HYPOTHYROIDISM

HYPOTHYROIDISM

Etiology
• Primary
Hashimoto thyroiditis, Radio active iodine
therapy for Graves’ disease, Subtotal
thyroidectomy, Subacute thyroiditis, Iodide
deficiency
• Secondary
Pituitary adenoma, pan hypopituitarism
• Tertiary
Hypothalamic disfunction (rare)
 HYPOTIROIDISM
Clinical finding
• Incidence : Various causes depending geographic &
enviromental factors
• Hashimoto thyroiditis the most common cause of
hypothyroidism
• Newborn infants (Cretinism)
• Fatigue, coldness, weight gain, constipation, menstrual
irregularities, muscle cramps
 HYPOTHYROIDISM
Physical findings:
Cool,rough, dry skin, puffy face and hands, hoarse
voice, slow reflexes
Cardiovascular sign : bradycardia, diminished CO,
low voltage QRS, cardiac enlargement
Pulmonary function : Respiratory failure
Intestinal paralysis: slowed , chronic constipation,
ileus
Renal function : Decresed GFR, renal impairement
Anemia, Severe muscle cramp, parestesias, muscle
weaknes
CNS symptoms: fatigue, inability to concentrate
 Pituitary- thyroid relationships in primary
hypothyroidism
TRH Hypothalamus : tertiary
TRH

TSH Pituitary : secondary

Tissues TSH

T3, T4

THYROID

Destroyed of thyroid gland

Thyroid : primary
 Complication
• Myxedema coma  end stage of untreated
hypothyroidism, cause by radiotherapy in Graves’
Disease
• Myxedema & Heart disease  CAD
• Hypothyroidism Neuropsychiatric disease 
depression, confuse, paranoid, manic
 Treatment Hypothyroidism
• Levothyroxine (T4), not liothyronine (T3) because rapid
absorption, short half life, transient effect. Dosis T4, 1X in the
morning to avoid insomnia 0.05 mg-0.2 mg/d

• Mixedema coma ICU, intubation & mechanical ventilation,

Treat infection, heart failure, IV drips with caution,
levothyroxin IV
EXAMPLES OF THYROID DISEASES

1° Hypothyroidism Hyperthyroidism
www.hsc.missouri.edu/~daveg/thyroid/thy_dis.html
 Complication
• Myxedema coma  end stage of
untreated hypothyroidism, Cause
Radiotherapy in Graves’ Disease
• Myxedema & Heart disease  CAD
• Hypothyroidism Neuropsychiatric
disease  depression, confuse,
paranoid, manic
 Definition
• Thyroiditis  heterogenous group of
inflamatory disorders the thyroid gland
• Etiologies range from autoimmune to
infectious origins
• Clinical course  Acute, subacute, or
chronic. Can be euthyroid, transient phase
thyrotoxicosis and / or hypothyroidism.
Painless or painfull
 Classification of thyroiditis
I. Autoimmune thyroiditis
Chronic autoimune thyroiditis
Hashimoto’s thyroiditis
Atrophic thyroiditis
Focal thyroiditis
Juvenile thyroiditis
Silent thyroiditis / Postpartum thyroiditis
II. Subacute thyroiditis
III. Acute suppurative thyroiditis
IV. Riedel’s thyroiditis
 Classification of thyroiditis
Hystologic classification Synonims
Chronic lymphocytic Chronic lymphocytic thyroiditis,
Hashimoto’s thyroiditis
Subacut lymphocytic thyroiditis,
Subacute lymphocytic Postpartum thyroiditis,
Granulomatous Sporadic painless thyroiditis
Subacut granulomatous thyroiditis
De Quervains thyroiditis
Suppurative thyroiditis
Microbial inflamatory Acut thyroiditis
Riedel’s struma
Invasive fibrosis Riedel’s thyroiditis
Terminology for Thyroiditis.

Type Synonim
Hashimoto’s thyroiditis Chronic lymphocytic thyroiditis
Chronic autoimmune thyroiditis
Lymphadenoid goiter
Painlesspostpartum thyroiditis Postpartum thyroiditis
Subacute lymphocytic thyroiditis
Painless sporadic thyroiditis Silent sporadic thyroiditis
Subacute lymphocytic thyroiditis
Painful subacute thyroiditis Subacute thyroiditis
de Quervain’s thyroiditis
Giant-cell thyroiditis
Subacute granulomatous
thyroiditis
Pseudogranulomatous thyroiditis
Terminology for Thyroiditis.

Type Synonim
Suppurative thyroiditis Infectious thyroiditis
Acute suppurative thyroiditis
Pyogenic thyroiditis
Bacterial thyroiditis
Drug-induced thyroiditis -
(amiodarone, lithium, interferon
alfa, interleukin-2)
Riedel’s thyroiditis Fibrous thyroiditis
 Hashimoto’s thyroiditis
(Chronic thyroiditis)
Hakaru Hashimoto (1912)  4
patients chronic disorder of the
thyroid diffuse lymphocytic
infiltration, fibrosis, parenchymal
atrophy, and eosinophilic change in
some acinar cells

Dr Hakaru Hashimoto
 Hashimoto’s thyroiditis
Hashimoto thyroiditis
is the most common
cause of hypothyroidism
& goiter
in the United States
Statosky J et al. Am Acad of Family physicians 2000;61:1054
 Hashimoto’s thyroiditis
Etiology & pathogenesis
HT is immunologic disorder which
lymphocytes become sensitized to thyroidal
antigens and autoantibodies are performed.
Thyroid antibodies in HT are:
1. Thyroglobulin antibody (Tg Ab)
2. Thyroid peroxidase antibody (TPO Ab) =
( Microsomal antibody)
3. TSH Receptor blocking antibody ( TSH - R
Ab block)
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 Manifestation
Hashimoto’s Thyroiditis

Symptom & Signs

HT usually presents with
goiter , euthyroid or mild
hypothyroidism.
Sex distribution : F/M 4:1
Painless & patients may be
anware of the goiter
 Laboratory findings

• T4 N/ low, TSH will be elevated.

RAIU may be high, normal or
low
• Tg Ab & TPO Ab positif
• Fine needle aspiration biopsy
 large infiltration
lymphocytes  Hurttle cells
Diagnostic procedures
• Test of thyroid autoimmunity:
TPOAb  95% + in HT & 90% Atrophic
thyroiditis
TgAb  less frequently +
Diagnostic specificity of thyroid
antibody tests is not absolute.
• Test for thyroid function TSH, fT4
• RAIU : normal, low or high.
• USG : diffusely reduced echogenecity
• FNAB not necessary,excep. rapidly
enlarging goiter
Diagnosis of Hashimoto’s thyroiditis
Diffuse goiter
Anti microsomal (or TPO) antibody
Anti-thyroglobulin antibody Positive

Sign symptom of
hypothyroidism
Hashimoto’s
Negative thyroiditis

US Biopsy Positive
*Simple goiter,
adenomatous goiter etc

Negative Other diseases*

Treatment Hashimoto’s
thyroiditis
 Treatment
• Goiter small & asymptomatic not
require therapy
• Levo-thyroxine is given over
hypothyroidism to supress TSH &
decreased serum thyroid antibody.
Levo-thyroxine in euthyroid, still
controversial
 Treatment
• Corticosteroids : regression pain,
reduction in size of the goiter,
thyroid antibody, not
recommended in benign disease.
• Surgery indicated pain, cosmetic,
or pressure symptoms after
levothyroxine and corticosteroid
therapy.
 Riedel’s thyroiditis
• Rare 1,06/100.000, middle age or elderly
women
• Etiology unknown (autoimmune
process or primary fibrotic disorder)
• Characterized  fibrosis replaces
normal thyroid parenchyma,1/3 cases
multifocal fibrosclerosis
 Riedel’s thyroiditis

• Thyroid fibrosis (stony hard,woody),

painless, progressive anterior neck mass,
• Generalized fibrosing (1/3 patients), pressure
symptoms  laryngeal nerve paralysis or
hypoparathyroidism (rare)
• Usually euthyroidism, hypothyroidism (30%)
• Laboratorium : non spesific
• USG/CT-Scan inconclusive
• Difinitive diagnosis  open Biopsy
 Riedel’s thyroiditis
• Treatment:
Corticosteroids  medical treatment of choice
Tamoxipen, methotrexate  inhibitor fibroblast
proliferation ( early stages)
Levothyroxine  hypothyroidism
Surgical care  diagnosis, relieving tracheal
compression
• Mortality  asphyxia (6-10%), extrathyroidal
fibrotic lesions may complicate the prognosis
 Subacute thyroiditis
• Cause unknown ( viral infection
(?) preceded URT infection,
coincidence viral disease (mumps,
measles, Echo virus, adeno virus,
epst. Barr virus, influenza)
• Women : Men (3-5:1)
• Onset: 20-60 yr
• Summer
 Subacute thyroiditis
• Palpation thyroid: enlarged, asymetrical,
nodul, firm, tender & painful.
• Thyrotoxicosis during inflamatory phase
 euthyroidism hypothyroidism
euthyroidism (4th phases)
• Laboratorium: ESR increase, leukocyt N/
increase, fT4,,TSH, RAIU
• Recovery 4-6 months, spontaneous
remitting
 Changes in serum T4 & Radiactive iodine uptake in
patients with subacute Thyroiditis 24-hour
T4 131 I
ug/dL uptake %

20 T4 40

15 30

10 20

5 10

0 131 I 0
Phase : Hyper Eu Hypo Eu
Weeks: 1 4 11 -
Woolf PD, Daly R :Am J Med 197;60:73
Laboratory findings during different phases of subacute thyroiditis

Phase T4 &/T3 Level TSH level RAIU value

Thyrotoxicosis High Low <5%

Hypothyroid Low Normal,or high Normal to high

Recovery Normal High to normal High to normal

 Treatment Subacute
thyroiditis
• Symptomatic: Acetaminophen 4X 0,5g, NSAID or
glucocorticoid (prednison 3 X 20 mg (7-10 days)
• Betablockers  symptoms of thyrotoxicosis
• L-thyroxine 0.1-0.15 mg /daily  hypothyroid
phase. Long-term L-thyroxine  permanent
hypothyroidism (10%)
• Antibioticsno value
• Thyroidectomy  rarely
 Clinical Differentiating of the Subtype Thyroiditis

NECK PAIN

YES N0

RAIU PRESENTING SYMPTOMS

INCREASED DECREASED HYPERTHYROIDISM HYPOTHYROIDISM

CHRONIC
MICROBIAL SUBACUTE RAIU LYMPHOCYTIC
INFLAMMATORY GRANULOMATOUS THYROIDITIS
THYROIDITIS THYROIDITIS

GRAVES DISEASE SUBACUT

LYMPHOCYTIC
THYROIDITIS

Statosky J et al. Am Acad of Family physicians 2000;61:1054

 Acute suppurative thyroiditis
• Rare, serious, bacterial inflamatory
disease, children, 20-40 yr, sex ratio
1:1
• Etiologi: Infectious: Staph. aureus,
strep.pyogenes, strep. pneumonia,
esch.coli, pseudomonas aeruginosa
• Infection by hematogenous, direct
trauma
 Acute suppurative thyroiditis

Symptoms and Signs :

• Neck pain, warm, tenderness, the
neck unable to extend
• Dysphagia, dysphonia, referred to
ear, mandibula, lymphadenopathy
• Systemic manifestation: fever,
chills, tachycardia, malaise
• Palpation: unilateral, erythematous
 Acute suppurative thyroiditis

• Thyroid function : Euthyroidism

• Laboratorium : TPO antibodies
absent, ESR high, PMN leukocytosis
• 24-hour 123I uptake normal
• FNA Biopsy : purulent material
• Treatment : antibiotics or
surgical drainage
 Chronic-pyogenic thyroiditis
Etiology :
• Salmonellatyphosa, syphilis,
tuberculosis, echinococcus,
actinomyces
Symptoms : Suppurative, non
suppurative
Treatment : antibiotic, drainage
Thyroid nodules &

Thyroid cancer
Thyroid nodules - prevalence
• Thyroid nodules common, increase
with age

• 30-60% of thyroids have nodules at

autopsy

• Palpation: 5-20% (>1cm)

• U/S: 15-50% (>2mm)

 Diagnostic approach
• Fine Needle Aspiration (FNA)
10-20% risk of suspicious cytology, therefore 
thyroid surgery
95% of histology will be benign, and surgery
“unnecessary
• Isotop Scann(CT)
rarely used for evaluation  80% of
nodules are “cold”
small cold nodules may be missed
• Ultrasonography (USG)
Diagnostic approach - ultrasound
Identifies solid v. cystic nodules

Identifies MNG

May aid FNA

Does not exclude malignancy

Diagnostic approach - other tests

Calcitonin
very high results diagnostic for MTC
risk of borderline false positives
not for routine use
Thyroglobulin
not helpful for exclusion of carcinoma :
overlap with benign disease
best for follow-up after thyroidectomy
Thyroid nodules & Thyroid cancer
• In 95% of cases , thyroid cancer
presents as a nodule or lump in the
thyroid nodul thyroid.
• Thyroid nodule  extremely
common, particularly women.
Prevelance in USA 4% in adult
population. F:M ratio 4:1.
• Thyroid cancer  rare. Incidence
0.004% per year
 Differentiation benign & Malignant lesions

• History : Family history of goiter suggests benign disease,

endemic goiter
• Physical characteristics:
Benign : older age, woman, soft nodule, multi nodular goiter.
Malignant : Children, young, male, solitary, firm nodule, vocal
cord paralysis, firm lymph nodes, distant metastasis
Differentiation benign & Malignant lesions

• Serum factors :
Benign : high titer of antibody
Malignant : calcitonin
• Scanning :
Benign: Hot nodule
Malignant: Cold nodule
• Biopsy (needle)
 Malignant thyroid
Carcinoma
• Papillary Carcinoma 75 %
• Folliculare Carcinoma 16 %
• Medullary Carcinoma 5%
• Anaplastic Carcinoma 3%
• Lymphoma 5 -10 %
 Thyroid nodule

Echography
Scan

Cold Hot

Low TSH
Normal TSH

Echography Follow-up 131

I /surgery

Cystic Solid Mixed

Evacuation
FNAC

Benign Malignant Suspecious

L-T4
Follow up Surgery
Management of the solitary nodule
Tru e s olitary n od u le?

No Y es

FNAC

B en ig n M alig n an t In d eterm in ate F ollic u lar

W atc h ? S u rg ery R ep eat F N A C S u rg ery

In d eterm in ate

S u rg ery
 Treatment
• Thyroidectomi
• Jodium 131Radioactive
• Thyroxine supression
 FNA POSITIF
MALIGNANCY

Differenteated Undifferenteated
Over 2cm, or
Under 2cm, no invasion multicentric, or invasive
Local removal to prevent
obstruction (palliative
Lobectomy and Near total thyroidectomy and therapy)
isthmusectomy modified neck dissection
X-ray therapy or
Levothyroxine for life Liothyronine, 75-100 chemotherapy (or both)
mcg/d for 3 mos, plus levothyroxine
discontinue 2 week. replacement therapy
Low iodine diet

Scan with 2-5 mCi 131 I Repeat after 12 months

Negatitive scan Positive scan

Levothyroxine for 50-150 mCi131 I (therapeutic dose)

life

No recurence X Ray therapy or chemo therapy (or both)

Recurrence + - Scan
cure
Treatment of thyroid cancer
• Papillary cancer
– < 1.5 cms Lobectomy & isthmusectomy
– > 1.5 cms Total thyroidectomy

• Follicular cancer Total thyroidectomy

• Hurthle Total thyroidectomy

• Medullary Total thyroidectomy & central neck

dissection