The document discusses hypothyroidism, its manifestations, causes, and management strategies, highlighting that iodine deficiency is the most common cause globally, while autoimmune diseases like Hashimoto’s thyroiditis are prevalent in iodine-sufficient areas. It presents symptoms, patterns of thyroid dysfunction, and various treatment plans, including lifelong thyroxine for hypothyroidism. The document also covers the diagnosis procedure using TSH and T4 tests, management during pregnancy, and complications like myxedema coma.

1. HYPOTHYROIDISM-
MANIFESTATIONS & MANAGEMENT
Dr. Sachin Verma MD, FICM, FCCS, ICFC
Fellowship in Intensive Care Medicine
Infection Control Fellows Course
Consultant Internal Medicine and Critical Care
Web:- http://www.medicinedoctorinchandigarh.com
Mob:- +91-7508677495

2. T3, T4 (-)
Hypothalamus
TRH (+)
Pituitary
T3, T4 (-)
TSH (+)
Thyroid

3. Hyperthyroidism Hypothyroidism

4. Patients of Thyroid Disorders Present As
With Goiter
Hypothyroid
Without Goiter
With Goiter
Hyperthyroid
Without Goiter
Euthyroid With Goiter
03/19/13 4

5. Hypothyroidism
Causes
With Goiter Without Goiter
 Hashimoto’s Thyroiditis  Hashimoto’s Thyroiditis
 I2 deficiency goiter  Post ablative(radioactive I 2)
 Drug induced goiter  After thyroidectomy
(Li, Amiodarone, PAS,  Congenital hypothyroidism
ethionamide, Rifampicin)
 Secondary hypothyroidism
 Due to goitrogens
(Sheehan syndrome)
 Riedel’s thyroiditis

6. HYPOTHYROIDISM
IODINE DEFICENCY is the most common cause
of hypothyroidism worldwide.
In Iodine sufficient areas, Autoimmune
disease (HASHIMOTO’S THYROIDITIS) is most
common.

7. HYPOTHYROIDISM
Common presentation
Symptoms Signs
 Dry & coarse skin- 76%  Ankle reflex absent- 77%
 Cold intolerance – 64%  Bradycardia - 58%
 Puffiness of face- 60%  Somnolence
 Sweating- 54%  Diastolic hypertension
 Wt gain-54%  Depression
 Paresthesia - 52 %  Anemia
 Constipation- 50%  Menorrhagia
 Aches & pains non specific  Infertility

8. HYPOTHYROIDISM
Uncommon Presentations.
 Hoarseness of voice
 Deafness
 Ascites
 Pericardial & pleural effusion
 Carpel tunnel syndrome
 Impotence
 Galactorrhoea & Amenorrhoea
 Cardiac failure
 Psychosis
03/19/13 8

9. Thyroid
• Thyroid Disease Can Brain
Have Widespread Effects • Depression
• Decreased Concentration
Liver
• General Lack of Interest
• Increased LDL
Cholesterol
• Elevated
Triglycerides Heart
• Decreased Heart Rate
Intestines • Increased/Decreased
• Constipation Blood Pressure
• Decreased GI • Decreased Cardiac
Activity Output
Kidneys
Reproductive
System • Decreased Function
• Decreased Fertility • Fluid Retention and
• Menstrual Abnormalities Edema
• May Harm Development of Infant

10. Hashimoto’s Thyroiditis
IN USA
Above 50 years Female – 10% Hypothyroid
Above 60 years Male – 10% Hypothyroid
In India prevalence rate of Hypothyroid is quite high
but data is not available.

11. Hashimoto’s Thyroiditis
 Commonest cause of hypothyroidism
 Most of the patients never develop goitre
 Symptoms develop very gradually
So difficult to Diagnose!
03/19/13 11

12. Hashimoto’s Thyroiditis
Painless Goiter/ No Goiter
Investigations
T3↓ T4 ↓
TSH↑
High titers of TPO ab. (almost 100%)
Treatment
Life long Thyroxin
03/19/13 12

13. Viral Thyroiditis
Painful Goiter (Usually small) , fever , sorethroat
Natural History:
Hyperthyroid 2 – 3 months
Hypothyroid 2-6 months
Euthyroid
03/19/13 Few Patients may remain Hypothyroid Life Long 13

14. Viral Thyroiditis: Treatment
Pain - Aspirin (600mg 4-6hrly) / NSAIDS
Steroids – 40- 60 mg/ day according to severity
Hyperthyroid – Propranolol
Hypothyroid – May require Thyroxin(50-100µgm)
Euthyroid – After 6 months – 1 year
No Drug Required
03/19/13 14

15. POST-PARTUM THYROIDITIS
Post-partum thyroiditis (PPT) is an autoimmune,
painless inflammation of the thyroid gland that
occurs within a year in 5% to 10% of all
pregnancies.
22/1/05 2

16. Etiology and Pathogenesis
Microchimerism:
(Fetal cells in maternal blood)
The presence of residual fetal cells which get
attached to the maternal thyroid gland during
pregnancy, induces autoimmune reactions as
maternal immunosuppression is lost after delivery.
22/1/05 8

17. Post Partum Thyroiditis
Natural History:
Hyperthyroid 2 - 3 months
Hypothyroid 2 - 6 months
Euthyroid
 25% of Postpartum Thyroiditis Patients will develop
Hypothyroidism after 5-10 years of delivery
03/19/13 17

18. Atypical Presentations of
Postpartum Thyroiditis
 A Thyrotoxic phase followed by a return to
normal thyroid function
 A Hypothyroid phase alone
22/1/05 13

19. Initial tests for diagnosis of
Thyroid Dysfunction
Primary Test
TSH
Additional Test
Free T4

20. TSH raised (>3.5-5.5 according to the lab)
Free T4 decreased
Total T4 decreased
.
03/19/13 20

21. Hypothyroidism: Initial Diagnosis
 Free T3 May be normal in 25%
cases of early hypothyroidism

22. Thyroid Ultrasound
Relatively unimportant test
Sensitive tool to ascertain size and number of
thyroid nodules.
Important tool in the follow up of a thyroid nodule
if it is not to be operated
03/19/13 22

23. Thyroid Scan
 WILL SHOW
 UPTAKE
 UPTAKE
 NORMAL UPTAKE
03/19/13 23

24. Thyroid Scan
UPTAKE WITH GOITRE ( cold)
Thyroiditis, Thyroid carcinoma
DO FNAC
03/19/13 24

25. Thyroid Scan
UPTAKE WITH GOITRE (hot)
Graves’ Disease
03/19/13 25

26. Thyroid Scan
NORMAL UPTAKE WITH GOITRE
Colloid Goitre, Puberty Goitre, Adenoma
DO FNAC
03/19/13 26

27. COMMON THYROID AUTOANTIBODIES*
ANTIGEN ANTIBODY
TSH receptor TSHRAb (TSH Receptor Antibody)
Thyroglobulin TgAb
Thyroid Peroxidase TPO Ab
* Williams’ textbook of Endocrinology: 10th edition; chapter, 10 pg 36

28. GROUP TPO Ab
General Population 8-10%
Graves Disease 50-80%
Autoimmune Thyroiditis 90-100%
Relatives of Patients 40-50%
Pregnant Women 14%
22/1/05 6
* Williams’ textbook of Endocrinology: chapter, 10 pg 361

29. Treatment Of Hypothyroidism
Dose of Levothyroxine depends on the degree of
Hypothyroidism, Age & General health condition of
the patient
Usually daily replacement dose is 1.6µgm/Kg body
weight
Start with Low Dose

30. Treatment Of Hypothyroidism
If Dose Missed, What To Do???
One Dose Missed Take Two Tablets
Two Dose Missed Take Three Tablets
Three Dose Missed Take Regular Dose

31. Treatment Of Hypothyroidism
WHEN SHOULD I TAKE IT ??
 EMPTY STOMACH 30 mins BEFORE CALORIC
MEAL

32. Follow up of a case of Hypothyroidism
Serum TSH levels should be measured after 6-8
weeks of therapy and dosages should be adjusted
accordingly
Target TSH levels should be between 1-2 mU/l
Once a stable TSH is achieved, it should be
estimated every year
03/19/13 32

33. Follow up of a case of Hypothyroidism
Patient on Thyroxine TSH NORMAL
WHAT SHOULD I DO??
Most of these patients are Hashimoto’s thyroiditis .
They will require life long treatment
Donot stop the drug Continue Thyroxine
03/19/13 33

34. INTERPRETATION OF
THYROID FUNCTION TESTS
03/19/13 34

35. Situation 1
TSH Free T3 Free T4
Normal Normal Normal
03/19/13 35

36. Diagnosis
Normal Euthyroid
03/19/13 36

37. Situation 2
TSH Free T3 Free T4
Normal
High Normal
/Decreased
03/19/13 37

38. Diagnosis
SubClinical /
Early Hypothyroidism
03/19/13 38

39. Situation 3
TSH Free T3 Free T4
Increased Decreased Decreased
03/19/13 39

40. Diagnosis
Hypothyroidism
03/19/13 40

41. Situation 4
TSH Free T3 Free T4
Low High High
03/19/13 41

42. Diagnosis
Hyperthyroidism
03/19/13 42

43. Situation 5
TSH Free T3 Free T4
Low Low or Normal Low
03/19/13 43

44. Diagnosis
Secondary
Hypothyroidism
Or Sheehan’s Syndrome
03/19/13 44

45. SHEEHAN’S SYNDROME
Female
Excessive blood loss during delivery
No lactation amenorrhoea
Weakness,lethargic, anemia
Depigmentation of areola, Shiny skin
Loss of pubic & axillary hair
Low B.P.

46. SHEEHAN’S SYNDROME
Treatment
 Hormone replacement therapy including glucocorticoid
(prednisone 5+2.5 mg/d), Thyroxine (75-150µgm/d)
If lady wants periods- estrogen & progesterone
preparations can be given.
GOAL To maintain T4 level in the upper half of range
TSH CANNOT BE USED TO MONITOR THERAPY

47. Hypothyroid And pregnancy
During pregnancy requirement of thyroxin
increases by 25-50µg/d during pregnancy
Even on mild Thyroxin hormone deficiency
there are chances of low IQ and developmental
delay of the child

48. Hypothyroid And pregnancy
Thyroid Hormone exists in two forms :
Free (Active) & Bound (with thyroxine binding
globuline).
In Pregnancy increased Estrogen, increases TBG
which in turn increases Total T4 & T3 level
However Free T4, Free T4 REMAINS NORMAL.
SO Free T4 should be used in the treatment and
follow up during pregnancy & not total T4

49. Hypothyroidism In Elderly
In Patients Above 60 Rule Out Coronary Artery
Disease
If Coronary Artery Disease Present Or Suspected:
Start Thyroxine With Low Dose And Then
Increase The Dose Gradually Otherwise Angina
May Precipitate.

50. Myxedema Coma
Precipitating factors :
Infection,
trauma, stroke, cardiovascular,
hemorrhage drug overdose, diuretics
Signs and Symptoms :
Usually older age presenting as :
 Mental confusion, hypothermia, bradycardia, ↓ Na,
↓ glucose, ↑ CO2, ↓ WBC, ↓ Hct, ↑
CPK
↓ EKG voltage
50

51. Myxedema Coma
Treatment
ICU transfer,
IV levothyroxine 500 µg bolus followed by 50-100µg/d
(same dose can be given through NG tube),
antibiotics,ventilation, hydrocortisone IV, passive
warming, careful volume management
As T4 to T3 conversion is impaired so leothyronine is
recommended but has a potential to provoke arrythmias.

52. Myxedema Madness.
When being crazy is not in your
head BUT IN THYROID
Delirium With Auditory Hallucinations &
Paranoid Delusions
Takes The Form Of Psycotic Depression Or Pure
Psycosis.
No Cognitive Impairement
Treatment- Thyroxine

53. Thank You

54. Sick Euthyroid Syndrome
Any acute, severe illness can cause abnormalities of
circulating TSH or Thyroid hormone levels in the absence
of underlying Thyroid disease.
Major cause - Release of cytokine IL-6
Most common pattern ----
LOW T3 SNDROME---- in total & unbound T3
levels with normal T4 & TSH
T4 T3 rT3
De iodination

55. Sick Euthyroid Syndrome
 LOW T4 SYNDROME ----
1. Very sick patient may exhibit a dramatic fall in Total T3 & T4
2. Poor prognosis
 In Acute Liver disease initially Total T3 & T4 levels due
to TBG release; these levels become subnormal as the disease
progress
 Renal disease is often accompanied by low T3 levels
 In early stages of HIV T3 & T4 levels rises,. T3 levels falls with
progression to AIDS , but TSH remains normal

56. Sick Euthyroid Syndrome
Diagnosis is supported by
 History of thyroid disease
 Previous thyroid function tests
History of Drugs that may affect thyroid hormones
Measurement of rT3 together with FT3 , FT4 and TSH
ONLY RESOLUTION OF TESTS WITH CLINICAL
RECOVERY CAN ESTABLISH THIS DISORDER