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Disorders of the Thyroid

THE THYROID GLANDPyramidal lobeLeft lobeRight lobeIsthmus Internal jugular vein Thyroid cartilago External carored arteri

http://arbl.cvmbs.colostate.edu/hbooks/pathphys/endocrine/thyroid/anatomy.html

THYROID GLAND HISTOLOGYThyroid hormone synthesis, storage and releaseCAPILLARY FOLLICULAR CELL COLLOIDTRAPPINGDEIODINATIONPROTEOLYSISSTORAGECOUPLINGORGANIFICATIONIPEROXIDASE

H2O2OXIDIZED IODIDE MIT DIT TGB MIT DIT T3TGB TGB T3 --TGB T4 --TGBT3T3T4DIT DIT T4TGB TGB Tyr Tyr

AA TGB TyrosineProteaseMIT DITIodinase Tyrosine?RELEASEICryer PE. Diagnostic endocrinology 1976:35T46 IBasic elements in regulation of thyroid functionTHYROIDTISSUETRHHYPOTHALAMUSPORTAL SYSTEMTSHANTERIORPITUITARYFREET3T3T4T4II_T4+T3+Usually Complain thyroid disease Thyroid enlargement which may be diffuse or nodularSymptom of thyroid deficiency or HypothyroidismSymptoms of thyroid hormon excess, or HyperthyroidismUsually Complain thyroid disease Complications of a Spesific form hyperthyroidism : Graves disease which may present which prominence of the eyes or exophthalmos and thickening of the skin over the lower legs (rare) or thyroid dermopathyPhysical Examination Inspection : Good light coming from behind the examiner, The patient is instructed to swallow a sip of water, Observe the gland as it moves up and down. Enlargement and nodularity can often be noted.Physical Examination Palpate the gland from behind the patient with the middle threes fingers on each lobe while the patients swallows. Nodules can be measured in a similar way.Physical Examination On physical examination the normal thyroid gland about 2cm in vertical dimension and about 1cm in horizontal dimention above the isthmusEnlarged thyroid gland is called Goiter The generalized enlargement is termed diffuse goiter, irreguler or lumpy enlargement is called nodular goiter

Diffuse goiterSimple diffus goiterHypertiroidismHashimoto thyroiditis Nodular goiter 1. Thyroid nodul 2. Thyroid cyst 3. Adenomatosa goiter 4. Subacut /chronis thyroiditis 5. Plummer thyroiditis15

THYROID DISEASESHYPERTHYROIDISMHYPOTHYROIDISMTHYROIDITISTHYROID NODULTHYROID DYSFUNCTION PREVALENCE

Hypothyroidism 2 %Sublinical hypothyroidism 5-7 %Hyperthyroidism 0,2 %Subclinical hyperthyroidism 0,1-6,0%18Prevalensi disfungsi tiroid yang paling banyak ditemukan adalah: A. Hipotiroidisme Bhipotiroidi subklinis C.Hipertiroidisme D. Hipotiroidisme subklinis E. Nodul tiroidHyperthyroidism & ThyrotoxicosisThyrotoxicosis is the clinical syndrome that results when tissues are exposed to high levels of circulating thyroid hormone.Thyroxicosis is due to hyperactivity of the thyroid gland or hyperthyroidismOccasionally, thyrotoxicosis may be due to other causes such us excessive ingestion of the thyroid hormone or excessive thyroid hormon from ectopis site19Pasien wanita 27 tahun datang dgn keluhan utama berat badan menurun drastis, palpitasi, perasaan demam berkeringat, nafsu makan meningkat akan tetapi berat badan menurun. Pagi harti kedua kaki rasa lumpuh.Pemeriksaan fisis nadi 124 permenit, pulsus celer, tensi 160/70 mm Hg. Eksoftalmus mata kanan.Diagnosis yang paling mungkin pada pasien ini adalah:tirotoksikosis B.hipertiroidea C. penyakit Graves D. penyakit Addison E. penyakit Plummer

Untuk menetapkan diagnosis maka pemeriksaan fisis yang dapat ditemukan adalah:tremor jari tangan B. vitilogo C. edema non pitting D. strabismus E. semua benar diatas

Seandainya terbukti pasien menderita Penyakit Grasves maka pemeriksaan yang diperlukan untuk membuktikan diagnosis adalah:A. TSH receptor antibody B. tiroksin C Scanning tiroid D Tiroglobulin E. buikan salah satu diatas

Pengobatan yang diberikan pada pasien ini adalah sebagai berikut KECUALI:PTU B. metrimazol C. beta bloker D. fenobarbital E. tirosin

Bila pada pemeriksaan fisis ditemukan struma difus yang sangat besar maka pilihan pengobatan adalah:A. Radio terapi dgn yodium 131 B. PTU C Strumektomi D. solutio lugol E. kemoterapi

Apabila pasien dilakukan strumektomi maka dapat terjadi komplikasi Dibawah ini ,KECUALI: A. Perdarahn pasca bedah B. hipoparatiroidisme C. parese n rekurens D. hipotiroid E tidak ada kecuali

Pemeriksaan yang paling bermanfaat untuk diagnosis: A. TSH B. ACTH C. Aldosteron D. FT4 E. cortisol

Bila hasil pemeriksaan PA menunjukkan karsinoma folikulare maka perlu dilakukan tindakan sebagai berikut:A.operasi ulang tiroidektomi total B. kemoterapi C, tiroksin D. Yodium 131 E. bukan salah satu doatas.

Conditions associated with thyrotoxicosisDiffuse toxic goiter (Graves disease)Toxic adenoma (Plummers disease)Toxic multinodular goiterSubacute thyroiditisHyperthyroid phase of Hashimotos thyroiditisThyrotoxicosis factitiaRare: Ovarian struma, metastatic thyroid carcinoma, hydatiform mole20Penyakit Graves disebut juga: A. Struma difusa toksik Bpenyakit Plummer C. Tirotoksikosis factitia D. Tiroiditis subakut E. Tiroiditis HashimotoGRAVES DISEASE (DIFFUSE TOXIC GOITER)GD is the most common form of thyrotoxicosis, may occur at any age, more commonly in females than in males (5X)The syndrome consist one or more of the following features:1. THYROTOXICOSIS2. GOITER3.OPHTHALMOPATHY(Exophthalmos)4. DERMOPATHY (Pretibial myxedema)21Gejala penyakit Graves merupakan suatu sindrom yang terdiri 1. Struma 2. Tirotoksikosis 3. Eksoftalmus 4. miksedema pretibial Tirotoksiskosis yang paling banyak ditemukan adalah : 1. Penyakit Hashimoto 2. Mlahidatidosa 3. Penyakit Plummer 4.Penyakit GravesETIOLOGY & PATHOGENESIS GD is currently viewed as an autoimmun disease of unknown cause Ther is a strong familial predisposition in that about 15%. 50% GD have circulating thyroid autoantibodies Peak incidence 20-40-yearT-lymphocytes sensitized to antigen within thyroid gland and stimulate B lymphocyte antibodies22Yang tersebut dibawah ini terkait dengan etiologi dan patogenesis Penyakit Graves A. Autoimun 2. predisposis familial 3. insidense paling tinggi 20-40ctahun 4. limposit B merangsang limposit T

CELL CELL STIMULATION BLOCKADEAntagonist AntibodyAgonist AntibodyTSHR-AbTSHRDavies TR. Graves disease in Werner & Ingbars : The thyroid ; 2000 ;520Autoimmune thyroiditis24T. Hashimoto, miksedema primer ,Penyakit Graves ekspressinya berbeda pada proses autoimun yang sama mengakibatkan respons imun berspektrum dpt brp antibodi sitotoksik,antibodi stimulatori,antibodi bloking atau cell mediated immunity. Hashimoto disebabkan clinical expresssion predominan adalah sel mediated immunity yang menyebabkan destruksi sel tiroid yang pada bentuk severe menyebabkan failure tiroid dan miksedema idiopatik.Clinical features Gravess disease Symptoms: in younger patients: palpitation, nervousness, easy fatigability, hyperkinesia, diarhhea, excessive sweating, intolerance to heat, weight loss, without loss appetiteSigns: Thyroid enlargement, exophthalmos, tachycardia, muscle weakness, tremor Older patients cardiovascular & myopatic predominate clinical manifestation palpitatation, dyspnea on exersice, tremor, nervousness, weight loss

Ophtamopathy Graves diseaseInfitratif sympathetic overstimulationLid retraction (Dalrymphes sign)Van Graves sign late palpebra supStellwats sign the wink eyes lateJefroys sign fold of forehead not seeMobiussign convergention of the eyes late Infiltratif autoimmuneExophthalmus, oculopathy congestif: cheimosis, conjunctivitis, periorbital edemaUlcerasi Cornea , neuritis optica, atrophi n opticus

The Eye signs of GravesDisease (ATA ) 0 No signs no symptoms 1 Only signs, no symptoms, (signs limited to upper lid retraction, stare,lid lag) 2 Soft tissue involvement (symptom & signs) 3 Proptosis (measured with Hertel exophthalmometer) 4 Extraocular muscle involvement 5 Corneal involvement 6 Sight loss (optic nerve involvement)Class Definition

DISEASE SEVERITYThyroid eye disease can be divided into

MILD disease

MODERATE disease

SEVERE diseaseMILD DISEASEUsually young patientDry eyes---->lubricantsLid retractionLid malposition-entropionMild proptosis

MODERATE DISEASE Thyroid myopathy

asymmetric involvement

tends to involve vertical muscles in Asians

LID RETRACTION

HERTEL EXOPHTHALMOMETEREXOPHTHALMOS : >18 MM

Computerised Axial TomographyThyroid DermopathyThickening of the skin,over the lower tibia due to accumulation glycosaminglicans , rare (2-3%)TSH-R Ab high titerOsteopathy in the metacarpal bones

51

Non Pitting oedema

Suspected hyperthyroidismTSH &FT4Normal FT4 &TSH Hyperthyroidism excludedLow TSH & Normal FT4Measure FT3 Normal FT3 High FT3Subclinical hyperthyroidismEvolving Graves diseaseOr toxic nodular goiterExcess thyroxine replacementNon thyroidal illnessRepeat tests in 2-3 months: annual follow-up if no progressionT3 Hyperthyroidism Low TSH & high FT4 Normal / high TSH & high FT4TSH- secreting pituitary adenoma.Thyroid hormone-resistance syndromeHyperthyroidismGravesdiseaseToxic nodular goiterThyroiditisGestational HyperthyroidismFactitious or iatrogenic hyperthyroidismThyroid CarcinomaStruma OvariiTumor secreting Chorionic gonadotropinFamilial nonautoimmun hyperthyroidismLaboratoy tests useful in DD of hyperthyroidism54Atypical fashion Graves DiseaseThyrotoxic periodic paralysis: usually Asian males, sudden attack flacid paralysis, hypokalemia, usualy subsides spontaneously. Prevention: K+ supplement & BetablockersThyrocardiac disease: primarily with symptoms of heart involvement: refrsctory AF insensitif digoxin or high output heart failure, no evidence underlying heart disease (50%). Treatment of thyrotoxicosis cure55Kerluahn kedua tungkai sering mengalami lumpuh terutam pada pagi hari pada pasien ini adalah akibat:krisis tiroid B. kadar hormon FT4 teralu tinggi C. hipokalemia D. anti tiroglobulin meningkat E. tpenyakit jantung tiroidPenyebab hal ini adalah :hipokalemia B. hiperkalemia C. stroke D. gagal jantung E. krisis tiroid

Pengobatan yang dapat diberikan adalah : A. Digoxin B. kortikosteroid C. kalium D. kalsium E. antagonis kalsium Atypical fashion Graves DiseaseApethetic hyperthyroidism: Older patients: weight loss, small goiter, slow AF, severe depression with none clinical features56Penyakit graves pada orang tua sering bermanifeastasi sebagai hipertiroid apetetik SEBAB pada orang tua gejala menonjol s tidak klasik dan kadang tanpa gejalaKrisis tirotoksik timbul pada : 1 operasi yang tidak dipersiapkan 2. Persalinan 4. RAI 131 Treatment modalities Anti-thyroidSurgeryI131 radioactiveTreatment of Graves Disease 1. Antithyroid drug therapy: Young pts, small glands, mild disease Propylthiouracil, methimazole (6m-15 mo), relaps 50-60%. PTU inhibits the conversion T4T3, effect more quickly compare to methimazole Methimazole - longer duration, single dose Therapy 3-6 months tapering dose and combination levothyroxin 0.1 mg/d 12-24 months Allergic reaction (rash), agranulocytosis, jaundice, liver failure

58PTU vmenekan Surgical treatmentSubtotal thyroidectomy treatment of choice for very large glands, or multinodular goiter, prepared wth anti thyroid drug (about 6 months)Complication : Hypothyroidism,recurent laryngeal nerve injury

Treatment of Graves diseaeTreatment of Graves diseaseRadioactive iodine therapyUSA NaI 131I euthyroid over 6-12 weeksComplication: hypothyroidism

Other medical measures:Beta-adrenergic blocking agents Propranolol 10-40 mg every 6 hours, multivitamin supplements, phenobarbital as sedative + to lower T4 levelsCholestyramine, 4 gr orally 3X daily lower T4Treatment of Graves diseaseComplication of Graves DiseaseThyrotoxic crisis (thyroid storm) Acute exacerbation symptoms thyrotoxicosis. May be mild & febrile until life threatning.

Etiology : after thyroid surgery in patients who has been inadequatlely prepared, RAI131, parturition in adequately controlled thyrotoxicosis or stressfull illnes.Thyrotoxic crisis(thyroid storm): Clinical manifestation: Fever, Sweating, flushing, tachycardia / AF, heart failure, agitation, delirium, coma, jaundice, nausea, vomiting and diarrhea.

75% death.

Prophiltriourasil (PTU): 4 x 300 mg atauNeomercazole 6 x 20 mg.Yodium : Sodium yodida IV 1 mg/12 jam, atau lugol 5% 3x10 tts /hr Propranolol (Inderal): IV 1-5 mg/6jam, atau tab 4x60-80 mg/hr via sonde lambungKortikosteroid: Dexamethason 2 mg/6 jamAntibiotik dianjurkan jika infeksi sebagai pencetus.Treatment of Thyrotoxic crisis (thyroid storm)

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