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Acquired Hypothyroidism

Acquired Hypothyroidism. Katrina L. Parker, MD. Acquired Hypothyroidism. The thyroid gland makes too little or no thyroid hormone Occurs anytime during childhood Usually affects infants starting at 6 months of age. Historical Review.

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Acquired Hypothyroidism

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  1. Acquired Hypothyroidism Katrina L. Parker, MD

  2. Acquired Hypothyroidism • The thyroid gland makes too little or no thyroid hormone • Occurs anytime during childhood • Usually affects infants starting at 6 months of age

  3. Historical Review • 1912 Dr. Hakaru Hashimoto described 4 patients with a chronic disorder of the thyroid • He termed it strumalymphomatosa • The thyroid glands had • Fibrosis • Diffuse lymphocytic infiltation • Parenchymal atrophy • Eosinophilic changes

  4. Etiology • Autoimmune disease • Delayed onset congenital hypothyroidism • Iodine deficiency • Medications • Anti depressants • Lithium • Amiodarone - 1 4-18% of patients • Radiation therapy • Radioactive iodine therapy • Thyroid surgery

  5. Causes of Acquired Hypothyroidism • Thyroidectomyor radioiodine therapy • Thyroid cancer • Thyroxicosis • Lingual thyroid • Isolated midline thyroid • TRH deficiency • Pituitary disorder • Chronic infections • Idiopathic

  6. Etiology • Environmental factors • High iodine intake • Selenium deficiency • Pollutants – tobacco smoke • Infectious disease- chronic hepatits C

  7. Incidence • 0.3 to 1.5 cases per 1000 population per year • 15-20 times more frequent in women than men •  in families with hypothyroidism or autoimmune disease • Associated with other autoimmune diseases • Type 1 DM • Celiac disease • Type 2 and Type 3 polyglandular autoimmune disorders

  8. Prevalence • Annual incidence 4 per 100 women and 1 per 1000 men • More common in certain populations • sporadic inheritance, sometimes autosomal recessive • post-partum thyroiditis affects 5% of women

  9. Absorption of thyroid hormone • Affected by • Iron supplements • Questran • Antacids containing Aluminum hydroxides • Calcium supplements • Soy products • Rifampin • Anti convulsants

  10. Hypothyroidism Classification

  11. Hypothyroidism and Concurrent Conditions • Depression • Euthyroid sick syndrome • Starvation • Critically ill • Corticosteroids and dopamine • Infertility

  12. Differential Diagnosis • Primary versus hypothalamic failure • Short stature • Coarse features R/O • Down Syndrome • Hurler & Hunter Syndrome • Generalized gangliosidosis

  13. Presentation of Hashimoto’s Thyroiditis • Euthyroidism and goiter • Subclinical hypothyroidism and goiter • Primary thyroid failure • Adolescent goiter • Painless thyroiditis or silent thyroiditis • Postpartum painless thyrotoxicosis • Alternating hypo- and hyperthyroidism

  14. Signs • Depression • Physical & mental sluggishness • Dry skin • Constipation • Weight gain with poor appetite • Dyspnea • Poor muscle tone • Menorrhagia • Diminished sweating • Hoarse voice or cry/large tongue

  15. Signs • Coarse, dry skin • Cool peripheral extremities • Puffy face, hands and feet (myxedema) • Bradycardia • Peripheral edema • Delayed tendon reflex relaxation • Carpal tunnel syndrome • Mild unexplained weight gain NOT morbid obesity

  16. Skin – dry, thick, scaly, coarse • Hair- brittle, dry, coarse, excessive • Lateral thinning of the eyebrows • Prominent axillary & supraclavicular fat pads in infants • Growth changes – short stature, infantile skeletal proportions with relatively short extremities • Infantile naso-orbital configuration • Delayed epiphyseal development

  17. Delayed closure of fontanelles • Delayed dental eruption • Delayed epiphyseal development • Menometrorrhagia or galactorrhea

  18. Labs • Decreased TT4 and FT4, elevated TSH • Thyroid antibodies • Anti- Thyroglobulin and anti thyroid perioxidase (TPO) • R/O TBG deficiency • Normocytic anemia • Elevated cholesterol and carotene in childhood but normal or low in infants • Decreased GH levels

  19. Imaging • Skeletal maturation is delayed • Ossification centers of the hip • Single stippled • Multiple small areas • Anterior beaking of the vertebrae • Coxa vara & coxaplana • Thyroid scan or ultrasound

  20. Treatment • Levothyroxine • The drug of choice • Dosage infants 10-12 mg/kg/day • Long standing hypothyroidism start with a low dose of 25-50 ug daily and gradually increase • Monitor TSH and FreeT4

  21. Treatment • T4 only • Currently the standard treatment • Involves supplementation of levothyroxine alone • T4 and T3 in combination • Involves administering both synthetic L-T4 and L-T3 simultaneously in combination • Desiccated Thyroid Extract • animal based thyroid extract • contains natural forms of l-t4 and l-t3e

  22. Glandular Concentrates • Sold in health food stores • Are not regulated by the FDA • Potency is not guaranteed

  23. QUESTIONS

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