Hypothyroidism

Dr. Farhana Yeasmin

Intern Doctor
Contents:

 Introduction
 Epidemiology
 Causes
 Clinical features
 Investigations
 Treatment
 Complications
 Prevention
Anatomy of Thyroid
Gland
Microscopic appearance of the thyroid gland
 Thyroid hormones:

[Link] (T4)

[Link]-iodothyronine (T3)

[Link]
Synthesis of Thyroid hormones

Thyroglobulin
Oxidation of
Iodide trapping formation and
iodide ion
secretion

Release of
Organification of
Thyroxine and
Thyroglobulin
Triiodothyronine
Functions of thyroid hormones:
Metabolic –  b. On fat :
  Increase-
a. On CHO :
 Increase- 1. Fatty acid mobilization
from the adipose tissue
1. Uptake of glucose by 2. Plasma FFA
cell
2. Glycolysis  Decrease –
3. Gluconeogenesis
4. Glucose absorption from 1. Plasma cholesterol,
GIT
triglyceride, phospholipid
5. Insulin secretion
Cont..
 On protein:  Increase BMR
 Increase synthesis of large
number of protein
enzymes, structural
proteins and transport  Body weight:
proteins.
 Increased
thyroid
hormone decreases body
weight and vice versa
Cont..
 Effect on CVS:  Effect on CNS:

 Increase-  Promotesnormal brain

1. Heart rate development
2. FOC
[Link] output  Effect on respiration:
4. Blood flow to tissue
 Mean pressure is normal  Increase rate and depth of
respiration
Cont..
 Effects on GIT:  Effect on growth:

 Increase-  Promotes normal growth

[Link] and food and skeletal development
intake
[Link] of GIT  Effect on muscle:
[Link] of digestive
juice  Promotes
protein
[Link] of CHO absorption
breakdown
Types of Thyroid
disease
Hypothyroidism:

Hypothyroidism is a disorder that occurs when the

thyroid gland does not make enough thyroid
hormone to meet the body’s need.
Women are affected approximately six times more
frequently than men.
Epidemiology:
Prevalence:
• A total of 289 individuals (95 males, 194 females)
aged between 10-77 years were studied and
thyroid dysfunction was found among 10.03% of
individuals ( males 8.42% and females 10.82%)
of them-
*sub-clinical hypothyroidism : 3.46%
*hypothyroidism : 3.80%
source: Bangladesh journal of medical science
Causes:
• Hashimoto’s thyroiditis
• Spontaneous atrophic hypothyroidism
Autoimmune • Graves’ disease with TSH receptor
blocking antibodies

• Radioactive iodine ablation

• Thyroidectomy
Iatrogenic • Drugs – carbimazole, methimazole,
propylthiouracil, amiodarone, lithium
Cont…
• Subacute (de Quervain’s) thyroiditis
Transient • Post-partum thyroiditis
thyroiditis
• In mountainous regions
Iodine
deficiency
• Dyshormogenesis
Congenital • Thyroid aplasia
Cont..

• Amyloidosis
• Riedel’s thyroiditis
Infiltrative • Sarcoidosis etc.

• TSH deficiency

Secondary
Hashimoto’s thyroiditis:
• Hashimoto’s thyroiditis (or ‘chronic autoimmune
thyroiditis’) is characterized by destructive
lymphocytic infiltration of the thyroid, ultimately
leading to a varying degree of fibrosis and
thyroid enlargement.
• It has atrophic and goitrous variants.
• Many present with a small or moderately sized
diffuse goitre
Cont..
• Which is characteristically firm or rubbery in consistency.
• Around 25% of patients are hypothyroid at presentation
• In the remainder, serum T4 is normal and TSH is normal or
raised, but they are at risk of developing overt
hypothyroidism in future
• Antithyroid peroxidase antibodies are present in the serum
in >90% of patients
Subacute (de Quervain’s) thyroiditis:
• In its classical painful form, subacute thyroiditis is a
transient inflammation of the thyroid gland occurring after
infection with Coxsackie, mumps or adenoviruses.
• The pain may radiate to the angle of jaw and ears, and is
made worse by swallowing, coughing and movement of the
neck.
Cont..
• Painless transient thyroiditis can also occur after viral
infection and in patients with underlying autoimmune
disease.
• Irrespective of the clinical presentation, inflammation in
the thyroid gland occurs
• And is associated with release of colloid and stored thyroid
hormones, but also with damage to follicular cells and
impaired synthesis of new thyroid hormones.
Cont..
• As a result, T4 and T3 levels are raised for 4-6 weeks until
preformed colloid is depleted.
• Thereafter, there is usually a period of hypothyroidism of
variable severity before the follicular cells recover
• And normal thyroid function is restored within

4-6 months
Post-partum thyroiditis:

• The maternal immune response, which is modified during

pregnancy to allow survival of the fetus, is enhanced after
delivery and may unmask previously unrecognized
subclinical autoimmune thyroid disease.
• Those affected are likely to have antithyroid peroxidase
antibodies in the serum in early pregnancy.
Iodine deficiency:
• Iodine is essential micronutrient and is a key component of
T4 and T3.
• WHO recommends a daily intake of iodine of 150mcg/day
for adult men and women;
• Higher levels are recommended in pregnancy as iodine
deficiency can cause cretinism.
Cont..
• Most affected patients are euthyroid with normal or
raised TSH levels
• Although hypothyroidism can occur with severe iodine
deficiency
• Suspected iodine deficiency can be assessed by
measuring iodine in urine(either a 24-hour collection or a
spot sample)
Amiodarone:

• The antiarrythmic agent amiodarone has a structure that is

analogous to that of T4 and contains huge amounts of
iodine.
• It also has a cytotoxic effect on thyroid follicular cells and
inhibits conversion of T4 to T3.
• Most patient receiving amiodarone have normal thyroid
function but upto 20% develop hypothyroidism or
thyrotoxicosis.
C/F:
Clinical features:

Symptoms-

[Link] gain
[Link] intolerance
[Link] , somnolence
[Link] skin
[Link] hair
[Link]
Cont..
Less common:
[Link]
[Link]
[Link] tunnel syndrome
[Link]
[Link]
[Link]
[Link] stiffness
[Link]
[Link]
Cont..
Signs:

[Link] gain

Less common

[Link] face
[Link] oedema
[Link] of lateral eyebrows
Cont..
[Link]
[Link]
[Link]
[Link] relaxation of reflexes
[Link]

Rare

[Link]
[Link] and pleural effusions
Investigations:
specific-
1)Serum TSH, free T4 & T3 levels
TSH T4 T3 Interpretation(s)

Mildly elevated Normal Normal Subclinical hypothyroidism

5-20mlU/L
Elevated >20mlU/L Low Low Primary hypothyroidism
Mildly elevated Low Low Primary/Secondary
5-20mlU/L hypothyroidism
Normal Low Low Secondary hypothyroidism
Undetectable Low Low Secondary hypothyroidism
Transient thyroiditis in
evolution
Undetectable or low Low Raised Over-treatment of
hypothyroidism with
liothyronine(T3)
Cont..
2) Thyroid peroxidase antibody

Non-specific
1)Serum enzymes:
- Raised creatine kinase(CK)
- Raised aspartate aminotransferase(AST)
- Raised lactate dehydrogenase(LDH)
Cont..
2)Plasma lipid profile- Hypercholesterolaemia
3)Hb% and PBF- Anaemia; normochromic normocytic or
macrocytic
4)Serum electrolyte- Hyponatremia
5)USG of the thyroid gland
6)ECG- sinus bradycardia with low voltage complexes and
ST-segment and T-wave abnormalities
Treatment:
• The goal of treatment is to normalize TSH, ideally in the lower
half of the reference range.

• Treatment is with Levothyroxine replacement.

• The average replacement dose of levothyroxine is

1.6mcg/kg(around 100mcg/day in a 70kg adult)

• In healthy younger adults it is safe to commence an estimated

full dose
Cont..
• In older individuals and those with a history of cardiovascular
disease, 50mcg/day should be given for 3weeks, before
increasing to estimated full dose

• Levothyroxine has a half-life of 7days and absorbed more in

fasting state, so it should be taken as a single daily dose
(usually in morning)
Cont..
• At least 10 weeks should pass before repeating thyroid function
tests (as TSH takes several weeks to reach a steady state) and
adjusting the dose.

• Patient feels better within 2-3 weeks

• It is important to measure thyroid function every 1-2 years once

the dose of levothyroxine is stabilized.
Dose adjustment of levothyroxine:
An approach to adult with suspected primary hypothyroidism :
Hypothyroidism in pregnancy:
• It rare during pregnancy
• If hypothyroidism occurs, probably it was present before
pregnancy (either known case or subclinical)
• Sometimes maybe difficult to diagnose as most of the symptoms
of pregnancy may simulate hypothyroidism.
• If there is any suspicion of hypothyroidism, diagnosis is
confirmed by clinical findings and thyroid function tests.
Cont..
• Complications of pregnancy with hypothyroidism-

• Prematurity
• Pre-eclampsia
• Abruptio placenta
• Abortion
• Still birth
• Congenital anomaly
• Postpartum haemorrhage
Cont..
• Treatment:

• Levothyroxine replacement therapy dose increased by

30-50% from early in pregnancy
• Monitoring to maintain TSH results within the
trimester-specific reference range is recommended in
early pregnancy and at least once in each trimester.
Consequence of prolonged hypothyroidism:

• Low pitched voice

• Poor hearing
• Slurred speech due to large tongue
• Carpal tunnel syndrome
• Myxedema (non-pitting)
Myxedema :
• The term myxedema indicates
severe hypothyroidism in which
there is accumulation of
hydrophilic mucopolysaccharides
in the ground substance of the
dermis and other tissues, leading to
thickening of facial features and
doughy induration of the skin.
Myxedema coma:
• This is a very rare presentation of hypothyroidism
• In which there is a depressed level of consciousness,
usually in older patient who appears myxoedematous.
• Body temperature maybe as low as 25°C
• Convulsions are common
• CSF pressure and protein content are raised
• The mortality rate is 50%.
Cont..
• Myxoedema coma is a medical emergency
• And treatment must begin before biochemical
confirmation of the diagnosis.
• Suspected case should be treated with an intravenous
injection levothyroxine of 20mcg 3 times daily until
there is sustained clinical improvement
Cont..

• In survivors, there is rise in body temperature within 24 hours

and, after 48-72 hours, it is usually possible to switch to oral
levothyroxine in a dose of 50mcg daily.
• Unless it is apparent that the patient has primary
hypothyroidism, the thyroid failure should also be assured to
be secondary to hypothalamic or pituitary disease and
treatment with hydrocortisone 100mg IM 3 times daily
pending the results of
Cont..
• T4 , TSH and cortisol measurement.
• Other measure include slow rewarming, cautious use of
intravenous fluids, broad-spectrum antibiotics and high-flow
oxygen.
Bibliography:

• Davidson’s principles and practice of medicine

24th edition
• Guyton and Hall textbook of medical physiology 14th
edition
• Short cases in clinical medicine 6th edition(ABM
Abdullah sir)
THANK YOU