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Endocrine Tutorial Hyperthyroidism • Clinical features Hyperthyroidism • Clinical features – – – – CVS: tachycardia, palpitations, atrial fib CNS: tremor, anxiety, lability, insomnia Heat intolerance; warm, moist, flushed skin Weight loss with increased appetite Hyperthyroidism • Clinical features – – – – CVS: tachycardia, palpitations, atrial fib CNS: tremor, anxiety, lability, insomnia Heat intolerance; warm, moist, flushed skin Weight loss with increased appetite • Causes Hyperthyroidism • Clinical features – – – – CVS: tachycardia, palpitations, atrial fib CNS: tremor, anxiety, lability, insomnia Heat intolerance; warm, moist, flushed skin Weight loss with increased appetite • Causes – – – – – Graves disease Exogenous thyroid hormone Functioning multinodular goitre/thyroid adenoma Thyroiditis Secondary (hypothal/pituitary dysfunction) Hypothyroidism • Clinical features Hypothyroidism • Clinical features – – – – – CVS: bradycardia, cardiomegaly, pericardial effusion CNS: slowed mental activity, apathy, fatigue, cretinism Cold intolerance; cool skin; myxedema; hair loss Weight gain with decreased appetite Coarsening of features Hypothyroidism • Clinical features – – – – – CVS: bradycardia, cardiomegaly, pericardial effusion CNS: slowed mental activity, apathy, fatigue, cretinism Cold intolerance; cool skin; myxedema; hair loss Weight gain with decreased appetite Coarsening of features • Causes Hypothyroidism • Clinical features – – – – – CVS: bradycardia, cardiomegaly, pericardial effusion CNS: slowed mental activity, apathy, fatigue, cretinism Cold intolerance; cool skin; myxedema; hair loss Weight gain with decreased appetite Coarsening of features • Causes – – – – Hashimoto thyroiditis Surgery / Radiation / Drug-induced Infiltration by tumour Secondary (hypothal/pituitary dysfunction) Graves disease • Epidemiology – What type of people get Graves disease? Graves disease • Epidemiology – Women, 20-40 yrs, (M:F = 1:7) Graves disease • Epidemiology – Women, 20-40 yrs, (M:F = 1:7) • Pathogenesis Graves disease • Epidemiology – Women, 20-40 yrs, (M:F = 1:7) • Pathogenesis – Autoimmune disorder – Activation of thyroid by thyroid autoantibodies • Anti-TSH R, anti-thyroglobulin, anti-T3/T4 – Associated with certain HLA types – Associated with other AI disorders • Hashimoto thyroiditis, pernicious anaemia, rheumatoid arthritis Graves disease • Gross findings – Mild symmetrical thyroid enlargement – Eyes: exophthalmos, lid retraction, lid lag – Skin: pretibial myxedema Graves disease • Microscopic findings Graves disease Normal thyroid Graves disease • Microscopic findings Hashimoto Thyroiditis • Epidemiology Hashimoto Thyroiditis • Epidemiology – Women, 45-65 yrs, (M:F = 1:10 to 20) Hashimoto Thyroiditis • Epidemiology – Women, 45-65 yrs, (M:F = 1:10 to 20) • Pathogenesis Hashimoto Thyroiditis • Epidemiology – Women, 45-65 yrs, (M:F = 1:10 to 20) • Pathogenesis – Autoimmune disorder – Destruction of thyroid by thyroid autoantibodies • Anti-TSH R, anti-thyroglobulin – Associated with certain HLA types – Associated with other AI disorders • SLE, pernicious anaemia, rh. Arthritis, Sjogrens, IDDM, Graves – May cause transient hyperthyroidism in early stages – Gradual destruction and fibrosis hypothyroidism Hashimoto Thyroiditis • Gross findings – Enlarged pale thyroid initially – Atrophic thyroid eventually Hashimoto Thyroiditis • Microscopic findings Hashimoto Thyroiditis • Microscopic findings Thyroiditis • Painful – Infectious • Adjacent sinusitis, mycobacteria, fungi – Subacute (granulomatous) • Post viral • Painless – Hashimoto’s – Fibrous • Fibrosis, atrophy, hypothyroidism Goitre • What is it? Goitre • What is it? – Enlarged thyroid – Due to impaired thyroid hormone synthesis Goitre • What is it? – Enlarged thyroid – Due to impaired thyroid hormone synthesis • Causes Goitre • What is it? – Enlarged thyroid – Due to impaired thyroid hormone synthesis • Causes – Iodine deficiency – Goitrogens – Inherited disorders Goitre • Pathogenesis – Hyperplasia of follicular epithelium – Increased thyroid hormone release (decreased colloid) – Involution of follicles when enough thyroid hormone released – Accumulation of colloid • Two forms: – Diffuse – Multinodular Goitre • Gross findings – Diffuse: Diffuse enlargement without nodules – Multinodular: Goitre • Microscopic findings – Diffuse (initial hyperplastic stage): • Hyperplastic and hypertrophied follicles • Decreased colloid – Diffuse (involution stage) • Dilated follicles, atrophic epithelium • Abundant colloid Goitre • Microscopic findings – Multinodular goitre: – Recurrent episodes of stimulation and involution • Hyperplastic and hypertrophied follicles with decreased colloid • Dilated follicles with atrophic epithelium and abundant colloid • Haemorrhage, fibrosis, calcification, cyst formation Thyroid neoplasms • Risk factors – – – – M:F = 1:4 Radiation therapy Hashimoto’s Multinodular goitre • Types – Follicular adenoma – Carcinoma • • • • Papillary Follicular Anaplastic Medullary Follicular adenoma • Morphology: Follicular carcinoma • Morphology: – Same as follicular adenoma! BUT – Vascular / capsular invasion – Haematogenous mets Papillary carcinoma • Morphology: Papillary carcinoma • Morphology: Causes of hyperparathyroidism Parathyroid hyperplasia Parathyroid adenoma Hyperadrenalism • Presentation – Cushing’s syndrome – Conn’s syndrome • Causes – Primary • Hyperplasia, adenoma, carcinoma – Secondary • Hypothalamic/pituitary disorders • Ectopic ACTH secretion • Activation of renin-angiotensin system Causes of hyperadrenalism hyperplasia carcinoma adenoma Causes of hypoadrenalism haemorrhage infection (TB) metastases Pancreatic islet cell tumour + Pituitary adenoma + Parathyroid hyperplasia = MEN I Phaeochromocytoma + Medullary carcinoma of thyroid + Parathyroid hyperplasia = MEN II