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住院病患甲狀腺疾病介紹與檢查

住院病患甲狀腺疾病介紹與檢查. 內分泌新陳代謝科 林立偉醫師 100/6. 大綱. When to consider thyroid disorder ? How to arrange examination of thyroid? What is Nonthyroidal illness syndrome ? How to treatment ?. Clinical presentation of thyrotoxicosis. When to suspect hyperthyroidism in hospitalized patient ?.

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住院病患甲狀腺疾病介紹與檢查

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  1. 住院病患甲狀腺疾病介紹與檢查 內分泌新陳代謝科 林立偉醫師 100/6

  2. 大綱 • When to consider thyroid disorder ? • How to arrange examination of thyroid? • What is Nonthyroidal illness syndrome ? • How to treatment ?

  3. Clinical presentation of thyrotoxicosis

  4. When to suspect hyperthyroidism in hospitalized patient ? • tachycardia Sinus tachycardia Af • consciousness change • Fever • Paralysis with hypokalemia • Others : BW loss . elevated liver enzyme

  5. Cardiovascular effect of hyperthyroidism • increase contractility and cardiac output • peripheral vascular resistance is decreased • Systolic hypertension with widened pulse pressure • 40% sinus tachycardiac • Atrial fibrillation occurs in 10 to 20 percent of patients with hyperthyroidism  tachyarrythmic cardiomyopathy • High- or normal-output congestive heart failure can occur in patients with severe hyperthyroidism • Pulmonary hypertension

  6. Thyrotoxic Periodic Paralysis(TPP) • more prevalent in Asians and inmales20~40 y/o • Thyroid hormone increases tissue responsiveness to beta-adrenergic stimulation which increases sodium-potassium ATPase activity on the skeletal muscle membrane • precipitated by events that are associated with an increased release of epinephrine orinsulin, both of which cause movement of potassium into cells

  7. Predisposing factors : Na/K ATP channel gene mutation Precipitating factors : CHO intake Exercise Symptoms : weakness, usually affecting proximal muscles, and the legs more than the arms Mild myalgia less than half of patients Hypokalemia : The degree of hypokalemia during an attack is variable; a report : the mean serum potassium level was 2.1 mmol/L

  8. Treatment : • KCl replacement ; but avoid reboundhyperkalemia • Propanolol • Restoration of euthyroidism • Propranolol, a beta adrenergic blocker, presumably reverses the excessive stimulation of the sodium-potassium ATPase and excessive drive of potassium into cells

  9. Thyroid storm • Severe thyrotoxicosis . Score • Cardinal presentation : • Tachycardia : • rates that can exceed 140 beats/min, along with congestive heart failure • Fever : • Consciousness change : • Agitation, delirium, psychosis, stupor, or coma (Others : GPT GOT elevation . vomiting diarrhea . jaundice ) • Precipitating factors : • surgery, trauma, infection, AMI or an acute iodine load

  10. Clinical presentation of hypothyroidism

  11. When to suspect hypothyroidism in hospitalized patient ? • Consciousness change • dementia . delirium • Hyponatremia • Pericardial effusion • Muscles complaint with CPK elevation • Edema • CO2 retention • Others : low temperature . constipation . sinus bradycardia

  12. Cardiovascular effect of hypothyroidism • decrease in cardiac output and cardiac contractility • reduction in heart rate • increase in peripheral vascular resistance and diastolic hypertension • However, heart failure due solely to hypothyroidism is rare • Hyperlipidemia  atherosclerosis CVD risk

  13. Hyponatremia • Cause : • Inappropriate ADH secretion • Decreased GFR  free water retention Correction to euthyroid Water restriction

  14. Hypothyroid myopathy • Common • Symptoms : weakness . myalgia . cramping • 25 % CPK elevation ( CPK 100 ~1000) • Rare Rhabdomyolysis

  15. Periorbital edema and nonpitting leg edema interstitial accumulation of glycosaminoglycans with associated extravascular water retention Some patients have pitting edema edema

  16. Myxedema coma frequently do not present in coma, but almost altered consciousness severe, long-standing hypothyroidism and precipitated by an acute event such as infection, myocardial infarction, cold exposure, or the administration of sedative drugs high mortality rate 40 %

  17. Others Fever and neck pain  subacute thyroiditis Special medications  drugs related thyroid dysfunction Neck lymadenopathy  thyroid cancer Metastatic cancer  thyroid cancer (papillary or follicular carcinoma metastatic to lungs bone) MEN2  medullary thyroid cancer

  18. Subacute thyroiditis Neck pain , tender and firm thyroid mass Fever (may present as chronic fever or FUO ) Tachycardia due to thyrotoxicosis ESR  Tc99m scan uptake  Treatment : NSAID and Steroid

  19. Drugs related thyroid dysfunction Inhibition of TSH : • Glucocorticoid ( more than 80mg/day hydrocortisol) • Dopamine Dubutamine • Octreotide Cause hyperthyroidism : • Contrast medium • Amiodarone

  20. Decrease thyroxine absorption : • PPI CaCo3 sucrafate • Interfere thyroid hormone metabolism : phenobarbital . Phenytoin . Cabamazepine . Rifampin • decrease T3 conversion : • Glucocorticoid (high dose > 100mg/day hydrocortisol) • PTU • Beta adrenergic antagonist

  21. Cause hypothyroidism : • Iodine containing drugs : • Contrast • Amiodarone • Others : • lithium . Interferon . Interleukin-2 . Sunitimab . Imatinib . thalidomide

  22. Iodine induced hypothyroidism High dose and sudden load of iodine can cause hypothyroidism (Wolff-Chaikoff effect) • inhibition thyroid hormone synthesis and secretion • transient and mild hypothyroidism for a few weeks In normal subjects : escape from Wolff-chaikoff effect  recovery thyroid function In subjects with autoimmune thyroid disease (especially Hashimoto disease) : impaired escape prolong hypothyroidism

  23. Amiodarone induced thyrotoxicosis ( AIT) • Type 1 : Jod-Basedow phenomenon : • Patients with nodular goiter are at increased risk • treatment : antithyroid drugs • Type 2 : painless thyroiditis • Destructive thyroiditis • treatment : steroid

  24. Amiodarone induced hypothyroidism Prevalence : 10% in patient with amiodarone in mean 21 months Patients with underlying autoimmune thyroid disease are at highest risk (due to failure to escape from the Wolff-Chaikoff effect) Check antimicrosomal antibody TSH before amiodarone Euthyroidism should be restored by replacement with thyroid hormone We suggest continuing amiodarone therapy in patients who develop amiodarone-induced hypothyroidism

  25. Physical examination • Palpation of thyroid gland • Enlargement (goiter) ? • Nodule or diffusely enlarged ?

  26. Laboratory examination • Thyroid function • TSH • Free T4 • T3 • Autoantibody • TSH receptor Ab (TRAb) • Antimicrosomal Ab ; Antithyroglobulin Ab

  27. TSH • more sensitivity than free T4 • check TSH to screening • after treatment . free T4 improved faster than TSH ( TSH return to nromal range about 6~8weeks ) • Central hypothyroidism : • Low free T4 • Low or low-normal TSH

  28. Subclinical • Subclinical hyperthyroidism • TSH  free T4 normal • Subclinical hypothyroidism • TSH  free T4 normal

  29. Autoantibody

  30. Thyroid sonography • Thyroid nodule • Benign • Malignancy  fine needle aspiration (cytology) • Malignant signs in sonography : • Irregular shape or border • Obvious Hypoechoic • microcalcification • Thyroid size • Parenchyma • adjacant tissure

  31. Hashimoto disease

  32. Thyroid nodule Thyroid cyst

  33. CT scan/MRI • CT scan/MRI : • intrathoracic goiter • lymphadenopathy

  34. Thyroid scan • Tc-99m scan / I-131 scan • hot nodule : uptake  • least malignancy risk • hyperfunctional nodule may cause hyperthyroidism • cold nodule : uptake  • Malignancy risk 20% Others : • Graves’ disease : diffuse uptake  • Subacute thyroiditis : no uptake

  35. Hot nodule Cold nodule

  36. Nonthyroidal illness syndrome (NTIs) • changes in thyroid function during severe illness • as physiologic protection which prevent excessive tissue catabolism • Very common • = euthyroid sick syndrome • Thyroid function change correlation to severity and time course of underlying illness • Assessment of thyroid function in patients is difficultamong those hospitalized especially in an intensive care unit

  37. Low T3 • Low T3 syndrome • Several mechanisms can contribute to the inhibition of deiodination (D1) and therefore to the low serum T3 concentrations • Inhibition factors : • Endogenous or iatrogenic glucocorticoid • Cytokine • Free fatty acid • High prevalence : 50% in hospitalized patient

  38. Low T4 • T4 Usually keep normal in mild and early stage of illness • T4 became low in severe and advanced stage of illness • prevalence : • 20 % hospitalized patients • 50 % patients in intensive care units

  39. Low free T4 • Free T4 usually normal in patients whose illness is not severe • free T4 become low in severe and advanced stage of illness

  40. Low TSH • Central hypothyroidism developed in chronic stage of illness

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