•Created by:

•Chaudhary Shraddha
•Dholariya Kinjal Guided by:
•Cholera Harita Dr.Seema Dhabaliya
Introduction
 Thyroid disorders:
 Hypothyroidism  Nontoxic goitre
 Hyperthyroidism and  Thyroid nodules & thyroid
thyrotoxicosis cancer
 Graves’ disease  Benign thyroid nodules
 Thyroiditis  Thyroid cancer
 Toxic adenoma  Papillary carcinoma
 Toxic multinodular goitre  Follicular carcinoma
 Thyrotoxicosis factitia
 Medullary carcinoma
 Anaplastic carcinoma
 Struma ovarii
 Lymphoma
 Hydatidiform mole  Cancer metastatic to the
 TSH-secreting pituitary thyroid
adenoma
Hypothyroidism
 Etiology:
 Primary:
 Hashimoto’s thyroiditis with or without goitre
 Radioactive iodine therapy for Graves’ disease
 Subtotal thyroidectomy for Graves’ disease or nodular goitre
 Excessive iodine intake
 Subacute thyroiditis
 Rare causes
 Iodide deficiency
 Goitrogens such as lithium; antithyroid drug therapy
 Inborn errors of thyroid hormone synthesis
 Secondary: Hypopituitarism
 Tertiary: Hypothalamic dysfunction (rare)
 Peripheral resistance to the action of thyroid hormone
Hypothyroidism
 Clinical features
Cardiovascular signs:  Renal function:
 Bradycardia  Impaired ability to excrete a water
 Low voltage ECG load
 Pericardial effusion  Anemia:
 Cardiomegaly  Impaired Hb synthesis
 Hyperlipidemia  Fe deficiency due to:
 Constipation, ascites  Menorrhagia
 Weight gain  Reduced intestinal absorption
 Folate def. due to impaired intestinal
 Cold intolerance absorption
 Rough, dry skin  Pernicious anemia
 Puffy face and hands  Neuromuscular system:
 Hoarse, husky voice  Muscle cramps, myotonia
 Yellowish color of skin due to  Slow reflexes
reduced conversion of carotene to  Carpal tunnel syndrome
vitamin A  CNS symptoms:
 Respiratory failure  Fatigue, lethargy, depression
 Menorrhagia, infertility, hyper-  Inability to concentrate
prolactinemia
Hypothyroidism
 Diagnosis:
 A FT4 and TSH is diagnostic of primary hypothyroidism
 Serum T3 levels are variable (maybe in normal range)
 +ve test for thyroid autoantibodies (Tg Ab & TPO Ab) PLUS an enlarged
thyroid gland suggest Hashimoto’s thyroiditis
 With pituitary myxedema FT4 will be  but serum TSH will be
inappropriately normal or low
 TRH test may be done to differentiate pituitary from hypothalamic
disease. Absence of TSH response to TRH indicates pituitary deficiency
 MRI of brain is indicated if pituitary or hypothalamic disease is suspected.
Need to look for other pituitary deficiencies.
 If TSH is  & FT4 & FT3 are normal we call this condition subclinical
hypothyroidism
Hashimoto’s Thyroiditis
 Hashimoto’s thyroiditis is a commom cause of hypothyroidism and
goitre especially in children and young adults.
 It is an autoimmune disease that involves heavy infiltration of
lymphocytes that totally destroys normal thyroidal architecture
 Three different autoantibodies are present: Tg Ab, TPO Ab, and
TSH-R Ab (block)
 It is familial and may be associated with other autoimmune diseases
such as pernicious anemia, adrenocortical insufficiency, idiopathic
hypoparathyroidism, and vitiligo.
 Shmidt’s syndrome consists of Hashimoto’s thyroiditis, adrenal
insufficiency, hypoparathyroidism, DM, ovarian failure, and (rarely)
candidal infections.
Hashimoto’s Thyroiditis
 Symptoms & Signs:
 Usually presents with goitre in a patient who is euthyroid or has mild
hypothyroidism
 Sex distribution: four females to one male
 The process is painless
 Older patients may present with severe hypothyroidism with only a small, firm
atrophic thyroid gland
 Transient symptoms of thyrotoxicosis can occur during periods of hashitoxicosis
(spontaneously resolving hyperthyroidism)
 Lab:
 Normal or low thyroid hormone levels, and if low, TSH is elevated
 High Tg Ab and/or TPO Ab titres
 FNA bx reveals a large infiltration of lymphocytes PLUS Hurthle cells
 Complications:
 Permanent hypothyroidism (occurs in 10-15% of young pts)
 Rarely, thyroid lymphoma
Management of Hypothyroidism
 Start patient on L-thyroxine 0.05-0.1mg PO OD. L-thyroxine treats
the hypothyroidism and leads to regression of goitre.
 If patient is elderly or has IHD start 0.025mg PO OD.
 Check TSH level after 4-6 weeks to adjust the dose of L-thyroxine.
 In case of secondary hypothyroidism monitor FT4 instead of TSH.
 Hypothyroidism during pregnancy:
 Check TFT every month. L-thyroxine dose requirement tends to go up as
the pregnancy progresses.
 If patient has concommitant hyperprolactinemia and
hypercholesterolemia, treat if not normalized after adequate thyroid
replacement.
Myxedema Coma
 Medical emergency, end stage of untreated hypothyroidism
 Characterized by progressive weakness, stupor, hypothermia,
hypoventilation, hypoglycemia, hyponatremia, shock, and death
 The patient (or a family member) may recall previous thyroid disease,
radioiodine therapy, or thyroidectomy
 Hx is of gradual onset of lethargy progressing to stupor or coma. A hx of
amenorrhea or impotence with pituitary myxedema
 PE reveals HR and marked hypothermia (as low as 24C)
 The pt is usually an obese elderly woman with yellowish skin, a hoarse
voice, a large tongue, thin hair, puffy eyes, ileus, and slow reflexes. An
anterior neck scar may be present. Scanty pubic or axillary hair with
pituitary myxedema
 Lab: low FT4, TSH high, normal, or low, cholesterol high or N, serum Na
low
 ECG: bradycardia and low voltage
 May be ppt by HF, pneumonia, excessive fluid administration, narcotics
Management of Myxedema Coma
 Initiate therapy if presumptive clinical diagnosis after TSH, FT3
FT4 drawn. Also draw serum cortisol, ACTH, glucose.
 General measures:
 Patient should be in ICU setting
 Support ventilation as respiratory failure is the major cause of death
in myxedema coma
 monitors ABG`s
 support blood pressure; hypotension may respond poorly to pressor
agents until thyroid hormone is replaced
 hypothermia will respond to thyroxin therapy ; in interim use passive
warming only
 hyponatremia will also be corrected by thyroxine therapy in majority
of cases
 hypoglycemia requires IV glucose
 avoid fluid overload
Management of Myxedema Coma
 Specific measure:
 L-thyroxine 0.2-0.5 mg IV bolus, followed by 0.1 mg IV OD until oral
therapy is tolerated
 Results in clinical response in hours
 Adrenal insufficiency may be precipitated by administration of thyroid
hormone therefore hydrocortisone 100 mg IV q 8h is usually given
until the results of the initial plasma cortisol is known.
 Identify and treat the underlying precipitant cause
Graves’ Disease
Most common form of thyrotoxicosis
May occur at any age but mostly from 20-40
5 times more common in females than in males
Syndrome consists of one or more of the following:
 Thyrotoxicosis
 Goitre
 Opthalmopathy (exopthalmos) and
 Dermopathy (pretibial myxedema)
It is an autoimmune disease of unknown cause
15% of pts with Graves’ have a close relative with the
same disorder
Graves’ Disease
 Pathogenesis:
 T lymphocytes become sensitized to Ag within the thyroid gland and
stimulate B lymphocytes to synthesize Ab to these Ag
 One such Ab is the TSH-R Ab(stim), which stimulates thyroid cell growth
and function
 Graves’ may be ppt by pregnancy, iodide excess, viral or bacterial
infections, lithium therapy, glucocorticoid withdrawal
 The opthalmopathy and dermopathy associated with Graves’ may involve
lymphocyte cytokine stimulation of fibroblasts in these locations causing
an inflammatory response that leads to edema, lymphocytic infiltration,
and glycosaminoglycans deposition
 The tachycardia, tremor, sweating, lid lag, and stare in Graves’ is due to
hyperreactivity to catecholamines and not due to increased levels of
circulating catecholamines
Graves’ Disease
Clinical features:
 I Eye features: Classes 0-6, mnemonic “NO SPECS”
 Class 0: No signs or symptoms
 Class 1: Only signs (lid retraction, stare, lid lag), no symptoms
 Class 2: Soft tissue involvement (periorbital edema, congestion
or redness of the conjunctiva, and chemosis)
 Class 3: Proptosis (measured with Hertel exopthalmometer)
 Class 4: Extraocular muscle involvement
 Class 5: Corneal involvement
 Class 6: Sight loss (optic nerve involvement)
Graves’ Disease
Clinical features:
 II Goitre:
 Diffuse enlargement of thyroid
 Bruit may be present
 III Thyroid dermopathy (pretibial myxedema):
 Thickening of the skin especially over the lower tibia
 The dermopathy may involve the entire leg and may extend onto the
feet
 Skin cannot be picked up between the fingers
 Rare, occurs in 2-3% of patients
 Usually associated with opthalmopathy and very TSH-R Ab
Graves’ Disease
 Clinical features:
 IV Heat intolerance  IX Neuromuscular:
 V Cardiovascular:  Nervousness, tremor
 Palpitation, Atrial fibrillation  Emotional lability
 CHF, dyspnea, angina  Proximal myopathy
 VI Gastrointestinal:  Myasthenia gravis
 Weight loss, appetite
 Hyper-reflexia, clonus
 Diarrhea
 Periodic hypokalemic
 VII Reproductive:
paralysis
 amenorrhea, oligo-  X Skin:
menorrhea, infertility
 Gynecomastia  Pruritus
 VIII Bone:  Onycholysis
 Osteoporosis  Vitiligo, hair thinning
 Thyroid acropachy  Palmar erythema
 Spider nevi
Graves’ Disease
 Diagnosis:
 Low TSH, High FT4 and/or FT3
 If eye signs are present, the diagnosis of Graves’ disease can be made
without further tests
 If eye signs are absent and the patient is hyperthyroid with or without a
goitre, a radioiodine uptake test should be done.
 Radioiodine uptake and scan:
 Scan shows diffuse uptake
 Uptake is increased
 TSH-R Ab (stim) is specific for Graves’ disease. May be a useful
diagnostic test in the “apathetic” hyperthyroid patient or in the pt who
presents with unilateral exopthalmos without obvious signs or laboratory
manifestations of Graves’ disease
Treatment of Grave’s Disease
There are 3 treatment options:
Medical therapy
Surgical therapy
Radioactive iodine therapy
Treatment of Grave’s Disease
A. Medical therapy:
 Antithyroid drug therapy:
 Most useful in patients with small glands and mild disease
 Treatment is usually continued for 12-18 months
 Relapse occurs in 50% of cases
 There are 2 drugs:
 Neomercazole (methimazole or carbimazole): start 30-40mg/D for 1-2m
then reduce to 5-20mg/D.
 Propylthiouracil (PTU): start 100-150mg every 6hrs for 1-2m then reduce to
50-200 once or twice a day
 Monitor therapy with fT4 and TSH
 S.E.: 5%rash, 0.5%agranulocytosis (fever, sore throat), rare: cholestatic
jaundice, hepatocellular toxicity, angioneurotic edema, acute arthralgia
Management of Grave’s disease
A. Medical therapy:
 Propranolol 10-40mg q6hrs to control tachycardia, hypertension
and atrial fibrillation during acute phase of thyrotoxicosis. It is
withdrawn gradually as thyroxine levels return to normal
 Other drugs:
 Ipodate sodium (1g OD): inhibits thyroid hormone synthesis and
release and prevents conversion of T4 to T3
 Cholestyramine 4g TID lowers serum T4 by binding it in the gut
Management of Grave’s disease
B. Surgical therapy:
 Subtotal thyroidectomy is the treatment of choice for patients with
very large glands
 The patient is prepared with antithyroid drugs until euthyroid
(about 6 weeks). In addition 2 weeks before the operation patient
is given SSKI 5 drops BID to diminish vascularity of thyroid gland
 Complications (1%):
 Hypoparathyroidism
 Recurrent laryngeal nerve injury
Management of Grave’s Disease
C. Radioactive iodine therapy:
 Preferred treatment in most patients
 Can be administered immediately except in:
 Elderly patients
 Patients with IHD or other medical problems
 Severe thyrotoxicosis
 Large glands >100g
 In above cases it is desirable to achieve euthyroid state first
 Hypothyroidism occurs in over 80% of cases.
 Female should not get pregnant for 6-12m after RAI.
Management of Grave’s Disease
Management of opthalmopathy:
 Management involves cooperation between the endocrinologist
and the opthalmologist
 A course of prednisone immediately after RAI therapy 100mg
daily in divided doses for 7-14 days then on alternate days in
gradually diminishing dosage for 6-12 weeks.
 Keep head elevated at night to diminish periorbital edema
 If steroid therapy is not effective external x-ray therapy to the
retrobulbar area may be helpful
 If vision is threatened orbital decompression can be used
Management of Grave’s Disease
Management during pregnancy:
 RAI is contraindicated
 PTU is preferred over neomercazole
 FT4 is maintained in the upper limit of normal
 PTU can be taken throughout pregnancy or if surgery is
contemplated then subtotal thyroidectomy can be performed
safely in second trimester
 Breastfeeding is allowed with PTU as it is not concentrated in the
milk
Toxic Adenoma
(Plummer’s Disease)
This is a functioning thyroid adenoma
Typical pt is an older person (usually > 40) who has
noted recent growth of a long-standing thyroid nodule
Thyrotoxic symptoms are present but no infiltrative
opthalmopathy. PE reveals a nodule on one side
Lab: low TSH, high T3, slightly high T4
Thyroid scan reveals “hot” nodule with suppressed
uptake in contralateral lobe
Toxic adenomas are almost always follicular adenomas
and almost never malignant
Treatment: same as for Grave’s disease
Toxic Multinodular Goitre
Usually occurs in older pts with long-standing MNG
PE reveals a MNG that may be small or quite large
and may even extend substernally
RAI scan reveals multiple functioning nodules in the
gland or patchy distribution of RAI
Hyperthyroidism in pts with MNG can often be ppt by
iodide intake “jodbasedow phenomenon”.
Amiodarone can also ppt hyperthyroidism in pts with
MNG
Treatment: Same as for Grave’s disease. Surgery is
preferred.
Subacute Thyroiditis
 Acute inflammatory disorder of the thyroid gland most likely due to viral
infection. Usually resolves over weeks or months.
 Symptoms & Signs:
 Fever, malaise, and soreness in the neck
 Initially, the patient may have symptoms of hyperthyroidism with palpitations,
agitation, and sweat
 PE: No opthalmopathy, Thyroid gland is exquisitely tender with no signs of local
redness or heat suggestive of abscess formation
 Signs of thyrotoxicosis like tachycardia and tremor may be present
 Lab:
 Initially, T4 & T3 are elevated and TSH is low, but as the disease progresses T4 &
T3 will drop and TSH will rise
 RAI uptake initially is low but as the pt recovers the uptake increases
 ESR may be as high as 100. Thyroid Ab are usually not detectable in serum
Subacute Thyroiditis
Management:
 In most cases only symptomatic Rx is necessary e.g.
acetaminophen 0.5g four times daily
 If pain, fever, and malaise are disabling a short course of NSAID
or a glucocorticoid such as prednisone 20mg three times daily for
7-10 days may be necessary to reduce the inflammation
 L-thyroxine is indicated during the hypothyroid phase of the
illness. 10% of the patients will require L-thyroxine long term
Other Forms of Thyrotoxicosis
 Thyrotoxicosis Factitia:
 Due to ingestion of excessive amounts of thyroxine
 RAI uptake is nil and serum thyroglobulin is low
 Struma Ovarii:
 Teratoma of the ovary with thyroid tissue that becomes hyperactive
 No goitre or eye signs. RAI uptake in neck is nil but body scan
reveals uptake of RAI in the pelvis.
 Hydatidiform mole:
 Chorionic gonadotropin is produced which has intrinsic TSH-like
activity.
 TSH-secreting pituitary adenoma:
 FT4 & FT3 is elevated but TSH is normal or elevated
 Visual field examination may reveal temporal defects, and CT or MRI
of the sella usually reveals a pituitary tumour.
Thyroid storm (Thyrotoxic crisis)
 Usually occurs in a severely hyperthyroid patient caused by a
precipitating event such as:
 Infection
 Surgical stress
 Stopping antithyroid medication in Graves’ disease
 Clinical clues
 fever hyperthermia
 marked anxiety or agitation coma
 Anorexia
 tachycardia tachyarrhythmias
 pulmonary edema/cardiac failure
 hypotension shock
 confusion
Thyroid storm (Thyrotoxic crisis)
 Initiate prompt therapy after free T4, free T3, and TSH drawn without
waiting for laboratory confirmation.
 Therapy
 1. General measures:
 Fluids, electrolytes and vasopressor agents should be used as
indicated
 A cooling blanket and acetaminophen can be used to treat the pyrexia
 Propranolol for beta–adrenergic blockade and in addition
causesdecreased peripheral conversion of T4T3 but watch for CHF.

 The IV dose is 1 mg/min until adequate beta-blockade has been achieved.

Concurrently, propranolol is given orally or via NG tube at a dose of 60 to 80
mg q4h
Thyroid storm (Thyrotoxic crisis)
 Therapy
 2. Specific Measures:
 PTU is the anti-thyroid drug of choice and is used in high doses: 1000 mg
of PTU should be given p.o. or be crushed and given via nasogastric
tube, followed by PTU 250mg p.o. q 6h. If PTU unavailable can give
methimazole 30mg p.o. every 6 hours.
 One hour after the loading dose of PTU is given –give iodide which
acutely inhibits release of thyroid hormone, i.e. Lugol’s solution 2-3 drops
q 8h OR potassium iodide (SSKI) 5 drops q 8h.
 Dexamethasone 2 mg IV q 6h for the first 24-48 hours lowers body
temperature and inhibits peripheral conversion of T4-T3
 With these measures the patient should improve dramatically in the first
24 hours.
 3. Identify and treat precipitating factor.
Nontoxic Goitre
 Enlargement of the thyroid gland from TSH stimulation which in turn
results from inadequate thyroid hormone synthesis
 Etiology:
 Iodine deficiency
 Goitrogen in the diet
 Hashimoto’s thyroiditis
 Subacute thyroiditis
 Inadequate hormone synthesis due to inherited defect in thyroidal
enzymes necessary for T4 and T3 biosynthesis
 Generalized resistance to thyroid hormone (rare)
 Neoplasm, benign or malignant
Nontoxic Goitre
 Symptoms and Signs:
 Thyroid enlargement, diffuse or multinodular
 Huge goitres may produce a positive Pemberton sign (facial flushing
and dilation of cervical veins on lifting the arms over the head) especially
when they extend inferiorly retrosternally
 Pressure symptoms in the neck with upward or downward movement of
the head
 Difficulty swallowing, rarely vocal cord paralysis
 Most pts are euthyroid but some are mildly hypothyroid
 RAI uptake and scan:
 Uptake may be normal, low, or high depending on the iodide pool
 Scan reveals patchy uptake with focal areas of increased and decreased
uptake corresponding to “hot” and “cold” nodules respectively
Management of Nontoxic Goitre
L-thyroxine suppressive therapy:
 Doses of 0.1 to 0.2mg daily is required
 Aim is to suppress TSH to 0.1-0.4 microU/L (N 0.5-5)
Suppression therapy works in 50% of cases if continued
for 1 year
If suppression does not work or if there are obstructive
symptoms from the start then surgery is necessary
Benign Thyroid Nodules
 Thyroid nodules are common especially among older women
 Etiology:
 Focal thyroiditis
 Dominant portion of multinodular goitre
 Thyroid, parathyroid, or thyroglossal cysts
 Agenesis of a thyroid lobe
 Postsurgical remnant hyperplasia or scarring
 Postradioiodine remnant hyperplasia
 Benign adenomas:
 Follicular
 Colloid or macrofollicular
 Hurthle cell
 Embryonal
 Rare: Teratoma, lipoma, hemangioma
Thyroid Cancer
Approximate frequency of malignant thyroid tumours

Papillary carcinoma (including mixed papillary 75%

and follicular
Follicular carcinoma 16%

Medullary Carcinoma 5%

Undifferentiated carcinomas 3%

Miscellaneous (e.g. lymphoma, fibrosarcoma, 1%

squamous cell ca, teratoma, & metastatic ca)
Papillary Carcinoma
 Usually presents as a nodule that is firm, solitary, “cold” on isotope
scan, and usually solid on thyroid US
 In MNG, the cancer is usually a “dominant nodule” that is larger,
firmer and different from the rest of the gland
 10% of papillary ca present with enlarged cervical nodes
 Grows very slowly and remains confined to the thyroid gland and
local lymph nodes for many years.
 In later stages they can spread to the lung
 Death usually from local disease or lung metastases
 May convert to undifferentiated carcinoma
 Many of these tumours secrete thyroglobulin which can be used as a
marker for recurrence or metastasis of the cancer
Follicular Carcinoma
 Differs from follicular adenoma by the presence of capsular or
vascular invasion
 More aggressive than papillary ca and can spread either by local
invasion of lymph nodes or by blood vessel invasion with distant
metastases to bone or lung
 Death is due to local extension or to distant bloodstream metastasis
with extensive involvement of bone, lungs & viscera
 These tumours often retain the ability to concentrate RAI
 A variant of follicular carcinoma is the “Hurthle cell” carcinoma.
These tumours behave like follicular cancer except that they rarely
take up RAI
 Thyroglobulin secretion by follicular carcinoma can be used to follow
the course of the disease
Management of Papillary and Follicular
Carcinoma
 Patients are classified into low risk and high risk groups
 The low risk group includes patients under age 45 with primary
lesions under 1cm and no evidence of intra- or extraglandular
spread. Lobectomy is adequate therapy for these patients.
 All other patients are considered high risk and require total
thyroidectomy. Modified neck dissection is indicated if there is
lymphatic spread.
 Surgery is usually followed by RAI ablation therapy
 Patient is placed on L-thyroxine suppressive therapy
 Regular F/U with thyroglobulin level, thyroid US, whole body scan
etc.
Medullary Carcinoma
 A disease of the C cells (parafollicular cells)
 More aggressive than papillary or follicular carcinoma but not as aggressive
as undifferentiated thyroid cancer
 It extends locally, and may invade lymphatics and blood vessels
 Calcitonin and CEA are clinically useful markers for DX and F/U
 80% of medullary ca are sporadic and the rest are familial. There are 4
familial patterns:
 FMTC without endocrine disease
 MEN 2A: medullary ca + pheochromocytoma + hyperparathyroidism
 MEN 2B: medullary ca + pheochromocytoma + multiple mucosal neuromas
 MEN 2 with cutaneous lichen amyloidosis
 The familial syndromes are associated with mutations in the ret proto-
oncogene (a receptor protein kinase gene on chrom. 10)
 Dx is by FNA bx. Pt needs to be screened for other endocrine abnormalities
found in MEN 2. Family members need to be screened for medullary ca and
MEN 2 as well.
Undifferentiated (Anaplastic) Carcinoma
 This tumour usually occurs in older patients with a long history of
goitre in whom the gland suddenly—over weeks or months—begins
to enlarge and produce pressure symptoms, dysphagia, or vocal
cord paralysis.
 Death from massive local extension usually occurs within 6-36
months
 These tumours are very resistant to therapy