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Transcript
Hyperthyroidism, hypothyroidism, endocrine ophthalmopathy Dr. Peter Lakatos 1st Department of Medicine, Semmelweis University Capacity of specialized tissues to function in an integrated fashion made possible by: • Nervous system (electrochemical signals) • Endocrine system (chemical signals – hormones) • Immune system Endocrinology - Starling, Croonian Lectures, 1905 Evolution of hormones • Alpha factor of yeast – GnRH • Glucagon of tobacco hornworm • VIP in earthworm • Cholecystokinine in hydra • PTHrp in fish Distinction Between Elevated Serum T4 of Thyrotoxicosis and Euthyroid Hyperthyroxinemia Increased binding proteins Estrogen Infectious hepatitis Opiates Genetic Anti-thyroxine antibodies Thyroid hormone resistance Amiodarone Porphyria Hyperemesis gravidarum Acute psychiatric disorders Causes of Transient or Permanent Hyperthyroidism Graves-Basedow disease Toxic goiter (autonomous adenoma) Toxic multinodular goiter Struma ovarii Iatrogen Thyroiditis (subacute) Differentiated thyroid tumors Rare causes Common Symptoms of Graves' Thyrotoxicosis Symptom Frequency, % Nervousness, jitteriness, irritability Increased perspiration Easy fatigability Heat intolerance Weight loss Tachycardia Muscle weakness Insomnia Increased appetite Reduced job performance; marital discord Eye complaints Hyperdefecation Anorexia Constipation 99 91 88 89 85 82 70 65 65 58 54 33 9* 4* *May be due to associated hypercalcemia. Causes of Transient or Permanent Hypothyroidism Destructive Postoperative Radioactive iodine External radiation to neck Infiltrative disease (eg, sarcoidosis, amyloidosis, lymphoma, metastatic carcinoma) Autoimmune Hashimoto's disease Following Graves' disease Thyroiditis (subacute, silent, postpartum) Drug-induced (iodides, lithium, thionamides) Hereditary or congenital Enzyme deficiency affecting thyroid hormone biosynthesis Agenesis Hormone resistance Endemic cretinism Hypothalamic-pituitary disorders Thyrotropin-releasing hormone deficiency Thyroid-stimulating hormone deficiency Idiopathic Goitrous and nongoitr. primary hypothyroidism with negative anti-thyroid antibodies Clinical Presentation of Thyroid Hormone Deficiency Symptoms Signs General Cold intolerance Fatigue Mild weight gain Nervous system Lethargy Memory defects Poor attention span Personality change Weakness Muscle cramps Joint pain Gastrointestinal system Nausea Constipation Cardiorespiratory system Decreased exercise tolerance Reproductive system Decreased libido Decreased fertility Menstrual disorders Skin and appendages Dry, rough skin Puffy facies Hair loss Brittle nails Hypothermia Mild obesity Hoarse voice Somnolence Slow speech Myxedema wit Psychopathology: myxedema madness Diminished hearing and taste Cerebellar ataxia Delayed relaxation of deep tendon refl. Carpal tunnel syndrome Musculoskeletal Normal strength Normal joint examination Large tongue Ascites Bradycardia Mild hypertension Pericardial effusion Pleural effusion Normal secondary sex characteristics Nonpitting edema of hands, face, ankles Periorbital swelling Pallor Yellowish skin (due to carotenemia) Coarse hair Dry axillae Type of Derangement Clinical Status Serum TSH Serum Free Thyroxine Hypothalamic failure or tumor Hypothyroid Usually normal Decreased Pituitary failure or tumor Hypothyroid Usually normal Decreased Resistance to thyroid hormone Variable Usually normal Increased Resistance to thyroid-stimulating hormone (TSH) Euthyroid Increased Normal Treated primary congenital hypothyroidism Euthyroid Increased Normal TSH-secreting pituitary tumors Hyperthyroid Increased Increased Serious organic nonthyroidal illnesses Euthyroid Variable Normal or increased Acute psychiatric disorders Euthyroid Normal Normal or increased Recovery from recent hyperthyroidism Hypothyroid or euthyroid Decreased Decreased or normal TSH suppression, dopamine Euthyroid Decreased Usually normal TSH suppression, glucocorticoids Euthyroid Normal or decreased Usually normal Non-steady state thyroxine administration Variable Variable Variable Treated primary congenital hypothyroidism Euthyroid Increased Normal Acute salsalate/salicylate loading Euthyroid Decreased then increased Increased then normal Long-term derangements: Transient derangements:
