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HYPOTHYROIDISM-
MANIFESTATIONS & MANAGEMENT

      Dr. Sachin Verma MD, FICM, FCCS, ICFC
         Fellowship in Intensive Care Medicine
           Infection Control Fellows Course
     Consultant Internal Medicine and Critical Care
   Web:- http://www.medicinedoctorinchandigarh.com
                Mob:- +91-7508677495
T3, T4 (-)
                       Hypothalamus
             TRH (+)
                       Pituitary
                                   T3, T4 (-)
             TSH (+)
                       Thyroid
Hyperthyroidism   Hypothyroidism
Patients of Thyroid Disorders Present As
                           With Goiter
  Hypothyroid
                           Without Goiter

                           With Goiter
  Hyperthyroid
                           Without Goiter
  Euthyroid With Goiter


03/19/13                                    4
Hypothyroidism
                      Causes
With Goiter                  Without Goiter
 Hashimoto’s Thyroiditis     Hashimoto’s Thyroiditis

 I2 deficiency goiter        Post ablative(radioactive I 2)

 Drug induced goiter         After thyroidectomy
  (Li, Amiodarone, PAS,       Congenital hypothyroidism
  ethionamide, Rifampicin)
                              Secondary hypothyroidism
 Due to goitrogens
                                (Sheehan syndrome)
 Riedel’s thyroiditis
HYPOTHYROIDISM
IODINE DEFICENCY  is the most common cause
 of hypothyroidism worldwide.


In Iodine sufficient areas, Autoimmune
 disease (HASHIMOTO’S THYROIDITIS) is most
 common.
HYPOTHYROIDISM
           Common presentation
 Symptoms                       Signs
 Dry & coarse skin- 76%        Ankle reflex absent- 77%
 Cold intolerance – 64%        Bradycardia - 58%
 Puffiness of face- 60%        Somnolence
 Sweating- 54%                 Diastolic hypertension
 Wt gain-54%                   Depression
 Paresthesia - 52 %            Anemia
 Constipation- 50%             Menorrhagia
 Aches & pains non specific    Infertility
HYPOTHYROIDISM
                Uncommon Presentations.
   Hoarseness of voice
   Deafness
   Ascites
   Pericardial & pleural effusion
   Carpel tunnel syndrome
   Impotence
   Galactorrhoea & Amenorrhoea
   Cardiac failure
   Psychosis

03/19/13                                  8
Thyroid
 • Thyroid Disease Can             Brain
   Have Widespread Effects         • Depression
                                   • Decreased Concentration
 Liver
                                   • General Lack of Interest
 • Increased LDL
   Cholesterol
 • Elevated
   Triglycerides                    Heart
                                    • Decreased Heart Rate
Intestines                          • Increased/Decreased
• Constipation                        Blood Pressure
• Decreased GI                      • Decreased Cardiac
 Activity                             Output

                                    Kidneys
Reproductive
System                              • Decreased Function
• Decreased Fertility               • Fluid Retention and
• Menstrual Abnormalities            Edema
• May Harm Development of Infant
Hashimoto’s Thyroiditis
                         IN USA
Above 50 years Female – 10% Hypothyroid
Above 60 years Male – 10% Hypothyroid


In India prevalence rate of Hypothyroid is quite high
but data is not available.
Hashimoto’s Thyroiditis

       Commonest cause of hypothyroidism
       Most of the patients never develop goitre
       Symptoms develop very gradually




                             So difficult to Diagnose!
03/19/13                                                 11
Hashimoto’s Thyroiditis
    Painless Goiter/ No Goiter

    Investigations
    T3↓ T4 ↓
    TSH↑
    High titers of TPO ab. (almost 100%)
    Treatment
    Life long Thyroxin


03/19/13                                    12
Viral Thyroiditis
Painful Goiter (Usually small) , fever , sorethroat
Natural History:
              Hyperthyroid 2 – 3 months

                     Hypothyroid 2-6 months



                            Euthyroid

03/19/13   Few Patients may remain Hypothyroid Life Long   13
Viral Thyroiditis: Treatment
Pain - Aspirin (600mg 4-6hrly) / NSAIDS
Steroids – 40- 60 mg/ day according to severity
Hyperthyroid – Propranolol
Hypothyroid – May require Thyroxin(50-100µgm)
Euthyroid – After 6 months – 1 year
                 No Drug Required



  03/19/13                                         14
POST-PARTUM THYROIDITIS
    Post-partum thyroiditis (PPT) is an autoimmune,
  painless inflammation of the thyroid gland that
  occurs within a year in 5% to 10% of all
  pregnancies.



22/1/05                                           2
Etiology and Pathogenesis
      Microchimerism:
                    (Fetal cells in maternal blood)

         The presence of residual fetal cells which get
     attached to the maternal thyroid gland during
     pregnancy, induces autoimmune reactions as
     maternal immunosuppression is lost after delivery.


22/1/05                                               8
Post Partum Thyroiditis
  Natural History:
                   Hyperthyroid 2 - 3 months


                   Hypothyroid 2 - 6 months



                           Euthyroid

   25% of Postpartum Thyroiditis Patients will develop
      Hypothyroidism after 5-10 years of delivery
03/19/13                                                  17
Atypical Presentations of
             Postpartum Thyroiditis
           A Thyrotoxic phase followed by a return to
             normal thyroid function

           A Hypothyroid phase alone




22/1/05                                                  13
Initial tests for diagnosis of
   Thyroid Dysfunction
           Primary Test


             TSH
          Additional Test

             Free T4
TSH raised (>3.5-5.5 according to the lab)

  Free T4 decreased

  Total T4 decreased

           .




03/19/13                                        20
Hypothyroidism: Initial Diagnosis

 Free T3 May be normal in 25%
 cases of early hypothyroidism
Thyroid Ultrasound

      Relatively unimportant test
      Sensitive tool to ascertain size and number of
           thyroid nodules.
      Important tool in the follow up of a thyroid nodule
           if it is not to be operated




03/19/13                                                     22
Thyroid Scan

               WILL SHOW
                UPTAKE
                UPTAKE
              NORMAL UPTAKE




    03/19/13                   23
Thyroid Scan
           UPTAKE WITH GOITRE ( cold)

             Thyroiditis, Thyroid carcinoma


                     DO FNAC



03/19/13                                      24
Thyroid Scan
           UPTAKE WITH GOITRE (hot)



             Graves’ Disease




03/19/13                              25
Thyroid Scan
           NORMAL UPTAKE WITH GOITRE



           Colloid Goitre, Puberty Goitre, Adenoma



                    DO FNAC

03/19/13                                             26
COMMON THYROID AUTOANTIBODIES*

    ANTIGEN                                        ANTIBODY



  TSH receptor                 TSHRAb (TSH Receptor Antibody)



  Thyroglobulin                                        TgAb



Thyroid Peroxidase                                   TPO Ab

                     * Williams’ textbook of Endocrinology: 10th edition; chapter, 10 pg 36
GROUP                                       TPO Ab


            General Population                                 8-10%

              Graves Disease                                  50-80%

          Autoimmune Thyroiditis                             90-100%

            Relatives of Patients                             40-50%

             Pregnant Women                                     14%

22/1/05                                                                                         6
                                    * Williams’ textbook of Endocrinology: chapter, 10 pg 361
Treatment Of Hypothyroidism
Dose of Levothyroxine depends on the degree of
 Hypothyroidism, Age & General health condition of
 the patient

Usually daily replacement dose is 1.6µgm/Kg body
 weight

Start with Low Dose
Treatment Of Hypothyroidism
  If Dose Missed, What To Do???

One Dose Missed     Take Two Tablets

Two Dose Missed     Take Three Tablets

Three Dose Missed   Take Regular Dose
Treatment Of Hypothyroidism
WHEN SHOULD I TAKE IT ??



 EMPTY STOMACH 30 mins BEFORE CALORIC
  MEAL
Follow up of a case of Hypothyroidism
  Serum TSH levels should be measured after 6-8
      weeks of therapy and dosages should be adjusted
      accordingly
  Target TSH levels should be between 1-2 mU/l

  Once a stable TSH is achieved, it should be
      estimated every year

03/19/13                                            32
Follow up of a case of Hypothyroidism
 Patient on Thyroxine            TSH NORMAL


           WHAT SHOULD I DO??

     Most of these patients are Hashimoto’s thyroiditis .
     They will require life long treatment
     Donot stop the drug Continue Thyroxine


03/19/13                                                    33
INTERPRETATION OF
           THYROID FUNCTION TESTS




03/19/13                            34
Situation 1

            TSH     Free T3   Free T4




           Normal   Normal    Normal


03/19/13                                35
Diagnosis
           Normal Euthyroid




03/19/13                      36
Situation 2

           TSH    Free T3    Free T4




                              Normal
           High   Normal
                            /Decreased


03/19/13                                 37
Diagnosis


       SubClinical /
          Early Hypothyroidism

03/19/13                         38
Situation 3

           TSH     Free T3      Free T4




       Increased   Decreased   Decreased


03/19/13                                   39
Diagnosis

           Hypothyroidism


03/19/13                    40
Situation 4

           TSH   Free T3   Free T4




           Low    High      High


03/19/13                             41
Diagnosis


           Hyperthyroidism


03/19/13                     42
Situation 5

           TSH      Free T3      Free T4




           Low   Low or Normal    Low



03/19/13                                   43
Diagnosis


        Secondary
      Hypothyroidism
   Or Sheehan’s Syndrome
03/19/13                   44
SHEEHAN’S SYNDROME
               Female

   Excessive blood loss during delivery

   No lactation amenorrhoea

   Weakness,lethargic, anemia

   Depigmentation of areola, Shiny skin
   Loss of pubic & axillary hair
   Low B.P.
SHEEHAN’S SYNDROME
Treatment
 Hormone replacement therapy including glucocorticoid
 (prednisone 5+2.5 mg/d), Thyroxine (75-150µgm/d)

If lady wants periods- estrogen & progesterone
 preparations can be given.

GOAL To maintain T4 level in the upper half of range

TSH CANNOT BE USED TO MONITOR THERAPY
Hypothyroid And pregnancy
During pregnancy requirement of thyroxin
 increases by 25-50µg/d during pregnancy

Even on mild Thyroxin hormone deficiency
 there are chances of low IQ and developmental
 delay of the child
Hypothyroid And pregnancy
Thyroid Hormone exists in two forms :

  Free (Active) & Bound (with thyroxine binding
  globuline).
In Pregnancy increased Estrogen, increases TBG
 which in turn increases Total T4 & T3 level
However Free T4, Free T4 REMAINS NORMAL.
SO Free T4 should be used in the treatment and
 follow up during pregnancy & not total T4
Hypothyroidism In Elderly
In Patients Above 60 Rule Out Coronary Artery
 Disease

If Coronary Artery Disease Present Or Suspected:


  Start Thyroxine With Low Dose And Then
 Increase The Dose Gradually Otherwise Angina
 May Precipitate.
Myxedema Coma
Precipitating factors :
  Infection,
            trauma, stroke, cardiovascular,
   hemorrhage drug overdose, diuretics


Signs and Symptoms :
   Usually older age presenting as :
   Mental confusion, hypothermia, bradycardia, ↓ Na,
             ↓ glucose, ↑ CO2, ↓ WBC, ↓ Hct, ↑
   CPK
  ↓   EKG voltage
                                                   50
Myxedema Coma
Treatment
 ICU   transfer,
 IV  levothyroxine 500 µg bolus followed by 50-100µg/d
   (same dose can be given through NG tube),
 antibiotics,ventilation, hydrocortisone IV, passive
   warming, careful volume management
 As  T4 to T3 conversion is impaired so leothyronine is
   recommended but has a potential to provoke arrythmias.
Myxedema Madness.
When being crazy is not in your
 head   BUT IN THYROID
Delirium With Auditory Hallucinations &
Paranoid Delusions
Takes The Form Of Psycotic Depression Or Pure
Psycosis.
No Cognitive Impairement

Treatment- Thyroxine
Thank You
Sick Euthyroid Syndrome
Any acute, severe illness can cause abnormalities of
 circulating TSH or Thyroid hormone levels in the absence
 of underlying Thyroid disease.

Major cause - Release of cytokine IL-6


Most common pattern ----
          LOW T3 SNDROME---- in total & unbound T3
                          levels with normal T4 & TSH

     T4                         T3              rT3
              De iodination
Sick Euthyroid Syndrome
 LOW T4 SYNDROME ----

1.   Very sick patient may exhibit a dramatic fall in Total T3 & T4

2.    Poor prognosis

 In Acute Liver disease initially Total T3 & T4 levels       due
     to TBG release; these levels become subnormal as the disease
     progress

 Renal disease is often accompanied by low T3 levels

 In early stages of HIV T3 & T4 levels rises,. T3 levels falls with
     progression to AIDS , but TSH remains normal
Sick Euthyroid Syndrome
 Diagnosis is supported by

 History of thyroid disease

 Previous thyroid function tests

History of Drugs that may affect thyroid hormones

Measurement of rT3 together with FT3 , FT4 and TSH

ONLY RESOLUTION OF TESTS WITH CLINICAL
 RECOVERY CAN ESTABLISH THIS DISORDER

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Thyroid final

  • 1. HYPOTHYROIDISM- MANIFESTATIONS & MANAGEMENT Dr. Sachin Verma MD, FICM, FCCS, ICFC Fellowship in Intensive Care Medicine Infection Control Fellows Course Consultant Internal Medicine and Critical Care Web:- http://www.medicinedoctorinchandigarh.com Mob:- +91-7508677495
  • 2. T3, T4 (-) Hypothalamus TRH (+) Pituitary T3, T4 (-) TSH (+) Thyroid
  • 3. Hyperthyroidism Hypothyroidism
  • 4. Patients of Thyroid Disorders Present As With Goiter Hypothyroid Without Goiter With Goiter Hyperthyroid Without Goiter Euthyroid With Goiter 03/19/13 4
  • 5. Hypothyroidism Causes With Goiter Without Goiter  Hashimoto’s Thyroiditis  Hashimoto’s Thyroiditis  I2 deficiency goiter  Post ablative(radioactive I 2)  Drug induced goiter  After thyroidectomy (Li, Amiodarone, PAS,  Congenital hypothyroidism ethionamide, Rifampicin)  Secondary hypothyroidism  Due to goitrogens (Sheehan syndrome)  Riedel’s thyroiditis
  • 6. HYPOTHYROIDISM IODINE DEFICENCY is the most common cause of hypothyroidism worldwide. In Iodine sufficient areas, Autoimmune disease (HASHIMOTO’S THYROIDITIS) is most common.
  • 7. HYPOTHYROIDISM Common presentation Symptoms Signs  Dry & coarse skin- 76%  Ankle reflex absent- 77%  Cold intolerance – 64%  Bradycardia - 58%  Puffiness of face- 60%  Somnolence  Sweating- 54%  Diastolic hypertension  Wt gain-54%  Depression  Paresthesia - 52 %  Anemia  Constipation- 50%  Menorrhagia  Aches & pains non specific  Infertility
  • 8. HYPOTHYROIDISM Uncommon Presentations.  Hoarseness of voice  Deafness  Ascites  Pericardial & pleural effusion  Carpel tunnel syndrome  Impotence  Galactorrhoea & Amenorrhoea  Cardiac failure  Psychosis 03/19/13 8
  • 9. Thyroid • Thyroid Disease Can Brain Have Widespread Effects • Depression • Decreased Concentration Liver • General Lack of Interest • Increased LDL Cholesterol • Elevated Triglycerides Heart • Decreased Heart Rate Intestines • Increased/Decreased • Constipation Blood Pressure • Decreased GI • Decreased Cardiac Activity Output Kidneys Reproductive System • Decreased Function • Decreased Fertility • Fluid Retention and • Menstrual Abnormalities Edema • May Harm Development of Infant
  • 10. Hashimoto’s Thyroiditis IN USA Above 50 years Female – 10% Hypothyroid Above 60 years Male – 10% Hypothyroid In India prevalence rate of Hypothyroid is quite high but data is not available.
  • 11. Hashimoto’s Thyroiditis  Commonest cause of hypothyroidism  Most of the patients never develop goitre  Symptoms develop very gradually So difficult to Diagnose! 03/19/13 11
  • 12. Hashimoto’s Thyroiditis Painless Goiter/ No Goiter Investigations T3↓ T4 ↓ TSH↑ High titers of TPO ab. (almost 100%) Treatment Life long Thyroxin 03/19/13 12
  • 13. Viral Thyroiditis Painful Goiter (Usually small) , fever , sorethroat Natural History: Hyperthyroid 2 – 3 months Hypothyroid 2-6 months Euthyroid 03/19/13 Few Patients may remain Hypothyroid Life Long 13
  • 14. Viral Thyroiditis: Treatment Pain - Aspirin (600mg 4-6hrly) / NSAIDS Steroids – 40- 60 mg/ day according to severity Hyperthyroid – Propranolol Hypothyroid – May require Thyroxin(50-100µgm) Euthyroid – After 6 months – 1 year No Drug Required 03/19/13 14
  • 15. POST-PARTUM THYROIDITIS Post-partum thyroiditis (PPT) is an autoimmune, painless inflammation of the thyroid gland that occurs within a year in 5% to 10% of all pregnancies. 22/1/05 2
  • 16. Etiology and Pathogenesis Microchimerism: (Fetal cells in maternal blood) The presence of residual fetal cells which get attached to the maternal thyroid gland during pregnancy, induces autoimmune reactions as maternal immunosuppression is lost after delivery. 22/1/05 8
  • 17. Post Partum Thyroiditis Natural History: Hyperthyroid 2 - 3 months Hypothyroid 2 - 6 months Euthyroid  25% of Postpartum Thyroiditis Patients will develop Hypothyroidism after 5-10 years of delivery 03/19/13 17
  • 18. Atypical Presentations of Postpartum Thyroiditis  A Thyrotoxic phase followed by a return to normal thyroid function  A Hypothyroid phase alone 22/1/05 13
  • 19. Initial tests for diagnosis of Thyroid Dysfunction Primary Test TSH Additional Test Free T4
  • 20. TSH raised (>3.5-5.5 according to the lab) Free T4 decreased Total T4 decreased . 03/19/13 20
  • 21. Hypothyroidism: Initial Diagnosis  Free T3 May be normal in 25% cases of early hypothyroidism
  • 22. Thyroid Ultrasound Relatively unimportant test Sensitive tool to ascertain size and number of thyroid nodules. Important tool in the follow up of a thyroid nodule if it is not to be operated 03/19/13 22
  • 23. Thyroid Scan  WILL SHOW  UPTAKE  UPTAKE  NORMAL UPTAKE 03/19/13 23
  • 24. Thyroid Scan UPTAKE WITH GOITRE ( cold) Thyroiditis, Thyroid carcinoma DO FNAC 03/19/13 24
  • 25. Thyroid Scan UPTAKE WITH GOITRE (hot) Graves’ Disease 03/19/13 25
  • 26. Thyroid Scan NORMAL UPTAKE WITH GOITRE Colloid Goitre, Puberty Goitre, Adenoma DO FNAC 03/19/13 26
  • 27. COMMON THYROID AUTOANTIBODIES* ANTIGEN ANTIBODY TSH receptor TSHRAb (TSH Receptor Antibody) Thyroglobulin TgAb Thyroid Peroxidase TPO Ab * Williams’ textbook of Endocrinology: 10th edition; chapter, 10 pg 36
  • 28. GROUP TPO Ab General Population 8-10% Graves Disease 50-80% Autoimmune Thyroiditis 90-100% Relatives of Patients 40-50% Pregnant Women 14% 22/1/05 6 * Williams’ textbook of Endocrinology: chapter, 10 pg 361
  • 29. Treatment Of Hypothyroidism Dose of Levothyroxine depends on the degree of Hypothyroidism, Age & General health condition of the patient Usually daily replacement dose is 1.6µgm/Kg body weight Start with Low Dose
  • 30. Treatment Of Hypothyroidism If Dose Missed, What To Do??? One Dose Missed Take Two Tablets Two Dose Missed Take Three Tablets Three Dose Missed Take Regular Dose
  • 31. Treatment Of Hypothyroidism WHEN SHOULD I TAKE IT ??  EMPTY STOMACH 30 mins BEFORE CALORIC MEAL
  • 32. Follow up of a case of Hypothyroidism Serum TSH levels should be measured after 6-8 weeks of therapy and dosages should be adjusted accordingly Target TSH levels should be between 1-2 mU/l Once a stable TSH is achieved, it should be estimated every year 03/19/13 32
  • 33. Follow up of a case of Hypothyroidism Patient on Thyroxine TSH NORMAL WHAT SHOULD I DO?? Most of these patients are Hashimoto’s thyroiditis . They will require life long treatment Donot stop the drug Continue Thyroxine 03/19/13 33
  • 34. INTERPRETATION OF THYROID FUNCTION TESTS 03/19/13 34
  • 35. Situation 1 TSH Free T3 Free T4 Normal Normal Normal 03/19/13 35
  • 36. Diagnosis Normal Euthyroid 03/19/13 36
  • 37. Situation 2 TSH Free T3 Free T4 Normal High Normal /Decreased 03/19/13 37
  • 38. Diagnosis SubClinical / Early Hypothyroidism 03/19/13 38
  • 39. Situation 3 TSH Free T3 Free T4 Increased Decreased Decreased 03/19/13 39
  • 40. Diagnosis Hypothyroidism 03/19/13 40
  • 41. Situation 4 TSH Free T3 Free T4 Low High High 03/19/13 41
  • 42. Diagnosis Hyperthyroidism 03/19/13 42
  • 43. Situation 5 TSH Free T3 Free T4 Low Low or Normal Low 03/19/13 43
  • 44. Diagnosis Secondary Hypothyroidism Or Sheehan’s Syndrome 03/19/13 44
  • 45. SHEEHAN’S SYNDROME Female Excessive blood loss during delivery No lactation amenorrhoea Weakness,lethargic, anemia Depigmentation of areola, Shiny skin Loss of pubic & axillary hair Low B.P.
  • 46. SHEEHAN’S SYNDROME Treatment  Hormone replacement therapy including glucocorticoid (prednisone 5+2.5 mg/d), Thyroxine (75-150µgm/d) If lady wants periods- estrogen & progesterone preparations can be given. GOAL To maintain T4 level in the upper half of range TSH CANNOT BE USED TO MONITOR THERAPY
  • 47. Hypothyroid And pregnancy During pregnancy requirement of thyroxin increases by 25-50µg/d during pregnancy Even on mild Thyroxin hormone deficiency there are chances of low IQ and developmental delay of the child
  • 48. Hypothyroid And pregnancy Thyroid Hormone exists in two forms : Free (Active) & Bound (with thyroxine binding globuline). In Pregnancy increased Estrogen, increases TBG which in turn increases Total T4 & T3 level However Free T4, Free T4 REMAINS NORMAL. SO Free T4 should be used in the treatment and follow up during pregnancy & not total T4
  • 49. Hypothyroidism In Elderly In Patients Above 60 Rule Out Coronary Artery Disease If Coronary Artery Disease Present Or Suspected: Start Thyroxine With Low Dose And Then Increase The Dose Gradually Otherwise Angina May Precipitate.
  • 50. Myxedema Coma Precipitating factors : Infection, trauma, stroke, cardiovascular, hemorrhage drug overdose, diuretics Signs and Symptoms : Usually older age presenting as :  Mental confusion, hypothermia, bradycardia, ↓ Na, ↓ glucose, ↑ CO2, ↓ WBC, ↓ Hct, ↑ CPK ↓ EKG voltage 50
  • 51. Myxedema Coma Treatment ICU transfer, IV levothyroxine 500 µg bolus followed by 50-100µg/d (same dose can be given through NG tube), antibiotics,ventilation, hydrocortisone IV, passive warming, careful volume management As T4 to T3 conversion is impaired so leothyronine is recommended but has a potential to provoke arrythmias.
  • 52. Myxedema Madness. When being crazy is not in your head BUT IN THYROID Delirium With Auditory Hallucinations & Paranoid Delusions Takes The Form Of Psycotic Depression Or Pure Psycosis. No Cognitive Impairement Treatment- Thyroxine
  • 54. Sick Euthyroid Syndrome Any acute, severe illness can cause abnormalities of circulating TSH or Thyroid hormone levels in the absence of underlying Thyroid disease. Major cause - Release of cytokine IL-6 Most common pattern ---- LOW T3 SNDROME---- in total & unbound T3 levels with normal T4 & TSH T4 T3 rT3 De iodination
  • 55. Sick Euthyroid Syndrome  LOW T4 SYNDROME ---- 1. Very sick patient may exhibit a dramatic fall in Total T3 & T4 2. Poor prognosis  In Acute Liver disease initially Total T3 & T4 levels due to TBG release; these levels become subnormal as the disease progress  Renal disease is often accompanied by low T3 levels  In early stages of HIV T3 & T4 levels rises,. T3 levels falls with progression to AIDS , but TSH remains normal
  • 56. Sick Euthyroid Syndrome Diagnosis is supported by  History of thyroid disease  Previous thyroid function tests History of Drugs that may affect thyroid hormones Measurement of rT3 together with FT3 , FT4 and TSH ONLY RESOLUTION OF TESTS WITH CLINICAL RECOVERY CAN ESTABLISH THIS DISORDER