Hypo Thyroid Is M

Hypothyroidism
Types of hypothyroidism
• They are divided into 3 types:
1. Primary hypothyroidism:
– Due to a cause within the thyroid gland itself.
2. Transient hypothyroidism
3. Secondary hypothyroidism:
– Due to failure of TSH production following
pituitary or hypothalamic disease
Causes of Primary Hypothyroidism
• Autoimmune hypothyroidism:
– Hashimoto’s thyroiditis
– Atrophic thyroiditis
• Iatrogenic:
– Radioactive iodine treatment
– Thyroidectomy
– Radiation treatment for cancer
• Drugs:
– Iodine excess
– Lithium
– Antithyroid drugs
• DR HIT (short name for causes)
• Drugs
• Radiation treatment/ Radioactive iodine treatment
• Hashimoto’s thyroiditis
• Iodine (deficiency and excess)
• Thyroidectomy
Causes of Primary Hypothyroidism
• Infiltrative disorders:
– Amyloidosis
– Sarcoidosis
• Congenital hypothyroidism
• Iodine deficiency
Causes of Transient hypothyroidism
• Silent thyroiditis, including postpartum thyroiditis
• Subacute thyroiditis
• Withdrawal of thyroxine treatment in individuals
with an intact thyroid
• After radioactive iodine treatment
Causes of secondary hypothyroidism
• Pituitary diseases:
– Tumors
– Pituitary surgery or irradiation
– Infiltrative disorders
– Trauma
• Hypothalamus diseases:
– Tumors
– Trauma
– Idiopathic
Causes of hypothyroidism
• Iodine deficiency: Most common cause of
hypothyroidism worldwide.
• In areas of iodine sufficiency: autoimmune
disease (Hashimoto’s thyroiditis) and
iatrogenic (treatment of hyperthyroidism) are
most common causes
Clinical features
Symptoms:
• Tiredness, weakness
• Dry skin
• Feeling cold
• Hair loss
• Difficulty concentrating and poor memory
• Constipation
• Weight gain with poor appetite
• Dyspnea
• Hoarse voice
• Menorrhagia (later oligomenorrhea or amenorrhea)
• Paresthesia
• Impaired hearing
Clinical features
Signs:
• Dry coarse skin; cool peripheral extremities
• Puffy face, hands, and feet (myxedema)
• Diffuse alopecia
• Bradycardia
• Peripheral edema
• Delayed tendon reflex relaxation
• Carpal tunnel syndrome
• Serous cavity effusions
Clinical features
Congenital Hypothyroidism
The majority of infants appear normal at birth
• Clinical features at time of birth:
– Prolonged jaundice
– Feeding problems
– Hypotonia
– Enlarged tongue
– Importantly, permanent neurologic damage
results if treatment is delayed.
Congenital Hypothyroidism
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Diagnosis of congenital hypothyroidism
Heel prick blood specimen
Neonatal screening programs have been established
based on measurement of TSH or T4 levels in heel-
prick blood specimens.
Treatment of congenital hypothyroidism
T4 is instituted at a dose of 10–15 µg/kg per day, and
the dose is adjusted by close monitoring of TSH levels.
T4 requirements are relatively great during the first
year of life, and a high circulating T4 level is usually
needed to normalize TSH.
Early treatment with T4 results in normal IQ levels,
but subtle neuro-developmental abnormalities may
occur in those with the most severe hypothyroidism
at diagnosis or when treatment is delayed or
suboptimal.
Autoimmune Hypothyroidism
• It includes:
– Hashimoto‘s thyroiditis
– Atrophic thyroiditis
• Subclinical hypothyroidism:
– Because the autoimmune process gradually reduces
thyroid function, there is a phase of compensation when
normal thyroid hormone levels are maintained by a rise in
TSH.
• Clinical hypothyroidism or overt hypothyroidism:
– Later, unbound T4 levels fall and TSH levels rise further
– Symptoms become more readily apparent at this stage.
Iatrogenic hypothyroidism
• Common cause of hypothyroidism.
• In the first 3–4 months after radioiodine
treatment, transient hypothyroidism may
occur due to reversible radiation damage.
Iodine deficiency
• It is responsible for endemic goiter and cretinism
• It is an uncommon cause of adult hypothyroidism
unless the iodine intake is very low
Investigations
• Thyroid function tests
• Thyroid antibody
• Other tests
Thyroid Function Tests
• Total T4 (thyroxine), Total T3 (triiodothyronine)
• Free T4 , Free T3
• TSH
• T3 -Uptake
• Free T4 Index, Free T3 Index
• Anti-Thyroid Antibodies
• Nuclear Scintigraphy
• FNAC of nodule
Thyroid function tests
• Serum TSH level: Gold standard test
• A normal TSH level excludes primary (but not
secondary) hypothyroidism.
• If the TSH is elevated, an unbound T4 level is needed
to confirm the presence of clinical hypothyroidism
• T4 level alone is inferior to TSH when used as a
screening test, because it will not detect subclinical
hypothyroidism.
• Circulating unbound T3 levels are normal in about
25% of patients, so T3 measurements are not
indicated.
Thyroid antibodies
• Anti Microsomal (TM ) Antibodies
• Anti Thyroglobulin (TG) Antibodies
• Anti Thyroperoxidase (TPO) Antibodies
• Anti Thyroxine antibodies
• Thyroid Stimulating (TSA) Antibodies
• Once clinical or subclinical hypothyroidism is
confirmed, the etiology is usually easily
established by demonstrating the presence of
TPO and Tg antibodies, which are present in
>95% of patients with autoimmune
hypothyroidism.
Other abnormal laboratory
findings in hypothyroidism
• Increased creatine phosphokinase
• Elevated cholesterol and triglycerides
• Anemia
Management
• Hypothyroidism is treated with thyroxine tablet (T4)
• It is usually given at a dose of 50 μg/day for 3 weeks,
followed by 100 μg/day for 3 weeks, followed by a
maintenance dose of 150 μg/day.
• The correct dose of T4 is that which restores serum
TSH to below 3 mU/L.
• It should be given on empty stomach in the
morning.
• In elderly patients and those with Ischaemic heart
disease, T4 is started at a lower dose of 25 μg/day.
• In a few patients with Ischaemic heart disease,
angina may develop or worsen with T4 therapy.
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