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Dr Bashir Ahmed Dar
Associate Professor Medicine
Chinkipora Sopore Kashmir
Email:  drbashir123@gmail. com
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Note

* This slide presentation on hyperthyroidism
is divided into two parts. Part-1 deals with
causes of hyperthyroidism....
Note

* You just try and ask yourself how much you

know about causes of hyperthyroidism.  The
answer sure will come i don...
Note

° Part-2 deals with signs , symptoms and

treatment and is also uploaded on
slideshare

° Treatment part in part -2 ...
Types of normal thyroid cells

Normal thyroid contains following
cells

1. Follicular cells

2. C cells

Other less common...
Primary,  Secondary and Tertiary Hypothyroidism or Hyperthyroidism

I

Hyperthyroidism or Hyperthyroidism or
Tertiary h; ....
E.   i_. 

l”

. l Primary Hyperthyroidism

    
   
     

 , ‘ T’ ’ This is

due to pathology 
within the
thyroid gland
90% of cases
are due to
thyroid
adenoma
which may
be benign or
malignant

~__a. . . ._. .
Primary Hyperthyroidism
ll? ”

 
 
      
 

  

An adenoma is a part of the

4 gland that has walled itself off
from the rest of the gland
_i' A single nodule responsible for
 the excess hormone secretion,  is
  called a "hot" nodule
‘r: ""Is>. .‘: ;—» H
c!  ~«...
Primary Hyperthyroidism
ll  Primary Hyperthyroidisrnclue to

. .‘«‘

Plummer's disease

H ‘ ,5  Plummer's disease

‘I ~ 5 ac‘.   V is named after ...
Primary Hyperthyroidism due t. o
Plummer's disease

Plummer disease,  also

called toxic multinodular
goitre,  having firm...
Primary Hyperthyroidism  to
Plummer's disease

   

Plummer disease,  which Its symptoms resemble
usually occurs in older
...
Primary Hyperthyroidism due to
Plummer's disease

° Typically,  persons affected by Plummer
disease develop a goitre many ...
iPr‘imary Hyperthyroidism due to

 

Plummer's disease

llnlike Graves disease
Plummer disease seldom
causes bulging of th...
Primary Hyperthyroidism due to

Plummer's disease

 

° A single nodule may become toxic and
produce excess hormones with ...
-: 
l

l Plummer's disease without eyesignsul
I or exophthalrnos

 

.  . i ~

‘ '.  .’ -i-'; --—. —.-

' S’ 1 "i2‘~'. -‘....
Primary Hyperthyroidism due to

 

Graves’ Disease

° Graves‘ disease.  Graves’ disease,  an
autoimmune disorder in which ...
ll,   Primaryl-lyperthyrcndism clue to
Graves’ Disease

l  . . Normally,  your immune

.  _   V’  system uses antibodies t...
Primary Hyperthyroidism  to
‘l Graves’ Disease

 
 
  

  
  
   
   
   

l In Graves‘ disease,  antibodies
j yo i: ..; ....
The Pathogenesis Of Graves Disease

Acivded B-col: 

GRAVES DISEASE

/ 
I
.  I I:  lNCREA8ED svimimo ADRENEPGIC ACTIVITY
a...
Primary Hyperthyroidism due to
infections ofth roid gland

- Primary hyperthyroidism can result due to
Infection of thyroi...
Primary Hyperthyroidism due to
infections of thyroid gland

Infectious thyroiditis especially acute
one is called Suppurat...
Primary Hyperthyroidisrn  to

       
   
   
     
     

  infections of thyroid gland

$, fl}; .__¢£L‘fl 1% J 1'  One th...
Primary Hyperthyroidism  to

  infections of thyroid gland

 V -:  1. rf  .1  Later there may be fibrosis
"  " and damage a...
.. .‘/ 

ll  Primary Hyperthyroidismldue to
ii p infections of thyroid gland

 Therefore one can see all three phases in t...
Acute Suppurative thyroiditis

 

° The thyroid gland is relatively resistant to
infections because of high concentration ...
Acute Suppurative thyroiditis

  
 

Acute Suppurative thyroiditis occur
due to following infections

    
 
   

  

Vira...
Acute Suppurative thyroiditis

Bacterial : 
Staphylococcal
Streptococcal
Enterobacterial
Mycobacterial -TB
Acute Suppurative thyroiditis

 

 Fungal: 
, / ‘V’ / -”, -.7;-': '-1

«, :4«’ Aspergillus
A‘ _, ,*'7"  Candida
:2. _ *
 i...
° In infective Suppurative thyroiditis the

symptoms and signs will be
- Swollen or enlarged gland
° Hot
° Tender

° Red

...
— ——~———‘r

 ——j——————jj—————
l Acute Suppurative thyroiditis

,3} : .. . -.. — . .
i

H, -<1 s
Histology of thyroid
shows infiltration
neutrophils, 
lymphocytes and
possibly micro
abscesses and tissue
necrosis
Sub Acute Thyroiditis

    

l-lave three types

Subacute painless lymphocytic thyroiditis I

Subacute painless postpartum...
Sub Acute Thyroiditis

 

- The two of these are named painless because
there are no symptoms or signs of thyroid
inflammat...
Si1l)a<‘i1lc 1*amtu1 'llm‘ni(l1tls ()1 DC

  

Qiicnraiirs (; l'£Llllll()lll£1.l()lIS Tliyioitlitis

° Usually viral etiol...
it De Quervain's thyroiditis is not associated
with autoimmune thyroiditis.
Si1l)a<‘11lc Painful 'llm‘ni(l1tls ()1 DC

  

(. )11c,1’'aii1's (; l‘£1ll11l()lll2ll()lIS 'lll1y1‘0i(litis

° The transie...
Slll); ?l(‘1ll(‘ Paniful 'l'lm‘ni(l1tls 01 De

   

Q1a1cn'ai11's (lrzimiloiiiatoiis 'l‘l1ymi(lilis

- But these anti bodi...
Slll); ?l(‘1ll(‘ Paniful 'l'lm‘ni(l1tls 01 De

Q1a1cn'ai11's (lrzimiloiiiatoiis 'l‘l1ymi(lilis

° It is unclear,  however,...
* Subacute painful thyroiditis or de
Quervain's thyroiditis is a self-limited but
painful disorder of the thyroid.  Physic...
Slll); ?l(‘1ll(‘ Paniful 'l'lm‘ni(l1tls 01 De

Q1a1cn'ai11's (lrzimiloiiiatoiis Tliymitlilis

- De Quervain's thyroiditis ...
Si1l)a<‘11lc Painful 'llm‘ni(l1tls ()1 DC

    

Q11ci’'aii1's (; l‘11ll11l()lll£ll()lIS 'lll1yT0i(litis

° Very occasiona...
Subacute Silent Painless

: . Z;  -
‘Z

  Lymphocytic Thyroiditis

    

° This type of thyroiditis is called "silent"
bec...
_ ,  Lymphocytic Thyroiditis

  

,  if ll We call it lymphocytic thyroiditis

  

Subacute Silent Painless

~.  because t...
Subacute Silent Painless Lymphocytic
Thyroiditis

Like in all other subacute forms of
thyroiditis
A ‘5
I

 

A Subacute Silent Painless Lyniphocytic 
Tl"iyi‘oiditis

Thus is very similar to
post-partum thyroiditis, 
but ...
Subacute.  Silent Painless l. yi11plioc}1ic

 

'll13i‘oi(litis

° As i said auto-immune

° An HLA association may be pres...
* Like postpartum thyroiditis,  there may be a
phase of high thyroid hormone levels

(thyrotoxicosis),  causing symptoms o...
)arute .1 en!   es

 
 

. )l1oc tic 'l‘l1'roi(lilis

° If low thyroid hormone levels are causing

severe symptoms,  you m...
t! .,-- . g__m, _ _ “ , ;_4  _
lift Subacute Silent Painless Lyinpliiocync

fl] Thyroiditis

 
     
     
 

I

  

__  7...
RAIU TEST

The patient swallows
radioactive iodine in the
form of capsule or fluid, 

I and its absorption by the
thyroid i...
RAIU TEST

Normal Results of
RAIU

6 hours:  3 - 16%
RAIU TEST

- Some testing centers only measure at 24
hours.  Values may vary depending on the
amount of iodine in your die...
’t  J ; 

   Toxic nodular goiter 
I :15; '11.. -*. "i"  E ’
I’.   (WW,   _ g 

I

 

*<{'
Uptake may be

concentrated into
a few (hot) areas

while the rest of

the thyroid gland
does not take up

any iodine (col...
l'lj. 'UlL' 7 l'utcnti. nl Rutliu-: imlidc . . ‘;In I lI| Ll| l‘. f.: ‘
: n llitlixztlimls Ill .1 lilnnml . 'mlulc
COLD NODULE

HOT NODULE

pyramidal

lobe 

GRAVE DISEASE

suppression of
reminder of gland

‘O

AUTONOMOUS NODULE

hot and...
RAIU TEST

- Lower-than-normal uptake may be due to
° Factitious hyperthyroidism
° Iodine overload

° Subacute silent pain...
RAIU TEST

° Subacute Silent (or painless) post partum
thyroiditis
° Drug induced thyroiditis
° Fibrous or Riedel‘s thyroi...
IO
.  .
~.  -__. __. _r .9;

  Si1bacuteSile11t;  Painless ‘FOS'l‘. p211‘ll.111'1,—
Tliyroiditis

  
      
   
   
    

...
Siibaciite Silent Painless l’ostpa1'tn1n

   

'lli}Toi<litis

° Like Hashimoto’s thyroiditis,  post-partum
thyroiditis is...
Siibarnte Silent Painless l’ostpa1'tnni

  

'lli3i‘oitlitis

° There is a suggestion that silent thyroiditis
is an autoim...
II  Subacute Silent Painless Post: partuin“ 
I

Thyroiditis

-yg. 
I

   
 

I I
I

Thyroid biopsy reveals lymphocytic
inf...
Siibarnte Silent Painless l’ostpa1'tnni

   

'lli3i‘oitlitis

° Thyroid peroxidase auto antibodies and, 
less commonly,  ...
Suhaciite Silent Painless l’ostpa1'tni1i

  

'lli3i‘0itlitis

° About8 percent of women who have been
pregnant develop po...
Siibarnte Silent Painless l’ostpa1'tnni

   

'lli}i‘oi<litis

° The condition is likely to recur with future
pregnancies....
Siibaciite Silent Painless l’ostpa1'tn1n
'lli}Toi<litis

   

- In some women,  the gland does not heal and
hormone levels...
Subaciite Silent Painless l’ostpa1'tni1i

   

'lli3i‘0itlitis

° 1 mean to say again that in post-partum
thyroiditis,  yo...
Subaciite Silent Painless l’ostpa1'tni1i

   

'lli3i‘0itlitis

° Then,  after a few weeks,  your thyroid gland
becomes de...
Suhaciite Silent Painless l’ostpa1'tni1i

   

'lli3i‘0itlitis

° Here also if low thyroid hormone levels are
causing seve...
Suliacute Silent Painless l’ostpa1'ti111i

 

'll1}1‘oitlitis

0 Cigarette smoking is also associatedwith.  an
increased i...
Suhaciite Silent Painless l’ostpa1'tni1i

   

'lli3i‘0itlitis

° Both of these painless thyroiditis entities
can be consi...
ll  Chronic Lymphocytic Thyroiditis or‘
l Hashimoto's Thyroiditis

   
       
      

  

It was the first disease to be
...
ll  Chronic Lymphocytic Thyroiditislordl

i
3

Hashimoto's Thyroiditis
'  v   Hashimoto's disease is about seven
‘ ‘ n tim...
J‘  Chronic Lympliokcg/ ktic. Tl1yroiditisor’
T ' Hashimoto's Thyroiditis

  

 

l;  The main problem in

H  this disorde...
J‘  Chronic Lympl1okc:3/ktic. Tl1yroiditisor’
' Hashimoto's Thyroiditis

 
 
   
  

  
 
   
      

.  V’  The T cells a...
Chronic Lymphocytic Throiditis or

Hashimoto's Th roiditis

 

° The most sensitive and specific of these
antibodies is ant...
Chronic Lymphocyic Thyroiditis or
Hashimoto's Th roiditis

   

° Anti-thyroid peroxidase (previously called
antimicrosoma...
ll  Chronic Lymphocytic Thyroiditis or“
7 Hashimoto's Thyroiditis

   

fa

H J‘ Note--TSH antibodies block the TSH

I, 
'...
Chronic Lymphocytic Thyroiditis or

 

Hashimoto's Th roiditis

- The thyroid gland may become firm or often
hard large,  ...
Chronic Lymphocytic Thyroiditis or
Hashimoto's Thyroiditis

In some cases,  the enlargement is

multinodular and may even ...
‘L -1* K "”” _  nodule composed of

 ~ ‘ s .    hyperplastic follicles. 
  .  El Note the lymphocytic

    
 
    
   
  
...
Chronic  .  ~ phoc,  }i' Thyroiditis or
Hashimoto's )Thyroiditis

, .
(y’§‘. , § When such dominant nodules
are composed o...
lliirthle cells are characterized as
enlarged epithelial cells with
abundant cosinophilic granular
cytoplasm as a result o...
l T .  

 
     

  
  

The thyroid gland may
ecome firm or often hard

large,  and lobulated not
painful to touch in

Has...
Grossly,  most cases of Hashimoto thyroiditis shows
diffuse and symmetric enlargement of the thyroid. 
The cut surface is ...
Chronic Lymphocytic Thyroiditis or

llnlargementof the thyroid is due
to lymphocytic infiltration

That may lead to fibrosi...
ll  Chronic Ly1npl1ocytioThyroiditis or if
Hashimoto's Thyroiditis
 The goitre of Hashimoto's thyroiditis may remain

unch...
Gross morphological changes within the
thyroid are seen in the general enlargement
which is far morelocally nodular and
ir...
l -. -E, ‘'.  L 'r_. T‘*_»‘a
Q3 ‘ . . =  

       
     
     

lymphocytes seen as
hypersensitivity reaction ‘

 -g  Hist...
Chronic Lymphocytic Thyroiditis or
Hashim to's T yroiditis

  
  
       

   
 

. .., v_---vv ,  u v . ., ».  vv
.  '4 u...
is

This image shows a large
lymphoid follicle with
prominent germinal center.  It
surrounded by small atrophic
thyroid fo...
Chronic Lymphocytic Thyroiditis or
Hashimoto's Thyroiditis

° Thus these accumulated Lymphocytes make

the antibodies that...
Chronic Lymphocytic Thyroiditis or
Hashimoto's Thyroiditis

* Atrophy of the colloid bodies is now not
lined by cuboidal e...
Chronic Lymphocytic Thyroiditis or
Hashimoto's Thyroiditis

° Severe thyroid atrophy presents often with
denser fibrotic b...
Chronic Lymphocytic Thyroiditis or
Hashimoto's Thyroiditis

* Antibodies are formed against thyroid
peroxidase & thyroglob...
Chronic Lymphocytic Thyroiditis or
Hashimoto's Thyroiditis

4* Diagnosis is usually made by detecting these
elevated level...
Chronic Lymphocytic Thyroiditis or
Hashimoto's Thyroiditis

* A rare but serious complication of thyroid
infiltration of l...
Chronic Lymphocytic Thyroiditis or
Hashimoto's Thyroiditis

° Preventable environmental factors, 
including high iodine in...
Chronic Lymphocytic Thyroiditis or
Hashimoto's Thyroiditis

° The genes implicated vary in different
ethnic groups and the...
Chronic Lymphocytic Thyroiditis or
Hashimoto's Thyroiditis

* Transient periods of thyrotoxicosis and
hypothyroidism somet...
Associations of
Hashimoto's thyroiditis

Hashimoto's thyroiditis and
hypothyroidism are associated with
other autoimmune c...
Associations of
Hashimoto's thyroiditis

Chronic active hepatitis

Polymyalgia rheumatica and giant cell arteritis
Primary...
Chronic Thyroiditis or Hashimoto's
Thyroiditis

° Hashimoto's typically involves a slow but
steady destruction of the glan...
Chronic Thyroiditis or Hashimoto's
Thyroiditis

* This cycling back and forth between

hypothyroidism and hyperthyroidism ...
Chronic Thyroiditis or Hashimoto's
Thyroiditis

* Hashimoto's when presenting as mania is
known as Prasad's syndrome after...
Chronic Thyroiditis or Hashimoto's
Thyroiditis
* Imaging tests/ Ultrasonogram

s This imaging modality is useful for
asses...
Chronic Thyroiditis or Hashimoto's
Thyroiditis

S Surgery/ Indications for surgery include the

following: 

A large goite...
Chronic Thyroiditis or Hashimoto's
Thyroiditis

* CT scan- to show a goiter's effect on nearby
structures. 

e Radioactive...
Chronic Thyroiditis or Hashimoto's
Thyroiditis

° Pharmacological

° Thyroid hormone replacement- orally
administered levo...
Chronic Thyroiditis or Hashimoto's
Thyroiditis

* Patients who are older than 50 years (and
younger patients with cardiac ...
Chronic Thyroiditis or Hashimoto's
Thyroiditis

* Prognosis

* With early diagnosis and levothyroxine
replacement therapy,...
Chronic Thyroiditis or Hashimoto's
Thyroiditis

* While you may improve in many ways
within a week,  the full impact of th...
Chronic Thyroiditis or Hashimoto's
Thyroiditis

° For example,  skin changes may take up to 3-
6 months to resolve. 

° Be...
Chronic Thyroiditis or Hashimoto's
Thyroiditis
* In the event that hypothyroidism is caused
by Hashimoto's thyroiditis,  i...
Differences Between Graves and Hashimotos

   

Gcnefic jaczogs EnVif°nfl1C| 'ua' '3C‘0($

Mumocal and euula:  immunity

/  ...
Differences Between Graves and
Hashimotos

4* In other words Hashimotos commonly
present with hypothyroidism but that does...
Riedel‘s thyroiditis

* Riedel‘s thyroiditis (also known as fibrous
thyroiditis) is a rare condition characterized
by an e...
Riedel‘s thyroiditis

* It may be associated with a diffuse fibrotic
process affecting multiple tissues
(idiopathic multif...
Additional causes of thyroiditis

* Drug-induced thyroiditis like amidarone, 
lithium and radioactive iodine etc
Additional causes of thyroiditis

° Radioactive iodine treatment for overactive
thyroid gland or radiotherapy for certain
...
Additional causes of thyroiditis

* The low levels of thyroid hormone after
radioactive iodine is usually permanent,  and
...
Primary Hyperthyroidism Due to
Congenital Causes
° Mutations ofTSH receptors may occur and
are
° Activating mutation of th...
Primary Hyperthyroidism Due to
Congenital Causes

* Mutations of the thyrotropin receptor
(TSHr) can be loss of function o...
Primary Hyperthyroidism Due to
Congenital Causes

° Rarely,  hyperthyroidism may be caused by
genetic mutations in the TSH...
Primary Hyperthyroidism Due to
Congenital Causes

° McCune-Albrightsyndrome

° Hyperthyroidism associated with McCune-
Alb...
-t

Neonatal Hyperthyroidism

Also called as
Fetal Graves Hyperthyroidism
Postpartum Hyperthyroidism

It is transient hype...
Neonatal Hyperthyroidism

° Rarely,  a newborn may have
hyperthyroidism,  or neonatal Graves’
disease.  This condition usu...
Neonatal Hyperthyroidism

4* In Graves’ disease (Autoimmune Disorders
During Pregnancy),  the mother's body
produces antib...
Neonatal Hyperthyroidism

4 The reason these babies are at risk is that
antibodies in the mother's bloodstream, 
called th...
Neonatal Hyperthyroidism

4 The higher these antibody levels in the
mother,  the higher the risk of
hyperthyroidism in the...
Neonatal Hyperthyroidism

4 Congenital thyrotoxicosis is due to the

passage from the mother to the foetus of
maternal imm...
Secondary Hyperthyroidism due to Growths
(Adenomas) of pituitary gland or hypothalamus

4 Excess secretion of Thyrotropin-...
Secondary Hyperthyroidism due to Growths
(Adenomas) of pituitary gland or hypothalamus

4 TRH can also be detected in othe...
Secondary Hyperthyroidism due to Growths
(Adenomas) of pituitary gland or hypothalamus

4 Continuous excess secretion of T...
Hyperthyroidism due to Pituitary resistance to T4 8; T3
without any adenoma in hypothalamus or pituitary

4 It is characte...
Hyperthyroidism due to Pituitary resistance to T4 & T3
without any adenoma in hypothalamus or pituitary

° Thyroid hormone...
Secondary Hyperthyroidism due
Struma Ovarii

* Struma ovarii is a rare ovarian tumor
defined by the presence of thyroid ti...
Secondary Hyperthyroidism due
Struma Ovarii
* The symptoms of struma ovarii are similar

to other ovarian tumors plus ther...
Secondary Hyperthyroidism due Struma
Ovarii

* The tumor can be characterized by
radiological imaging;  however,  the fina...
Secondary Hyperthyroidism due to Chronic
Gonadotropin-Secreting Tumors

* There is abundant evidence that human
chorionic ...
Secondary Hyperthyroidism due to
Chronic Gonadotropin-Secreting Tumors

 Also called Gestational thyrotoxicosis when
witho...
Secondary Hyperthyroidism due to
Chronic Gonadotropin-Secreting Tumors

* There is abundant evidence that human
chorionic ...
Secondary Hyperthyroidism due to
Chronic Gonadotropin-Secreting Tumors

* During early pregnancy,  secretion of the
placen...
Secondary Hyperthyroidism due to
Chronic Gonadotropin-Secreting Tumors

* Elevations of hCG are particularly
pronounced in...
Secondary Hyperthyroidism due to
Chronic Gonadotropin-Secreting Tumors

* HCG-induced gestational hyperthyroidism
without ...
-t

Drug induced thyroiditis

Due to

Interferon
Amiodarone
Lithium

Radiation thyroiditis

Trauma to thyroid even excessi...
° Exogenous thyroid hormone

° Iodine-induced hyperthyroidism (ie,  lod-
Basedow phenomenon)

° Eating too much of foods t...
Causes of elevated serum thyroxine concentrations
Thyrotoxicosis

Increased Serum protein
binding

Increased serum thyroxi...
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HYPERTHYROIDISM PART-1 BY DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR
HYPERTHYROIDISM PART-1 BY DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR
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HYPERTHYROIDISM PART-1 BY DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR

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This slide presentation on hyperthyroidism is divided into two parts.Part-1 deals with causes of hyperthyroidism.I have tried to explain and give clear understanding about the causes of hyperthyroidism which to my knowledge is made very simple and easily understandable.

Part-2 deals with signs symptoms and treatment.Treatment part has been explained in detail.I hope you will enjoy reading it.

Publicado en: Salud y medicina
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HYPERTHYROIDISM PART-1 BY DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR

  1. 1. Dr Bashir Ahmed Dar Associate Professor Medicine Chinkipora Sopore Kashmir Email: drbashir123@gmail. com
  2. 2. .. _ _ . x . . it I) / u . . .2, . : . L A . .. . .. z .7. . ,
  3. 3. Note * This slide presentation on hyperthyroidism is divided into two parts. Part-1 deals with causes of hyperthyroidism. I have tried to explain and give clear understanding about the causes of hyperthyroidism which to my knowledge is made very simple and easily understandable.
  4. 4. Note * You just try and ask yourself how much you know about causes of hyperthyroidism. The answer sure will come i don't know. ~* Please read this slide and see how much difference it will bring in your understanding.
  5. 5. Note ° Part-2 deals with signs , symptoms and treatment and is also uploaded on slideshare ° Treatment part in part -2 slide has been explained in detail. I hope you will enjoy reading both the slides
  6. 6. Types of normal thyroid cells Normal thyroid contains following cells 1. Follicular cells 2. C cells Other less common cells in the thyroid gland include immune system cells (lymphocytes) and supportive (stromal) cells
  7. 7. Primary, Secondary and Tertiary Hypothyroidism or Hyperthyroidism I Hyperthyroidism or Hyperthyroidism or Tertiary h; .'p~: tli~, ioid%sm Secondary tiypolhi, -rc'd: sm' Hyperthyroidism or , Pmiar; hypothi'ic: dism Disease of the twp: -tha'arr: us Dlsease c. ‘ the p: tuitar, ' gseage or me iimogd Hypolhalarr. -us l. '.al<es TRH: Tesis Pitutary to l. la! <e TSH
  8. 8. E. i_. l” . l Primary Hyperthyroidism , ‘ T’ ’ This is due to pathology within the thyroid gland
  9. 9. 90% of cases are due to thyroid adenoma which may be benign or malignant ~__a. . . ._. .
  10. 10. Primary Hyperthyroidism
  11. 11. ll? ” An adenoma is a part of the 4 gland that has walled itself off from the rest of the gland
  12. 12. _i' A single nodule responsible for the excess hormone secretion, is called a "hot" nodule ‘r: ""Is>. .‘: ;—» H c! ~«— 3*“ ' I Palpable nodules are generally > 1 cm. Multiple nodules suggest benign multinodular goiter
  13. 13. Primary Hyperthyroidism
  14. 14. ll Primary Hyperthyroidisrnclue to . .‘«‘ Plummer's disease H ‘ ,5 Plummer's disease ‘I ~ 5 ac‘. V is named after the j_ , American . l physician Henry ; 1 Stanley Plummer
  15. 15. Primary Hyperthyroidism due t. o Plummer's disease Plummer disease, also called toxic multinodular goitre, having firm thyroid nodules, and overproduction of thyroid hormone -hyperthyroidism
  16. 16. Primary Hyperthyroidism to Plummer's disease Plummer disease, which Its symptoms resemble usually occurs in older people, is of unknown with swelling of the thyroid gland those of hyperthyroidism '
  17. 17. Primary Hyperthyroidism due to Plummer's disease ° Typically, persons affected by Plummer disease develop a goitre many years before the onset of symptoms of hyperthyroidism ° Most patients are over age 50 before the characteristic accelerated heart rate and other cardiac conditions appear
  18. 18. iPr‘imary Hyperthyroidism due to Plummer's disease llnlike Graves disease Plummer disease seldom causes bulging of the eyes or exophthalmos
  19. 19. Primary Hyperthyroidism due to Plummer's disease ° A single nodule may become toxic and produce excess hormones with background of other suppressed multiple nodules in a multinodular goiter
  20. 20. -: l l Plummer's disease without eyesignsul I or exophthalrnos . . i ~ ‘ '. .’ -i-'; --—. —.- ' S’ 1 "i2‘~'. -‘. ‘- ‘t — ‘ . '*s. ..‘. . __ l h ‘J '13-‘- I‘ ti —— _t’-f-; _r—_<. **:
  21. 21. Primary Hyperthyroidism due to Graves’ Disease ° Graves‘ disease. Graves’ disease, an autoimmune disorder in which antibodies produced by your immune system stimulate your thyroid to produce too much T-4, is the most common cause of hyperthyroidism
  22. 22. ll, Primaryl-lyperthyrcndism clue to Graves’ Disease l . . Normally, your immune . _ V’ system uses antibodies to H help protect against ‘~ lg. -1 S viruses, bacteria and l other foreign substances that invade your body I I 1-. V-‘9 ‘ . . . - , _-‘ ~' , ,, , ., j i , l I I . I. l ’ l
  23. 23. Primary Hyperthyroidism to ‘l Graves’ Disease l In Graves‘ disease, antibodies j yo i: ..; . _ mistakenly attackyour thyroid ‘ * H. “' and occasionally attack the * tissue behind your eyes (Graves' I ‘I ‘ ophthalrnopathy) and the skin, often in your lower legs over the i shins (Graves' derrnopathy)
  24. 24. The Pathogenesis Of Graves Disease Acivded B-col: GRAVES DISEASE / I . I I: lNCREA8ED svimimo ADRENEPGIC ACTIVITY a ueueouc mt: . WM. Aniooaios siiimiaie swmmdm . D 1 T3" . "team Ex whlatrus 1 Ho" Tn‘ » on waimpumrng gone TICIIVC-33$
  25. 25. Primary Hyperthyroidism due to infections ofth roid gland - Primary hyperthyroidism can result due to Infection of thyroid gland resulting in thyroiditis that causes leak of thyroxine hormone in blood due to damage of thyroid tissue and vessels.
  26. 26. Primary Hyperthyroidism due to infections of thyroid gland Infectious thyroiditis especially acute one is called Suppurative thyroiditis. Thyroiditis is classified as
  27. 27. Primary Hyperthyroidisrn to infections of thyroid gland $, fl}; .__¢£L‘fl 1% J 1' One thing should be taken note of ‘ that in any infection of thyroid at ' ~‘-: _: 1 A, . gland the thyroxine or ° ‘ll thyroglobulin may leak into blood circulation due to damage of thyroid tissue and thyroid vessels This usually happens during early periods of infection
  28. 28. Primary Hyperthyroidism to infections of thyroid gland V -: 1. rf .1 Later there may be fibrosis " " and damage and destruction of thyroid cells as well as depletion of colloid due to leakage leading to hypothyroidism , ,r"°’ If regeneration and healing l of thyroid cells take place then there will be it euthyroid-normal thyroid N , State
  29. 29. .. .‘/ ll Primary Hyperthyroidismldue to ii p infections of thyroid gland Therefore one can see all three phases in thyroiditis I -1.. f _ _, —- ~ ———, , — s, , T—, , x''' owever ISIS not necessary t at one may notice a l, three phases or you may see only one or only two or all _ the three phases __ _
  30. 30. Acute Suppurative thyroiditis ° The thyroid gland is relatively resistant to infections because of high concentration of antiseptic iodine in it with ample supply of blood and lymphatics, and the anatomical isolation of the gland from other neck structures
  31. 31. Acute Suppurative thyroiditis Acute Suppurative thyroiditis occur due to following infections Viral ---including mumps, measles, influenza, infectious mononucleosis, adenoviral or Coxsackie virus infections, following the common cold
  32. 32. Acute Suppurative thyroiditis Bacterial : Staphylococcal Streptococcal Enterobacterial Mycobacterial -TB
  33. 33. Acute Suppurative thyroiditis Fungal: , / ‘V’ / -”, -.7;-': '-1 «, :4«’ Aspergillus A‘ _, ,*'7" Candida :2. _ * inf g Histoplasma , , r" A Pneumocystis ll ‘T’ /1 i, it I fr ’. i~, .-’ Parasitic: Echinococcosis, cysticercosis , ,, " | I ‘ I‘ l N t‘ i ll. ' / '1 ‘ 1". ‘- li . ‘ ‘Ki: ‘K ‘x ‘f'_ 53"‘ V x, xx, Q, -~ . . “ ‘~ “Li ‘ ~‘ . _: ‘ ": _‘~. f 5
  34. 34. ° In infective Suppurative thyroiditis the symptoms and signs will be - Swollen or enlarged gland ° Hot ° Tender ° Red ° With may be fever , rigo and chills
  35. 35. — ——~———‘r ——j——————jj————— l Acute Suppurative thyroiditis ,3} : .. . -.. — . . i H, -<1 s
  36. 36. Histology of thyroid shows infiltration neutrophils, lymphocytes and possibly micro abscesses and tissue necrosis
  37. 37. Sub Acute Thyroiditis l-lave three types Subacute painless lymphocytic thyroiditis I Subacute painless postpartum thyroiditis . ..’ Subacute painful thyroiditis or de i 5 Quervain's thyroiditis ,
  38. 38. Sub Acute Thyroiditis - The two of these are named painless because there are no symptoms or signs of thyroid inflammation ° Although the etiology appears to be different for the 3 subtypes, the clinical courses and histology in the form of lymphocyte infiltrations are the same - Recognizing these conditions is important; because it is self-limiting and no specific treatment may be required
  39. 39. Si1l)a<‘i1lc 1*amtu1 'llm‘ni(l1tls ()1 DC Qiicnraiirs (; l'£Llllll()lll£1.l()lIS Tliyioitlitis ° Usually viral etiology. ° Episodes usually follow upper respiratory infections associated with various viruses, includinginfluenza, adenovirus, mumps, HlNl influenza and coxsackievirus.
  40. 40. it De Quervain's thyroiditis is not associated with autoimmune thyroiditis.
  41. 41. Si1l)a<‘11lc Painful 'llm‘ni(l1tls ()1 DC (. )11c,1’'aii1's (; l‘£1ll11l()lll2ll()lIS 'lll1y1‘0i(litis ° The transient presence of auto antibodies that bind to TSH and block the thyroid stimulation, or thyroid anti microsomal (thyroid peroxidase) antibodies and thyroglobulin antibodies has been noted in the acute phase of this disease
  42. 42. Slll); ?l(‘1ll(‘ Paniful 'l'lm‘ni(l1tls 01 De Q1a1cn'ai11's (lrzimiloiiiatoiis 'l‘l1ymi(lilis - But these anti bodies have been attributed to a virally induced autoimmune response and has not been implicated in the pathologic process. - Serum thyroid auto antibodies and thyroglobulin and microsomal anti bodies may be present
  43. 43. Slll); ?l(‘1ll(‘ Paniful 'l'lm‘ni(l1tls 01 De Q1a1cn'ai11's (lrzimiloiiiatoiis 'l‘l1ymi(lilis ° It is unclear, however, whether the destructive thyroiditis in De Quervain's patients is caused by direct viral infection of the gland or by the host's response to the viral infection ° As it is very hard to find viral particles in thyroid gland
  44. 44. * Subacute painful thyroiditis or de Quervain's thyroiditis is a self-limited but painful disorder of the thyroid. Physical examination, elevated erythrocyte sedimentation rate, elevated thyro globulin level and depressed radioactive iodine uptake (RAIU) confirm the diagnosis
  45. 45. Slll); ?l(‘1ll(‘ Paniful 'l'lm‘ni(l1tls 01 De Q1a1cn'ai11's (lrzimiloiiiatoiis Tliymitlilis - De Quervain's thyroiditis usually causes a fever and pain in the neck, jaw or ear. It can also cause your thyroid gland to release too much thyroid hormone into the blood leading to symptoms of an overactive thyroid gland - hyperthyroidism ° Then often followed by a spell of hypothyroidism lasting a few weeks or months, before the thyroid gland recovers completely.
  46. 46. Si1l)a<‘11lc Painful 'llm‘ni(l1tls ()1 DC Q11ci’'aii1's (; l‘11ll11l()lll£ll()lIS 'lll1yT0i(litis ° Very occasionally, the condition may recur or the low levels of thyroid hormones caused by it can be permanent and may require long-term treatment with thyroid hormone replacement medication
  47. 47. Subacute Silent Painless : . Z; - ‘Z Lymphocytic Thyroiditis ° This type of thyroiditis is called "silent" because it is painless, as is postpartum thyroiditis, even though the thyroid may be enlarged ° Like postpartum thyroiditis, silent painless lymphocytic thyroiditis is probably an autoimmune condition
  48. 48. _ , Lymphocytic Thyroiditis , if ll We call it lymphocytic thyroiditis Subacute Silent Painless ~. because there is lot of infiltration of If lymphocytes in thyroid tissue like all ° other subacute forms of thyroiditis It is subacute because its course is limited for few months only
  49. 49. Subacute Silent Painless Lymphocytic Thyroiditis Like in all other subacute forms of thyroiditis
  50. 50. A ‘5 I A Subacute Silent Painless Lyniphocytic Tl"iyi‘oiditis Thus is very similar to post-partum thyroiditis, but is not related to . , pregnancy or giving of , birth and can occur in both ‘ men and women.
  51. 51. Subacute. Silent Painless l. yi11plioc}1ic 'll13i‘oi(litis ° As i said auto-immune ° An HLA association may be present, suggesting a genetic predisposition to subacute lymphocytic thyroiditis. ° Increased thyroid antibodies have been proposed as possible mechanisms
  52. 52. * Like postpartum thyroiditis, there may be a phase of high thyroid hormone levels (thyrotoxicosis), causing symptoms of an overactive thyroid gland. '° This may then be followed by a phase of symptoms of an underactive thyroid gland, before the symptoms eventually go away within around 12 to 18 months.
  53. 53. )arute .1 en! es . )l1oc tic 'l‘l1'roi(lilis ° If low thyroid hormone levels are causing severe symptoms, you may need to take thyroid hormone replacement until the condition gets better. In a few cases, the low thyroid levels can be permanent
  54. 54. t! .,-- . g__m, _ _ “ , ;_4 _ lift Subacute Silent Painless Lyinpliiocync fl] Thyroiditis I __ 7 thyroiditis can only be ‘-‘~ , '-". ;‘: ‘: diagnosed correctly by uptake test-—RAIU TEST
  55. 55. RAIU TEST The patient swallows radioactive iodine in the form of capsule or fluid, I and its absorption by the thyroid is studied after 4-6 ° hours and after 24 hours with the aid of a scintillation counter
  56. 56. RAIU TEST Normal Results of RAIU 6 hours: 3 - 16%
  57. 57. RAIU TEST - Some testing centers only measure at 24 hours. Values may vary depending on the amount of iodine in your diet. Normal value ranges may vary slightly among different labs.
  58. 58. ’t J ; Toxic nodular goiter I :15; '11.. -*. "i" E ’ I’. (WW, _ g I *<{'
  59. 59. Uptake may be concentrated into a few (hot) areas while the rest of the thyroid gland does not take up any iodine (cold areas)
  60. 60. l'lj. 'UlL' 7 l'utcnti. nl Rutliu-: imlidc . . ‘;In I lI| Ll| l‘. f.: ‘ : n llitlixztlimls Ill .1 lilnnml . 'mlulc
  61. 61. COLD NODULE HOT NODULE pyramidal lobe GRAVE DISEASE suppression of reminder of gland ‘O AUTONOMOUS NODULE hot and cold nodules ‘5. i TOXIC MULTINODULAR RAlU<596 THYROIDITIS
  62. 62. RAIU TEST - Lower-than-normal uptake may be due to ° Factitious hyperthyroidism ° Iodine overload ° Subacute silent painless lymphocytic thyroiditis
  63. 63. RAIU TEST ° Subacute Silent (or painless) post partum thyroiditis ° Drug induced thyroiditis ° Fibrous or Riedel‘s thyroiditis ° Chronic thyroiditis or Hashimoto's thyroiditis
  64. 64. IO . . ~. -__. __. _r .9; Si1bacuteSile11t; Painless ‘FOS'l‘. p211‘ll.111'1,— Tliyroiditis Patients that test positive for thyroid auto antibodies either '~ 2 before their pregnancy or , during the third trimester are , at much higher risk of developing postpartum thyroiditis
  65. 65. Siibaciite Silent Painless l’ostpa1'tn1n 'lli}Toi<litis ° Like Hashimoto’s thyroiditis, post-partum thyroiditis is an autoimmune condition, but it only happens in women who have recently given birth
  66. 66. Siibarnte Silent Painless l’ostpa1'tnni 'lli3i‘oitlitis ° There is a suggestion that silent thyroiditis is an autoimmune disease characterized by lymphocyticinfiltration of the thyroid and by transient hyperthyroidism, followed occasionally by transient hypothyroidism and eventual recovery
  67. 67. II Subacute Silent Painless Post: partuin“ I Thyroiditis -yg. I I I I Thyroid biopsy reveals lymphocytic infiltration in these forms of thyroiditis as in Hashimoto thyroiditis l'l{’; (-9->‘>> 7 I But without lymphoid follicles and I, scarring
  68. 68. Siibarnte Silent Painless l’ostpa1'tnni 'lli3i‘oitlitis ° Thyroid peroxidase auto antibodies and, less commonly, anti thyroglobulin antibodies are almost always positive during pregnancy and the postpartum period in these patients. Thus, these painless thyroid disorder s would appear to be a variant of Hashimoto thyroiditis
  69. 69. Suhaciite Silent Painless l’ostpa1'tni1i 'lli3i‘0itlitis ° About8 percent of women who have been pregnant develop postpartum thyroiditis within a few months of giving birth. Postpartum thyroiditis is believed to be an autoimmune condition and initially causes hyperthyroidism that usually lasts for 1 to 2 months then hypothyroidism and finally recovery
  70. 70. Siibarnte Silent Painless l’ostpa1'tnni 'lli}i‘oi<litis ° The condition is likely to recur with future pregnancies. As with subacute thyroiditis, women with postpartum thyroiditis often develop hypothyroidism before the thyroid gland is completely healed.
  71. 71. Siibaciite Silent Painless l’ostpa1'tn1n 'lli}Toi<litis - In some women, the gland does not heal and hormone levels remain low. These women must take thyroid hormone replacement for the rest of their lives
  72. 72. Subaciite Silent Painless l’ostpa1'tni1i 'lli3i‘0itlitis ° 1 mean to say again that in post-partum thyroiditis, your immune system attacks your thyroid gland within around six months of giving birth, causing a temporary rise in thyroid hormone levels (thyrotoxicosis) and symptoms of an overactive thyroid gland.
  73. 73. Subaciite Silent Painless l’ostpa1'tni1i 'lli3i‘0itlitis ° Then, after a few weeks, your thyroid gland becomes depleted of thyroid hormone, leading to low levels of thyroid hormone and symptoms of an underactive thyroid gland ° However, not every woman with post- partum thyroiditis will go through both these phases
  74. 74. Suhaciite Silent Painless l’ostpa1'tni1i 'lli3i‘0itlitis ° Here also if low thyroid hormone levels are causing severe symptoms, you may need to take thyroid hormone replacement until the condition gets better. ° In most women with the condition, thyroid function returns to normal within 12 months after the baby is born, although the low thyroid hormone levels can sometimes be permanent
  75. 75. Suliacute Silent Painless l’ostpa1'ti111i 'll1}1‘oitlitis 0 Cigarette smoking is also associatedwith. an increased incidence of postpartum thyroiditis
  76. 76. Suhaciite Silent Painless l’ostpa1'tni1i 'lli3i‘0itlitis ° Both of these painless thyroiditis entities can be considered subtypes of Hashimoto's thyroiditis and have an autoimmune basis. charcterised by lymphocytic infiltration of thyroid gland. ° Anti-thyroid antibodies are common in all three and the underlying histology is similar
  77. 77. ll Chronic Lymphocytic Thyroiditis or‘ l Hashimoto's Thyroiditis It was the first disease to be 1 recognized as an autoimmune l disease and was first described X by the Japanese specialist la; Hakaru Hashimoto in a paper ; M ' published in Germany in 1912
  78. 78. ll Chronic Lymphocytic Thyroiditislordl i 3 Hashimoto's Thyroiditis ' v Hashimoto's disease is about seven ‘ ‘ n times more common in women than in men between 30 to 50 years of age ‘. . . _ People who get Hashimoto's disease -‘ ' i» . » . oftenhave family members who have and sometimes have other autoimmune diseases themselves
  79. 79. J‘ Chronic Lympliokcg/ ktic. Tl1yroiditisor’ T ' Hashimoto's Thyroiditis l; The main problem in H this disorder is that the i T cells [for some l unknown reason) la? » 4.. , ‘ recognize the patient's ‘ , own thyroid antigens as f . ‘ I I i‘ 3:; "'- '—”-9 . ,— _ 1‘ A. _ . . , ' 1! _‘, ‘"’ " i 5‘ ~'. g. ‘H I «fl ‘ '. I‘ . ' f . “ 't‘~ 'fi- ’. I V, )r 3 -r . ‘ . ~ » OTCI I1 l -; .~ A -r . .3‘ V . . g . .r, ,‘ 2?-ts
  80. 80. J‘ Chronic Lympl1okc:3/ktic. Tl1yroiditisor’ ' Hashimoto's Thyroiditis . V’ The T cells are cytotoxic to thyroid epithelial cells (not good), and they stimulate B cells to make anti-thyroid r " antibodies [also not good], such as anti- - __ . ‘ peroxidase antibody, anti-thyroglobulin "‘_s. § antibody, and anti-TSH-receptor antibody
  81. 81. Chronic Lymphocytic Throiditis or Hashimoto's Th roiditis ° The most sensitive and specific of these antibodies is anti-peroxidase antibody (the other antibodies can also be present in Graves disease). ° The most interesting (I think) is anti-TSH- receptor antibody. lt blocks the action of TSH, leading to hypothyroidism
  82. 82. Chronic Lymphocyic Thyroiditis or Hashimoto's Th roiditis ° Anti-thyroid peroxidase (previously called antimicrosomal antibody, sensitive but not specific as 20% of adult women without disease have these antibodies)
  83. 83. ll Chronic Lymphocytic Thyroiditis or“ 7 Hashimoto's Thyroiditis fa H J‘ Note--TSH antibodies block the TSH I, ' receptor in Hashimoto's disease but stimulate the TSH receptor in Graves’ disease n_, M. ‘
  84. 84. Chronic Lymphocytic Thyroiditis or Hashimoto's Th roiditis - The thyroid gland may become firm or often hard large, and lobulated not painful to touch in Hashimoto's thyroiditis.
  85. 85. Chronic Lymphocytic Thyroiditis or Hashimoto's Thyroiditis In some cases, the enlargement is multinodular and may even show one or two dominant nodules.
  86. 86. ‘L -1* K "”” _ nodule composed of ~ ‘ s . hyperplastic follicles. . El Note the lymphocytic Hashimoto thyroiditis showing a dominant '4 . . , _/ infiltrate m the lower ’ ff part of the image
  87. 87. Chronic . ~ phoc, }i' Thyroiditis or Hashimoto's )Thyroiditis , . (y’§‘. , § When such dominant nodules are composed ofusual follicular or Hiirthle cells, the term follicular or Hiirthle cell adenoma may be applied
  88. 88. lliirthle cells are characterized as enlarged epithelial cells with abundant cosinophilic granular cytoplasm as a result ofaltered mitochondria. They generally stain pink and are prominently found in histological sections of thyroid glands affected with Hashimoto's
  89. 89. l T . The thyroid gland may ecome firm or often hard large, and lobulated not painful to touch in Hashimoto's thyroiditis
  90. 90. Grossly, most cases of Hashimoto thyroiditis shows diffuse and symmetric enlargement of the thyroid. The cut surface is yellowish-gray and firm
  91. 91. Chronic Lymphocytic Thyroiditis or llnlargementof the thyroid is due to lymphocytic infiltration That may lead to fibrosis later or change into lymphoma and is not due to tissue hypertrophy
  92. 92. ll Chronic Ly1npl1ocytioThyroiditis or if Hashimoto's Thyroiditis The goitre of Hashimoto's thyroiditis may remain unchanged for decades, but usually it gradually increases in size. l "s . - '°‘ Occasionally the course is marked by symptoms of mild I ‘l thyrotoxicosis ' hormones are leaked into circulation due to damage of . I thyroid tissue 1; o. ._. Especially during the early phase of the disease when l
  93. 93. Gross morphological changes within the thyroid are seen in the general enlargement which is far morelocally nodular and irregular than more diffuse patterns (such as that of hyperthyroidism) While the capsule is intact and the gland tself is still distinct from surrounding tissue
  94. 94. l -. -E, ‘'. L 'r_. T‘*_»‘a Q3 ‘ . . = lymphocytes seen as hypersensitivity reaction ‘ -g Histologically whatever T __;3j». _.j; §:z' __ cells present in thyroid ) "'g; .i; i', “_p, r-g_’, g , increase in number as well as j1l’; ;+’§’_7}*2;’. .f, *‘j-. f; i.jg: ~.jr. e; there is infiltration T ‘iii, ’ )? ,"f; ‘- 2 lymphocytes and B
  95. 95. Chronic Lymphocytic Thyroiditis or Hashim to's T yroiditis . .., v_---vv , u v . ., ». vv . '4 u r . 4 '>. ‘ . , . . w. "~v&'~' ~ R , . B—cells often be seen as secondary lymphoid follicles (germinal centers, not to be confused with the normally present colloid—filled follicles that constitute the thyroid)
  96. 96. is This image shows a large lymphoid follicle with prominent germinal center. It surrounded by small atrophic thyroid follicles . i . Ir. . u . . nu. .. . -wM. r.i loan IIOMN. .. u4|W | l.I. |.l¢| lz2l
  97. 97. Chronic Lymphocytic Thyroiditis or Hashimoto's Thyroiditis ° Thus these accumulated Lymphocytes make the antibodies that start the autoimmune process
  98. 98. Chronic Lymphocytic Thyroiditis or Hashimoto's Thyroiditis * Atrophy of the colloid bodies is now not lined by cuboidal epithelial cells but get converted to I-Iiirthle cells, cells with intensely eosinophilic, granular cytoplasm, a metaplasia from the normal cuboidal cells that constitute the lining of the thyroid follicles '~* So now lined also by Hurthle cells
  99. 99. Chronic Lymphocytic Thyroiditis or Hashimoto's Thyroiditis ° Severe thyroid atrophy presents often with denser fibrotic bands of collagen that remains within the confines of the thyroid capsule
  100. 100. Chronic Lymphocytic Thyroiditis or Hashimoto's Thyroiditis * Antibodies are formed against thyroid peroxidase & thyroglobulin and against TSH receptors that cause gradual destruction of follicles in the thyroid gland. * People with HLA—DR5 gene has are at risk of developing I-lashimoto's thyroiditis
  101. 101. Chronic Lymphocytic Thyroiditis or Hashimoto's Thyroiditis 4* Diagnosis is usually made by detecting these elevated levels of anti-thyroid antibodies in the serum, but seronegative (without circulating autoantibodies) thyroiditis is also possible
  102. 102. Chronic Lymphocytic Thyroiditis or Hashimoto's Thyroiditis * A rare but serious complication of thyroid infiltration of lymphocytes is lymphoma, generally the B-cell type, non-Hodgkin lymphoma * Meaning accumulation of lymphocytes in thyroid cells proliferate into lymphoma
  103. 103. Chronic Lymphocytic Thyroiditis or Hashimoto's Thyroiditis ° Preventable environmental factors, including high iodine intake, selenium deficiency, as well as infectious diseases and certain drugs, have been implicated in the development ofautoimmune thyroid disease in genetically predisposed individuals
  104. 104. Chronic Lymphocytic Thyroiditis or Hashimoto's Thyroiditis ° The genes implicated vary in different ethnic groups and the incidence is increased in patients with chromosomal disorders, including Turner, Down’s, and Klinefelter syndromes usually associated with autoantibodies against thyroglobulin and thyroperoxidase
  105. 105. Chronic Lymphocytic Thyroiditis or Hashimoto's Thyroiditis * Transient periods of thyrotoxicosis and hypothyroidism sometimes occur, and rarely the illness may progress to full hyperthyroid Basedow-Graves disease with active orbitopathy (bulging, inflamed eyes)
  106. 106. Associations of Hashimoto's thyroiditis Hashimoto's thyroiditis and hypothyroidism are associated with other autoimmune conditions like Addison's disease Diabetes mellitus Hypogonadism Hypoparathyroidism Pernicious anaemia. Alopecia areata, totalis, and universalis
  107. 107. Associations of Hashimoto's thyroiditis Chronic active hepatitis Polymyalgia rheumatica and giant cell arteritis Primary biliary cirrhosis Rheumatoid arthritis, Sj6gren's syndrome, systemic lupus erythematosus. Systemic sclerosis (scleroderma). Vitiligo.
  108. 108. Chronic Thyroiditis or Hashimoto's Thyroiditis ° Hashimoto's typically involves a slow but steady destruction of the gland that eventually results in the thyroid's inability to produce sufficient thyroid hormone -- the condition known as hypothyroidism. - Along the way however, there can be periods where the thyroid sputters back to life, even causing temporary hyperthyroidism, then a return to hypothyroidism
  109. 109. Chronic Thyroiditis or Hashimoto's Thyroiditis * This cycling back and forth between hypothyroidism and hyperthyroidism is characteristic of Hashimoto's disease. ~* So, for example, periods of anxiety/ insomnia/ diarrhea/ weight loss may be followed by periods of depression / fatigue / constipation / weight gain
  110. 110. Chronic Thyroiditis or Hashimoto's Thyroiditis * Hashimoto's when presenting as mania is known as Prasad's syndrome after Ashok Prasad, the psychiatrist who first described it
  111. 111. Chronic Thyroiditis or Hashimoto's Thyroiditis * Imaging tests/ Ultrasonogram s This imaging modality is useful for assessing thyroid size, echotexture, and, most importantly, whether thyroid nodules are present. * Fine-needle aspiration of any dominant or suspicious thyroid nodules to exclude malignancy or the presence of a thyroid lymphoma in fast-growing thyroid goiters.
  112. 112. Chronic Thyroiditis or Hashimoto's Thyroiditis S Surgery/ Indications for surgery include the following: A large goiter with obstructive symptoms, such as dysphagia, voice hoarseness, and stridor, caused by extrinsic obstruction of airflow Presence of a malignant nodule, as demonstrated by cytologic examination A Presence of a lymphoma diagnosed on fine- needle aspiration S Cosmetic reasons (eg, large, unsightly goiters)
  113. 113. Chronic Thyroiditis or Hashimoto's Thyroiditis * CT scan- to show a goiter's effect on nearby structures. e Radioactive iodine uptake and scan are used to classify a nodule as hot or cold. A cold thyroid nodule would indicate a higher risk for malignancy and would need a fine needle aspiration biopsy
  114. 114. Chronic Thyroiditis or Hashimoto's Thyroiditis ° Pharmacological ° Thyroid hormone replacement- orally administered levothyroxine sodium, usually for life. The dose should be titrated to the individual patient's needs. The aim is to restore a clinically and biochemically euthyroid state
  115. 115. Chronic Thyroiditis or Hashimoto's Thyroiditis * Patients who are older than 50 years (and younger patients with cardiac disease) should be started on a low dose of 25 micrograms (0.025 mg) per day. Their clinical and biochemical state is then re- examined after 6-8 weeks
  116. 116. Chronic Thyroiditis or Hashimoto's Thyroiditis * Prognosis * With early diagnosis and levothyroxine replacement therapy, the prognosis is excellent and patients may achieve normal thyroid levels. However, normal levels do not always equate with normal functioning
  117. 117. Chronic Thyroiditis or Hashimoto's Thyroiditis * While you may improve in many ways within a week, the full impact of thyroid medicine may take quite some time
  118. 118. Chronic Thyroiditis or Hashimoto's Thyroiditis ° For example, skin changes may take up to 3- 6 months to resolve. ° Because of the generally permanent and often progressive nature of Hashimoto’s thyroiditis, it is usually necessary to treat it throughout one’s lifetime and to realize that dosage of medicine required may have to be adjusted from time to time
  119. 119. Chronic Thyroiditis or Hashimoto's Thyroiditis * In the event that hypothyroidism is caused by Hashimoto's thyroiditis, it is recommended that the TSH levels be kept under 3.0
  120. 120. Differences Between Graves and Hashimotos Gcnefic jaczogs EnVif°nfl1C| 'ua' '3C‘0($ Mumocal and euula: immunity / aiocking a inhibitor eaciocs ism TSBAD A006 ouec: lymphocyte Cyjokmes Cytotoxic T lymphocyte sIimu! aI2on" IFN - 7. IL - 1. INF - u TNFI3 (l. ympb0!0xifll Cyzoiune‘? Cyloloxi antibody Gf8V¢$' oI$¢3$Q ’ ”3$hifl0‘°. $ $9333 Remissvon 1 Myxedema
  121. 121. Differences Between Graves and Hashimotos 4* In other words Hashimotos commonly present with hypothyroidism but that does not mean they cant have hyperthyroidism- due to TS blocking antibodies * Graves disease commonly presents as hyperthyroidism —due to TS stimulatory antibodies
  122. 122. Riedel‘s thyroiditis * Riedel‘s thyroiditis (also known as fibrous thyroiditis) is a rare condition characterized by an extensive fibrotic process of unknown etiology involving the thyroid and adjacent structures
  123. 123. Riedel‘s thyroiditis * It may be associated with a diffuse fibrotic process affecting multiple tissues (idiopathic multifocal fibrosclerosis) and may be unilateral or diffuse. * Four times more women are affected than men, with the highest prevalence occurring in individuals between 30 and 60 years of age
  124. 124. Additional causes of thyroiditis * Drug-induced thyroiditis like amidarone, lithium and radioactive iodine etc
  125. 125. Additional causes of thyroiditis ° Radioactive iodine treatment for overactive thyroid gland or radiotherapy for certain cancers can also damage the thyroid gland, leading to symptoms of an overactive thyroid gland or symptoms of an underactive thyroid gland ° Following external radiation to the neck
  126. 126. Additional causes of thyroiditis * The low levels of thyroid hormone after radioactive iodine is usually permanent, and may cause symptoms of an underactive thyroid gland that will need to be managed with lifelong thyroid hormone replacement treatment.
  127. 127. Primary Hyperthyroidism Due to Congenital Causes ° Mutations ofTSH receptors may occur and are ° Activating mutation of the TSH receptor ° Activating mutation of Gsa (McCune- Albright syndrome)
  128. 128. Primary Hyperthyroidism Due to Congenital Causes * Mutations of the thyrotropin receptor (TSHr) can be loss of function or gain of function thus patient can have congenital hyper or hypothyroidism
  129. 129. Primary Hyperthyroidism Due to Congenital Causes ° Rarely, hyperthyroidism may be caused by genetic mutations in the TSH receptor that cause it to be permanently in the "on" position (activating mutations) ° Two forms of this genetic hyperthyroidism have been reported, one that runs in families (familial form) and one that occurs by itself (sporadic form)
  130. 130. Primary Hyperthyroidism Due to Congenital Causes ° McCune-Albrightsyndrome ° Hyperthyroidism associated with McCune- Albrightsyndrome is rare. This syndrome includes polyostotic fibrous dysplasia, café- au-lait spots, or other endocrinopathies. The most common endocrinopathy is precocious puberty, but hyperthyroidism also can be observed
  131. 131. -t Neonatal Hyperthyroidism Also called as Fetal Graves Hyperthyroidism Postpartum Hyperthyroidism It is transient hyperthyroidism as was discussed in subacute post-partum thyroiditis lasting only for few months in mothers but can now also occur in new born babies
  132. 132. Neonatal Hyperthyroidism ° Rarely, a newborn may have hyperthyroidism, or neonatal Graves’ disease. This condition usually occurs ifthe mother has Graves’ disease during pregnancy or has been treated for it before pregnancy
  133. 133. Neonatal Hyperthyroidism 4* In Graves’ disease (Autoimmune Disorders During Pregnancy), the mother's body produces antibodies that stimulate the thyroid gland to produce increased amounts of thyroid hormone. These antibodies cross the placenta and similarly affect the fetus
  134. 134. Neonatal Hyperthyroidism 4 The reason these babies are at risk is that antibodies in the mother's bloodstream, called thyrotropin receptor-stiinulatin g antibodies (TSHR-SAb), can cross the placenta, and cause an overactive thyroid in the fetus.
  135. 135. Neonatal Hyperthyroidism 4 The higher these antibody levels in the mother, the higher the risk of hyperthyroidism in the unborn baby or newborn
  136. 136. Neonatal Hyperthyroidism 4 Congenital thyrotoxicosis is due to the passage from the mother to the foetus of maternal immunoglobulins that stimulate the foetal thyroid. 4 The condition is self-limiting because the infant can clear the maternal iininuiioglobuliii from its circulation. This process takes 3-4 months
  137. 137. Secondary Hyperthyroidism due to Growths (Adenomas) of pituitary gland or hypothalamus 4 Excess secretion of Thyrotropin-releasing hormone (TRH) by hypothalmus will increase TSH & Prolactin. Excess levels of TRH also inhibit dopamine resulting in a disinhibition of prolactin and a subsequent decrease in GnRH release (prolactin inhibits GnRH)
  138. 138. Secondary Hyperthyroidism due to Growths (Adenomas) of pituitary gland or hypothalamus 4 TRH can also be detected in other areas of the body including the gastrointestinal system and pancreatic islets, as well as in the brain
  139. 139. Secondary Hyperthyroidism due to Growths (Adenomas) of pituitary gland or hypothalamus 4 Continuous excess secretion of TRH & TSH will happen under such conditions and feedback suppression will have no effect on it since hypothalmic & pituitary insensitivity to feedback mechanism or even if it is sensitive will still produce increased secretion of TRH or TSH independent of feedback 4 Functioning thyroid carcinoma metastases any where in the body also gives rise to hyperthyroidism
  140. 140. Hyperthyroidism due to Pituitary resistance to T4 8; T3 without any adenoma in hypothalamus or pituitary 4 It is characterized by thyroid hormone resistance in the pituitary gland while peripheral tissues retain apparent ‘normal responsiveness. 4 Since the pituitary is resistant, normal amounts of thyroid hormones do not inhibit pituitary TSH secretion. As a result, TSH secretion is excessive, causing overproduction of thyroid hormones resulting in hyperthyroidism
  141. 141. Hyperthyroidism due to Pituitary resistance to T4 & T3 without any adenoma in hypothalamus or pituitary ° Thyroid hormone resistance [sometimes Refetoff syndrome) describes a rare syndrome where the thyroid hormone levels are elevated but the thyroid stimulating hormone (TSH) level is not suppressed, or not completely suppressed as would be expected
  142. 142. Secondary Hyperthyroidism due Struma Ovarii * Struma ovarii is a rare ovarian tumor defined by the presence of thyroid tissue comprising more than 50% of the overall mass. Most commonly, they occur as part of a teratoma
  143. 143. Secondary Hyperthyroidism due Struma Ovarii * The symptoms of struma ovarii are similar to other ovarian tumors plus there is hyperthyroidism
  144. 144. Secondary Hyperthyroidism due Struma Ovarii * The tumor can be characterized by radiological imaging; however, the final diagnosis is made upon pathological and histological examination of the tissue itself * The vast majority of struma ovarii are benign; however, malignant disease is found in a small percentage of cases
  145. 145. Secondary Hyperthyroidism due to Chronic Gonadotropin-Secreting Tumors * There is abundant evidence that human chorionic gonadotropin (hCG) is a weak thyrotropin (TSH) agonist, thus it stimulates TSH receptors causing hyperthyroidism
  146. 146. Secondary Hyperthyroidism due to Chronic Gonadotropin-Secreting Tumors Also called Gestational thyrotoxicosis when without tumors only just because of increased HCG * Hyperthyroidism is the most common endocrinopathy in pregnancy ~* Hyperthyroidism during pregnancy is most commonly caused by Graves’ disease but HCG during pregnancy can also cause hyperthyroidism -Gestational hyperthyroidism
  147. 147. Secondary Hyperthyroidism due to Chronic Gonadotropin-Secreting Tumors * There is abundant evidence that human chorionic gonadotropin (hCG) is a weak thyrotropin (TSH) agonist, thus it stimulates TSH receptors causing hyperthyroidism
  148. 148. Secondary Hyperthyroidism due to Chronic Gonadotropin-Secreting Tumors * During early pregnancy, secretion of the placental hormone hCG may result in subclinical or overt hyperthyroidism * This form of hyperthyroidism is typically transient and limited to the first 3 to 4 months of gestation
  149. 149. Secondary Hyperthyroidism due to Chronic Gonadotropin-Secreting Tumors * Elevations of hCG are particularly pronounced in twin pregnancies 4" Only rarely, hyperthyroidism is caused by trophoblastic tumors, hydatiform moles, and choriocarcinomas that secrete high amounts of hCG . * In men, choriocarcinomas can arise in the testicular carcinomas
  150. 150. Secondary Hyperthyroidism due to Chronic Gonadotropin-Secreting Tumors * HCG-induced gestational hyperthyroidism without an underlying neoplastic process is typically limited to the first trimester and, if required, it can be managed with standard antithyroid medications. ° Propylthiouracil is the preferred drug because of lower transplacental transfer and of greater experience with its Lise in pregnancy
  151. 151. -t Drug induced thyroiditis Due to Interferon Amiodarone Lithium Radiation thyroiditis Trauma to thyroid even excessive palpation of gland
  152. 152. ° Exogenous thyroid hormone ° Iodine-induced hyperthyroidism (ie, lod- Basedow phenomenon) ° Eating too much of foods that contain iodine
  153. 153. Causes of elevated serum thyroxine concentrations Thyrotoxicosis Increased Serum protein binding Increased serum thyroxine- binding globulin concentrations Inherited Estrogens: pregnancy, exogenous, tumoral production Hepatitis. hepatoma HIV infection Carcinoma ofpancreas, hepatoma Psychiatric and Medical Illness Drugs Methadone, heroin, clofibrate, 5-llurouracil Familial clysalbuminemic hyperthyroxinemia Increased serum transthyretin binding or concentrations Propranolol (high doses) Amiodarone Radiographic contrast agents used for cholecystography Anti-T4 immunoglobulins
  154. 154. ‘€§:39“1‘= ;-. ,, at a I I Teachers open the door, but you musl enter by yoursell ». ',Ir-u a- {ax}. --0

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