hipotiroidismo adquirido
TRANSCRIPT
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HIPOTIROIDISMO ADQUIRIDO!
Fabián Leonardo Forero Castañeda!Fellow 2° año Endocrinología Pediátrica!
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Tomado de : Williams. Textbook of Endocrinology. 2014.
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Introducción!
• Causa más común de alteraciones tiroides.!• Principal causa : tiroiditis!• Compromiso primario: tiroides (Subclínico o
manifiesto).!• Compromiso central: secundario- terciario : eje
pituitaria- hipotalámico.!• Efectos :!• Crecimiento!• Desarrollo puberal !• Desempeño escolar.!
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Tomado de: Hypothyroidism. Pediatrics in Review. Aug 2014.
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Tomado de : Williams. Textbook of Endocrinology. 2014.
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Tomado de: Hypothyroidism. Pediatrics in Review. Aug 2014.
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Manifestaciones Clínicas!
• Disminución de la velocidad de crecimiento!• Talla Baja!• Alteración en el desempeño escolar!• Pereza- Fatiga!• Intolerancia al frío!• Constipación!• Piel seca, fría y pálida!• Cabellos y uñas frágiles .!• Facies rechoncha!• Dolores musculares !• Ganancia de peso!• Bocio!!!
Hypothyroidism in children: diagnosis and treatment. Nuvarte Setian*. Jornal de Pediatria Copyright © 2007 by Sociedade Brasileira de Pediatria.
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Tomado de : Williams. Textbook of Endocrinology. 2014.
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Clínica del Hipotiroidismo Central!• Cefalea!• Alteraciones visuales!• Inherentes a los déficits hormonales.!
Hypothyroidism in children: diagnosis and treatment. Nuvarte Setian*. Jornal de Pediatria Copyright © 2007 by Sociedade Brasileira de Pediatria.
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Hallazgos al Examen !o Bocio (39%)!o Talla Baja!o Sobrepeso aparente!o Facies rechoncha, torpe o embotado.!o Expresión plácida!o Bradicardia!o Pseudohipertrofia muscular!o Hiporreflexia tendones profundos!
Hypothyroidism: Etiology,Diagnosis, andManagement. JaimeP.Almandoz,MB,BCha,b,HosseinGharib,MD. MedClinNAm96(2012)203–221.
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Otros Hallazgos Endocrinológicos !• Desarrollo puberal retrasado (más frecuente)!• Adelanto en el desarrollo (Menos frecuente)!• Galactorrea (Hiperprolactinemia)!• Hormona del crecimiento: Normal o disminuida.!• IGF-1 bajo.!• Agrandamiento de la silla turca.!
Hypothyroidism: Etiology,Diagnosis, andManagement. JaimeP.Almandoz,MB,BCha,b,HosseinGharib,MD. MedClinNAm96(2012)203–221.
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Tiroiditis Autoinmune Crónica (Hashimoto)!• Causa más común!• Prevalencia= 0,08% !• 1/1250 niños!• Atrofia tiroidea o bocio.!• >Niñas 2:1 >blancos!• Cambios no detectados al examen!• Presentaciones:!Ø Eutiroideo 55%!Ø Hipotiroideo 45%!Ø Hipertiroideo 5%!
Hashimoto's thyroiditis in childhood: presentation modes and evolution over time. Filippo De Luca, Simona Santucci, Domenico Corica, Elda Pitrolo, Marika Romeo and Tommaso Aversa. De Luca et al. Italian Journal of Pediatrics 2013, 39:8!
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Tomado de : Williams. Textbook of Endocrinology. 2014.
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Tiroiditis Autoinmune Crónica (Hashimoto)!• NHANES III (National Health and Nutrition
Examination Survey) 1988-1994:!• 6,3% adolescentes (12-19ª) +Antitiroglobulina!• 4,8% +Antiperoxidasa (AntiTPO)!• Probabilidad 2 veces > mujeres!• Hispanicas > Blancas > Negras!• 2% TSH >4,5 mU/L!
!
PREVALENCIA 0,08%!
Subclinical Hypothyroidism in Children: Natural History and When to Treat. Gianni Bona, Flavia Prodam, Alice Monzani Università del Piemonte Orientale “A. Avogadro”, Department of Health Sciences, Novara, Italy. J Clin Res Pediatr Endocrinol 2013;5(Suppl 1):23-28
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Historia Natural!• Estudio 160 niños (Edad 9,1ª)!• 105 con Acs + y TSH normal por 5 años:!• 65% eutiroideos!• 10% > TSH leve (5-10mU/L)!• 25% TSH >10mU/L!
• Estudio 87 niños con >TSH 5-10mU/L:!• 41% revierten!• 20% persisten!• 39% desarrollan Hipotiroidismo manifiesto!Hashimoto's thyroiditis in childhood: presentation modes and evolution over time. Filippo De Luca, Simona Santucci, Domenico Corica, Elda Pitrolo, Marika Romeo and Tommaso Aversa. De Luca et al. Italian Journal of Pediatrics 2013, 39:8
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Patogénesis!
• ATRÓFICA: !• Citotoxicidad:! celular y Acs dependientes de complemento.!• Apoptosis folicular!• Acs bloqueantes del receptor de TSH.!!• TIROIDITIS BOCIÓGENA:!• Infiltración células linfocíticas- plasmáticas!• Producción de Acs estimulantes del crecimiento !• Exceso TSH!
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Entidades asociadas!
• Sindrome Down!• 28% Acs+ (AntiTPO)!• 14% Subclínico (HS)!• 7% Manifiesto (HM)!• 5% Hipertiroidismo!• La frecuencia aumenta con el tiempo (25ª= 35%)!
Subclinical Hypothyroidism in Children: Natural History and When to Treat. Gianni Bona, Flavia Prodam, Alice Monzani Università del Piemonte Orientale “A. Avogadro”, Department of Health Sciences, Novara, Italy. J Clin Res Pediatr Endocrinol 2013;5(Suppl 1):23-28
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Entidades asociadas!
• Síndrome de Turner:!• 41% Acs+ (AntiTPO)!• 8% HS o HM !• Progresión 15% (1ª década) a 30% (3ª década).!• Incidencia anual 3,2%!
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Entidades asociadas!
• Sd Klinefelter: 1/8 pacientes!• DM 1: 30% Acs+ 5% HS/ HM!• Enfermedad Celíaca: 23%Acs+ (26% HS)!• APS I (Autoimmune Polyglandular Syndrome)(APECED-
Whitaker Syndrome) 10% .!• APS II (Schmidt Syndrome) 70%.!• Gastritis Autoinmune 30%!• IPEX Syndrome!• Obesidad: 10-23% (>leptina)!
!“Screening desde el Dx y posteriormente anual”!
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Complicaciones!
• Efusión pericardica y pleural!• Encefalopatía de Hashimoto!
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Diagnóstico!
• TSH!
• T4L!
• T4T + SBGs(Serum Binding Globulines)!
Hypothyroidism: Etiology,Diagnosis, and Management. JaimeP.Almandoz,MB,BCha,b,HosseinGharib,MD. MedClinNAm96(2012)203–221!
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Hypothyroidism: Etiology,Diagnosis, and Management. JaimeP.Almandoz,MB,BCha,b,HosseinGharib,MD. MedClinNAm96(2012)203–221!
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Tomado de: Hypothyroidism. Pediatrics in Review. Aug 2014.
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Diagnóstico!
• Primario: >TSH <T4L!• TSH 5-10 mU/L: repetir (Normal 70%). En obesos no
dar tto.!• HS (TSH 5-10mU/L , T4L n)!• Central: TSH normal o baja, T4L <! <Ratio TSH 8am/4pm (<1,3 vs >1,5).! TSH > (Inmunorreactiva)!
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Tomado de : Williams. Textbook of Endocrinology. 2014.
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Diagnóstico!
• Hashimoto (TAC) .!• AntiTPO 90%!• AntiTG 50%!• TRAbs 9%!• Antipendrina 81%!
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Tomado de: Hypothyroidism. Pediatrics in Review. Aug 2014.
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Diagnóstico!
• Ultrasonografia (US):!• Raramente indicada (Sólo 1/3 muestra cambios) !• La mitad muestra cambios a los 14meses.!!• IRM silla turca contrastada : central!• BACAF : bocio marcadamente asimétrico o nódulo
prominente, o en crecimiento.!• Edad Ósea: retrasada!
Thyroid disease in children: part 1 State-of-the-art imaging in pediatric hypothyroidism
Jennifer L. Williams & David L. Paul & George Bisset III. Pediatr Radiol (2013) 43:1244–1253!
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Thyroid disease in children: part 1 State-of-the-art imaging in pediatric hypothyroidism Jennifer L. Williams & David L. Paul & George Bisset III. Pediatr Radiol (2013) 43:1244–1253!
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Thyroid disease in children: part 1 State-of-the-art imaging in pediatric hypothyroidism Jennifer L. Williams & David L. Paul & George Bisset III. Pediatr Radiol (2013) 43:1244–1253!
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Tratamiento !• LEVOTIROXINA- LT4!!100 mcg/m2 dia!!Objetivos:!TSH en la mitad inferior del rango (0,5-2 mU/L)!T4L en la mitad superior (Variable)!T4T en la mitad superior (9-13 ug/dl)!!!
Hypothyroidism. Díaz Alejandro, Lippman Elizabeth. Pediatrics in Review. American Academy of Pediatrics. Aug 2014.
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Tomado de: Hypothyroidism. Pediatrics in Review. Aug 2014.
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Sobretratamiento!
• Craneosinostosis!• Comportamiento adverso: hiperactividad!• Bajo desempeño escolar!• >Densidad mineral ósea!
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Pronóstico!
• Cohortes 18 niños a 4 años Hipotiroidismo Subclínico (HS):!
• 10 persistieron HS!• 7 eutiroideos!• 1 Manifiesto (HM)!!• Cohorte Taiwan 22 ptes a 6.4 años Hashimoto:!• 11 eutiroideos!
!Hypothyroidism. Díaz Alejandro, Lippman Elizabeth. Pediatrics in Review. American Academy of Pediatrics. Aug 2014.
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Hasta cuando tratar?!
• “Continuar terapia LT4 hasta que sea completado el crecimiento y desarrollo, momento en el cual se suspenderá y se hará medición 1 mes después para determinar persistencia”.!
!Hypothyroidism. Díaz Alejandro, Lippman Elizabeth. Pediatrics in Review. American Academy of Pediatrics. Aug 2014.
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Conclusiones!
• El eutiroidismo: forma más frecuente de presentación al tiempo de dx de la tiroidits de Hashimoto (TH), seguida de HS, HM y del Hipertiroidismo subclínico o manifiesto.!
• Los patrones de presentación dependen de la edad.!• La tendencia al deterioro en la función tiroidea es
frecuentemente observada tanto en eutiroideo como en HS.!
• El rx de HM es mayor en aquellos con HS al momento del dx.!
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• GRACIAS!
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ETIOLOGIA!