Thyroid gland diseases. Diffuse toxic goiter. hypothyreosis. Endemic goiter. Etiology. Clinical picture.

Diagnostics. Complications. Principles of treatment. Thyrotoxic

crisis. Hypothyreoid coma. Emergency care

Structure and location of thyroid gland

Physiological actions of thyroid hormones

Protein metabolismProtein metabolism – – stimulation of protein synthesisstimulation of protein synthesis;; CarbohydrateCarbohydrate metabolismmetabolism – – acceleration of their resorption from acceleration of their resorption from intestine and consumption by a liverintestine and consumption by a liver;; Fat metabolismFat metabolism - - acceleration of lipolysisacceleration of lipolysis, , cholsterol synthesis and cholsterol synthesis and metobolismmetobolism;;Liquid exchangeLiquid exchange - - intensification of water evacuation by kidneysintensification of water evacuation by kidneysMineral homeostasisMineral homeostasis – – regulation of regulation of Са, К, Р, С Са, К, Р, Сl metabolism.l metabolism.Increased oxygen consumption with all tissues (except of brain tissue, spleen and testes); Increased heat production; Increased amount of catecholamine receptors in myocardium;Regulation of respiratory centre;Stimulation of erythropoiesis;Stimulation of bone tissue formation and resorption.

Influence of thyroid Influence of thyroid hormones on an hormones on an

organismorganism::

Influence of thyroid Influence of thyroid hormones on an hormones on an

organismorganism::Nervous system and psychicNervous system and psychicNervous system and psychicNervous system and psychic

Cardiovascular systemCardiovascular systemCardiovascular systemCardiovascular system

Skin and intertgumentsSkin and intertgumentsSkin and intertgumentsSkin and intertguments

Digestive systemDigestive systemDigestive systemDigestive system

Musculosceletal apparatusMusculosceletal apparatusMusculosceletal apparatusMusculosceletal apparatus

Reproductive systemReproductive systemReproductive systemReproductive system

Endemic goitreEndemic goitre

This is a disease manifested This is a disease manifested with thyroid gland enlargement. with thyroid gland enlargement. It develops in certain It develops in certain biogeochemical regions biogeochemical regions characterized by iodine characterized by iodine deficiency in the environmentdeficiency in the environment

EthiologyEthiology

• Iodine deficiency is the main obvious factorIodine deficiency is the main obvious factor• Additional factors:Additional factors:• deficiency of microelements deficiency of microelements cobalt, copper, fluorine, cobalt, copper, fluorine,

zinc, molybdenumzinc, molybdenum (participate in iodine metabolism) (participate in iodine metabolism);;Influence of Influence of strumogensstrumogens – – substances which decelerate substances which decelerate biosynthesis of thyroid hormonesbiosynthesis of thyroid hormones HHypersecretionypersecretion of of thyrotrophic hormone (TTH) by thyrotrophic hormone (TTH) by hypophysishypophysis

• Diseases of digestive tract, a liver with disordered iodine Diseases of digestive tract, a liver with disordered iodine absorption.absorption.

Palpation of thyroid glandPalpation of thyroid gland Position of patient is upright with relaxed neck muscles, the neck is

slightly bended forward.

Position of a doctor may be behind (I variant) or before the patient (II variant).

A doctor performs palpation with tip of his fingers. In I variant of palpation examiner puts four fingers of both hands (except of thumbs) in projection of left and right parts of cricoid process. In II variant the examiner puts thumbs of his fingers in the same points (see next pictures).

A patient is asked to swallow saliva (a gland goes up and becomes more accessible both a review and palpation).

During swallowing doctor’s fingers slide across thyroid gland lobes and the isthmus.

The following properties of the gland are to be assessed: location, pain, size, symmetry, consistency, structure (homogenous or with nodes).

Palpation may be performed, if a doctor

stands behind or before the patient, his arms are put at

the zone of projection of the gland

Classification of thyroid gland Classification of thyroid gland enlargementenlargement ( (WHPOWHPO, 1995), 1995)

Degre Characteristics 0 Thyroid gland is not palpate, its sizes

are less then a medial phalange of human’s thumb

I а Thyroid gland is more than a distale phalange medial phalange of human’s thumb, a gland may be palpated bu is not visible in any position of patient’s head

І б Thyroid gland is palpable and visible in if the patient bends his head backward

II Thyroid gland is palpable and visible in any position of a patient

ІІІ «Sick neck», changed configuration of te neck, thyroid gland is visible t te distance

Classification of thyroid gland Classification of thyroid gland enlargementenlargement ( (WHPOWHPO, , 20012001))

Degree of enlargement – 0Goitre is absent (sizes of both lobules

don’t exceed medial phalange of human’s

thumb

Degree of enlargement - І Thyroid gland is palpable but is not

visible in normal position of patient’s

neck: nodal formations which don’t cause

thyroid gland enlargement

Degree of enlargement - ІІ Thyroid gland is visible in any position of

the patient

Diagnostics

•1. Anamnesis – residence in endemic region

• 2. Palpation of thyroid gland – thyroid gland is enlarged, painless, homogenous, mild-elastic

• 3. Level of thyroid hormones: Т4,Т3 - normal, ТТH normal or increased3. Ultrasound examination of thyroid gland

Nodal goitre

Treatment

• 1. 1. Thyroid hormonesThyroid hormones – – L-thyroxinL-thyroxin - 5 - 500-100 -100 ммcgcg//dd;;2. 2. Iodinum preparationsIodinum preparations – 1 – 10000-200-200 м мcgcg//dd

• Prophylaxis of iodine defficiensyProphylaxis of iodine defficiensy• Iodinum-containing productsIodinum-containing products ( (saltsalt, , bredbred, , milkmilk); );

22. . Iodinum preparationsIodinum preparations:: iodide potassiumiodide potassium, , lipiodollipiodol 100-200 100-200 ммcgcg//dd..

Epidemiology

Spreading of thyrotoxicosis is about 0,5 %

DTG often develops in the age 20-50 years.

Females develop this disease in 5-7 times

more often than males

Diffuse toxic goitre (DTG)Diffuse toxic goitre (DTG)

Ethiology and provoking factors

stress;Infectious diseases;insolation;smocking;Inflammatory processes in thyroid

glandHormonal disbalanceheredity

Pathogenesis

• Deficiency of T-supressors

• CD4+, CD8+

• T- and B-lymphocytes recognizing thyroid gland antigens

• antigenspecific stimulation of B-lymphocytes

• Production of stimulating antibodies to TTH receptors

Clinical patternComplaints

• Nervous system –tearfulness, depression, deranged sleep, irritability, oversweating

Cardiovascular system – Permanent palpitation, periodical

intermissions, dyspnea• Metabolism – poor tolerance to heat, low body weight while

appetite is increased, muscular weakness

Digestive tract - increased appetite; abdominal pain; periodical

diarrhoea

Ophthalmopathy – feeling of protrusion of eyes, dacryagogue;

photophobia

Interguments – brittle hair, loosing hair.

Objective examination

Red dermographism.

Cardiovascular system – tachicardia, extrasystoly, atrial

fibrillation; Intensification of І heart sound, systolic murmur, Heart failure; Systolic arterial hypertension Sex glands – Disorders of menstrual function and

problems with pregnancy in females, impotence in males Nervous system – Emotional lability, irritability; Tremor of the body (symptom of «telegraph post»)

especially nails of hands (Mary symptom).

• Metabolism – subfebrile body temperature, skin is warm

Low body weight.

Ostheoporosis.

Skin is warm and moist, mild, velvet-like;

Pretibial myxedema

• Thyroid gland is enlarged, of solid-elastic

consistency, systolic murmur above it

• Sex glands – mastopathy, gynecomastia

Ophthalmopathy

• Exophthalmos* Dalrimpl’s sign (wide eye slits)

* Graefe’s sign (white space above cornea if a patient changes point of view from up to down)

* Mebius sign (convergention disorders)

* Elinek’s sign (eyelids hyperpigmentation)

* Stellwag’s sign (rare blinking)

* Rosenbach’s sign (tremor of closed eyelids)

* Kocher’s sign – exposure of the sclera between the lower edge of the upper eyelid and the upper edge of the iris when the eyes are fixed on the upwardly moved object

Laboratory and instrumental examination

• ECG: synus tachicardia, extrasystoly, paroxysmal tachycardia, atrial fibrillation;

Ultrasound examination of a heart: high heart output;

Rogr - cardiomegaly• Metabolism – Increased serum Ca, excretion

of Ca with urine • Digestive tract – Changes of indexes of liver

function

Ocular symptoms

Grefe’s sign

Degrees of severity of thyrotoxicosisMild

Heart rate - less than 100 b/min Body mass defficiensy - less than 10 % Work capacity - preserved or slightly limited

Moderate

Heart rate - 100 - 120 b/min Body mass defficiensy - 10 - 20 % Changes of other organs and systems - ophthalmopathy Work capacity - decreased

Severe

Heart rate - more than 120 b/min, atrial fibrillation Body mass defficiensy - more than 20 % Changes of other organs and systems - ophthalmopathy;

dystrophy of parenchimal organs Work capacity - lost.

Diagnostics of DTGAnamnesis

Provoking factors

Clinical pattern

Signs of thyrotoxicosis and diffuse enlargement of thyroid gland

Laboratory tests

1) Common and free Т3 і Т4 are increased;

2) Increased level of common Т3 and normal Т4 (Т3 – thyrotoxicosis)

3) Decreased level of thyrotrophic hormone (TTH)

4) Increased consumption of radioactive iodinum J131 with thyroid gland

5) High level of antibodies to TTH receptors

Instrumental diagnostics

1) Ultrasound examination of thyroid gland (enlargement and diffuse

decreased density);2) Scintigraphy (insuspiction on retrosternal

goitre and in nodal goitre)

3) Puncture biopsy of thyroid gland is executed for diagnostics of all nodal formations in the gland

Laboratory and instrumental examination

• ECG: synus tachicardia, extrasystoly, paroxysmal tachycardia, atrial fibrillation;

Ultrasound examination of a heart: high heart output;

Rogr - cardiomegaly• Metabolism – Increased serum Ca, excretion

of Ca with urine • Digestive tract – Changes of indexes of liver

function

Ultrsound examination of thyroid gland

Radioisotopic scanogrm of thyrid gland

Puncture biopsy of thyroid gland

Treatment

Antithyroid preparations (propilthiouracil, tiamazol (merkasolil) within 1-2 yearsMercasolil (5 mg) – 30-60 mg per os, gradually decrease dosage till 5-15 mg.Beta-adrenobloquers (metoprolol 50-200 mg/d, bisoprolol 5-10 mg/d, propranolol 80-120 mg/d

Surgical treatmentIndications

Large goitre (over 45 cm3);Compresstion or displacement of trachea,

esophagus or large vessels;Retrosternal goitre;Severe thyrotoxicosis with atrial

fibrillation;No stable effect of medicamentous

treatment.Intolerance of antithyreoid drugs, allergy;Nodal goitre with thyrotoxicosis.

Thyrotoxic crisis

Provoking factors

Trauma or rude palpation of thyroid gland;

Operation on thyroid gland or usage of J131 without previous

medicamentous correction;

Any operative treatment in persons with hidden and unrecognized

thyrotoxicosis;

Inflammatory and infectious diseases;

Abrupt stop of antithyroid drug therapy;

overheating;

Physical and psychic trauma;

Pregnancy and delivery.

Clinical manifestation

Acute beginning; Nervous excitation or psychosis, fear of death; Skin is hot and moist, chande of profound sweating on

skin dryness, face is hyperemud, cianosis of limbs, tongue and lips are dry.

Muscular weakness, adynamia, pareses; Tachicardia, atrial fibrillation, elevation of BP with its

following sudden dropacute left entricular failure; Nausea, vomiting, diarrhoea

Lab tests

Anemia, leukocitosis, decreased hematocrit; elevated Т3

and Т4

Treatment

Inhibition of production and secretion of thyreoid hormpones;

Inhibition of nervous system irritation;

Restoration of adrenal glands function;

Correction of cardiovascular disorders;

Normalization of voter and salt metabolism acid-alkaline

balance;

Treatment of hypoxia, hypertermia

1. Complete physical and emotional rest. Mercasolil 20-30 mg per os.

2. Hydrocortison 200-400 мг (prednisolon 3-5

мг/кг), 0,05 % strophanthin 0,5 ml i/v.

3. Anaprilin 80 mg per os.

4. Reserpin 0,5 mg per os.

5. In nervous excitation – droperidol 2,5 mg.

6. Permanent oxygen therapy, applictaion of cold.

7. In low BP – cordiamin 2 ml subcutaneously.

Hypothyreosis

A disease caused by prolobged permanent thyroid hormones deficiency with following decrease of metabolism and functional disorders in different organs and systems

Epidemiology

Spreading in population 0,2 – 1 %;

Among newborns 0,025 % (1 : 4000);

People over 65 years – 2 – 4 %.

Subclinical and primary hypothyreosis is observed in 7-10 % females and 2 – 3 % males.

Ethiology of congenital hypothyreosis

Primary:

1) Abnormal thyroid gland development – dysgenesia;

2) Disorders of зу Т3 і Т4 syntesis;3) Defect of TTH receptors;4) Iodinum defficiency (endemic cretinism)

Secondary:

Congenital defects of hypophisis – isolated ТТГ defficiency

Tertiary:

Congenital defects of hypothalamus

Perypheral:

resistanse to thyroid hormons

Acquired hypothyreosis

Primary:

1) strumectomia;2) X-ray rtherapy of treatment with radioactive iodinum;

3) medicamentous-induced (зокрема, imidazol derivtives, litium preparation,

iodinum preparations, beta-bloquers, interferon, interleukin-2);

4) authoimmune thyreoiditis, infectious affections of the gland (tuberculosis,

scleroderma etc.);

5) trauma, hemorrhage, tumor;

6) Iodinum deficiency

Secondary

1) Brain commotion;

2) Tumors and metastases;

3) Brain hemorrage, thrombembolism, atherosclerosis;

4) Inflammations ( authoimmune and infectious);

5) Chemical intoxications including drugs (reserpin, parlodel,

apomorphin affect hypophysis, serotonin containing drugs –

affect ypothalamus)

Perypheral:

Inactivation of circulationg Т3, Т4, ТТH, resistance of receptors

Face in hypothyreosis

Hypothyreosis in bnewborns

Pretibial myxoedema

Pretibial myxedema

Clinical patternComplaints

• Metabolism – body mass gain• Skin – dryness, induration and change of color (“wax-

like”), rugged face features, enlargement of foots, speech is not clear, decreased hearing.

Nervous system - somnolence, indisposition, depression,

decreased memory and intellect, frequent headaches,

dizziness; sensitiveness to cold, parestesias, deranged

vision.

Musculoskeletal system – musculaer pains and crumps,

weakness.

• Cardiovascular system – pain in heart region, dyspnea in physical load.

• Digestive system – constipation, decrease appetite, nausea

• Respiratory system – frequent bronchitis exacerbations, pneumonias (body temperature is normal).

• Urogenital system – decreased diuresis, pyelonephritis, decreased potention in males, menstrual-ovarial cycle disorders in females.

Objective examination

• Metabolism - hypothermia, overweight

Skin – dry, cold, yellow, it is nit possible to make skin fold, symptom of dirty elbows and колін; dryness and brittlessness of hair, psilosis, loosing of external parts od eyebroves; nails are sick, with streaks; face is pastous, enlarged lips and a tongue with teeth pattern, hoarse voice

Myxedematous edema (myxaedema)– accumulation of gucosaminoglacals (hialuronic and chondroitinsulfate acids), with accumulation of liquid and sodium in tissues (skin, subcutaneous fat, vocal slits, mucous memvranes.

Nervous system – disordered coordination, poor vision.

Digestive system –tonque enlqrgement with teeth patter on its sides, hepatomegaly, dyskinesia of bile dicts and intestine, ascites.

Cardiovascular system - bradicardia, extrasystoly

Apex beat is low, relative cardiac dullness borders are displaced, weak heart sounds, systolic murmur at the apex, signs of heart failure. BP low or normal.

Respiratory system – superficial breathing, pleuricy.

Thyroid gland – is of normal size or slightly enlarged,mild or of moderat density, painless.

Laboratory and instrumental diagnostics

• Blood – hyperlipoproteidemia, increased level of cholesterol and triglicerides. Anemia (normochromic, hypochromic iron-deffiicency or В12- iron-deffiicency)

Nervous system - Eectroencephalography: decreased amplitude of waves, narroving of vision fields, increased intraocular pressure.

Musculoskeletal system – osteoporosis, sinovial fluid.

Cardiovascular system - ECG: low voltage, sinus

bradicardia, disordered conduction ( P-Q

prolongation), extrasystoly.

Ultrasound of a heart – pericardial effusion, left

ventricular wall sickness.

Digestive system – achlorhydria and authimmune

gastritis.

Urogenital system - decreased diuresis, renal blood

flow and glomerular filtration, moderate proteinuria.

Dry hear

Falling of external eyebroves hair

Periorbital edema

Edematous face dry skin

Diagnostics

Changes of Т3, Т4, ТТH.

Subclinical hypothyreosis – increased TTH, normal Т4.

Primary hypothyreosis – increased TTH, decreased Т4.

Secondary hypothyreosis – decreased TTH, decreased Т4 thyroliberin test is negative

Tertiary hypothyreosis – decreased TTH, decreased Т4 thyroliberin test is positive

Treatment Ethiological treatment of the cause Pathogenetic thyroid hormones 1) poor Т4 (levothyroxin, L-thyroxin, euthirox) – for

prolonged замісної treatment;

2) poor Т3 (thriiodtironin) – is used for diagnostics;3) Combined preparations (tireocomb, tireotom, novotirol)

– is difficult to choose proper dosage.

Hypothyroid comaCauses : unproper treatment of hypothyreosisProvoking factors: overcooling, infections, physical trauna,

operations, myocardial infarction, stress, bleeding, usage of tranquillisers

Clinical manifestation: gradual beginning; affection of nervous system (weaklness, somnolence, inhivited conscioussness), hypothermia, cardiovascular disorders (marked bradicardia, weak heart sounds, hypotension), respiratoryt disorders (bradypnoe, hypercapnia), ishuria, dynamic intestinal obsruction.

- 3) lab tests: anemia, increasd ESR, low serum level of Т3 and Т4, hyperpotassiemia, acidosis, hypoxia.

Treatment

1. Corticosteroids – for prevention of adrenal insufficiency

(hydrocortison 100-150 mg or prednisolon 30-50 mg i/v.

2. 200 мcг of thyroxin, glucous 40% - 60 ml, ISS 500 мл, 5%

ascorbic acid 5 0 i/v.

3. Oxygen. Artificial lung ventilation.

4. In edema and high BP – diuretics (lasix 2 ml i/m), in hypotesion

- mesaton 1% - 0,5-1,0 ml i/v, corglivon 0,06% - 1,0.

5. Antibiotics.

•Thank you!