Clinical Manifestations Symptoms
 Tiredness/weakness -
 Weight gain with poor appetite
 Dry skin
 Cold sensation
 Hair loss(diffuse alopecia)
 Nail growth is retarded
 Poor concentration/memory loss
 Constipation
 Dyspnea
 Hoarseness of voice
 Hearing Impairment
 Carpal tunnel syndrome
 Menorrhaqia(miscarriage)
 Paresthesia

10. Clinical Manifestations Signs
 Cold peripheral extremities
 Dry, coarse and yellow skin
 Puffiness of face, hands and feet
 Pre tibial non pitting edema
 Hair loss and brittle nails
 Bradycardia/ diastolic hypertension
 Slow relaxation of tendon reflex (woltmans sign)
 Serous cavity effusions
 Normal/enlarged/atrophied thyroid gland
 Hypothyroidism in children
 Delayed growth in children and delayed appearance of permanent teeth
 Delayed or precocious puberty
 Pseudohypertrophy of muscles

11. Maternal Hypothyroidism
 One of the most common endocrine disorders in pregnancy .
 Overt hypothyroidism found in 1.3 per 1000 pregnant women and
subclinical hypothyroidism in 23 per 1000 pregnant women .
 Most common cause: endemic iodine deficiency .
 Women with hypothyroidism carry an increased risk of infertility,
miscarriage, and obstetric complications
 Foetal complications: premature birth, low-birth weight (LBW), fetal
distress in labor, fetal death, perinatal death, and congenital
hypothyroidism .
 Even an untreated subclinical hypothyroidism during pregnancy can
lead to cognitive impairment in the offspring.

12. CONGENITAL HYPOTHYROIDISM
 1 in 4000 newborns
 2: 1 incidence in males as compared to males
 Can be
• Transient - if the mother has TSH-R blocking antibodies
• Permanent- majority
 Causes
• 80-85% cases - Thyroid gland dysgenesis
• 10-15% cases- Inborn errors of Thyroid hormone synthesis
• 5% cases- TSH-R antibody mediated
 Gene Mutations include:
PROP-1, PIT-1, TSH-receptor, TSH beta, Thyroid Peroxidase,
Thyroglobulin, Pendrin

13. Clinical manifestations
 Majority- appear normal at birth
 Few cases are diagnosed on the basis of clinical features &
biochemical screening
• Clinical Features include:
 Prolonged jaundice
Feeding problems
Hyotonia
 Enlarged tongue, Umbilical hernia
 Delayed bone maturation
• Complications:
 4 times increased chances forCongenital malformations (Cardiac)
 Permanent neurological damage

14. Diagnosis and Treatment
 Neonatal Screening programs
 Measurement of TSH or T4
 Heel prick blood sample
 • Treatment dose:
 T3 = 10-15 ug/kg per day
 Regular TSH monitoring

15. Management

16. Treatment- Clinical Hypothyroidism
 Dose of Levothyroxine (T4)
 Ideal time of taking?
 Goal of treatment?
 TSH monitoring?
 Symptom relief?
 Risk of over-treatment?
 Issues with adherence?
 Do not feel any difference after missing few doses
 If misses single dose?
 Increased requirements?

17. Subclinical hypothyroidism
 Indications of treatment
 TSH > 10 mlU/L
 TSH < 10 mIU/L
1. Symptoms, Goitre
2. Family history of autoimmune thyroid disease
Planning pregnancy or pregnant
3. .TPO antibody positive
4. Evidence of heart disease, dyslipidemia
5. Infertilitv
6. Psychiatic disorders
 Dose
 Start with low dose- 25-50 ug/day

18. Pregnancy
 Thyroid function should be monitored
 Before conception- therapy to target TSH in normal range
 TFT
1. Every 4 weeks in first half of preghancy
2. every 6-8 weks after 20 weeks
 Levothyroxine dose is increased by 45%
 After delivery dose- Pre pregnancy levels

19. Elderly
 Require 20% less dose than younger specially cardiac
patients
Starting dose 12.5 to 20g/day
 Gradual increments in 2-3 months

20. Levothyroxine (T4) – Drug Interaction
 Increase LT4 dose with
1. Drugs that reduce thyroxine production: lithium, iodine-containing drugs, and
amiodarone
2. Drugs that/reduce thyroxine absorption: sucralfate, ferrous sulfate,
cholestyramine, colestipol, aluminum-containing antacids, and calcium
supplements
3. Drugs that increase thyroxine metabolism: rifampin, phenobarbital,
carbamazepine, warfarin, and oral hypoglycemic agents
 Decrease LT4 dose with
1. Drugs that displace thyroxine from binding proteins: furosemide, mefenamic
acid, salicylates, vitamin C

21. Myxedema Coma
 Myxedema coma is a rare life-threatening condition.It is the
decompensated state of severe hypothyroidism in which-the
patient is hypothermic and unconscious.
 The condition occurs most often among elderly women in the
winter months and appears to be precipitated by cold.
 Myxedema coma, occasionally called myxedema crisis, is a rare
life- threatening clinical condition that represents severe
hypothyroidism with physiological decompensation.
 The condition usually occurs in patients with long-standing,
undiagnosed hypothyroidism.

22. Why term Myxedema ?
 Myxedema is also used to describe
the dermatologic changes that occur in
hypothyroidism which refers to
deposition of mucopolysaccharides in
the dermis, which results in swelling of
the affected area.

23. Factors precipitating
 Infection, Exposure to cold temperatures,
 Trauma
 Burns
 Cerebrovascular accident , Myocardial infarction
 Congestive heart failure
 Respiratory acidosis
 Medications - sedatives, narcotics, amiodarone , rifampin, beta blockers.
 Decreased drug metabolism leading to overdosing of medications particularly
sedatives, hypnotics, and anaesthetic agents; this can precipitate myxedema coma.
 Metabolic disturbances - hypoglycemia, hyponatremia, acidosis and hypercapnia.

24. Myxedema Coma
 20-40% mortality
 Almost always - Elderly patient
 Precipitating conditions- That impair respiration
1. Drugs, Pneumonia, CHF, MI
2. CVA, GI bleed
 Levothyroxine
• (Initial-200-400 ug IV bolus or through Nasogastric tube f/b
• Daily oral dose 1.6 ug/kg
 Liothyronine (T3)
• Since T4->T3 conversion is impaired
• 5-20 ug followed by 2.5-10 ug 8 hrly

25.  Supportive therapy
1. External warming
2. Parenteral Hydrocortisone (50 mg every 6 hrly)
3. Treat precipitating factor
4. Ventilatory support, ABG
5. Hypertonic saline or IV detrose

26. Thank you