Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
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
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.
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
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18. Atypical Presentations of
Postpartum Thyroiditis
A Thyrotoxic phase followed by a return to
normal thyroid function
A Hypothyroid phase alone
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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
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
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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%
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* 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
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
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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