curs patologia functionala a tiroidei 2015

7/25/2019 Curs Patologia Functionala a Tiroidei 2015

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Patologia functionala a tiroideiHiper- si hipotiroidism


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Hipertiroidismul

Definitie Clasificare Tablou clinic

Explorari paraclinice Etiopatogenie Anatomie patologica Fiiopatologie

E!olutie, complicatii Tratament

"articularitati Boala Basedo# $ra!es $usa %ipertiroidiata

&indromul "lummer Tiroida in sarcina Tiroidite subacute &truma o!arii


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Hipertiroidismul

Definitie'totalitatea manifestarilor clinice si bioc%imicedeterminate de excesul %ormonilor tiroidieni liberi la

ni!elul receptorilor tisulari responsi!i

Clasificare' cu functie tiroidiana crescuta

cu tiroida nefunctionala, (blocata)


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Clasificare (RIC)

Cu productie tiroidianacrescuta

Fara productie de hormoni

- Boala $ra!es

-

$usa multinodulara %ipertiroidiata- *odulul tiroidian toxic +sd "lummer-

- "araneoplaic. coriocarcinom, mola%idatiforma +%C$ T&/.lie-

-

tireotropinomul- sd de reistenta la %% Tir

- Tiroidita subacuta

-

Tiroidita postpartum- atrogen

- Tireotoxicoa factitia sau alimentara(%amburger)

-

Carcinom tiroidian folicular metastaat- &truma o!arii


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Tablou clinic scadere ponderala cu apetit crescut

palpitatii dispnee astenie, fatigabilitate intoleranta la caldura, %ipersudoratie %iperacti!itate, iritabilitate

tulburari de dispoitie, insomnie tranit accelerat

tegumente calde, fine, umede ta%icardie, fibrilatie atriala, C cu debit

crescut

tremor fin, %iperineie, %iperreflexie retractie palpebrala caderea parului, onicolia miopatie, %ipotrofie musculara


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Particularitati

Exoftalmie +in boala Basedo# $ra!es- 3ixedem pretibial


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ParticularitatiExoftalmie +in boala Basedo# $ra!es-



GO- QOL Chestionar n limba romn+Calitatea !ie4ii n oftalmopatia din boala $ra!es.Basedo#-

$6.768 +$ra!es9 op%t%almopat%:. ;ualit: of life- e!aluea< calitatea !ie4ii pacien4ilor cu oftalmopatiedin boala $ra!es.Basedo# $6.768 aprecia< dou< aspecte' +1- func4ia !iual



GO- QOL Chestionar n limba romn+Calitatea !ie4ii n oftalmopatia din boala $ra!es.Basedo#-



Hertel Exophtalmometer


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! "ara simptomatologie oculara

#O

numai simptome$non-infiltrati%&

a&sen'a(ie de corp strin) hiperlacrimare)b&retrac(ie palpebral

*

S

le'iuni de (esuturi moi edem palpebral) chemosis $edem con+uncti%al&

,& absentea& minimeb& moderatec& marcate

.P

proptosis Protru'ia marcat a globilor oculari$/0oftalmie 1 . mm&

,& absentaa& .-2 mm

b& 3-4 mmc& 1 5 mm

2/

afectarea mu6chilore0traoculari

- diplopie) asinergism de con%ergen() oculofrontal 6i oculona'al,& fara modificaria& limitare la pri%irea lateralab& restrictie e%identa a miscariic& glob ocular fi0

3C le'iuni corneene ulcer cornean,& absentaa& ero'iune superficialab& ulcer cornealc& necro'a sau perforatie

7S

afectarea ner%ului optic$scaderea 89&

pn la cecitate,& absentaa& *,:*,-*,:7,

b& *,:4,-*,:*,,c& ; *,:*,,

CLASIFICAREA WERNER (NOSPECS)



Nodulul autonom tiroidian

(sdr. Plummer)



Teste diagnostice

"unc(ionale eglaul axei tiroidiene /ormoni +totaliHliberi-

Transport =i efecte periferice 3etabolismul iodului Autoimunitatea $enetica



=eglarea 80ei >iroidiene T/

T&/

TIH T

Deiodae' D1, D2, D

8eptina

T, T/ , T&/

D2

D2

D1



>este >SH



The relationship between serum TSH and free T4 concentration is shown for normal subjects (N) and in thetypical abnormalities of thyroid function: A, primary hypothyroidism !, central or pituitary"dependenthypothyroidism #, thyroto$icosis due to autonomy or abnormal stimulation of the %land &, TSH"dependentthyroto$icosis or thyroid hormone resistance' Note that linear chan%es in the concentration of T4 correspond

to lo%arithmic chan%es in serum TSH'

>SH : >2 : f>2



T&/



>h@roid hormones e%aluation

Hormone Metric SI Units Jariations unrelated to t%:roid disease

Total T4 4".. u%/dl 01".41 n2 !indin% protein chan%escompetitors for T4 bindin%

3ree T4 1'15 1'6"'. n%/dl .1"7 p2 2ethodolo%ic factorsAlbumin chan%es&ilution effects

Total T* 67".67 n%/dl .'."'6 n28 !indin% protein chan%escompetitors for T* bindin%

A%e"related chan%esNutrition, illness, dru%s

3ree T*1'*5

1'"1'7 n%/dl *"9 p28 2ethodolo%ic factors as for T4and influences on total T*

e;erse T* .7"47 n%/dl 1'"1'6 n2 Nutrition, illness, sur%ery, dru%s

TSH 1'*"4'1 m-/l .".7 p2< &iurnal ;ariation, pulsatile secretion2edications

TSH "subunit =1' u%/dl =.11 p2 ostmenopausal womenrimary Hypo%onadism

Thyro%lobulin ."1 u%/l .'7"*1 p2> ?ariation in assay standards and antibodies

Values in children may be higher# Assumes biologic potency of -!" Umg$ %ependent on serum &SH and amount of thyroid tissue


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&ubclinical t%:roid diseases

defined as abnormal T&/ despite normal le!elsof free t%:roxinesubclinical TSH fT4

hyperthyroidism N

hypothyroidism N

Bals%em et al, A/7, 2011

Bioc%emical definition of t%:roid d:sfunctionCondition >SH $mAB:l& >h@roid hormones Comments

6!ert %:pert%:roidism K01 Ele!ated TI or T

6!ert %:pot%:rpodism LI5 8o# TI

&ubclinical %:pert%:roidism K 01 *ormal TI and T Clearl: lo# T&/

01 0I *ormal TI and T 8o# but detectable

&ubclinical %:pot%:roidism I5 10 *ormal TI 3ildl: ele!ated T&/

L 10 *ormal TI 3aredl: ele!ated


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T&/ fTI correlation

&erum T&/ . log.linear relations%ip #it% circulating t%:roid%ormone le!els 2 x fTI 100 x T&/

Fatourec%i J,Mayo Clin Proc, 200?M /oerman et al, 2010,EJE

0 I > 12 1@ 20 2I 2> 2

100

10

1

01

001

fTI +pmolHl-

T&/+mNH1-

n O 22: O 00>>@xP112Q5

2 O 02@


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R%at is (normal)S

Diagnosis depends of t%e limits of >SH (normal), (references), (discrimination) !alues too simplistic, impl:ing t%at e!er:t%ing not being normal must be corrected

absolute %ealt% does not exist

discriminationD %alues cut.off !alues important for medical decisions re;uire no#ledge of t%e disease

pre!alence t%e sensiti!it: and specificit: of diagnostic tests clinical conse;uences of a false positi!e H negati!e diagnosis

specifications concerning specimen collection en!ironmental and p%:siological conditions tec%ni;ues and timing preparation and storage anal:tical and t%e statistical met%ods

Brabant et al, EJE, 2006


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T&/ assa:s


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Rang CV, C%ang TC, C%en 3F Associations bet#een subclinical t%:roid disease and metabolic s:ndrome Endocr W 2012

T&/

?,0?5 consecuti!e %ealt%: subects +5,21I 3, ,>>1 R-


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elationship of TSH (after 411 m % TH i';') and thyroid wei%ht (%) in women with clinicallyeuthyroid multinodular %oiter (with permission from Smeulers @, &octer , ?isser T@, Hennemann+: esponse to thyrotrophin"releasin% hormone and triiodothyronine suppressibility in euthyroid

multinodular %oitre' #lin ndocrinolo%y 6:*9,.66)'

T/ si masa tiroidiana


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Gusa endemica

T&/ O ,5 mNH8

fTI O 1,5 pmolH8


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Gusa endemica

T&/ O 0,15 mNH8

fTI O 2,5 pmolH8


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Transport

C i t t A ti il


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Bn this patient with +ra;esC &isease, the mi$ture of antibodies shifted durin% antithyroidtherapy from dominance by TSAb, to a dominant effect by TS!Ab and T!BB, leadin% tospontaneous de;elopment of hypothyroidism' 3rom TaDasu et al, @' ndocrinol' Bn;est'1:47"40., .6'

Coexistenta Anticorpilor


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/COG=8"B8 >B=OBEB8!8

E!identiaa $usa si caracterul difu sau nodular al acesteia *odulul K 1 cm H confirma nodulul L 1 cm C%istii tiroidieni /iper!asculariatie si calcificari

3asoara Dimensiuni tiroida calcul !olum FI$d#Jd*Jd.&K Dimensiuni nodul +in dinamica-

Diferentiaa *odulii tiroidieni de cei extratiroidieni *odulii de c%isti

T t f l i


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Teste morfologice

ECOGRA!A T!RO!"!A#A


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ECOGRA!A T!RO!"!A#A


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adio odo Captarea

Jalori crescute &inte< crescut< de /Tir /ipertiroidism+gusa polinodulara, $ra!es, "lummer-

Deple4ie %ormonalerapia chirurgicala


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Sarcina 6i func(ia tiroidei


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&arcina modifica ec%ilibrul tiroidian' aport de iod crescut +200 ugHi- !olum circulant H de distributie cresterea F$ cu turno!erului iodului imunosupresie interferente %C$ T&/ ni!el crescut de TB$ acti!itatea deiodaei tip pacentara

*ecesar de / tiroidieni pentru de!oltarea fetala Tiroida fetala functioneaa dupa 12 saptamani

fTI si fT in primul trimestru



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Patel et al., Delivery of maternal thyroid hormones to the fetus, TEM 2011, 22,

5, 164-10

Hi i idi l


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Hipertiroidia neonatala


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>iroiditele


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Hipotiroidismul

Definitie Clasificare Tablou clinic

Etiopatogenie E!olutie, complicatii Tratament

"articularitati 3ixedemul congenital

Etiologia hipotiroidismului


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Etiologia hipotiroidismului

"rimar

iatrogen sau autoimun

&ecundar

&dr &%ee%an, tumori%ipofiare, deficitcongenital de T&/

isgene!ii tiroidiene


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isgene!ii tiroidiene&emne de mixedem congenital' la nou n


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/ipotiroidismul neonatal efini"ie

Clasificare'Congenital +1'000.I000-

"ermanent Tranitor

Dobandit

mpact asupra de!oltarii +neuropsi%ice, staturale, pubertare-

Teste' screening pentru %ipotiroidie neonatala

"rofilaxie si Tratament' aportul de iod la mama, %ormoni tiroidieni la copil


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Fatul depinde de T, TI De!oltarea fetusului depinde de / tiroidieni, in special in ceea ce

pri!este &istemul *er!os

Fatul depinde deTI.Tprodusi de mama pana in sapt >.11

Fatul foloseste TI.Tmaterne pentru de!oltarea %ipotalamusului,%ipofiei si glandei tiroide

&istemul *er!os Central depinde de %ormonii tiroidieni. "roliferare neuronala. 3aturare neuronala. 3ieliniare neuronala. Formarea sinapselor

l i l i


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e!#oltarea sistemului ner#os

1 Di!iiune 2 3igrare Agregare siI

Diferentiere

5 &inaptogenea @3oarte cel Q earanare

> 3ieliniare

=e(eaua de cone0iuni neurale


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(este mai pu(in dens

#reierul cu aport suficientde iod

#reierul cu deficit de iod


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!i"otiroidism #on$enital

Clinica deceleaa 1'5000.1'10000+10X 1 luna, 5X primele luni,Q0X primul an, 100X la .I ani-

Bncidenta' 1 la 000

Nna din cele mai obisnuite caue

trata$ilede retard mental


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Cretinism

&tatura scunda,disarmonica,retardare mentala

.4 ani, hipotiroidism

se;er con%enital

luni,hipotiroidism con%enital:fata infiltrata, limba marita

C it ii t it i l d


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Bndicator ScopBodarea srii"ropor4ia de consum casnic a sSH neonatal

propor4ia cu ni!el peste 5 mNH8 KX

Criterii pentru monitori'area programelor decontrol al carentei iodate


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Bndicatori de pre%alenta ai deficitului de iodcriterii pentru o problema importanta de s


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&creening pentru %ipotiroidie neonatala

J l i d f i


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Jalori de referinta

3i d l d lt


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3ixedem la adult

" fil i


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"rofil sanguin

fTI , TI , T T&/ Z . %ipotiroidism primar, * sau . %ipotiroidism central Dislipidemie mixta b +colesterol Z P T$ Z- C[ Z, A8T, A&T Z Anemie macrocitara AT"6 ZZZ . marer etiologic de autoimunitate *a . aparent &AD/, mai ales in %ipotiroidismul central

"8 Z . in %ipotiroidismul primar

T


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Tratament

Administrare orala de %ormoni tiroidieni

Tratament prompt, imediat dupa diagnostic

Doe progresi! crescatoare la I.> sapt

3entinerea terapiei permanente esteCNCA8A

Complianta

T


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Tratament

9arsta Eo'a 'ilnicag

recomandatag:Mgc

,-7 luni *3-3, 5-#,

7-#* luni 3,-43 7-5

#-3 ani 43-#,, 3-7

7-#* ani #,,-#3, 2-3

N#* ani #,,-*,, *-.

Tiro$ina (T4)


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=ecomandarile O


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Jerificarea tratamentului

#onsecinele pe termen lun% ale tratamentul H# sunt strIns le%ate decalitatea urmJririi e;oluiei pacienilor sub tratament'

$aminarea clinicJ include e;aluarea creKterii Ki deG;oltJrii neuro"motoriisi trebuie efectuata la fiecare cIte;a luni Ln timpul primilor * ani de ;iaJ'

CO!CLABB


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CO!CLABB

curs patologia functionala a tiroidei 2015

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