HYPOTHYROIDISM

Hypothyroidism results from suboptimal levels of thyroid hormone. Thyroid deficiency can affect all body
functions and can range from mild, subclinical forms to myxedema, an advanced form. The most common
cause of hypothyroidism in adults is auto immune thyroiditis (hashimoto’s disease), in which the immune
system attacks the thyroid gland. Symptoms of hyperthyroidism may later be followed by those of
hypothyroidism and myxedema. Hypothyroidism also commonly occurs in patients with previous
hyperthyroidism who have been treated with radioiodine, antithyroid medications or whohave had
surgery. It occurs most frequently in older women . radiation therapy for head and neck cancer can also
cause hypothyroidism in older men; therefore, testing of thyroid function is recommended for all patients
who receive such treatment.

Causes of Hypothyroidism

 Chronic lymphocytic thyroiditis (hashimoto’s disease)

 Atrophy of thyroid gland with aging
 Therapy for hyperthyroidism ( radioactive iodine, thyroidectiomy)
 Medications ( lithium, iodine compounds, antithyroid medications)
 Radiation to head and neck for treatment of head and neck cancers, lymphoma
 Infiltrative diseases of the thyroid ( amyloidosis, scleroderma)
 Iodine deficiency and iodine excess

Pathophysiology

More than 95% of patients with hypothyroidism have primary or thyroidal hypothyroidism, which refers
to dysfunction of the thyroid gland itself. When thyroid dysfunction is caused by the failure of pituitary
gland, the hypothalamus, or both, it is known as central hypothyroidism. It may be referred to as pituitary
or secondary hypothyroidism if it is caused entirely by a pituitary disorder, and hypothalamic or tertiary
hypothyroidism if it is attributable to a disorder of hypothalamus resulting in inadequate secretion of TSH
because of decreased stimulation by the TRH. When thyroid deficiency is present at birth , the condition
is known as cretinism. In such instances, the mother may also suffer from thyroid deficiency.

The term myxedema refers to the accumulation of mucopolysaccharides in the subcutaneous and
other interstitial tissues. Although myxedema occurs in a long-lasting hypothyroidism, the term is used
appropriately only to describe the extreme symptoms of severe hypothyroidism.

Clinical manifestations

Early symptoms of hypothyroidism are nonspecific but extreme fatigue makes I difficult for the person to
complete a full day’s work or participate in usual activities. Reports of hairloss, brittle nails and dry skin
are common, and numbness and tingling of the fingers may occur. On occasion, the voice may become
husky, and the patient may complain of hoarseness. Menstrual disturbances such as menorrhagia or
amenorrhea occur., in addition to loss of libido. Hypothyroidism affects women five times more frequently
than men and occurs most often between 30 and 60 years of age.

Severe hypothyroidism results in subnormal temperature and pulse rate. The patient usually
begins to gain weight even without an increase in food intake, although severely hypothyroid patients
may be cachectic. The skin becomes thickened because of an accumulation of mucopolysaccharides in the
subcutaneous tissues ( the origin of the term myxedema). The hair thins and falls out; the face becomes
expressionless and masklike. The patient often complains of being cold even in a warm environment.

At first, the patient may become irritable and may complain of fatigue, but as condition
progresses, the emotional responses are subdued. The mental processes become dulled, and the patient
appears apathetic. Speech is slow and, the tongue enlarges and hands and feet increase in size. The
patient frequently complains of constipation. Deafness may occur.

Advanced hypothyroidism may produce personality and cognitive changes characteristic of

dementia. Inadequate ventilation and sleep apnea can occur with severe hypothyroidism. Pleural
effusion, pericardial effusion, and respiratory muscle weakness may also occur.

Severe hypothyroidism is associated with an elevated serum cholesterol level, atherosclerosis,

coronary artery disease and poor left ventricular function. The patient with advanced hypothyroidism is
hypothermic and abnormally sensitive to sedatives, opioids, and anesthetic agents. Therefore; these
medications are administered only with extreme caution.

Patients with unrecognized hypothyroidism who are undergoing surgery are at increased risk for
intraoperative hypotension and postoperative heart failure and altered mental status.

Myxedema coma describes the most extreme, severe stage of hypothyroidism, in which the
patient is hypothermic and unconscious. Myxedema coma may follow increasing lethargy, progressing to
stupor then coma. Undiagnosed hypothyroidism may be precipitated by infection or other systemic
disease or by the use of sedatives or opioid analgesic agents. The patient’s respiratory drive is depressed,
resulting in alveolar hypoventilation, progressive carbon dioxide retention, narcosis and coma. These
symptoms along with cardiovascular collapse and shock, require aggressive and intensive therapy if the
patient is to survive. Even with early vigorous therapy, however mortality is high.