HYPOTHYROI
DISM
INTRODUCTION
Hypothyroidism is the condition resulting from insufficient
synthesis of thyroid hormones.
Burden of hypothyroidism in India:
• Prevalence of adult hypothyroidism is 3.9% and that of subclinical
cases is 9.4%
• Female rate: 11.4% , male rate: 6.2%
• Prevalence of congenital hypothyroidism is 1 in 2640 neonates
• Prevalence of subclinical hypothyroidism increases with age and
about 35% of the cases show anti-TPO antibodies (autoimmune-
mediated)
Risk factors: Women >60 years, pregnancy, patients with
autoimmune disorders and/or type 1 diabetes, positive
thyroid peroxidase antibodies, family history.
TYPES AND CAUSES
• CLINICAL TYPES
I. OVERT HYPOTHYROIDISM
(TSH increased T3 + T4 decreased, Symptoms+)
II. SUBCLINICAL HYPOTHYROIDISM
(TSH increased, T3 + T4 normal)
• ETIOLOGICAL TYPES
I. PRIMARY HYPOTHYROIDISM
(TSH increased T3 + T4 decreased)
II. SECONDARY HYPOTHYROIDISM
(TRH/TSH normal/decreased, T3 + T4 decreased)
III. THYROID HORMONE RESISTANCE
(TSH increased, T3 + T4 increased)
PRIMARY HYPOTHROIDISM
• Autoimmune hypothyroidism
e.g. Hashimoto’s thyroiditis
• Iatrogenic causes
e.g. thyroidectomy, radioiodine therapy or external irradiation
• Iodine deficiency
• Drug mediated
e.g. thalidomide, lithium, amiodarone, interferon-alpha,
interleukin-2
• Congenital hypothyroidism (Cretinism)
e.g. thyroid agenesis, dysgenesis or defects in hormone
synthesis
SECONDARY
HYPOTHROIDISM
• Pituitary hypothyroidism (TSH deficiency)
Pituitary resection, pituitary tumors affecting thyrotrophs, Sheehan’s
syndrome
• Hypothalamic hypothyroidism (TRH deficiency)
Brain injury involving hypothalamus, tumors of hypothalamus
THYROID HORMONE RESISTANCE
• Tissues (peripheral tissues and anterior pituitary) become
resistant to the effects of T4 and T3. Features of
hypothyroidism may not develop but features of
hypometabolism (similar to hypothyroidism) may be seen.
Normal levels of T3 and T4 will be seen.
PATHOGENESIS
CLINICAL FEATURES
• General: tiredness, lethargy, somnolence, weight gain,
poor appetite, cold intolerance
• Skin: cool, coarse, dry and flaky
• Colour: pallor/yellow due to carotenemia
• Hair: sparse, brittle, loss of eyebrows
• Nails: brittle
• Skeletal: short stature
• Muscular: pain, stiffness, cramps, muscle weakness,
hypotonia, pseudo-myotonic reflex
• Neurological: higher functions show memory impairment and
mental slowing and depression. VIII CN deafness, carpal tunnel
syndrome, sensory ataxia, cerebellar ataxia, acute encephalopathy
• Cardiovascular system: diastolic hypertension, bradycardia,
cardiomegaly with pericardial effusion
• Gastrointestinal system: macroglossia, GIT hypermotility,
ascites, achlorhydria
• Reproductive system: menorrhagia, amenorrhea, infertility and
abortion (female) and impotence, scrotal effusion (male)
• Metabolic: hypothermia, hypercholesterolemia, decreased insulin
requirement
• Respiratory system: vocal cord edema, pleural effusion,
respiratory muscle weakness
• Hematology: normocytic normochromic anemia, iron deficiency
anemia (menorrhagia), megaloblastic anemia (associated with
pernicious anemia)
INVESTIGATIONS AND
DIAGNOSIS
Serum thyroxine (T4) levels
Free T4 index
Serum TSH concentration
• TSH levels >20 mIU/L (primary hypothyroidism)
• TSH levels <20 mIU/L (secondary hypothyroidism, subclinical
hypothyroidism)
Serum cholesterol
Serum sodium
Serum CPK, LDH, SGOT
ECG – bradycardia, T wave flattening
MANAGEMENT
• Hypothyroidism is treated with levothyroxine (T4), with doses
ranging from 50 to 200 mcg/day. It is taken orally once a day,
preferably in the morning, before meal. Most patients require
lifetime treatment and periodic evaluations.
• Young patients, without risk of CAD – starting dose of 75-100
mcg/day, adjusted every 4 weeks to reach final replacement level.
• Elderly patients and patients with CAD – initial dose of 12.5-25
mcg/day and increased by 25-50 mcg every 4 weeks to avoid
precipitating angina and heart failure.
• Aim – to achieve euthyroid status with TSH, T4 and T3 levels in
the normal range. TSH is the most sensitive indicator and
treatment is aimed towards normalizing TSH levels
SUBCLINICAL
HYPOTHYROIDISM
Subclinical hypothyroidism refers to mildly elevated TSH
with normal T4 levels. Patients usually do not have any
symptoms.
SCH may be associated with increased risk of CAD
events, CHF, and fatal stroke.
Evaluation:
• Elevated TSH with normal T4, measured every 2-3 months
• Test for anti-TPO antibodies
• Assessment for CAD
Indications of treatment: level of TSH>10mIU/L,
positive anti-TPO, presence of symptoms, presence of
cardiovascular risk factors
CONGENITAL
HYPOTHYROIDISM
SYMPTOMS: lethargy, somnolence, constipation, poor feeding, cold to
touch, delayed dentition, mental retardation.
SIGNS
• Dry, cool, mottled skin, hoarse cry, coarse face, broad flat nose, large protruding
tongue, puffy face
• Abdomen – protuberant, umbilical hernia, hypotonia
• Skull – large posterior fontanelle
INVESTIGATIONS
• Cord blood and serum T4, TSH
• X-ray: knee (lower femoral/upper tibial epiphysis absent), foot (cuboidal epiphysis
absent), skull (wide sutures, large fontanelles, suprasellar calcification)
MANAGEMENT: If disease is diagnosed early and treated immediately
after birth, thyroid hormone replacement can completely cure the
disease.
MYXOEDEMA COMA
• Myxoedema coma is defined
as severe hypothyroidism
leading to decreased mental
status, hypothermia, along
with bradycardia,
hypoventilation,
hyponatremia and
hypoglycemia.
• It is a medical emergency.
• Older women are usually
affected.
• Precipitating factors:
MANAGEMENT
• Patient should be admitted in the ICU
• Treatment to be started immediately.
• Measurements of serum TSH, T4, T3 and cortisol to be taken to
rule out associated adrenal insufficiency.
• THYROID HORMONE ADMINISTRATION
• 300 mcg thyroxine given intravenously over 5-10 minutes
initially, followed by 100 mcg per day until patient becomes
alert and can take thyroxine orally. The preparation can be
administered through Ryle’s tube.
• SUPPORTIVE MEAUSRES
• Hydrocortisone, 100 mg IV bolus followed by 100 mg every 8
hours till adrenal insufficiency is excluded.
• Cover with blankets to correct hypothermia.
• IV fluids, electrolytes and glucose.
• Mechanical ventilation, if required.
HASHIMOTO THYROIDITIS
• Hashimoto Thyroiditis is a chronic
autoimmune inflammation of the
thyroid with lymphocytic
infiltration.
• It may be associated with other
autoimmune disorders like type 1
diabetes mellitus, Addison’s
disease, vitiligo and pernicious
anemia.
• More common in women.
• Diffuse goiter with firm or
rubbery consistency.
• Symptoms of Hypothyroidism.
INVESTIGATIONS
• TFT shows hypothyroidism.
• Positive anti-TPO antibodies and anti-
Tg antibodies (in >90% of the
patients).
• HPE: lymphocytic infiltration,
lymphoid germinal centers,
destruction of follicles and fibrosis.
TREATMENT
• Thyroxine (2-3 mcg/kg/day) corrects
hypothyroidism as well as helps in
goiter shrinkage.
• Glucocorticoids for goiter shrinkage.
• Surgery, if medical management is
not effective.
THANK YOU
