Hipertiroidisme

Kepaniteraan ilmu penyakit dalam

RSUD CILEGON UNIVERSITAS YARSI
DEFINISI (Sudoyo,W Aru,dkk.2006)
TIROTOKSIKOSIS
Manifestasi klinis kelebihan hormon
tiroid yang beredar dalam sirkulasi
HIPERTIROID
Tirotoksikosis yang diakibatkan
hiperaktifitas dari kelenjar tiroid


Tirotoksikosis
vs
hipertiroidisme

Apapun sebabnya, manifestasi klinisnya sama
Efek ini disebabkan ikatan T3 dengan T3-inti
makin penuh

(Sudoyo,W Aru,dkk.2006)
THE THYROID GLAND
www.univ-st-etienne.fr/lbti/Mednucl/AtlasEnd/thyroide/
O
OH
I
I
I
I
OH
O
NH
2

Thyroxine (T
4
)
O
OH
I
I
I
OH
O
NH
2

3,5,3-Triiodothyronine (T
3
)
THYROID HORMONES
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.
Key players for the thyroid include:
TRH - Thyrophin Releasing Hormone
TSH - Thyroid Stimulating Hormone
T
4
/T
3
- Thyroid hormones
PITUITARY-THYROID AXIS
HM Goodman, BASIC MEDICAL ENDOCRINOLOGY 3
rd
Ed.


+
Negative Feedback Loop
Thyroid Disease Can
Have Widespread Effects
Thyroid
Increased LDL
Cholesterol
Elevated
Triglycerides
Liver
Constipation
Decreased GI
Activity
Intestines
Decreased Fertility
Menstrual Abnormalities
May Harm Development of Infant

Reproductive
System
Depression
Decreased Concentration
General Lack of Interest
Brain
Decreased Heart Rate
Increased/Decreased
Blood Pressure
Decreased Cardiac
Output
Heart
Decreased Function
Fluid Retention and
Edema
Kidneys
Thyroid Disease Affects
Many Body Systems and Overall Health










Hormon tiroid berfungsi untuk mengendalikan
kecepatan metabolisme tubuh. Hormon tiroid
mempengaruhi kecepatan metabolisme tubuh melalui
dua cara :
1. Merangsang hampir setiap jaringan tubuh untuk
menghasilkan protein.
2. Meningkatkan jumlah oksigen yang digunakan oleh
sel.
(fitriani,2010)
http://yosefw.wordpress.com/2008/06/10/penggunaan-obat-antitiroid-pada-pasien-hipertiroidisme/








etiologi















Etiologi

Hipertiroidisme primer : penyakit Graves, struma multinodosa
toksik, adenoma toksik, metastasis karsinoma tiroid fungsional,
struma ovarii, mutasi reseptor TSH, obat kelebihan yodium
(fenomena Jod Basedow).
2


Tiroiditis silent, destruksi tiroid (tanpa amiodarone, radiasi,
infark adenoma), asupan hormon tiroid yang berlebihan
(tirotoksikosis factitia)
2


Hipertiroidisme sekunder: adenoma hipofisis yang mensekresi
TSH, sindrom resistensi hormon tiroid, tumor yang mensekresi
HCG, tirotoksikosis gestasional
2










Lebih dari 90 % hipertiroidisme adalah
akibat penyakit graves dan nodul tiroid
toksik.
Signs and Symptoms Of Hyperthyroidism
Bulging Eyes/Unblinking Stare
Menstrual Irregularities or
Light Period
Excessive Vomiting in Pregnancy
First-Trimester Miscarriage
Family History of
Thyroid Disease
or Diabetes
Nervousness
Irritability
Difficulty Sleeping
Swelling (Goiter)
Frequent Bowel Movements
Warm, Moist Palms

Hoarseness or
Deepening of Voice
Difficulty Swallowing
Rapid or Irregular Heartbeat

Infertility
Weight Loss
Heat Intolerance
Increased Sweating
Persistent
Sore or Dry Throat
Common Signs and Symptoms
of Hyperthyroidism
Nervousness
Irritability
Difficulty Sleeping
Bulging Eyes
Unblinking Stare
Goiter
Rapid Heartbeat
Increased Sweating
Heat Intolerance
Unexplained Weight Loss
Scant Menstrual Periods
Frequent Bowel Movements
Warm, Moist Palms
Fine Tremor of Fingers
May Include:





























TABLE1.MAJOR SYMPTOMS AND SIGNS OF HYPERTHYROIDISM AND OF GRAVES DISEASE AND CONDITIONS
ASSOCIATED WITH GRAVES DISEASE
5


Manifestations of hyperthyroidism
Symptoms
Hyperactivity, irritability, altered mood, insomnia
Heat intolerance, increased sweating
Palpitations
Fatigue, weakness
Dyspnea
Weight loss with increased appetite (weight gain
in 10 percent of patients)
Pruritus
Increased stool frequency
Thirst and polyuria
Oligomenorrhea or amenorrhea, loss of libido
Signs
Sinus tachycardia, atrial fibrillation
Fine tremor, hyperkinesis, hyperreflexia
Warm, moist skin
Palmar erythema, onycholysis
Hair loss
Muscle weakness and wasting
Congestive (high-output) heart failure, chorea, periodic
Paralysis (primarily in Asian men), psychosis*


























Manifestations of Graves disease
Diffuse goiter
Ophthalmopathy
A feeling of grittiness and discomfort in the eye
Retrobulbar pressure or pain
Eyelid lag or retraction
Periorbital edema, chemosis, scleral injection
Exophthalmos (proptosis)
Extraocular-muscle dysfunction
Exposure keratitis
Optic neuropathy
Localized dermopathy
Lymphoid hyperplasia
Thyroid acropachy

Conditions associated with Graves disease
Type 1 diabetes mellitus
Addisons disease
Vitiligo
Pernicious anemia
Alopecia areata
Myasthenia gravis
Celiac disease
Other autoimmune disorders associated with the HLA-DR3
Haplotype


Diagnosis
Diawali oleh kecurigaan klinis. Berdasarkan indeks
klinis Wayne and Newcastle yang didasarkan
anamnesis dan pemeriksaan klinis yang teliti.
Dilanjutkan dengan pemeriksaan penunjang untuk
konfirmasi diagnosis anatomis, status tiroid dan
etiologi
diagnosis
Untuk fungsi tiroid
diperiksa kadar hormon
beredar TT4, TT3,
dalam keadaan tertentu
sebaiknya fT4 dan fT3,
dan TSH
Untuk fase awal
penentuan diagnosis,
perlu T4, T3, dan TSH
Namun pada pemantauan
hanya T4 saja.
Investigations
Thyroid function test:
TSH- Undetectable
T4 - Raised
T3 - Raised
RAIU- Raised
TSH-receptor antibodies(TRAb)-elevated in Gravess
disease
Isotope scanning- Increased uptake
Treatment of Hyperthyroidism
Anti thyroid drugs
Beta blockers
MEDICAL
Sub total thyroidectomy
SURGICAL
Radio active iodine
Lugol's solution
IODINE
HYPERTHYROIDISM
Type title here
Anti thyroid drugs
Chemically block hormone synthesis
Enhance evolution to remission
Best indicated for children,adolescents,young adults
and pregnant women.
Propylthiouracil-100-150mg every 6or 8 hrs
Carbimazole- 40-60mg daily initially for 3 weeks,then
reduce to 20-40mg for another 8 weeks and
maintain at 5-20mg daily for 18-24 months.
Methimazole-active metabolite of Carbimazole
Duration of treatment
18-24 months
Side effects- Rash
Leukopenia
Agranulocytosis
Control of adrenergic symptoms
Adrenergic antagonists:
Propranolol-40-120mg/day
Ablative therapy(Surgery & Iodine)
Indications:
Relapse or recurrance following drug therapy
A large goiter
Failure to follow medical regimen.
Radioactive iodine is simple,effective and
economical
Complications of ablative therapy
Immediate complications of surgery:
Bleeding,injury to recurrant laryngeal nerve
and thyroid crises.
Other complications
Hypothyroidism
Radiation thyroiditis

Complications of thyrotoxicosis
1)Cardiac- Heart failure
Atrial fibrillation

2)Thyrotoxic crises: or storm:
Fulminating increase in signs and symptoms of
thyrotoxicosis.
Occurs in medically untreated or inadequately
treated patients.May be precipitated by surgery
or sepsis
The syndrome is characterized by extreme
irritability,delirium or coma,fever 41C or
more,tachycardia,restlessness,hypotension,vomiti
ng and diarrhea.
Treatment of thyroid crisis
Provide supportive care;
Treat dehydration
Administer glucose and saline
Vitamin B complex and glucocorticoids
Digitalization is required in those with atrial
fibrillation
Immediate and large doses of anti thyroid
agents(Eg-propylthiouracil 100mg every 2h)
Iodine intravenously or by mouth
Propranolol 40-80mg every 6h
Dexamethasone(2mg every 6h) and to be tapered
later.
Treatment of ophthalmopathy and
Dermopathy
Methylcellulose eye drops
Tinted glasses
Persistant diplopia can be corrected by surgery
Papilloedema,loss of visual field or acuity requires
urgent treatment with prednisolone 60 mg daily.
Majority of patients require no treatment other than
reassurance.
Dermopathy of Graves rarely requires treatment