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THYROID
FUNCTIONS
NORMAL THYROID GLAND
Actions of the thyroid
Controls body temperature
How body burns calories
Thyroid hormones:
T3
T4
DIAGNOSTICS
How do we diagnosis these disorders??
Thyroid stimulation hormone (TSH) test
Normal levels of TSH are 0.4-
4.5milliunits/L. ( 0,3-5 ulU/ml )
Thyroid hormone test
In adults, a normal total T3 level is 80-
230 ng/dL ( 75-200 ng/dl ). Total T4
levels should be at 5-14 mcg/dL.
( 4,5-11,5 mcg/dl )
DISEASES OF THE
THYROID GLAND
Congenital diseases
Inflammation
Functional abnormality
Diffuse and Multinodular
goiters
NEOPLASIA
THYROID DISORDERS
Hypothyroidism
Underactive thyroid
Hyperthyroidism
Overactive thyroid
Goiter
Thyroid enlargement
CAUSES OF HYPERTHYROIDISM
1. Graves Disease – Diffuse Toxic Goiter
2. Plummer’s Disease – Toxic Mono Nodular Goiter
3. Toxic phase of Sub Acute Thyroiditis - SAT
4. Toxic Single Adenoma – STA
5. Pituitary Tumours – excess TSH
6. Molar pregnancy & Choriocarcinoma
7. Metastatic thyroid cancers (functioning)
8. Struma Ovarii ( Ovarian teratoma )
9. Iodine/thyroid hormone excess
SIGNS AND SYMPTOMS OF HYPERTHYROIDISM
Hoarseness/
Nervousness/Tremor Deepening of Voice
Nervousness/Tremor
Restlessness
Anxiety
Irritability
Sleeplessness or insomnia
Exhaustion
EpidEmiology of gravEs’ disEasE
- Cause of 50 – 80% of cases of hyperthyroidism
- Prevalence: 0.6% of population
- Incidence: 0.5/1000/year
- Female/male ratio: 5/1 – 10/1
- Incidence: 20 – 40 years of age
- Concordance rate: monozygotic twins 35%;
dizygotic twins 3%
- Predisposition: 79% genetic; 21% nongenetic
- Female siblings and female children have 5 – 8%
TRIGGER OF GRAVE , S DISEASE
1.Viral/bacterial infections
2.Stress
3.Smoke
4.Radiation
5.Exposure to iodide
6.Drug
Grave's Disease , toxic diffuse goiter,
Basedow , disease , struma difusa
It is hyperfunction of thyroid gland
due to autoimmune disease in which
autoantibodies called thyroid
stimulating immunoglobulins,
activate TSH receptors producing
excessive secretion of thyroid
hormones although TSH hormone
itself is low.
MANIFESTATIONS
Exophthalmos , diplopia, deterioration in hand
writing , heat intolerance
Increased BMR and heat intolerance.
Cardiovascular symptoms ; tachycardia, arrhythmias
like .Atrial fibrillation, cardiac ischemia and high
cardiac output failure.
Insomnia, irritability and hyperreflexia, nervousness
Mentally and physically hyperactive
Loss of weight and increase food intake., osteophorosis
Malabsorbtion and diarrhea, sweating, muscle weaknes
Dermopathy ( pretibial myxedema ) in a minority of
patients
Dr. Mohamed Z Gad 1 February 2018
In Graves’ disease,
the antibodies do
not destroy the
thyroid but act as if
they are TSH (i.e.,
they bind and
activate the TSH
receptor) (agonist)
(Anti) TSHR antibodies ( TSI, LATS )
- secreted by lymphocytes
in all patients with Grave’s
disease.
- It has the same action of TSH
on the thyroid gland.
- Can cross the placenta and
stimulate the fetal thyroid
gland.
Autoantibodies (IgG) can cross the placenta and affect the
fetus
T3-thyro toxicosis:
TSH: undetectable or
FT3:
FT4: ↔
UNDER SECRETION OF THYROID HORMONES
(HYPOTHYROIDISM)
Defined as low free T4 level with a normal or high TSH.
Types of hypothyroidism
1- Primary : Thyroid gland dysfunction
Most common :
1- Congenital hypothyroidism (in neonates)
2- Chronic lymphocytic thyroiditis (Hashimoto`s thyroiditis)
Autoimmune disease of thyroid
Thyroid gland is enlarged
3- Iodine deficiency
4- Thyroid surgery
5- Radioactive iodine treatment
Idiopathic
TIROIDITIS HASHIMOTO
Hipotiroid karena proses imunologik
Prognosis kurang baik krn proses
autoimun
Lab : T3 ↓ / T4 ↓
TSH ↑
anti peroksidase tiroid ( TPO )
antibodies positif
Anti-TPO antibodies ( TPO ) are the most common anti-
thyroid autoantibody, present in approximately 90 % of
Hashimoto's thyroiditis, 75% of Graves' disease
TRAbs are present in 70 – 100 % of Graves' disease
so TRAbs are most commonly associated with
Grave ‘ disease
Thyroglobulin antibodies are specific for thyroglobulin, a
660kDa matrix protein involved in the process of thyroid
hormone production. They are found in 70% of Hashimoto's
thyroiditis, 60% of idiopathic hypothyroidism, 30% of
Graves' disease .TgAb (thyroglobulin antibody) is important
to test for in those who have thyroid cancer.
CLINICAL FEATURES OF HYPOTHYROIDISM
IN HYPOTHYROIDISM
Measurement of the serum TSH level is the
most sensitive screening test for this
disorder.
The TSH level is increased in primary
hypothyroidism
The TSH level is not increased in patients
with hypothyroidism due to primary
hypothalamic or pituitary disease.
T4 levels are decreased
Clinical Picture of Simple Nodular Goitre
Three women of the himalayas with typical endemic
goiters.
INVESTIGATIONS OF
GOITER
ThyroidFunction
TSH ( 0.4 –5.0 mU/L)
Free T4 9.1 – 23.8 pM
Free T3 2.23-5.3 pM
THYROID FUNCTION TESTS
1- Tests to establish whether there is
thyroid dysfunction
Thyroid hormone ( FT3 and FT4 )
in the serum / plasma , TSH , TRH , BMR
2- Tests to elucidate the cause of the
thyroid dysfunction,as for examples :
1. Thyroid autoantibodies : Anti
thyroglobulin, Anti thyroid peroxidase,
TSH receptor antibodies
2. Serum thyroglobulin
THYROID FUNCTION TESTS
3. Thyroid enzyme activity
4. Biopsy of the thyroid
5. RAIU , Thyroid scanning , Perchlorate test
6. ECG, Serum cholesterol, Tendon reflexes
7. Thyroid ( T3 ) suppression test, TRH/TSH
stimulation test
5. Imaging : UG, CT scan, MRI
EVALUATION TEST OF HYPOTHALAMUS ,
PITUITARY AND THYROID GLAND .
1. TRH/F TEST
1. HYPERTHYROID : RESPOND TRH TO TSH :
DECREASE OR NEGATIVE
2.TO DIFFER SECONDARY HYPOTHYROID AND
TERTIARY HYPOTHYROID .
3. PRIMARY HYPOTHYROID : IS NO VALUE
2. TSH STIMULATION TEST with R I U /
R A I U : TO DETERMINE THE ABNORMALITY
OF THYROID OR PITUITARY LEVEL
3. THYROID SUPPRESSION TEST
TO DETERMINE THYROID GLAND FUNCTION
4. TSH , FT3 and FT4 SERUM
51
THERAPY
1. SURGERY
2. ISOTOP AMINISTRATION ( I 131 )
3. ANTI THYROID DRUG
A. TIOURASIL (TU), PROPYLTHIOURACIL(PTU),
KARBIMAZOL, THIOUREA , METHIMAZOLE :
INHIBIT PHASE : IODINATION, COUPLING
AND OXIDATION .
PTU DAN PROPANOLOL ALSO INHIBIT
A CHANGE T4 TO T3 IN PERIPHER.
B. KJ : INHIBIT HYDROLYSIS THYROGLOBULIN
STIMULATED BY TSH
C. THIOCYANATE DAN PERCHLORAT E ARE ABLE TO
COMPETE WITH IODIDE AT CONCENTRATION PHASE .
D. THIOCARBAMIDE INHIBIT PEROXIDASE ENZYME
QUESTION 1
• weight loss over the last few weeks associated with an increase in
appetite
hypo)?
• Hyperthyroidism
QUESTION 1B
3.Thyroid-stimulating immunoglobulins
• Feeling cold
symptoms?
• Hypothyroidism
RADIOACTIVE IODIDE
The beta radiations of 131I destroy thyroid
parenchyma, so decreasing hormonal
release.
Advantages:
Easy administration (orally).
Effective.
It is not expensive.
Suitable for old ages and cardiac patients
with moderate to severe hyperthyroidism
and unfit to surgery.
Adverse effects:
As with iodine therapy, overdoses may cause
iodism (metallic taste, excessive salivation, with painful
salivary gland, diarrhea, productive cough, running
eyes & nose, sore throat and rashes mimic chicken-
pox).
Overdose is treated by large dose of sodium or
potassium iodide to compete with the radioiodine
uptake by the gland, and then hasten excretion by
fluids and diuretics.
Local pain & congestion at the site of the gland
Hypothyroidism
Malignant changes in the thyroid after many years
treatment
1. Severe thyrocardiac disease