Slide 1:In the Name of God, Most Gracious, Most Merciful


Slide 2:GREETINGS FROM THE DEPT. OF MEDICINE


Slide 4:The history of man…


Slide 5:… is plagued by disease


Slide 6:Today … We discuss …


Slide 7:THYROID DISORDERS


Slide 8:THYROTOXICOSIS


Slide 9:MYXOEDEMA


Slide 10:CRETINISM


Slide 11:MEDICAL EMERGENCIES


Slide 12:THYROID DISEASE COMPLICATING PREGNANCY


Slide 13:5 % OF THE WORLD POPULATION SUFFERS FROM THYROID DISEASE


Slide 14:CONGENITAL HYPOTHYRIODISM IS ONE OF THE MOST COMMON CAUSES OF PREVENTABLE MENTAL RETARDATION WORLD-WIDE


Slide 15:20 MILLION PEOPLE IN THE WORLD HAVE VARIOUS DEGREES OF BRAIN DAMAGE CAUSED BY IODINE DEFICIENCY IN UTERO


Slide 16:MEDICAL MANAGEMENT OF THYROID DISEASE By- MOHAMMAD SADIQ III YR. M.B.B.S. M.M.C.R.I.


Slide 17:THYROID DISORDERS The conditions we will deal with here are: Thyrotoxicosis Hypothyroidism Medical Emergencies > Myxoedema coma > Thyrotoxic crisis Congenital Hypothyroidism (Cretinism) Thyroid Disease complicating pregnancy


Slide 18:THYROID DISORDERS MEDICAL MANAGEMENT Proper Clinical Diagnosis Laboratory Evaluation Treatment Monitoring of patient Proper management is based upon:


Slide 19:THYROTOXICOSIS INTRODUCTION “Defined as the state of thyroid hormone excess & is not synonymous with hyperthyroidism which is the result of excessive thyroid function”


Slide 20:HYPOTHYROIDISM ETIOPATHOGENESIS Iodine deficiency remains the leading cause World-wide. In areas of iodine sufficiency the causes are: Hashimoto’s thyroiditis Spontaneous Atrophic thyroiditis Iatrogenic causes


Slide 21:HYPOTHYROIDISM PRESENTING COMPLAINT HASHIMOTO’S THYROIDITIS: Symptoms of Goitre more than that of Hypothyroidism. ATROPHIC THYROIDITIS: Symptoms of Hypothyroidism more than that of Goitre


Slide 22:HYPOTHYROIDISM QUEEN ANNE’S SIGN MYXOEDEMA FACIES


Slide 23:THYROID DISEASE CLINICAL PRESENTATION Cardinal Features HYPERTHYROIDISM: Presents with warm, moist skin ? sweating, Heat intolerance Von Muller’s Paradox HYPOTHYROIDISM: Presents with tiredness, weakness Myxoedema Dry coarse skin, Cool peripheral extremities Cold intolerance


Slide 24:THYROID DISEASE CLINICAL PRESENTATION Dept. of General Medicine HYPERTHYROIDISM: Diabetes Mellitus Palpitations Diarrhoea Eyes: Stellwag’s sign Fatigue & wt. loss (Elderly patients) HYPOTHYROIDISM: Pleural Effusion Pericardial Effusion Constipation Carpal Tunnel Syndrome Bradycardia Peripheral edema Hoarse voice (phone diag)


Slide 25:THYROID DISEASE GI PRESENTATION Transit time leads to diarrhoea in thyrotoxicosis


Slide 26:THYROID DISEASE Dept. of Dermatology HYPERTHYROIDISM: Pretibial myxoedema Thyroid acropachy HYPOTHYROIDISM: Diffuse alopaecia Pretibial Myxoedema


Slide 27:THYROID DISEASE CLINICAL PRESENTATION Dept. of Neurology HYPERTHYROIDISM: Fine tremor Hyperreflexia Muscle wasting Proximal myopathy Hypokalemic periodic paralysis HYPOTHYROIDISM: Paraesthesia Pseudomyoclonus Delayed tendon reflexes Difficulty in concentration Poor memory


Slide 28:THYROID DISEASE Dept. of OBG HYPERTHYROIDISM: Oligomenorrhoea HYPOTHYROIDISM: Menorrhagia


Slide 29:THYROID DISEASE


Slide 30:THYROTOXICOSIS CVS MANIFESTATION C/F: Palpitations Sinus Tachycardia Bounding pulse Widened pulse pressure Aortic Systolic Murmur Worsening of Angina Atrial Fibrillation (>50yrs)


Slide 31:THYROTOXICOSIS MANAGEMENT OF ATRIAL FIBRILLATION VR responds little to Digoxin. Good response to addition of ? - blockers. CARDIOVERSION to revert to sinus rhythm. (Only after TSH/T4 ? ) Anti coagulation with Warfarin / Aspirin. Generally control of serum T4 causes a return to sinus rhythm. Drugs provide symptomatic relief.


Slide 32:THYROTOXICOSIS GRAVES’ OPTHALMOPATHY Gritty sensation, Discomfort, ? lacrymation Exopthalmous Periorbital oedema, Chemosis, Scleral injection


Slide 33:THYROTOXICOSIS MANAGEMENT - GRAVES’ OPTHALMOPATHY Reassurance Methyl cellulose drops ? ? grittiness, discomfort Tinted glasses / Side shields ? ? excess lacrymation Complications: Corneal Ulcer: Lid lengthening Sx Papilloedema/Loss of acuity/Field defects: URGENT trt. with PREDNISOLONE 60mg/d


Slide 34:GRAVES’ OPTHALMOPATHY EFFECT OF THERAPY BEFORE AFTER


Slide 35:THYROTOXICOSIS MANAGEMENT


Slide 36:THYROTOXICOSIS MEDICAL MANAGEMENT 1. ANTITHYROID DRUGS: > Carbimazole > Propyl thiouracil Dosage of Carbimazole: 0-3 weeks ? 40-60 mg daily 4-8 weeks ? 20-40 mg daily Maintainence ? 5-20 mg daily for 18-24 months ADR: Rash, Agranulocytosis C/I: Lactating Mothers


Slide 37:THYROTOXICOSIS MEDICAL MANAGEMENT 2. RADIOACTIVE I131 : MOA: > Destroys functioning thyroid cells > Inhibits their ability to replicate Dose: 180-370 MBq (5-10mCi) orally (Dep. on goitre size) 4-6 weeks to be effective (long lag period) ?-blockers control symptoms in lag period. Severe cases: Carbimazole within 48 hrs of I131


Slide 38:THYROTOXICOSIS MEDICAL MANAGEMENT 3. Role of ?-blockers: ONLY SYMPTOMATIC RELIEF (within 12-24 h) Propronolol: 160 mg/day Nadolol: 40-80 mg/day T3 toxicosis : I131(555-110Mbq), Hemithyroidectomy


Slide 39:THYROTOXICOSIS EFFECT OF TREATMENT BEFORE AFTER


Slide 40:THYROTOXICOSIS EFFECT OF TREATMENT BEFORE AFTER


Slide 41:THYROTOXICOSIS SPECIAL CASES PENDRED’S SYNDROME: Dyshormonogenesis (?T4) + Deafness 1. HAMBURGER THYROTOXICOSIS 2.


Slide 42:HYPOTHYROIDISM MEDICAL MANAGEMENT Life long therapy with Levothyroxine (T4) is the sheet anchor Start slowly with 50?g/day OD – 3 weeks Then ? to 100?g/day OD – 3 weeks Finally ? to 150?g/day OD Hypothyroidism following Grave’s Disease ? 75-125?g/day OD Improvement takes 2-3 weeks


Slide 43:HYPOTHYROIDISM MEDICAL MANAGEMENT RATIONALE IN USING T4 IN HASHIMOTO’S: Treatment of Hypothyroidism Goitre shrinkage T4 vs. T3 – Why T4? T3 in high doses causes: Angina Arrythmias Heart Failure


Slide 44:HYPOTHYROIDISM MONITORING THERAPY Correct dose of drug: Restores serum TSH to lower part of reference range when T4 is ? / slightly ?. Advise & reinforce need for regular medication. TFT screening every 1-2 years. ? T4 & ? TSH - ?


Slide 45:HYPOTHYROIDISM EFFECT OF TREATMENT BEFORE AFTER


Slide 46:HYPOTHYROIDISM EFFECT OF TREATMENT BEFORE AFTER


Slide 47:THYROID DISORDERS INVESTIGATIONS


Slide 48:MEDICAL EMERGENCIES HYPERTHYROID CRISIS (= Thyrotoxic crisis / Thyroid storm) MYXOEDEMA COMA 2 Situations :


Slide 49:HYPERTHYROID CRISIS


Slide 50:HYPERTHYROID CRISIS MANAGEMENT Rehydrated Broad spectrum antibiotic Propronolol 80 mg 6th hrly orally / 1-5 mg 6th hrly i.v. Large doses of Propyl thiouracil 600 mg loading dose & 200-300 mg every 6 hrs orally/NGT/PR is the DOC. Stable Iodine 1 hr later. Saturated sol of KI / Na iopodate 500 mg/d orally restores normal levels of T3 within 48-72 hrs. Others: Glucocorticoids, Cooling, Oxygen


Slide 51:MYXOEDEMA COMA CLINICAL PICTURE ? level of consciousness usually in an elderly patient who appears myxoematous Body temperature as low as 25oC Convulsions CSF pressure & proteins ? Mortality rate around 50% (EARLY DETECTION is essential)


Slide 52:MYXOEDEMA COMA MANAGEMENT TREATMENT must begin IMMEDIATELY Triiodothyronine i.v. bolus 20?g followed by 20?g 8th hourly till there is sustained clinical improvement. Liothyronine (T3) i.v. / NGT 10-25 ?g 8-12th hourly (v. rapid) T3 (25?g) + T4 (200?g) as a single initial i.v. bolus followed by daily trt. with Levothyroxine 50-100 ?g 8th hrly. Others: Slow rewarming (if <30oC), Cautious use of i.v. fluids, Broad Spectrum antibiotics, High flow oxygen, Assisted ventilation


Slide 53:CRETINISM “Children who are hypothyroid from birth / before are called cretins.” WHO IS A CRETIN? “What should have been an angel of God has been a pariah of nature just for the want of a little iodine in mother’s blood.”


Slide 54:CRETINISM GUESS MY AGE? 22 yr. old female Pot belly Umbilical hernia Coarse facial features Supra clavicular pad of fat


Slide 55:CRETINISM GUESS MY AGE? 17 yr. old female Congenital hypothyroidism Large ears Enlarged protruded tongue Wide set eyes Depressed nasal bridge Short limbs Estim. bone age : 9 months


Slide 56:CRETINISM RADIOLOGICAL PICTURE


Slide 57:CRETINISM MANAGEMENT Monitoring of thyroid status of mother is important If mother is… Euthyroid Dev. normal until birth Manifests at birth Treatment started at birth has good prognosis Hypothyroid Iodine def. is commonest cause MR is more severe Less responsive to trt. Deaf mutism & rigidity + Intake of iodised salt has ? this


Slide 58:CRETINISM TREATMENT Sodium Levothyroxine 100?g tab is the DOC Dose: Neonates: 10-15 ?g/kg/day Older children: 4-8 ?g/kg/day Neonates & Children < 1yr.: INITIATE trt. on DIAGNOSIS DON’T WAIT for INVESTIGATIONS


Slide 59:CRETINISM MONITORING Assess Clinical Milestones Periodic TFT Radiological estimation of bone age annually Antenatal screening: > Regular TFT – mother > Foetus USG


Slide 60:THYROID DISEASE COMPLICATING PREGNANCY HYPERTHYROIDISM HYPOTHYROIDISM


Slide 61:THYROID DISEASE COMPLICATING PREGNANCY HYPERTHYROIDISM - MANAGEMENT Carbimazole is the drug used Crosses placenta and also treats foetus Imp to use the smallest dose possible Review every 4 weeks Discontinue Carbimazole 4 weeks before EDD If Hyperthyroid mother wants to feed? Radioactive Iodine is C/I


Slide 62:THYROID DISEASE COMPLICATING PREGNANCY HYPOTHYROIDISM - MANAGEMENT Why treat? On the basis of serum TSH measurements most pregnant women with primary hypothyroidism require an additional 50?g thyroxine to their usual dose ( TBG ? in pregnancy).


Slide 63:MEDICAL MANAGEMENT OF THYROID DISORDERS CONCLUSION Thyroid disease may have a variable clinical presentation. Hence, it is very essential to have a high degree of caution before declaring a patient euthyroid. It is better to do a TFT in all suspected cases. The cost of the TFT is noting compared to the dire consequences of a missed diagnosis. Treatment must be started immediately in all suspected cases of thyroid storm/myxoedema coma/cretinism as a delay in treatment might be fatal to the patient or may land the child in permanent mental retardation.


Slide 64:THANK YOU