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Hipertiroid
Hipertiroid
Thyroid
cartilago
Pyramidal
lobe
Left lobe
Isthmus
Right lobe
Internal
jugular vein
External
carored
arteri
THYROID GLAND HISTOLOGY
http://arbl.cvmbs.colostate.edu/hbooks/pathphys/endocrine/thyroid/anatomy.html
Thyroid hormone synthesis, storage and release
TRAPPING ORGANIFICATION
I I PEROXIDASE
OXIDIZED
H2O2 IODIDE MIT DIT T3
TGB TGB
COUPLING STORAGE
Tyrosine?
Tyr Tyr
DIT DIT T4
Iodinase
AA TGB TGB TGB
Tyrosine
RELEASE TGB
PROTEOLYSIS
T3 T T3 --
Protease
3T TGB
T4
4 T4 --
TGB
CAPILLARY FOLLICULAR CELL
COLLOID Cryer PE. Diagnostic endocrinology 1976:35
HYPOTHALAMUS
Basic elements in TRH
regulation of thyroid
function
T3
PORTAL SYSTEM
I
ANTERIOR
PITUITARY
T4
+
“FREE” T3 _ TSH
T4 T3
TISSUE
I +
THYROID
T4
Usually Complain thyroid
disease
• Thyroid enlargement which
may be diffuse or nodular
• Symptom of thyroid deficiency
or Hypothyroidism
• Symptoms of thyroid hormon
excess, or Hyperthyroidism
Usually Complain thyroid
disease
Complications of a Spesific form
hyperthyroidism : Graves’ disease
which may present which prominence
of the eyes or exophthalmos and
thickening of the skin over the lower
legs (rare) or thyroid dermopathy
Physical Examination
• Inspection : Good light coming
from behind the examiner, The
patient is instructed to swallow a
sip of water, Observe the gland as
it moves up and down.
Enlargement and nodularity can
often be noted.
Physical Examination
• Palpate the gland from
behind the patient with the
middle threes fingers on
each lobe while the patients
swallows. Nodules can be
measured in a similar way.
Physical Examination
• On physical examination the normal
thyroid gland about 2cm in vertical
dimension and about 1cm in horizontal
dimention above the isthmus
• Enlarged thyroid gland is called Goiter
• The generalized enlargement is termed
diffuse goiter, irreguler or lumpy
enlargement is called nodular goiter
THYROID DISEASES
HYPERTHYROIDISM
HYPOTHYROIDISM
THYROIDITIS
THYROID NODUL
THYROID DYSFUNCTION PREVALENCE
• Hypothyroidism 2%
• Sublinical hypothyroidism 5-7 %
• Hyperthyroidism 0,2 %
• Subclinical hyperthyroidism 0,1-6,0%
Hyperthyroidism & Thyrotoxicosis
• GD is currently viewed as an
autoimmun disease of unknown cause
• Ther is a strong familial predisposition
in that about 15%. 50% GD have
circulating thyroid autoantibodies
• Peak incidence 20-40-year
• T-lymphocytes sensitized to antigen
within thyroid gland and stimulate B
lymphocyte antibodies
Autoimmune thyroiditis
Agonist Antagonist
TSHR-Ab Antibody Antibody
TSHR
CELL CELL
STIMULATION BLOCKADE
Davies TR. Graves’ disease in Werner & Ingbar’s : The thyroid ; 2000 ;520
Clinical features
Graves’s disease
• Symptoms: in younger patients: palpitation,
nervousness, easy fatigability, hyperkinesia,
diarhhea, excessive sweating, intolerance to
heat, weight loss, without loss appetite
• Signs: Thyroid enlargement, exophthalmos,
tachycardia, muscle weakness, tremor
Older patients cardiovascular & myopatic
predominate clinical manifestation
palpitatation, dyspnea on exersice, tremor,
nervousness, weight loss
Ophtamopathy Graves disease
• Infitratif sympathetic overstimulation
Lid retraction (Dalrymphe’s sign)
Van Graves sign late palpebra sup
Stellwat’s sign the wink eyes late
Jefroy’s sign fold of forehead not see
Mobius’sign convergention of the eyes late
• Infiltratif autoimmune
Exophthalmus, oculopathy congestif: cheimosis,
conjunctivitis, periorbital edema
Ulcerasi Cornea , neuritis optica, atrophi n
opticus
DISEASE SEVERITY
MILD disease
MODERATE disease
SEVERE disease
MILD DISEASE
Thyroid myopathy
asymmetric involvement
TSH &FT4
• Apethetic hyperthyroidism:
Older patients: weight loss,
small goiter, slow AF, severe
depression with none clinical
features
Treatment modalities
• Anti-thyroid
• Surgery
• I131 radioactive
Treatment of Graves’ Disease
1. Antithyroid drug therapy:
Young pts, small glands, mild disease
Propylthiouracil, methimazole (6m-15 mo),
relaps 50-60%.
PTU inhibits the conversion T4T3, effect
more quickly compare to methimazole
Methimazole - longer duration, single dose
Therapy 3-6 months tapering dose and
combination levothyroxin 0.1 mg/d 12-24
months
Allergic reaction (rash), agranulocytosis,
jaundice, liver failure
Treatment of Graves’ diseae
• Surgical treatment
Subtotal thyroidectomy treatment of
choice for very large glands, or
multinodular goiter, prepared wth anti
thyroid drug (about 6 months)
Complication :
Hypothyroidism,recurent laryngeal
nerve injury
Treatment of Graves’ disease
• Radioactive
iodine therapy
USA NaI 131I
euthyroid over 6-
12 weeks
Complication:
hypothyroidism
Treatment of Graves’ disease
• Other medical measures:
Beta-adrenergic blocking agents
Propranolol 10-40 mg every 6
hours, multivitamin supplements,
phenobarbital as sedative + to
lower T4 levels
Cholestyramine, 4 gr orally 3X
daily lower T4
Complication of Graves’
Disease
Thyrotoxic crisis (thyroid storm)
Acute exacerbation symptoms thyrotoxicosis.
May be mild & febrile until life threatning.
Clinical manifestation:
Fever, Sweating, flushing, tachycardia
/ AF, heart failure, agitation, delirium,
coma, jaundice, nausea, vomiting and
diarrhea.
75% death………….
Treatment of Thyrotoxic crisis
(“thyroid storm”)
• Prophiltriourasil (PTU): 4 x 300 mg atau
• Neomercazole 6 x 20 mg.
• Yodium : Sodium yodida IV 1 mg/12 jam,
atau lugol 5% 3x10 tts /hr
• Propranolol (Inderal): IV 1-5 mg/6jam, atau
tab 4x60-80 mg/hr via sonde lambung
• Kortikosteroid: Dexamethason 2 mg/6 jam
• Antibiotik dianjurkan jika infeksi sebagai
pencetus.