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Thyroid
Apical
Membran
e
Basal Membrane
Colloid
B A SIC TH YR O ID FU N C TIO N
Maintains Basal Metabolic Rate
(BMR)
Oxygen requirements
FEEDBACK REGULATION
THE HYPOTHALAMIC-PITUITARY-THYROID AXIS
Hormones derived from the pituitary that regulate
the synthesis and/or secretion of other hormones are
known as trophic hormones.
Kontrolkelenjar tiroid
Hormon tirotropin (TRH) yang dikeluarkan oleh
hipotalamus.
Menstimulasi pituitari anterior untuk
memproduksi tiroid stimulating hormon (TSH).
TSH akan memacu tiroid untuk memproduksi
tiroksin atau T4 (karena mengandung 4 atom
yodium).
Tiroksin akan menuju sel-sel sasaran.
Bila sel-sel sasaran kebutuhannya telah
mencukupi maka tiroksin akan memiliki efek
umpan balik negatif, artinya tiroksin akan
menghambat hipotalamus untuk memproduksi
TRH dan menghambat pituitari anterior untuk
memproduksi TSH.
Hypothalamus
TRH
+
Pituitary
TSH
+
TSHR-Ab
Thyroid
Iodine
T3 / T4
+
Ginjal, hati,
Otot, Otak, dsb
Pengatura
n Faal
Kelenjar
Tiroid
pump
2. Increase synthesis of
uncoupling protein UCP3
3. Increase protein synthesis and
degradation
4. Increase lipid synthesis and
degradation
ATP
ADP
Thyroid Function
1. Follicle cells make thyroglobulin protein
2.
3.
4.
5.
24 30 jam.
Dilakukan proses deiodinasi guna
mempertahankan hormon aktif sesuai dengan
kebutuhan.
3 macam deiodinasi
Deiodinasi tipe I (DI) :
Konversi T4 @ T3 di perifer. Tidak berubah waktu hamil
Deiodinasi tipe II (DII)
:
Konversi T4 @ T3 secara Lokal (di Placenta, Otak, SSP).
Penting untuk mempertahankan kadar T3 lokal
Deiodinasi tipe III (DIII) :
Mengubah T4 menjadi rT3 dan T3 @ T2. Khususnya di
Plasenta untuk mengurangi masuknya hormon ibu yang
berlebihan ke fetus.
aktif.
THYROID HORMONES
OH
OH
O
NH2
I
O
Thyroxine (T4)
OH
NH2
I
O
OH
3,5,3-Triiodothyronine (T3)
LOW
LOW
NORMAL
Subclinical Hypothyroidism
HIGH
Pituitary Hyperthyroidism
HIGH
NORMAL
LOW
Pituitary Hypothyroidism
Thyroid Tests
1. Thyroid Function
2. Iodine Kinetics
3. Thyroid Structure
4. FNA
5. Thyroid Antibodies
6. Thyroglobulin
Thyroid Testing
Radioactive Iodine Uptake and Scan
(RAIU/Scan)
123-RAIU/Scan or 131-RAIU/Scan
Indications:
biochemically hyperthyroid pt
No role in euthyroid or hypothyroid pts
RAIU produces a number.
T4
Protein* binding
+ 0.03% free T4
80% (peripheral)
20%
T3
Protein* binding
freeless
T3 than T4)
(10-20x
Total T460-155 nM
Total T30.7-2.1 nM
T3RU/THBI 0.77-1.23
+ 0.3%
*
TBG
75%
TBPA 15%
Albumin
10%
RAIU /Scan
Increased RAIU
Graves Disease
Toxic Nodules
MNG
Adenoma
Iodine Deficiency
RAIU /Scan
Decreased RAIU
Thyroiditis
Chronic painless
Postpartum
Subacute
Amiodarone-induced
Thyroiditis Factitia
Iodine Excess
Contrast dye
Diet
Amiodarone
Struma ovarii:
(ectopic thyroid hormone production
from thyroid tissue in an ovarian
teratoma)
Thyroid Scan
Thyroid nodule: risk of malignancy 6.5%
only 5-10% of nodules
Cold nodule
16-20% malignant
Warm Nodule
(indeterminant)
5% malignant
Hot Nodule
Thyroid N odules
Structural disorders of the thyroid
5%)
SPEC > 95%
FN A R esults
Nondiagnostic: repeat FNA
Benign: macrofollicular or "colloid"
B enign Lesions
Papillary Carcinoma
Surgical Specimen
FNA
Thyroid nodules
U/S more sensitive than P.E., particularly for
TSH-R ab block
Thyroglobulin ab
Microsomal ab
Autoimmune
Thyroid Disease
TSH-R ab stim
Hashimotos
Graves Dx
(hypothyroid)
(hyperthyroid)
Thyroid Antibodies
Hashimotos
Thyroglobulin AB (<40 KIU/L)
Thyroid peroxidase AB (< 35 KIU/L)
Graves
Palpasi
Tiroid
Kelenjar
52
Goiter
G O ITER
54
Cretinsm
Mental Deficiency
Deafness
Motor Disorder
Short Stature
Cretinsm
Endemic Goiter
Normal
deficient
Iodine-
Hypothyroidism
1 Hypothyroidism
Hyperthyroidism
www.hsc.missouri.edu/~daveg/thyroid/thy_dis.html
Juvenile Hypothyroidism
Congenital Hypothyroidism
www.hsc.missouri.edu/~daveg/thyroid/thy_dis.html
Graves Disease
exophthalmos
due to
edema
in the orbits
Conjunctival injection
Periorbital edema
Chemosis
Due to thyroid autoAbs that
cross-react w/ Ags in
fibroblasts, adipo-cytes, +
myocytes behind the eyes.
Endem ic G oiter
71
www.drsarma.in
72
www.drsarma.in
M yxedem a
www.drsarma.in
73
M yxedem a
74
www.drsarma.in
Thyroid Cancer
Thyroid Cancer
Papillary Thyroid Ca (PTC): 75%
Follicular Thyroid Ca (FTC): 15
20%
Medullary Thyroid Ca (MTC): <
5%
Anaplastic: < 5 %
Lymphoma: rare
Hashimotos is a risk factor
Metastatic to thyroid: rare
Breast, Renal cell, melanoma
and lung Ca
MTC
FMTC
MEN2A
MTC, HyperPTH, Pheo
MEN2B
MTC, Pheo, Mucosal neuromas
Stage 2
Stage 4
Stage 3
thyroid dysfunction
Hypothyroid (postpartum exacerbation of Hashimotos):
40%
Hyper-/Hypothyroid (postpartum thyroiditis): 25%
Hyperthyroid Thyroiditis (postpartum thyroiditis): 24%
Hyperthyroid Graves: 20%
high-normal range.
TSH levels often remain suppressed w/ FT4 or FT3 in
these ranges + cant be accurately used for titrating
ATD.
If unable to use ATD- surgery (subtotal thyroidectomy) can
be done during 2nd trimester.
1st trimester: risk of miscarriage
3rd trimester: risk of preterm labor
D rugs Aff
ecting Thyroid Function
Somatostatin,
Glucocorticoids
Dopamine
T = Tyrosyl ring
(aka Inner ring)
P = Phenolic ring
(aka Outer ring)
TSH
factors.
Increase LT4/hyperthyroidism will increase sensitivity to
3) Iron or Calcium
Also binds T4 & T3
5) Androgens/corticosteroids
Decrease TBG, increase FT4 level
Need to decrease LT4 in some patients
5) Diabetes
Increase LT4/hyperthyroidism will increase insulin/OHA
requirements.
Decrease LT4/hypothyroidism will decrease insulin/OHA
requirements.
The End!