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- 1. Thyroid gland Dr. Rahaf Abu khalaf
- 2. • A 34-year-old woman comes to the physician because of a 3- month history of fatigue and a 4.5-kg (10-lb) weight loss despite eating more than usual. Her pulse is 115/min and blood pressure is 140/60 mm Hg. Physical examination shows warm, moist skin, and a diffuse, non-tender swelling over the anterior neck. Ophthalmologic examination shows swelling of the eyelids and proptosis bilaterally. Which of the following is the most likely cause of this patient's symptoms?
- 3. • A- Nongranulomatous thyroid inflammation • B- Thyrotropin receptor autoantibodies • C- Granulomatous thyroid inflammation • D- Parafollicular cell hyperplasia • E- Thyroid peroxidase autoantibodies • F- Constitutively active TSH receptor
- 4. • A- Nongranulomatous thyroid inflammation • B- Thyrotropin receptor autoantibodies • C- Granulomatous thyroid inflammation • D- Parafollicular cell hyperplasia • E- Thyroid peroxidase autoantibodies • F- Constitutively active TSH receptor
- 5. Function of Thyroid hormone : • Only free hormone is active. T3 binds nuclear receptor with greater affinity than T4 : • 7Bs • 1- brain maturation and development • 2- bone growth • 3- B- adrenergic effects : >> increase CO, HR, SV , contractility. • 4- basal metabolic rate increase ( NaK ATPase activity ) >> • 5- blood sugar increase • 6- break down of lipids • 7- stimulate surfactant synthesis in babies
- 6. Clinical features • Hyperthyroidism : • General : • Skin : • Eyes : • Goiter : • CVS : • Musculoskeletal : • Endocrinology : • Neuropsychiatric system :
- 9. Labs Thyroid Function test : (initial screening test ) Over hyperthyroidism and thyrotoxic phase thyroidisitis : Subclinical hyperthyroidism : Thyrotropic adenoma : Normal labs :
- 10. Clinical features • Hypothyroidism : • Symptoms related to decreased metabolic rate • Symptoms related to generalized myxedema • Symptoms related to hyperprolactinemia • Impaired cognition , depression, hypertension
- 12. Labs : TSH : best initial test FT4 >> conformitory for primary hypothyroidism Overt hypothyroidism : A- primary hypothyroidism B- secondary and tertiary hypothyroidism
- 13. Hyperthyroidisim : Etiology : • 1- Hyperfunctioning thyroid gland : • A- Graves disease : 60-80 % of cases • B- Toxic MNG : 15-20 % • C- TSH producing pituitary adenoma (thyrotropic adenoma ) • D- B-HCG mediated Hyperthyroidism • 2- Destruction of the thyroid gland : • A- thyroiditis >>> subacute granulomatous thyroiditis • Subacute lymphocytic thyroiditis
- 14. • 3- Exogenous thyrotoxicosis : • • 4- Ectopic hormone production :
- 15. Graves disease : • * - Acute to chronic hyperthyroidism • Cause : Autoimmune due to TSH receptor autoantibodies ( high TRAB ) • Epdimeology : MCC in US , peak incidence 20-30 F>M • Goiter : diffuse and smooth painless • RAIU thyroid scintigraphy : diffuse • Other findings : pretibial myxedema , graves opthalmopathy
- 19. Pathology
- 20. Diagnostics TSH and T4 Thyroid antibodies Thyroid scintigraphy >> diffuse uptake of RAI
- 21. Toxic MGA • Epidemiology : • F>M • Age > more than 60 • 2nd most common cause of hyperthyroidism
- 22. Clinical features : • Painless with multiple palpable nodules • And symptoms of thyrotoxicosis • Diagnostics : • Thyroid function test • Thyroid US : • Thyroid scintigraphy
- 23. Subacute thyroiditis • Subacute granulomatous thyroiditis : • Viral infection : mumps , influenza • Granulomatous inflammation • Inflammation manfist with triphasic response : • 1- thyrotoxic phase • 2- hypothyroid phase • 3- Euthyroid phase • Painful goiter
- 24. • Subacute lymphocytic thyroidits : • 1- Drugs : • 2- Post partum thyroiditis : • Associated with increased titers of thyroid peroxidase antibody • Painless
- 25. • A 78-year-old woman is brought to the physician by her son because of progressive memory loss for the past year. She feels tired and can no longer concentrate on her morning crossword puzzles. She has gained 11.3 kg (25 lb) in the last year. Her father died from complications of Alzheimer disease. She has a history of drinking alcohol excessively but has not consumed alcohol for the past 10 years. Vital signs are within normal limits. She is oriented but has short-term memory deficits. Examination shows a normal gait and delayed relaxation of the achilles reflex bilaterally. Her skin is dry, and she has brittle nails. Which of the following is the most likely underlying etiology of this woman’s memory loss?
- 26. • A- Thiamine deficiency • B- Autoimmune thyroid disease • C- Normal pressure hydrocephalus • D- Vitamin B12 deficiency E- Alzheimer disease
- 27. • A- Thiamine deficiency • B- Autoimmune thyroid disease • C- Normal pressure hydrocephalus • D- Vitamin B12 deficiency E- Alzheimer disease
- 28. Hypothyroidism • Primary hypothyroidism : insufficient thyroid hormone production 1- hashimoto thyroiditis : 2- postpartum thyroiditis : ( subacute lymphocytic thyroiditis ) 3- subacute granulomatous thyroiditis : 4- iatrogenic : 5- Nutritional ( insufficient intake of iodine ) : 6- Riedel thyroiditis : 7- wolf chaikoff effect
- 29. • Secondary hypothyroidisim : • Pituitory disorders • Tertiary hypothyroidism : • Hypothalamus
- 30. Hashimoto thyroiditis • It’s the most common form of thyroiditis and most frequent cause of hypothyroidism in the US • F>M • Occur in most age groups but commonly 30-50
- 31. Clinical features • Early : • Primary asymptomatic • Goiter >> diffuse painless rubbery thyroid with moderate symmetrical enlargement • Hashitoxicosis : • Late stage : • Thyroid may be normal sized or small • Hypothyroidism
- 32. Diagnostics : • Early stage >> transient hyperthyroidism • Progression >> subclinical hypothyroidism • Late stage >> overt hypothyroidism • Anitbody detection : • Anti TPO antibody positive ( Anti microsomal antibodies ) • Anti TG antibodies positive • Lipid profile >> high LDL and low HDL
- 33. • RIUT >> is variable
- 34. Pathology
- 35. Complications • Permanent hypothyroidism • Myxedema coma • Thyroid lymphoma
Editor's Notes
- 4 > elevation of basal metabolism >> promoted thermogenesis Upregulation of B adrenergic receptors >> hyperstimulation of sympathetic nervous system
- General > heat intolerance , excessive sweating due to increase cutaneous blood flow , weight loss due to increase MR , diarrhea Skin > onycholysis , thyroid acropathy ( nail clubbing ) Goiter >> diffuse CVS : palpitations >> irregular pulse , ( due to A Fib , irregular beats ) Hypertension with wide pulse pressure Fine tremor and responds well to BB Hyperthyroid myopathy ( weakness, pain and atrophy associated with hyperthyroidism ) affects individuals more than 40 affects proximal muscles more than distal muscles CK is normal Osteopathy >> osteoporosis due to direct effect of T3 over osteoclast Endocrinology >> oligo\ amenorrhea \ anovulatory \ infertility Neuropsychiatry >> restlessness \ insomnia \ anxiety \ restlessness Anxiety , depression , restlessness , hyperreflexia
- Subclinical hyperthyroisdim : the combination of low serum TSH and normal T3 and T4 patients usually do not exhibit symptoms of thyrotoxicosis is often transient but may progress to overt hyperthyroidism Normal labs >> Serum cholesterol : decrease total cholesterol, LDL and HDL levels
- 1- fatigue, decreased physical activity , cold intolerance, decreased sweating, hair loss, brittle nails and cold and dry skin , weight gain , constipation bradycardia , myopathy with elevated CK , delayed relaxation of deep tendon reflexes , carpel tunnel syndrome 2- puffy appearance , hoarse voice, difficulty articulating words , pretibial and periorbital edema , myxedema coma 3- abnormal menstrual cycle , galactorrhea , decreased libido erectile dysfunction generalized decrease in the basal metabolic rate >> decrease o2 and substrate consumption leading to > apathy, slow cognition and dry skin, alpocia , cold intolerance Decresed sympathetic activity >> decrease sweating , constipation and bradycardia Hyperprolactenima >> is stimulated by increase in TRH >> decrease FSH and LH , testosterone and increase in breast tissue growth Symptoms related to myedema >> accumulation of GAC and hyolurinc acid in the dermal layer
- 4- like struma ovarii , metastatic follicular thyroid cancer Exogenous thyrotoxicosis >> thyrotoxicosis dur to excessive intake of thyroid hormone Low TSH high T3 and T4 low Thyroglobulins \ low RAI uptake
- IgG type 2 hypersensitivity reaction Etiology : genetics : 50% of patients have family history of autoimmune disorders \ associated with HLA-DR3 HLAB8 alleles Autoimmunity >> b and t mediated disorder Pathophysiology Clinical features : triad : diffuse goiter and bruit may be heard \ ophthalmopathy ( exophthalmos , lid-lag lid retraction ) pretibial myxedema
- Activated b and t cells infilitrate retro-orbital space targeting orbital fibroblast >> cytokines release >> local inflammatory response >> fibroblast proliferation and differentiation into adipocytes >> production of HA and GAC >> increase in the volume of intraorbital fat and muscle tissue
- Papiilary infoldings of hyperplastic thyroid follicles
- Pathophysiology >> Iodine deficiency or thyroid dysfunction >> increase TSH production >> hyperplasia of thyroid nodules ( non- toxic multinodular goiter ) Mutiple mutations of TSH receptors occur in long standing goiter >> autonomous function of some nodules >> hyperthyroidism
- It’s a transient patchy inflammation of the thyroid gland depending of the underlying cause >> two types The disease is self limiting in most cases but few patients may experience relapses or perminant hypo
- Damage to follicular cells with lymphocytic infilitration
- Hashimoto thyroiditis is the most common cause of hypothyroidism in the United States and is characterized by progressive destruction of thyroid tissue by antithyroid peroxidase antibodies and antithyroglobulin antibodies. Initially, it may manifest with transient hyperthyroidism, before progressing to hypothyroidism. Hypothyroidism results in a generalized decrease of the basal metabolic rate, which can present with weight gain, fatigue, dry skin and brittle nails, along with concentration and memory impairment.
- 4- post thyroidectomy , radioiodine therapy 5- it’s the most common cause of hypothyroidism worldwide 6- chronic autoinflammatory disorder charachterized by conversion of regular thyroid parenchyma to diffuse fibrous growth
- Pathophysiology : unknown etiology > genetics and environmental factors may play a role Immunological >> may associated with HLA DR3 DR5 Cellular t cells and humoral immune responses are activated >> active B lymphocyte produce antibodies towards thyroid peroxidase and thyroglobulins > destruction of thyroid tissue Association >>> non hodgekin lymphoma and autoimmune diseases
- Hashitoxicosis : transient hyperthyroidism due to rupture of follicules
- Diffuse lymphocytic infilitration ( cytotoxic t lymphocyte ) , Oncocytic metaplastic cells ( Hurthle cells ) and fibrotic tissue
- Myxedema coma : condition of severe hypothyroidism characterized by altered mental status , hypothermia , myxedema , hypoventilation hypotension or bradycardia , Etiologies : nonadherence to Thyroxene , infectious , trauma