Disorder of thyroid gland - HYPERTHYROIDISM

(graves disease , thyrotoxicosis )

Definition

When the body produces too much thyroid hormone (T4&T3) due to an overactive thyroid
gland. So that there is increased body’s metabolism which causes raised heart rate , high
blood pressure and fatigue.

• Most serious form of hyperthyroidism is Graves disease. It is an autoimmune disease of

unknown etiology characterized by diffuse thyroid enlargement and excessive thyroid
hormone secretion .

• Thyrotoxicosis – clinical syndrome of hyper metabolism result from excessive circulating

levels of T4, T3 or both.
Etiology

• Thyroiditis

• Goiter

• Too much iodine intake

• Stressful life events

• Cigarette smoking

• Taking too much thyroid hormone medication

• Overactive thyroid nodule , (toxic nodular goiter or multinodular goiter.

• Noncancerous pituitary gland tumor

Pathophysiology

• In graves disease patient develops antibodies to TSH receptor

• These antibodies attach to the receptors and stimulate the thyroid

gland to release T4and T3 .

• The excessive release of thyroid hormone leads to the thyrotoxicosis

• This leads to remission and exacerbations

• And at last destruction of the thyroid tissue causing hypothyroidism.

Clinical manifestations
• Fatigue
• Tremors in the hands
• Sleeping disturbances
• Nervousness
• Irritability
• Unintended weight loss
• Skin sweating ,moist warm skin , palmar erythema, thin hair
• Brain hyperthermia , heat intolerance
• Goiter (enlargement of thyroid )
• On auscultation of thyroid gland – bruits.(reflection of increased blood supply)
• Ophthalmopathy(abnormal eye appearance or fun.)
• Exophthalmos (protrusion of eyeballs from the orbits and diplopia
• Acropachy (clubbing of digits)
Diagnostic measures

• History and physical examination

• The main diagnostic finding is decreased TSH

• BMR increased

• Ophthalmoscopic examination

• ECG

• Radioactive iodine uptake

Complications
• Thyrotoxicosis ( thyrotoxic crisis or thyroid storm) – is an acute , severe
and rare condition that occurs when excessive amount of thyroid
hormone are released into the circulation .
• It result from infection ,trauma ,surgery
• Patient prone to get thyrotoxicosis are those having thyroidectomy
• In thyrotoxicosis symptoms of hyperthyroidism are severe
• c/m include – tachycardia, heart failure ,shock, hyperthermia,
restlessness, irritability ,seizure ,abdominal pain ,vomiting , diarrhea ,
delirium and coma.
• Treatment include drug therapy and symptomatic treatment
Management

• The goal of management is to block adverse effect of excessive

thyroid hormone , suppress over secretion and prevent complication

• Treatment options are – Antithyroid medications, Radioactive iodine

therapy and surgical intervention .

 Drug therapy

• Antithyroid drugs – Propyl thiouracil (PTU) and Methimazole (inhibit the synthesis of
thyroid hormones.
• Radioactive iodine – iodine is used with other antithyroid drug and to prepare the
patient for thyroidectomy or thyrotoxicosis. - this destroys thyroid tissue thus limiting
thyroid hormone secretion.
• Iodine administration in large dose rapidly inhibit synthesis of T3& T4and block this
hormones into circulation .it also decreases the vascularity of thyroid gland .
• The iodine is available in the form of saturated solution of potassium iodide (SSKI) and
Lugols solution
• Beta adrenergic blockers :symptomatic relief of thyrotoxicosis. These blocks the SNS
there by decreasing tachycardia ,nervousness, irritability.
• Propranolol is used with other drugs and Atenolol is the drug of choice for hyperthyroid
patient with asthma or heart disease.
 Surgical therapy Thyroidectomy
Indication – large goiter causing tracheal compression ,unresponsiveness to
antithyroid ,thyroid cancer .
Subtotal thyroidectomy : Removal of significant portion of the thyroid gland
Endoscopic thyroidectomy most commonly using
Nutritional therapy
• High caloric diet (4000-5000cal/day) six full meals a day and snacks high in
protein ,CHO, minerals and vitamins.
• Ptn should be 1-2kg/of body weight
• Avoid high fiber food (these further stimulate hyperactive GI tract)
• Avoid caffeine containing liquids such as coffee , tea and cola .
Nursing diagnosis

• Activity intolerance related to fatigue

• Imbalanced nutrition
Hypothyroidism

Hypothyroidism is a condition characterized by abnormally low thyroid hormone

production.

Hypothyroidism means that the thyroid gland can't make enough thyroid hormone

to keep the body running normally.

Etiology
• Autoimmune thyroiditis hashi moto's thyroiditis, atrophic autoimmune thyroiditis

• Iatrogenic thyroidectomy, radioiodine therapy

• Thyroiditis - subacute thyroiditis silent thyroiditis, postpartum thyroiditis

• Iodine deficiency

• Drugs - carbimazole, methimazole, propyl- thiouracil, iodine, amiodarone, lithium, interferons,

thalidomide, sunitinib, rifampicin

• Congenital hypothyroidism - thyroid aplasia or hypoplasia, defective biosynthesis of thyroid

hormones

• Disorders of the pituitary or hypothalamus (secondary hypothyroidism)Damage to the pituitary gland

Types of hypothyroidism
Primary hypothyroidism

The thyroid gland is unable to produce sufficient thyroid hormone.

Secondary hypothyroidism is very rare, and caused by problems with the pituitary
gland, which normally signals the thyroid to produce hormone. When the pituitary is
damaged, it does not produce enough thyroid stimulating hormone (TSH), resulting
in low levels of thyroid hormone being made by the thyroid gland.

Subclinical hypothyroidism is a condition in which there is an elevation of thyroid

stimulating hormone levels with normal thyroid hormone levels.
Clinical manifestations

• Increased sensitivity or intolerance of • Poor concentration/ reduced attention span

cold • Joint and/or muscle aches and pains,
• Temperatures cramps
• Fatigue, weariness, lethargy • Heavy or irregular menstrual periods
• Weakness • A pale appearance
• Dry, rough and/or cold skin • Fluid retention swollen face, hands, ankles
• Dry and brittle hair and/ or hair and/ or feet
thinning • Difficulty falling or maintaining sleep
• Constipation • Breathlessness
• Unexplained weight gain • Goitre (enlarged thyroid gland)
• Depression or low mood • Difficulty getting pregnant
• Hoarse/ deep voice, slow speech • Slow heart rate
Diagnostic evaluation
• Medical and family history

• Physical exam checks thyroid gland and look for changes such as dry skin, swelling,
slower reflexes and a slower heart rate

• Blood tests measure thyroid antibodies can check for thyroid autoimmune disease

Measurement of thyroid stimulating hormone

• Primary hypothyroidism high TSH, low T4Secondary hypothyroidism low TSH,

low T4

• High TSH with normal T4 levels suggests subclinical hypothyroidism

 Management
• The goal of treatment is to return blood levels of TSH and T4 to the normal range and
to control symptoms
• Thyroid replacement should be taken daily on an empty stomach usually in the form of
levothyroxine.(T4). High fiber diet, antacids, calcium and iron tablets interfere with
absorption.
• Brand names for levothyroxine include synthroid, levoxyl, levothyroid
• Repeat blood tests will need to be checked in 6 to 8 weeks to make sure the prescribed
dose is adequate
• Once the optimal dose is determined, levels are usually checked yearly
• Life long therapy is needed by most people
• Taking too much thyroid supplement can be dangerous
Associated with atrial fibrillation (an irregular heartbeat)
Can cause accelerated bone loss (osteoporosis)
MYXOEDEMA (GULL DISEASE )
• A severe form of hypo thyroidism which characterized by swelling and thickening
of skin that can occur when the condition is left untreated or is not treated
sufficiently.
• It is 7-8 times more common in females than in males and caused by hypo activity
of thyroid gland in adult. It is also caused by the hypo secretion of pituitary TSH.
Clinical manifestation:
• Skin color becomes yellow due to accumulation of mucinous protein deposit in the cutaneous
tissue and skin shows appearance of puffy swellings.
• Puffy face and swelling in neck region.
• Irregular fat deposition, specially in clavicular, and buttock region.
• Loss of hair from eyebrows, pubis, axillae.
• Tongue and larynx are thickened.
• Low BMR, blood sugar level
• Reduced heart rate and cardiac output and low blood pressure.
• Less appetite.
• Less peristaltic activity in Gl tract.
• Cholesterol level becomes high.
• Slow muscle contractibility.
• Lethargic and sleepy.
• May loss of memory.
Cretinism:
Definition
• Cretinism (congenital myxedema) refers to the congenital hypothyroidism or
underactivity of thyroid glands during early childhood leading to stunted growth and
mental retardation.“

• The term cretin was derived from the French word Chrétien, literally meaning
"Christian" or "Christ like" as the diseased were mentally retarded and incapable of
doing sin.
• It is either due to extreme iodine deficiency, i.e. endemic cretinism or due to
decreased synthesis of thyroid hormones i.e. sporadic cretinism.
• It is characterized by dwarfism, physical and mental deficiencies or under
development with a peculiar infantile facial expression
• Big nose, scanty hair, low body temperature, low heartbeat, low blood pressure,
large head
• Thick legs, pot belly, pigeon chest, protruding tongue, swollen eyelids, short neck,
dry skin, deformed bones and teeth and uncoordinated gait
• Retarded sexual development, which includes delayed development of sex glands,
sex organs and secondary sexual characters.
• It is typically diagnosed during infancy or childhood; however, the best preventive
strategy is the screening of neonates. It is important to diagnose and treat cretinism
early; a delay may lead to irreversible damage. It is treated early with thyroid
hormones and trace iodine supplementation of the diet.
Difference between hypo and hyper thyroidism
Hypothyroidism Hyperthyroidism
• T3 and T4 levels are decreased • T3 and T4 levels are increased.

• BMR becomes low • BMR becomes high.

• Perspiration becomes decreased • Perspiration becomes increased.
• Impaired intestinal glucose absorption • Enhanced intestinal glucose absorption.
• Low blood cholesterol • High blood cholesterol.
• Decreased protein anabolism • Increased protein anabolism.
• Weight gain • Weight loss.
• Decreased appetite • Increased appetite.
• Low body temperature • High body temperature.
• Cold intolerance • Heat intolerance.
• Dry palm • Moist palm.
• Sleepiness, tiredness • Restlessness, insomnia.
• Goiter may or may not be present • Goiter present
GOITER
• A goiter is defined as an enlargement of thyroid gland. When thyroid gland is
enlarged, it can produce too much, too little or just enough thyroid hormone.

Risk factors include:

• Being a woman and over age 40

• Being pregnant or in menopause

• Having a family history of autoimmune disease or goiter

• Having been exposed to radiation as a child or having had radiation treatment to

neck or chest

• Having a diet low in iodine

Etiology:

Most common cause of goitre worldwide is iodine deficiency in diet

Graves' disease

Congenital hypothyroidism

Thyroiditis

Pituitary gland tumors

Clinical manifestation:

• No symptoms at all, other than having some swelling at the base of

neck

• Tightness in the throat

• Coughing

• Hoarseness

• Trouble swallowing

• Trouble breathing
Diagnostic assessment:
• Physical examination

• Hormone tests T3, T4 & TSH

• Antibody tests for hashimoto's disease (an autoimmune disease that causes the
body's immune system to attack the thyroid gland. This leads to the thyroid gland
becoming inflamed and eventually damaged, reducing its ability to produce
hormones)

• Antibody test for graves' disease

• Ultrasound to see the size of thyroid and whether there are nodules

• CT scan & MRI of the neck to check windpipe biopsy

Management
Treatment will depend upon the cause

• Close observation

• Given iodine supplementation given in preparations to take by mouth

• If the goiter is due to hashimoto's thyroiditis, and are hypothyroid, will be given thyroid
hormone supplement as a daily pill

• Medication

• Surgery thyroidectomy

• Radiofrequency ablation (RFA) - used to shrink the goiter and alleviate pressure related
symptoms, without the need for surgery
Thyroid cancer /nodules

• The term thyroid nodule refers to an abnormal growth of thyroid cells that forms a
lump within the thyroid gland. The most of thyroid nodules are benign (non
cancerous), a small percentage of thyroid nodules are malignant. They become
more common as people get older.

Etiology

• Thyroid cyst

• Follicular adenoma

• Prominent nodule in multi nodular goitre

Clinical manifestation:

• An abnormally large lymph node (a swollen gland) in the neck that does not go
away over a few months

• Hoarseness that has no known cause and does not go away

• Difficulty breathing or shortness of breath

• Difficulty swallowing hard or firm foods or an unusual sensation (a lump) when

swallowing

• Unexplained chronic cough or throat clearing

Diagnostic measures
• Patient's history, including- Any past head or neck irradiation, Radiation exposure
and ,Family history

• Physical examination of the thyroid and neck for thyroid enlargement, enlarged lymph
nodes or signs of local obstruction caused by an enlarged thyroid gland.

• Blood tests, including TSH (thyroid stimulating hormone) test.

• Neck ultrasound, including cervical lymph nodes

• Fine needle aspiration (FNA) biopsy

• Thyroid scan with low dose radioactive iodine or else technetium, a short living isotope
used in nuclear medicine scans, if the blood testing shows that the TSH is below normal
Management
• Benign thyroid nodules: Radioactive iodine ablation should be considered for hyper
functioning thyroid nodules.

• May be surgically removed, especially if growing or if over 4 cm in diameter

Malignant thyroid nodules:

• A total thyroidectomy is usually indicated for FNA cytology that is either diagnostic
of or suspicious for malignancy

• Often followed by treatments with radioiodine and thyroid supplement therapy to

suppress TSH production

• External beam radiation including gamma knife radiation for some patients with
extensive and invasive cancer.
Hyperparathyroidism

Hyperparathyroidism (HPT) is the most common type of parathyroid disease. In HPT

one or more glands are overactive. As a result, the glands make too much PTH. This

may result in too much calcium in the blood a condition called hypercalcemia.
Clinical manifestation
Abdominal pain
Constipation
Nausea and vomiting
Flank pain
Hematuria
Polyuria
Stupor, coma
Weakness.
Loss of reflexes
Bradycardia
Hypercalcemia: Gastric and duodenal ulcer
• Pancreatitis
• Constipation
• Cardiac arrythmia & hypertension
• Weakness, easy fatigability
• Neuropsychologic disorders
• Hypercalcemic crisis
• Hypercalciuria:
• Nephrolithiasis
• Nephrocalcinosis
• Polyuria
• Bone loss:
• Osteopenia
• Osteoporosis
• Bone fractures
• Osteitis fibrosa cystica
Diagnostic measures
• 25 hydroxy vitamin D blood test people with primary HPT commonly
lack vitamin D. This test helps doctor monitor vitamin D levels in
blood
• Bone densitometry (DEXA, DXA) bone densitometry also called DEXA
or DXA uses a very small dose of ionizing radiation to produce pictures
of the inside of the body (usually the lower spine and hips) to
measure bone loss
• Ultrasound
• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI)
Management
• Bisphosphonates do not affect serum calcium but do preserve bone density and
therefore reduce fracture risk
• Cinacalcet (a calcium sensing receptor agonist) reduces PTH secretion and
therefore serum calcium. It is used in patients with primary hyperparathyroidism
in whom surgery would not be appropriate, has been declined or has been
unsuccessful
• Secondary hyperparathyroidism should be managed by treating the underlying
cause. Cinacalcet may be used for patients in whom this fails or who are on
dialysis. Phosphate binders and calcium/vitamin D supplements may also be used
for example in chronic kidney disease
• Tertiary hyperparathyroidism may also be treated with surgical intervention
(partial parathyroidectomy). Sometimes residual parathyroid tissue is reimplanted
elsewhere in the body (eg. the forearm), where it is more accessible if future
problems arise
Surgical management
Elective Para thyroidectomy the treatment of choice for symptomatic disease is

surgical removal of the hyperactive parathyroid glands along with intraoperative PTH

monitoring. Surgery may be also recommended in some asymptomatic or low

symptomatic patients. Parathyroidectomy (PTX) should only be performed by highly

experienced surgeons
HYPOPARATHYROIDISM

Hypoparathyroidism (parathyroid related hypocalcemia) is a disorder in

which the parathyroid glands in the neck do not produce enough

parathyroid hormone (PTH).

ETIOLOGY
• Injury to the parathyroid glands during thyroid or neck surgery
• Autoimmune attack on the parathyroid glands (common)
• Very low magnesium level in the blood
• Radioactive iodine hyperthyroidism (very rare) treatment for
Hyperthyroidism
Clinical manifestations
• Tingling lips, fingers and toes (most common)
• Muscle cramps (most common)
• Muscle spasms called tetany (can affect the larynx, causing breathing
difficulties)
• Abdominal pain.
• Abnormal heart rhythm
• Brittle nails
• Cataracts.
• Calcium deposits in some tissues
Diagnostic evaluation

• PTH blood test

• Calcium blood test
• Magnesium
• 24 hour urine calcium test
• Electrocardiogram (ECG) to check for an abnormal heart rhythm
• Computed tomography (CT) scan to check for calcium deposits in the
brain.
Management
The goal of treatment is to reduce symptoms and restore the calcium
and mineral balance in the body.
• Calcium carbonate and vitamin D supplements. Blood levels are
measured regularly to make sure that the dose is correct. A high
calcium, low phosphorous diet is recommended
• Injections of PTH may be recommended for some people
• People who have life threatening attacks of low calcium levels or
prolonged muscle contractions are given calcium through a vein (IV).
Precautions are taken to prevent seizures or larynx spasms. The heart
is monitored for abnormal rhythms until the person is stable. When
the life threatening attack has been controlled, treatment continues
with medicine taken by mouth
Complication

• Hypoparathyroidism in children may lead to poor growth, abnormal

teeth and slow mental development
• Increases the risk for Addison disease, cataract ,Parkinson disease and
pernicious anaemia
• Careful examination from head to toe showed prominent supraorbital ridges,
prognathism, widening of teeth spaces , macroglossia with thick lips, large ears
and fleshy nose , patient also had spade like hands and feet and also had deep,
husky voice which was not before. Systemic examination was normal. Soon all
these features we suspected the provisional diagnosis of 'acromegaly'
Disorders of ant .pituitary
ACROMEGALY
• Is a rare condition characterize by an overproduction of GH.
ETIOLOGY AND PATHOPHYSIOLOGY
Benign pituitary tumor (adenoma)
Excessive GH secretion results overgrowth of tissues and bones in the
hands, feet and face
Due to epiphyseal closure
CLINICAL MANIFESTATIONS
• Enlarged hands and feet with joint pain
• Carpel tunnel syndrome
• Enlargement of face, feet and head
• Enlargement of tongue- speech difficulties
• Sleep apnea – upper airway narrowing and obstruction from increased amount of pharyngeal soft
tissue
• The skin become thick ,leathery and oily
• Peripheral neuropathy and muscle weakness
• Menstrual disturbances in women
• Visual changes- pressure on optic nerve
• Headaches
• Hyperglycemia, manifestations of DM – polydipsia(increase thirst ,poly urea )
• The life expectancy is reduced by 5-10 yrs
• More prone for cardiac and respiratory , DM and colorectal cancer