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thyroid-disorders and Thyroid Regulation
- 1. Thyroid Disorders Hasan AYDIN,MD Yeditepe University Medical Faculty Department of Endocrinology and Metabolism
- 2. PLASMA T4 +FT4 HYPOTHALAMUS - TRH ANT. PITUITARY - TSH THYROID T4 and T3 PLASMA T3 + FT3 TISSUES FT4 to FT3 TSH -R
- 3. Thyroid Hormones THEY ARENOT ESSENTIAL FOR LIFE, BUT ARE EXTREMELY HELPFUL
- 4. THYROID GLAND DISORDERS ✧THYROIDHORMONE EFFECTS: - Affects every single cell in the body - Modulates: - Oxygen consumption - Growth rate - Maturation and cell differentiation - Turnover of Vitamins, Hormones, Proteins, Fat, CHO
- 5. Thyroid Gland Disorders ✧Overproduction of thyroid hormones ✧ Underproduction of thyroid hormones ✧ Thyroid nodules ✧ Thyroiditis
- 6.
- 7. Thyroid Gland Disorders ✧TSH High usually means Hypothyroidism - Rare causes: - TSH-secreting pituitary tumor - Thyroid hormone resistance - Assay artifact ✧ TSH low usually indicates Thyrotoxicosis - Other causes - First trimester of pregnancy
- 8. Thyroid Gland Disorders ✧THYROTOXICOSIS: -is defined as the state of thyroid hormone excesss ✧HYPERTHYROIDISM: - is the result of excessive thyroid gland function
- 9. Abnormalities of Thyroid Hormones -Thyrotoxicosis - Primary - Secondary - Without Hyperthyroidism - Exogenous or factitious - Hypothyroidism - Primary - Secondary - Peripheral
- 10. Causes of Thyrotoxicosis PrimaryHyperthyroidism - Grave´s disease - Toxic Multinodular Goiter - Toxic adenoma - Functioning thyroid carcinoma metastases - Activating mutation of TSH receptor - Struma ovary - Drugs: Iodine excess
- 11. Causes of Thyrotoxicosis -Thyrotoxicosis without hyperthyroidism - Subacute thyroiditis - Silent thyroiditis - Other causes of thyroid destruction: - Amiodarone, radiation, infarction of an adenoma - Exogenous/Factitia - Secondary Hyperthyroidism - TSH-secreting pituitary adenoma - Thyroid hormone resistance syndrome - Chorionic Gonadotropin-secreting tumor
- 12. Thyrotoxicosis ✧ Symptoms: - Hyperactivity -Irritability - Dysphoria - Heat intolerance & sweating - Palpitations - Fatigue & weakness - Weight loss with increased appetite - Diarrhea - Polyuria - Sexual dysfunction ✧ Signs: - Tachycardia - Atrial fibrillation - Tremor - Goiter - Warm, moist skin - Muscle weakness, myopathy - Lid retraction or lag - Gynecomastia - Exophtalmus
- 13.
- 14. Differential Diagnosis - Panicattacks - Psychosis - Mania - Pheochromocytoma - Hypoglycemia - Occult malignancy
- 15. Treatment - Reducing thyroidhormone synthesis: - Antithyroid drugs (Methimazole, Propylthyouracil) - Radioiodine (131I) - Subtotal thyroidectomy - Reducing Thyroid hormone effects: - Propranolol - Glucocorticoids - Benzodiazepines - Reducing peripheral conversion of T4 to T3 - Propylthyouracil
- 16. Treatment: Special Considerations - Thyrotoxiccrisis or Thyroid storm: - It´s a life-threatening exacerbation of thyrotoxicosis, acompanied by fever, delirium, seizures, coma, vomiting, diarrhea, jaundice. - Mortality rate reachs 30% even with treatment - It´s usually precipitated by acute illness, such as: - Stroke, infection,trauma, diabetic ketoacidosis, surgery, radioiodine treatment - Propylthyouracil IV or Nasogastric tube - Radioiodine (131I) - Propranolol
- 17.
- 18. Definition ✧ A deficiencyof thyroid hormones, which in turn results in a generalized slowing down of metabolic processes. ✧ In infants and children => marked slowing of growth and development, with serious permanent consequences including mental retardation.
- 19. Causes of Hypothyroidism ✧Primary - Congenital - Acquired - Transient ✧ Secondary - Pituitary - Hypothalamic
- 20. Hypothyroidism ✧ Symptoms: - Tiredness -Weakness - Dry skin - Sexual dysfunction - Hair loss - Difficulty concentrating ✧ Signs: - Bradycardia - Dry coarse skin - Puffy face, hands and feet - Diffuse alopecia - Peripheral edema - Delayed tendon reflex relaxation - Carpal tunel syndrome
- 21.
- 22. Special Considerations ✧ Myxedemacoma - Reduced level of consciousness, seizures - Hypotension/shock - Hypothermia - Hyponatremia ✧ Usually in elderly hypothyroid pts. ✧ Usually precipitated by intercurrent illnesses that impairs ventilation
- 24. Treatment: Special Considerations ✧ Elderlypatients ✧ Coronary Artery Disease ✧ Poor adrenal gland reserve ✧ Childrens
- 25.
- 26. Goiter is adiffuse or nodular enlargement of the thyroid gland resulting from excessive replication of benign thyroid epithelial cells. Definitions A thyroid nodule is a discrete lesion within the thyroid gland that is palpably and/or ultrasonog- raphically distinct from the surrounding thyroid parenchyma
- 27. Etiology of NontoxicGoiter ✧ Iodine deficiency ✧ Goitrogen in the diet ✧ Hashimoto's thyroiditis ✧ Subacute thyroiditis ✧ Inherited defect in thyroidal enzymes necessary for T 4 and T 3 biosynthesis
- 28. Multinodular Goiter Clinical Issues ✧Hyperthyroidism ✧ Suspicion of malignancy ✧ Compressive/obstructive symptoms ✧ Cosmetic concerns
- 29. MULTINODULAR GOITER Presentation ✧ Asymptomatic -Neck mass discovered by patient or physician - Abnormal CXR ✧ Symptomatic - Pressure symptoms - Hoarseness - Thyrotoxicosis
- 30. NODULAR GOITER Suspicious Noduleor Goiter ✧ High suspicion - Family history of medullary thyroid carcinoma - Rapid tumor growth - A nodule that is very firm or hard - Fixation of the nodule to the adjacent structures - Paralysis of the vocal cord - Regional lymphadenopathy - Distant metastasis ✧ Moderate suspicion - Age of either<20 or >70 years - Male sex - History of head and neck irradiation
- 31. ✧Ultrasonographic Cancer RiskFactors for a Thyroid Nodule - hypoechogenicity, - microcalcifications, - irregular margins, - increased nodular flow visualized by Doppler, - the evidence of invasion or regional lymphadenopathy Ultrasound
- 32. Multinodular Goiter :Evaluation ✧ TSH ✧ FT4, T3 ✧ Radionuclide Scan / RAIU ✧ US ✧ CT Scan (without contrast) ✧ FNA biopsy
- 33. Multinodular Goiter Fine NeedleAspiration Evaluation ✧Biopsy all accessible nodule(s) ✧Biopsy suspicious nodule(s) cold on scan; firm by palpation; growing in size ✧Results less reliable in large goiters
- 34.
- 35. FNA results ✧Malignant- ptneeds to have surgical management ✧Benign- observation with interval ultrasounds and clinical examinations ✧Indeterminate- radioisotope scan- perform suppression scan and if cold
- 36.
- 37. Thyroid adenoma isa benign neoplastic growth contained within a capsule. Benign Neoplasms of the Thyroid Embrional adenoma Fetal adenoma Microfollicular adenoma Macrofollicular adenoma Papillary cystadenoma Hurtle cell adenoma
- 38. Thyroid Cancer ✧ Papillary(mixed papillary and follicular)75% ✧ Follicular carcinoma 16% ✧ Medullary carcinoma 5% ✧ Undifferentiated carcinomas 3% ✧ Miscellaneous (lymphoma, fibrosarcoma, 1%
- 39. Papillary Carcinoma ✧ veryslowly grow and remain confined to the thyroid gland and local lymph nodes for many years. ✧ In older patients, more aggressive and invade locally into muscles and trachea. ✧ in later stages, they can spread to the lung.
- 40. Follicular Carcinoma ✧ ischaracterized by the presence of small follicles, colloid formation is poor. ✧ capsular or vascular invasion. ✧ more aggressive and local invasion of lymph nodes or by blood vessel invasion with distant metastases to bone or lung.
- 41. Follicular Carcinoma ✧ rare''functioning thyroid cancer'' is almost always a follicular carcinoma. ✧ more likely to respond to radioactive iodine therapy. ✧ In untreated patients, death is due to local
- 42. Medullary Carcinoma ✧ adisease of the C cells (parafollicular cells) derived ✧ calcitonin, histamin, prostaglandins, serotonin, other peptides ✧ more aggressive , but not undifferentiated thyroid cancer. ✧ locally into lymph nodes and into surrounding muscle and trachea.
- 43. Medullary Carcinoma ✧ About80% are sporadic ✧ the remainder are familial. four familial patterns: - without associated endocrine disease (FMTC); - MEN 2a medullary carcinoma, pheochromocytoma, and hyperparathyroidism; - MEN 2B, medullary carcinoma, pheochromocytoma, and multiple mucosal neuromas;
- 44. Undifferentiated (Anaplastic) Carcinoma ✧ smallcell, giant cell, and spindle cell carcinomas. ✧ usually occur in older patients with a long history of goiter in whom the gland suddenly - over weeks or months- begins to enlarge and produce pressure symptoms, dysphagia, or vocal cord paralysis.
- 45. Lymphoma ✧ only typeof rapidly growing thyroid cancer that is responsive to therapy ✧ as part of a generalized lymphoma or may be primary in the thyroid gland. ✧ occasionally with long-standing Hashimoto's thyroiditis
- 46. Cancer metastatic tothe thyroid ✧ Cancers of the breast and kidney, bronchogenic carcinoma, and malignant melanoma. ✧ The primary site of involvement is usually obvious, ✧ Occasionally , the diagnosis is made by needle biopsy or open biopsy of a rapidly enlarging cold thyroid nodule.
- 47. Management of Thyroid Cancer Papillaryand Follicular Carcinoma: - Low-risk group under age 45 with primary lesions under 1 cm and no evidence of intra- or extraglandular spread. - For these patients, lobectomy is adequate therapy - All other patients high-risk, and for these total thyroidectomy and-if there is evidence of lymphatic spread -a modified neck dissection are indicated. - Prophylactic neck dissection is not necessary.
- 48. Management of Thyroid Cancer ✧Follow-up at intervals of 6-12 months should include careful examination of the neck for recurrent masses. ✧ If a lump is noted, needle biopsy is indicated to confirm or rule out cancer. ✧ Serum TSH should be checked
- 49.
- 50. Definition Infectious or autoimmuneinflammatory diseases of thyroid gland
- 51. • Hashimoto thyroiditis •Subacute granulomatous thyroiditis • Infectious thyroiditis • Radiation & Trauma induced thyroiditis • Subacute Lymphocytic thyroiditis • Postpartum thyroiditis • Drug induced thyroiditis Classification
- 52. HASHIMOTO’s THYROIDITIS Chronic LymphocyticThyroiditis •Is the most prevalent form of thyroid autoimmune disease (3-4 % of popul.) and most common cause of hypothyroidism •Is characterized by gradual thyroid failure, goitre or both •Is more common in middle age •Clusters in families •May be associated with other autoimmune disorders Dr. Hakaru Hashimoto
- 53. Subacute Granulomatous (de Quervain’s)Thyroiditis •Most frequent cause of thyroid pain and tenderness •Postviral inflammatory process (Coxsackievirus, mumps, measles, adenovirus, other) •Strongly associated with HLA-B35, most common in 40-50 years old women
- 54. Clinical Presentation •Hoarseness,dysphagia •Fever, palpitation,nervousness, lassitude •Tender, enlarged, firm and often nodular •Previous viral infection (in 1-3 weeks) •Pain over thyroid,upper neck, jaw, throat,ears
- 55. Treatment of DeQuervain’s Thyroiditis ✧Anonsteroidal antiinflammatory drug - Aspirin: 2.4-3.6 g in divided doses - Naproxen: 1.0-1.5 g in divided doses ✧Prednisone : 30-40 mg qd ✧A beta blocker - Propranolol : 40-120 mg - Atenolol : 25-50 mg
- 56. Infectious Thyroiditis ✧Acute (withabscess formation) - Gram-positive or negative organisms (via blood or a fistula from the piriform sinus adjacent to the larynx) ✧Chronic - Mycobacterial - Fungal - Pneumocystis
- 57. Infectious Thyroiditis ✧Acute - Usuallyunilateral neck pain and tenderness - Fever, chills, a unilateral neck mass (fluctuant) - USG, FNAB, drainage and antibiotics ✧Chronic - Bilateral, less prominent neck pain - Some patients have hypothyroidism
- 58. Radiation and Trauma-Induced Thyroiditis ✧RadiationThyroiditis - Radioiodine treatment of Graves disease - Develops 5-10 days later and is mild ✧Trauma-induced Thyroiditis - Palpation, thyroid biopsy, surgery, car seat
- 59. Subacute Lymphocytic Thyroiditis (Painless, Silent,Lymphocytic) ✧A variant form of Hashimoto’s thyroiditis ✧Associated with HLA-DR3 ✧Postulated initiating factors : - Excess iodine intake - Various cytokines
- 61. Treatment of Subacute LymphocyticThyroiditis ✧ Most patients need no treatment ✧ Symptomatic treatment during the hyperthyroid phase : propranolol or atenolol ✧ T4 ( 50-100 µg daily) given for 8-12 wks, discontinued and reevaluated 4-6 wks later
- 62. Postpartum Thyroiditis •Occurs in3-16% of pregnancies (25 % in T1DM) •Is seen within 1 year after parturition •Is likely to recur after subsequent pregnancies •Thyrotoxicosis is mild and transient •Antithyroid antibodies are elevated •RAIU is low
- 63. Presentation of Postpartum Thyroiditis ✧Transienthyperthyroidism (2-8 wks) followed by hypothyroidism (2-8 wks) and then recovery 20-30 % ✧Transient hyperthyroidism alone 20-40 % ✧Transient hypothyroidism alone 40-50 %
- 64. Drug-Induced Thyroiditis ✧Interferon-alpha thyroiditis ✧Interleukin-2thyroiditis ✧Amiodarone
- 65. Riedel’s Thyroditis ✧ Isa fibrotic process associated with a mononuclear cell inflammation that extends beyond the thyroid into soft tissue ✧ Can involve the parathyroids, the recurrent laryngeal nerve, trachea, mediastinum, ant. chest wall
- 66. Treatment of Riedel’s Thyroiditis ✧Thyroxine ✧ Surgery ✧ Glucocorticoids ✧ Tamoxifen ✧ Methylprednisone pulse therapy + azathioprine