Thyroid Hormone disorders

Anatomy of the Thyroid Gland

Thyroid gland Produces and Secretes 2 Metabolic Hormones

Two principal hormones
1-Tetraiodothyronine or Thyroxine (T4 ) 2-triiodothyronine (T3)

Thyroid-Stimulating Hormone (TSH)

Regulates thyroid hormone production, secretion

Is regulated by the negative feedback action of T4 and T3

Hypothalamic-Pituitary-Thyroid Axis Negative Feedback Mechanism

Thyroid Hormone Action

Thyroid Hormone Plays a Major Role in Growth and Development

Thyroid hormone initiates or sustains differentiation and growth Essential for neural development and maturation and function of the brain and CNS Normal thyroid hormone function is important for reproductive function

Clinical disorders
1.Hyperfunction (hyperthyroidism)

A. Thyrotoxicosis:
It results when tissues are exposed to excessive levels of T4, T3, or both.

Causes
TSH-secreting pituitary tumors.

Symptoms of thyrotoxicosis
Nervousness and anxiety palpitations Heat intolerance, hot and sweaty loss of weight along with an increased appetite Scanty or irregular menses in women.

B. Gravesdisease
It is an autoimmune condition. The serum contains specific TSH immunoglobulins (TSIs) that bind to the TSH receptors on the follicular cells of thyroid gland. like natural TSH, stimulate the cells to secrete thyroid hormone.

Symptoms of Graves disease

Graves disease is manifested by thyrotoxicosis symptoms (as before) and exophthalmos.

Lab tests
1.An elevated 24-hour radioactive iodine uptake (RAIU) indicates true hyperthyroidism.
2.Thyrotoxicosis ( TSH, T3, T4 )

3. In Graves disease ( TSH, T4,T3, TSIs)

Treatment

1. Antithyroid drug (PTU blocks thyroid hormone synthesis) .

2. Radioiodine therapy ( I 131 )

3. Surgical removal of the thyroid gland

2. Hypofunction (hypothyroidism)
Disorder in which the thyroid gland fails to secrete an adequate amount of thyroid hormone. May be primary or secondary

Causes
1.Chronic autoimmune thyroiditis (Hashimotos disease)
2. Iatrogenic hypothyroidism 3. Iodine deficiency

Signs and symptoms

a. In adult ( Myxedema) lethargy, fatigue , weakness and loss of energy Decreased heart rate Cold intolerance Dry skin Weight gain , Buffy face and thickened subcutaneous tissue

Constipation Depression Menestrual irregularities. physical and mental sluggishness

Buffy face-bags under the eyes

Signs and symptoms

b. In children (Cretinism)
Large size (despite poor feeding habits) and increased birth weight Puffy face and swollen tongue hoarse cry Low muscle tone Cold extremities Persistent constipation Lack of energy, sleeping most of the time Little or no growth (dwarf) They are described as "good babies"

Signs and Symptoms

C- Simple Goiter
The thyroid gland is normal but is unable to secrete thyroid hormones due to deficiency of iodine in the diet. Consequently, TSH is increased due to -ve feedback mechanism, leading to increased size of thyroid gland. It can be best managed by administration of iodine in diet.

Lab tests
Thyroid function test: ( T3 ,T4 ,TSH ) in adults.

Treatment
Levothyroxine (L-thyroxine,T4) is the drug of choice for thyroid hormone replacement .

RULE

High TSH ------------- hypothyroidism Low TSH ------------- hyperthyroidism

THYROID HORMONE CASES

CASE 1
A 44-year-old woman presents to the office because of fatigue. She has felt sluggish for months and thinks she may be anemic. She has started taking iron pills but isn't feeling any better. She has noticed some thinning of her hair and feels as if her skin is dry. On examination, her blood pressure and pulse are normal. Her skin is diffusely dry. Her thyroid gland feels diffusely enlarged non-tender, and has no nodules. Lab tests show a normal complete blood count (CBC), glucose, and electrolytes. Her thyroidstimulating hormone level (TSH) is elevated, and T4 level is reduced.

Questions

1- How could this case be diagnosed?

2- What type of treatment would you suggest?

CASE 2
A 27-year old female came to the clinic with a threemonth history of heat intolerance, sweats, tremors and severe muscle weakness which had limited her ability to climb stairs. Her appetite had increased remarkably despite weight loss. She was also bothered by the pounding of her heart and some minor difficulty in swallowing. There was a positive family history of thyroid disease. She previously had received iodide drops with improvement in her symptoms but her disease recurred despite continued administration. Later, she stopped taking the drops. Her other medical problems include diabetes which was controlled with diet and Lente insulin.

She had a history of non compliance with her clinic visits. Physical findings: -Blood pressure of 180/90 mmHg -Pulse of 110 beats/min. -hypereflexia -Diffusely enlarged thyroid gland Lab values : TSH: 0.05 mU/L FT4: 3.1 ng/dl(N=0.7-1.9) After physical and laboratory investigations, the case was diagnosed as thyrotoxicosis.

Questions
1- Mention the signs and symptoms suggestive for
thyrotoxicosis?

2-Why were iodide drops initially effective in

improving the symptoms, but later ineffective? 3-When is iodide mainly indicated? This patient was started on PTU. One week later, she complained that her symptoms were worse and the medication was not working. She admitted missing doses because difficulty of swallowing, cough and sore throat.

4-PTU was ineffective in this case because:

a- The patients non compliance b- Prior iodide loading of the gland c- Slow onset of action of PTU d- a&b e- a&c 5- What may be the cause of patients complaints of sore throat and cough? And What are the measures taken for management of having sour throat and cough?

CASE 3
LG is a 25-year-old pregnant woman who presents with a history of anxiety, nervousness, and difficulty sleeping for the past 3 months. She complains of feeling hot and sweaty, and has noticed her heart beating irregularly at times during the day. Her eyes were prominent and stare. The case was diagnosed as Hyperthyroidism.

Questions
1. What is the cause of LGs symptoms and what clues lead you to this conclusion? 2. What diagnostic tests would you order to confirm her diagnosis? What would these tests show? 3- How could you treat this case? 4- Is radioactive iodine contraindicated as a drug therapy during pregnancy? Why?
Canaris GJ, et al. Arch Intern Med. 2000;160:523-534.

CASE 4
A 19-year-old woman develops secondary amenorrhea followed by symptoms of palpitations nervousness, heat intolerance and sweating. A pregnancy test is positive and T3 and T4 values are high.

Questions
1. What is the clinical picture of this case?
2. How could this case be managed as the patient is probably pregnant? 3. Is radioactive iodine contraindicated as a drug therapy during pregnancy? Why?

Canaris GJ, et al. Arch Intern Med. 2000;160:523-534.

CASE 5
Elizabeth C., a child, was born at term weighing 7 lb.. The

mother's pregnancy had been normal but breast feeding was

not established and the infant was fed on National dried milk. No abnormality was noticed by her parents until the onset of

vomiting, and difficulty in taking feeds at the age of 6 weeks.

When first examined at 8 weeks the infant's appearance was suggestive of cretinism and there was enlargement of the thyroid gland. When admitted to the hospital at the age of 4 months the features of cretinism were definite.

Questions
1. Mention the cause and the main signs and symptoms of cretinism? 2. How is cretinism treated? 3. What is Pituitary dwarfism? 4. What is the difference between cretinism and dwarfism?