Hypothyroidism final
-
Upload
drutkarshdeshmukh -
Category
Health & Medicine
-
view
608 -
download
0
Transcript of Hypothyroidism final
Hypothyroidism
ESIC – PGIMSR, MGM Hospital,
Mumbai
Presenter:
DR.UTKARSH DESHMUKHDNB General Medicine
Index:1.Case of Hypothyroidism2.Discussion of Hypothyroidism 3.Subclinical Hypothyroidism4.Myxedema Coma
History
• A 50 year female patient Mrs. Pramilabai Residing at Mumbai was working as maid came to our hospital with complaints of Generalized tiredness, cold intolerance, decrease
appetite since 18 months. Constipation & Somnolence since 12 months. Hoarseness of voice & forgetfulness, since 6 months. Difficulty in walking & getting up from squatting
position since 6 months. Since last 3 months swelling over face & feet.
CASE
History
• No H/o headache , vomiting or altered sensorium, seizures.
• With exception of H/O deafness no other H/S/O other cranial nerve involvement.
• No H/S/O sensory, autonomic or cerebellar involvement.
• No H/S/O cardiac, respiratory, renal involvement.
CASE
History• Past History:
• History of similar complaints 3 years back & taken treatment but she was noncompliant. ( Details of Treatment Not available)
• No H/O any other major illness.
• Personal History:• Mixed diet, constipation & somnolence was present.
• Obstetric & Gynecology• One son 25 year old
• Attained menopause 5 years back.
• Family History: • No history of similar complaints in family members
CASE
Examination
General Examination• Patient was conscious, oriented.• BMI 21 kg / m2 (No weight loss, Despite of loss of Appetite)
• Afebrile
• Pulse: 58/min regular (Sinus bradycardia)
• BP: 136/94 mm Hg (Diastolic Hypertension)
• RR: 16/min pallor:- present• Face:• Perorbital swelling with baggy eyelids.• Expressionless face with rough & dry skin of face.
CASE
Examination
General Examination cont….• Thyroid examination was normal• No Icterus, cyanosis, clubbing,
lymphadenopathy.• JVP not raised, Non- pitting pedal edema
present. • Skin all over body: thick & dry.• Examination of spine & skull normal.
CASE
ExaminationSystemic Examination [CNS]
• Higher function : -• Conscious, oriented.
• Speech slow, sluggish & hoarseness of voice.
• Memory impaired.
• Cranial Nerves : - Conductive deafness (VIII)• Motor examination:-
• Nutrition – Normal
• Tone – hypotonia• Power – Grade IV/V around hip joint bilaterally Rest WNL
• Co-ordination – Normal
• No abnormal movements
CASE
Examination
Systemic Examination [CNS]cont….
• Sensory examination : - Normal• Reflexes• Superficial reflexes:- Normal• Deep tendon Reflexes: -
Hung up reflexes-- specially ankle, bicep, triceps
• Cerebellar, autonomic examination normal• Gait : normal but slow
CASE
Examination
Systemic examination [CVS]• Sinus bradycardia and diastolic hypertension, rest
WNL
Systemic examination RS & Per-abdomen WNL
CASE
Patient
• Slow speech , expressionless face.• Here Watch for movements of the hand rather the
muscle
CASE
VID-20130813-WA0000.mp4
Investigations• Hemogram• Hb – 10 gm/dl, WBC 8000/mm3, platelets 322,000
• Peripheral smear – Normocytic normochromic
• Thyroid function test• TSH – 110 µ U/ml (Normal 0.3-4.3)
• T4 – 0.5 µg/dl (Normal 5.5-11.5)
• T3 - 20 ng/dl (Normal 75-135)
• BUN – 15 mg/dl, Sr. creatinine 0.7 mg/dl• LFT – normal ECG – Sinus bradycardia Anterior
wall ischemia.• X-ray chest – WNL• Lipid profile Chole- 250 mg/dl, Tg – 200 mg/dl.
CASE
Treatment
Tab. Thyroxine 50 µ gm
TSH – 75 µ U/ml
Thyroxine increased to100 µg/dl
TSH – 35 µ U/ml
Thyroxin increased to 150 (OPD visit TSH 3 µ U/ml)
After 1 weeks
After 2 weeks
CASE
Treatment
Other Treatment StatinsAntinatianginal sos AntiplateletAntihypertensive
Discussion Hypothyroidism
DICUSSION
Introduction
• Definition: - “ It is a deficiency in thyroid hormone secretion by thyroid gland, resulting in state of circulating level of thyroid hormone and reduced action at the cellular level”.
• Etiology:Primary hypothyroidism ( 99 %)
Autoimmune Thyroiditis (Hashimoto`s Thyroiditis)Iodine deficiency.Iatrogenic : Surgery, I131 .Drugs : Iodine Excess, lithium, antithyroid drugs.Congenital hypothyroidism & Infiltrative disorders.
DICUSSION
Introduction (cont….)
Secondary hypothyroidismHypopituitarism • Tumor • Surgery / irradiation• Infiltrative disorders• Sheehan`s syndrome
Hypothalamic diseases (Tertiary Hypothyroidism): - Tumor, trauma, infiltrative disorders
Isolated TSH deficiency
DICUSSION
Introduction (cont…)
Transient Hypothyroidism Silent Thyroiditis , including postpartum thyroiditis Sub-acute thyroiditis Withdrawal of thyroxin therapy After surgery or I131
DICUSSION
Statistics
Epidemiology : - • Prevalence - 0.1 to 2%• 5 – 8 times more common in women.• More common in adult women with small
body size at birth & during childhood.• Prevalence is also increased in elderly patients.• The Framingham study: Above 65 yrs of age
hypothyroidism women 5.9% Men 2.4%
DICUSSION
Statistics (cont…) India• In population-based study in Cochin on
971 adult • Prevalence of hypothyroidism – 3.9%• Subclinical hypothyroidism – 9.4%
• Studies from Mumbai • Congenital hypothyroidism:- 1 out of 2640 neonate
compared to 1 out of 3800 world wide.• Population based study : 800 children with thyroid
diseases 79% had hypothyroidism.
DICUSSION
Clinical Features
GENERAL
• Lethargy, Somnolence
• Weight gain, Goiter• Cold Intolerance
CARDIOVASCULAR
• Bradycardia, Angina• CHF, Pericardial
Effusion Hyperlipidemia.
DICUSSION
NEUROMUSCULAR
• Aches and pains• Muscle stiffness• Carpel tunnel
syndrome• Deafness, Hoarseness• Cerebellar ataxia• Delayed DTR
Myotonia (pseudomytonia)
• Depression, Psychosis
Clinical Features
HAEMATOLOGICAL• Normocytic /
normchromic Anemia• Iron def. Anemia.
REPRODUCTIVE SYSTEM• Infertility, Amenorrhea
Menorrhagia• Impotence.
GASTRO-INTESTINAL• Constipation, Ileus, • Ascites.
Dermatological• Dry flaky skin and hair• Myxoedema, malar
flushes• Vitiligo Carotenimia
Alopecia
DICUSSION
Algorithm for Hypothyroidism
Measure TSH
Elevated TSH
Measure FT4
Normal Low
Sub-clinical hypo
TPO + TPO -
T4 repl Annual FU
Primary hypothyroid
TPO + TPO -
Hashimoto
Others
Normal TSH
TPO: Thyroid PeroxidiseFU: Follow Up
Next Slide
Algorithm for Hypothyroidism
Measure TSH
Elevated TSH Normal TSH
Considering Pituitary
No Yes
No tests Measure FT4
Low Normal
No testsEvaluate PituitarySick EuthyroidDrugs effect
Treatment
• Goal : Normalize TSH level (Generally in Lower Half of reference value)
• Treatment : Once daily dosing with Levothyroxine sodium (1.6µg/kg/day) this comes to 100 - 150 mcg per day
• Timing:- single dose empty stomach.
• Monitor TSH levels at 6 to 8 weeks, after initiation of therapy or dosage change
DICUSSION
How to Start ?
• Available Tab: – 25, 50 and 100 mcg tablets.
• Starting dose
Healthy patients at 1.6µg/kg/day. (Usually 100 – 150 µg/day)
Healthy patients Elderly
< 50 µg/day.
Dose ↑ by 25 µg, if needed, at 6 to 8 weeks intervals.
For patients with heart disease -
12.5 to 25 µg/day and
increase by 12.5 to 25 µg/day, if needed.
DICUSSION
SUBCLINICAL HYPOTHYROIDISM
DICUSSION
Subclinical Hypothyroidism
Definition: -
“Biochemical evidence of thyroid hormone deficiency in patients who have few or no apparent clinical features of hypothyroidism”.
Prevalence: - World wide 1- 10% Sex: - Highest rate in females > 75 yrs.
DICUSSION
Subclinical Hypothyroidism (cont…)
CausesInadequate treatment of overt
hypothyroidism.Transient elevation of TSH: Systemic
illnessRare Causes
Heterophil antibodyTSH producing pituitary tumorThyroid hormone resistance
Laboratory errors.
DICUSSION
Subclinical Hypothyroidism (cont…) Risk Factors
Women, > 60 yrs. Autoimmune disease: • Diabetes Mellitus type I• Rheumatoid arthritis• Autoimmune thyroid disorder
Post-partum thyroiditis / Sub-acute thyroiditis.
Prior H/O hyperthyroidism following: surgery or RAI – 131 therapy.
Head / neck Radiotherapy. Drugs: - Lithium, Amiodarone, Iodine.
DICUSSION
Subclinical Hypothyroidism (cont…)
EFFECTS OF SH ON BODY
Associated with elevated cholesterol.Altered endothelial function & carotid
intimal thickness.Associated with increased risk of CHD.Impaired mood & cognition.
DICUSSION
Subclinical Hypothyroidism (cont…)
DiagnosisAsymptomatic.Diagnosed during routine thyroid function test.Subclinical Hypothyroidism• Mild: - TSH < 10 mU/L Common• More severe: - 10 – 20 mU/L.
DICUSSION
High TSH
TSH > 10 mU/L TSH 5-10 mU/LFor > 3 months
L levothyroxine TPO Antibody & Other
Positive Negative
No Treatment &Follow up
Yearly
High TSH
TSH > 10 mU/L TSH 5-10 mU/LFor > 3 months
L levothyroxine TPO Antibody & Other
Positive Negative
No Treatment &Follow up
Yearly
Other: -Increased lipids, young age, pregnancy, anovulation.
Subclinical Hypothyroidism (cont…)
MANAGEMENT Target of the treatment
TSH: - 0.5 – 3.0 mU/L.Levothyroxine: - 25 – 50 µg / Day.
Subclinical Hypothyroidism (cont…)
BENEFITS OF TREATMENT Improve cardiac function. Improve mood and cognition. Improve symptoms. Prophylaxis against progression. Help to decrease size of goiter. Improve lipid status. Improve quality of life.
MYXEDEMA COMA
DICUSSION
Myxedema Coma Definition: - “It is serious form of thyroid
hormone deficiency associated with altered mental status, hypothermia, Bradycardia high mortality rate around 50%.
Precipitating factors :
• Infection (Pneumonia), Sepsis.
• CVS: - Congestive Cardiac Failure, MI
• CNS: - Cerebrovascular Accidents
• GIT : - GIT bleeding
• Cessation of thyroxin therapy
• Drug : - Sedatives, Antidepressants, diuretics.
DICUSSION
Exposure to cold
Hypoventilation
Hypoxia Hypercapnia
Myxedema
HypoglycemiaDilutional Hyponatremia
Infection
Pathogenesis
Myxedema Coma (cont…)
Clinical Features & Investigations• Mental confusion, hypothermia, bradycardia.• ↓ Na, ↓ glucose, ↑ CO2,• ↓ WBC, ↓ Hematocrit, ↑ CPK• ↓ EKG voltage, myxedema.
DICUSSION
Treatment
Hormone replacementSupportive TreatmentTreatment of precipitating Factors
DICUSSION
Myxedema Coma (cont…)
Treatment :-
Admission in ICU
Hormone replacement
Inj. Levothyroxine (T4 ) 500 µgm IV Follwed by 50-100 µgm for several days
Can also be given nasogastric tube in same dose
Inj. Levothyronine (T3 ) 10 -20 µgm ( Excess dose Provoke arrhythmia)
Treatment ICU transfer, T3 100 µg IV sixth hourly, 500 µg of T4 , antibiotics, ventilation, hydrocortisone IV, passive warming, careful
volume management
DICUSSION
Myxedema Coma (cont…)
Supportive Treatment Oxygen (Ventilation, if necessary) External warming (If Temperature < 30º C)oSpace blankets
Inj. Hydrocortisone 50 mg IV 6 hrly.
Treatment of precipitating Factors Broad spectrum antibiotics Hypertonic saline Glucose
Avoid sedatives
DICUSSION
References
1. Desai PM. Disorders of the Thyroid Gland in India. Indian J Pediatr. 1997;64:11–20. [PubMed]
2. Jameson AL, Weetman AP. Disorders of Thyroid gland. In: Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, Loscalzo, editors.Harrison`s Principles of Internal Medicine.18th ed.USA.The McGraw-Hill Companies, Inc;2009.
DICUSSION
References
3. Sawin C, Castelli W, et al. The aging thyroid. Thyroid deficiency in the Framingham Study. Arch Intern Med. 1985;145(8): 1386-8.
4. Bajaj S, Singh SK.Hypothyroidism.In:Bajaj S, et al,editors Manual of Clinical Endocrinology 1st ed. India.Endocrine Society Of India Osmania General Hospital,Inc.2012
DICUSSION
Take Home Massage
Hypothyroidism is common disease which is more common in women
It is one of the condition which can be very well controlled with single dose tablet
So patient must be screened by doing TSH & FT4 to rule out Hypothyroidism & Subclinical Hypothyroidism
Compliance is very importantTreatment for lifelong in case of
hypothyroidism.
DICUSSION