1 / 55

BENIGN DISEASES OF THE THYROID

BENIGN DISEASES OF THE THYROID. Rivka Dresner Pollak M.D Endocrinology. Thyroid gland- anatomy. Thyroid gland- anatomy. sternocleidomastoid. strap muscles. trachea. thyroid. jugular v. esophagus. carotid a. vertebra. Recommended and Typical Values for Dietary Iodine Intake.

Download Presentation

BENIGN DISEASES OF THE THYROID

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. BENIGN DISEASES OF THE THYROID Rivka Dresner Pollak M.D Endocrinology.

  2. Thyroid gland- anatomy

  3. Thyroid gland- anatomy sternocleidomastoid strap muscles trachea thyroid jugular v. esophagus carotid a. vertebra

  4. Recommended and Typical Values for Dietary Iodine Intake Recommended Daily Intake μg I/day Adults 150 During pregnancy 200 Children 90-120 Typical Iodine intakes North America 75-300 Europe (Germany, Belgium) 50-70 Switzerland 130-160 Chile <50-150

  5. Free T4, T3 P Protein Bound Thyroid hormone Serum thyroid hormone binding Feedback control Thyroid secretion Tissue action Hormone metabolism Fecal excretion

  6. THYROXINE BINDING GLOBULIN Estrogen  Androgen = Glucocorticoids = Acute illness N Chronic illness  Liver dis.  THYROID HORMONES TRANSPORT AND METABOLISM TRANSPORT TBG = thyroxine binding globulin TTR = transthyretin % binding- mostly to TBG T4 - 99.5 T3- 95 METABOLISM DEIODINASE TYPE 1 & 2

  7. T4 T4 T4 T4 T4 T4 TBG T4 T4 TBG Serum protein binding of thyroid hormones “Pill effect” Total T4 Bound Free  synthesis By liver

  8. Hypothalamus Regulation of Thyroid hormone secretion (-) TRH (+) Pituitary (+) TSH (-) T4, T3 Thyroid

  9. Assessment of bioactive thyroid hormones Check free hormone levels: Free T4 Free T3 Check thyroid hormone “biosensor’: TSH

  10. Thyroid function tests FT4 pmol/L FT3 nmol/L TSH 21 3.0 1.2 10 4 0.15 Hypo Hyper Hypo Hyper 1o Hypo 1o Hyper

  11. Laboratory tests in thyroid disease Anti-thyroid antibodies: Anti-thyroid peroxidase (TPO) Thyroid stimulating antibodies: TSI-Thyroid stimulating imunoglobulins TSH receptor Antibody Thyroglobulin

  12. 2. Thyroid scanning Radioactive isotopes of I (131I, 123I) Pertechnetate Generates Data on: - Anatomy - Physiology

  13. Normal thyroid scan

  14. “Hot nodule”

  15. “Cold” nodule

  16. Multinodular goiter (MNG) Pertechnetate scan CHEST X-RAY

  17. Radio Active Iodine Uptake (RAIU) 50 Hyperthroidism 40 Normal 30 Hyperthyroidism with Rapid turnover 20 10 Hypothroidism 0 2 0 6 12 18 24 Time (hours)

  18. Function Structure Thyroiditis Goiter Hyperthyroidism Hypothyroidism Etiology Nodular Diffuse RX Function nl  Benign Malignant Thyroid abnormalities

  19. Hyperthyroidism-Etiology • Diffuse toxic goiter (Graves’ disease)- most common in young people • Toxic adenoma (Plummers’ diesease) • Toxic mulitinodular goiter (MNG) • Subacute thyroiditis-Hyperthyroid phase • Hyperthyroid phase of Hashimotos’ thyroiditis • (“Hashitoxicosis) • Factitious hyperthyroidism • Rare causes: -TSHoma • -Hydatidiform mole/choriocarcinoma • - Multiplex pregnancy • - Struma ovarii

  20. Graves’ disease • Diffuse toxic goiter • Opthalmopathy • Dermopathy • Acropathy (clubbing) Etiology: Autoimmune Anti-TSH receptor antibodies (stimulating, blocking, neutral) Anti-thyroid antibodies  expression of HLA-DR3  association with: -diabetes mellitus-type 1 myasthenia gravis -Addison’s disease lupus - pernicious anemia

  21. Graves’ disease • Epidemiology : incidence 0.3-1.5/1000 • Female: Male 5:1 • Most Common cause of hyperthyroidism

  22. T4, T3 (+) (-) TSH (+) Thyroid Stimulating Immunoglobulins (TSI) Thyroid and pituitary function in Graves’ disease

  23. Graves’ disease- Clinical features Signs: Symptoms: Fatigue palpitations Weight loss Heat intolerance Frequent bowel movements Sweating hyperkinesia Tachycardia Muscle wasting  pulse pressure Eye signs Diffuse goiter Lymphadenopathy Splenomegaly Hyperreflexia In the elderly: cardiovascular symptoms, myopathy

  24. Graves’ Disease- Goiter

  25. Graves disease- Opthalmopathy Extrathyroidal TSHR is present in retro-orbital adipocytes, muscle cells and fibroblasts

  26. Grave’s Opthalmopathy Class 0 — No symptoms or signs Class I — Only signs, no symptoms (eg, lid retraction, stare, lid lag) Class II — Soft tissue involvement Class III — Proptosis Class IV — Extraocular muscle involvement Class V — Corneal involvement Class VI — Sight loss (optic nerve involvement)

  27. Graves’ disease dermopathy

  28. Graves disease- diagnosis • Clinical hyperthyroidism • Biochemistry: FT4, TT3 , TSH • cholesterol  • Serology: anti-TSH receptor antibodies • anti-thyroid antibodies

  29. 1. Antithyroid drugs: Thionamides- Propylthiouracil (PTU) Methimazole (MMI) b-blockers 3. Definitive therapy: 131I- side effects: hypothyroidism Surgery- subtotal thyroidectomy side effects: anesthesia morbidity hypoparathyroidism recurrent laryngeal nerve damage hypothyroidism Treat for 12 months ~30% remission 70% Recurrence Or non-remission Follow-up Graves’ disease- therapy

  30. Anti-thyroid thionamide drugs PTU (propylthiouracil) MMI (methimazole) Dosage:TID Once daily Effect: T4, T3  synthesis T4, T3  synthesis inhibits T4→T3(high dose) (slow) Agranulocytosis*: Non-dose dependent Dose dependent (> 40 mg/day)   > 40 yrs Pregnancy:  placental transfer  placental transfer aplasia cutis *occurrence 0.3-0.6%

  31. Treatment of Graves' Orbitopathy • Treatment of patients with Graves' orbitopathy has three components: • Reversal of hyperthyroidism, if present • Symptomatic treatment • Treatment with a glucocorticoid, orbital irradiation, orbital decompression surgery to reduce inflammation in the periorbital tissues • Anti thyroid drugs and thyroidectomy are safe; Radioactive iodine may worsen the situation.

  32. FT 3 FT 4 The effect of high- dose PTU Pulse rate: 140 50 10 9 45 8 120 7 40 6 Normal range 100 35 5 4 30 3 80 2 25 Upper limit of normal 1 20 0 0 1 2 3 4 5 6 Days 1200 PTU dose mg/day: 600

  33. Subacute thyroiditis Etiology: (Post) viral inflammation of thyroid Symptoms & signs: Hyperthyroidism Painful swelling of thyroid Pain irradiation to ear Fever Sometimes “silent” Laboratory: ESR  acute phase reactants (CRP)

  34. Subacute thyroiditis- therapy A self limited disease Therapy depends on symptoms/signs Non-steroid anti-inflammatory agents (NSAIDS) b-blockers Corticosteroids Outcome - in 6 months 90% euthytroid

  35. Primary - TSH↑ 1. Hashimoto’s thyroiditis 2. Post 131I therapy for Grave’s disease 3. Post thyroidectomy 4. Excessive I intake (amiodarone-procor) Secondary TSH↓ or normal: Hypopituitarism due to adenoma, destructive lesion, ablation TSH↓ Tertiary: Hypothalamic dysfunction (rare) Hypothyroidism- classification

  36. Hypothyroidism- clinical features Signs: Symptoms: Fatigue Weakness Weight gain Cold intolerance Constipation Cramps Paresthesias (carpal tunnel) Coarse features Bradycardia Myxedema Anemia Laboratory: serum thyroid hormones,  cholesterol anemia (iron def., megaloblastic)

  37. Hypothyroidism

  38. Hypothyroidism- myxedema

  39. Hypothyroidism- differential diagnosis Serum FT4 and TSH FT4, TSH normal/low Secondary hypothyroidism FT4, TSH borderline high TSH TRH test Excessive response Primary hypothyroidism

  40. Hypothyroidism- therapy • Levothyroxine 0.05-0.3 mg/day • Combined L-T4 and L-T3 may be beneficial with • respect to well-being • In elderly patients (at high risk for CVD), • “go low, go slow”

  41. Hypothyroidism- treatment After Before

  42. Thyroid Storm and Myxedema Coma – rare endocrine emergencies

  43. THYROID STORM Acute life threatening exacerbation of thyrotoxicosis Clinical setting History of Graves’ disease and discontinuation of medications/ previously undiagnosed hyperthyroidism. Acute onset of hyperpyrexia (over 40 ˚C) Sweating Marked tachycardia, often with atrial fibrillation Nausea, vomiting, diarrhea Agitation, tremulousness, delirium Occasionally “apathetic” – without restlessness and agitation, but with weakness, confusion, and cardio-vascular dysfunction.

  44. THYROID STORM DIAGNOSIS: Largely based on the clinical findings and clinical suspicion. Elevated serum FT4, FT3. Low TSH MANAGEMENT 1. Supportive care Fluids, Oxygen, Cooling blanket,cetaminophen 2. Specific measures Propranolol, 40-80 mg every 6 hours. Antithyroid drugs – PTU. Glucocorticoids - Dexamethasone, 2 mg every 6 hours (due to reduction in glucocorticoids half life)

  45. Myxedema Coma Extreme hypothyroidism: • Coma • Hypothermia • Hypoventilation • Hypoglycemia • Hyponatremia • Bradycardia Laboratory: FT4 , FT3, TSH Co2 retention

  46. Myxedema Coma- therapy Ventilation Precipitating factors Treat: T4 or T3 I.V. Corticosteroids-50-100mg hydrocortisone every 8 hours

More Related