Thyroid Abnormalities

Himawan Sanusi

THE THYROID GLAND

Pyramidal lobe

Left lobe

Right lobeIsthmus

Internal jugular vein

Thyroid cartilago

External carored arteri

22

Basic elements in regulation of thyroid function

THYROID

TISSUE

TRH

HYPOTHALAMUS

PORTAL SYSTEM

TSH

ANTERIORPITUITARY

“FREE”

T3

T3

T4

T4

I

I

_

T4

+

T3

+

Usually Complain thyroid disease

Complications of a Spesific form hyperthyroidism: Graves’ disease which may present which prominence of the eyes or exophthalmos and Thickening of the skin over the lower legs (rare) or thyroid dermopathy

Diffuse goiter• Simple diffus goiter• Hypertiroidism• Hashimoto thyroiditis

Nodular goiter 1. Thyroid nodul 2. Thyroid cyst

3. Adenomatosa goiter 4. Subacut /chronis thyroiditis 5. Plummer thyroiditis

Definition• Thyroiditis heterogenous group of

inflamatory disorders the thyroid gland• Etiologies range from autoimmune to

infectious origins• Clinical course Acute, subacute, or

chronic. Can be euthyroid, transient phase thyrotoxicosis and / or hypothyroidism. Painless or painfull

I. Autoimmune thyroiditisChronic autoimune thyroiditis

Hashimoto’s thyroiditisAtrophic thyroiditisFocal thyroiditisJuvenile thyroiditis

Silent thyroiditis / Postpartum thyroiditis II. Subacute thyroiditis III. Acute suppurative thyroiditisIV. Riedel’s thyroiditis

Classification of thyroiditis

Classification of thyroiditisHystologic classification

Chronic lymphocytic

Subacute lymphocyticGranulomatous

Microbial inflamatory

Invasive fibrosis

Synonims

Chronic lymphocytic thyroiditis,Hashimoto’s thyroiditisSubacute lymphocytic thyroiditis,Postpartum thyroiditis,Sporadic painless thyroiditisSubacut granulomatous thyroiditisDe Quervains thyroiditisSuppurative thyroiditisAcut thyroiditis

Riedel’s strumaRiedel’s thyroiditis

Terminology for Thyroiditis.

Type Synonim

Hashimoto’s thyroiditis Chronic lymphocytic thyroiditis Chronic autoimmune

thyroiditis Lymphadenoid goiter

Painlesspostpartum thyroiditis Postpartum thyroiditis Subacute lymphocytic thyroiditis

Painless sporadic thyroiditis Silent sporadic thyroiditis Subacute lymphocytic thyroiditis

Painful subacute thyroiditis Subacute thyroiditis de Quervain’s thyroiditis

Giant-cell thyroiditis Subacute granulomatous

thyroiditis Pseudogranulomatous thyroiditis

Terminology for Thyroiditis.

Type Synonim

Suppurative thyroiditis Infectious thyroiditis Acute suppurative thyroiditis Pyogenic thyroiditis

Bacterial thyroiditis

Drug-induced thyroiditis - (amiodarone, lithium, interferon alfa, interleukin-2)

Riedel’s thyroiditis Fibrous thyroiditis

Hakaru Hashimoto (1912) 4 patients chronic disorder of the thyroid diffuse lymphocytic infiltration, fibrosis, parenchymal atrophy, and eosinophilic change in some acinar cells

Hashimoto’s thyroiditis(Chronic thyroiditis)

Dr Hakaru Hashimoto

Hashimoto thyroiditisis the most common

cause of hypothyroidism & goiter

in the United States

Hashimoto’s thyroiditis

Statosky J et al. Am Acad of Family physicians 2000;61:1054

Hashimoto’s thyroiditisEtiology & pathogenesis

HT is immunologic disorder which lymphocytes become sensitized to thyroidal antigens and autoantibodies are performed.Thyroid antibodies in HT are:1. Thyroglobulin antibody (Tg Ab)2. Thyroid peroxidase antibody (TPO Ab) =

( Microsomal antibody) 3. TSH Receptor blocking antibody ( TSH - R Ab block)

CELL CELL STIMULATION BLOCKADE

Antagonist Antibody

Agonist Antibody

TSHR-Ab

TSHRTSHR

Davies TR. Graves’ disease in Werner & Ingbar’s : The thyroid ; 2000 ;520

Autoimmune thyroiditis

Clinical Manifestation Clinical Manifestation Hashimoto’s ThyroiditisHashimoto’s Thyroiditis

Symptom & SignsHT usually presents with goiter , euthyroid or mild hypothyroidism.

Sex distribution : F/M 4:1

Painless & patients may be anware of the goiter

Laboratory findingsLaboratory findings

• T4 N/ low, TSH will be elevated. RAIU may be high, normal or low

• Tg Ab & TPO Ab positif• Fine needle aspiration biopsy large infiltration lymphocytes Hurttle cells

Diagnostic procedures• Test of thyroid autoimmunity:

TPOAb 95% + in HT & 90% Atrophic thyroiditis

TgAb less frequently + Diagnostic specificity of thyroid antibody tests is not absolute.

• Test for thyroid function TSH, fT4• RAIU : normal, low or high.• USG : diffusely reduced echogenecity• FNAB not necessary,excep. rapidly

enlarging goiter

Diffuse goiter

Anti microsomal (or TPO) antibody Anti-thyroglobulin antibody Positive

Hashimoto’s thyroiditis

PositiveUS Biopsy

Other diseases*Negative

Negative

Sign symptom of hypothyroidism

*Simple goiter, adenomatous goiter etc

Diagnosis of Hashimoto’s thyroiditis

Treatment Hashimoto’s thyroiditis

TreatmentTreatment• Goiter small & asymptomatic not

require therapy• Levo-thyroxine is given over

hypothyroidism to supress TSH & decreased serum thyroid antibody. Levo-thyroxine in euthyroid, still controversial

TreatmentTreatment•Corticosteroids : regression

pain, reduction in size of the goiter, thyroid antibody, not recommended in benign disease.

•Surgery indicated pain, cosmetic, or pressure symptoms after levothyroxine and corticosteroid therapy.

Riedel’s thyroiditis

• Rare 1,06/100.000, middle age or elderly women

• Etiology unknown (autoimmune process or primary fibrotic disorder)

• Characterized fibrosis replaces normal thyroid parenchyma,1/3 cases multifocal fibrosclerosis

Riedel’s thyroiditis

• Thyroid fibrosis (stony hard,woody), painless, progressive anterior neck mass,

• Generalized fibrosing (1/3 patients), pressure symptoms laryngeal nerve paralysis or hypoparathyroidism (rare)

• Usually euthyroidism, hypothyroidism (30%)• Laboratorium : non spesific• USG/CT-Scan inconclusive• Difinitive diagnosis open Biopsy

Riedel’s thyroiditis• Treatment:

Corticosteroids medical treatment of choice Tamoxipen, methotrexate inhibitor fibroblast

proliferation ( early stages) Levothyroxine hypothyroidism

Surgical care diagnosis, relieving tracheal compression

• Mortality asphyxia (6-10%), extrathyroidal fibrotic lesions may complicate the prognosis

Subacute thyroiditis• Cause unknown ( viral infection

(?) preceded URT infection, coincidence viral disease (mumps, measles, Echo virus, adeno virus, epst. Barr virus, influenza)

• Women : Men (3-5:1)• Onset: 20-60 yr• Summer

Subacute thyroiditis• Palpation thyroid: enlarged, asymetrical,

nodul, firm, tender & painful.• Thyrotoxicosis during inflamatory phase

euthyroidism hypothyroidism euthyroidism (4th phases)

• Laboratorium: ESR increase, leukocyt N/ increase, fT4,,TSH, RAIU

• Recovery 4-6 months, spontaneous remitting

20

0

15

10

5

1Eu Hypo EuHyper4 11 -

Phase :Weeks:

0

30

20

10

40

24-hour 131 I

uptake %T4

ug/dL

T4

131 I

Changes in serum T4 & Radiactive iodine uptake in patients with subacute Thyroiditis

Woolf PD, Daly R :Am J Med 197;60:73

Laboratory findings during different phases of subacute thyroiditis

Phase

Thyrotoxicosis

Hypothyroid

Recovery

T4 &/T3 Level

High

Low

Normal

TSH level

Low

Normal,or high

High to normal

RAIU value

<5%

Normal to high

High to normal

Treatment Subacute thyroiditis

• Symptomatic: Acetaminophen 4X 0,5g, NSAID or glucocorticoid (prednison 3 X 20 mg (7-10 days)

• Betablockers symptoms of thyrotoxicosis• L-thyroxine 0.1-0.15 mg /daily hypothyroid

phase. Long-term L-thyroxine permanent hypothyroidism (10%)

• Antibioticsno value• Thyroidectomy rarely

NECK PAIN

RAIU

PRESENTING SYMPTOMS

YES N0

INCREASED

RAIU

SUBACUTE GRANULOMATOUS

THYROIDITIS

MICROBIAL INFLAMMATORY

THYROIDITIS

HYPERTHYROIDISMDECREASED HYPOTHYROIDISM

CHRONIC LYMPHOCYTIC THYROIDITIS

GRAVES DISEASE SUBACUT LYMPHOCYTIC THYROIDITIS

Clinical Differentiating of the Subtype Thyroiditis

Statosky J et al. Am Acad of Family physicians 2000;61:1054

Acute suppurative thyroiditisAcute suppurative thyroiditis

• Rare, serious, bacterial inflamatory disease, children, 20-40 yr, sex ratio 1:1

• Etiologi: Infectious: Staph. aureus, strep.pyogenes, strep. pneumonia, esch.coli, pseudomonas aeruginosa

• Infection by hematogenous, direct trauma

Symptoms and Signs :• Neck pain, warm, tenderness, the

neck unable to extend• Dysphagia, dysphonia, referred to

ear, mandibula, lymphadenopathy• Systemic manifestation: fever,

chills, tachycardia, malaise• Palpation: unilateral, erythematous

Acute suppurative thyroiditisAcute suppurative thyroiditis

• Thyroid function : Euthyroidism• Laboratorium : TPO antibodies

absent, ESR high, PMN leukocytosis

• 24-hour 123I uptake normal• FNA Biopsy : purulent material•Treatment : antibiotics or

surgical drainage

Acute suppurative Acute suppurative thyroiditisthyroiditis

Chronic-pyogenic Chronic-pyogenic thyroiditisthyroiditis

Etiology : • Salmonellatyphosa, syphilis,

tuberculosis, echinococcus, actinomyces

Symptoms : Suppurative, non suppurative

Treatment : antibiotic, drainage

Thyroid nodules & Thyroid nodules &

Thyroid cancerThyroid cancer

Thyroid nodules - prevalence• Thyroid nodules commonThyroid nodules common, increase , increase

with agewith age

• 30-60%30-60% of thyroids have nodules at of thyroids have nodules at autopsyautopsy

• Palpation: Palpation: 5-20% (>1cm)5-20% (>1cm)

• U/S: U/S: 15-50% (>2mm)15-50% (>2mm)

Thyroid nodules & Thyroid cancerThyroid nodules & Thyroid cancer• In 95% of cases , thyroid cancer

presents as a nodule or lump in the thyroid nodul thyroid.

• Thyroid nodule extremely common, particularly women. Prevelance in USA 4% in adult population. F:M ratio 4:1.

• Thyroid cancer rare. Incidence 0.004% per year

Benign thyroid adenomaEtiology :

Focal thyroiditis Multinodular goiter Post surgical remnant hyperplasiaBenign adenoma : Follicular Rare: Teratoma, lipoma, hemangioma

Differentiation benign & Malignant lesions

• History : Family history of goiter suggests benign disease, endemic goiter

• Physical characteristics: Benign : older age, woman, soft nodule, multi nodular goiter. Malignant : Children, young, male, solitary, firm nodule, vocal cord paralysis, firm lymph nodes, distant metastasis

• Serum factors : Benign : high titer of antibody Malignant : calcitonin

• Scanning : Benign: Hot nodule Malignant: Cold nodule

• Biopsy (needle)

Differentiation benign & Malignant lesions

Malignant thyroid Malignant thyroid CarcinomaCarcinoma

• Papillary Carcinoma 75 %• Folliculare Carcinoma 16 %• Medullary Carcinoma 5 %• Anaplastic Carcinoma 3 %• Lymphoma 5 -10 %

Diagnostic approach• Fine Needle Aspiration (FNA)

10-20% risk of suspicious cytology, therefore thyroid surgery95% of histology will be benign, and surgery “unnecessary

• Isotop Scann(CT)rarely used for evaluation 80% of nodules are “cold”small cold nodules may be missed

• Ultrasonography (USG)

Diagnostic approach - ultrasound

Identifies solid v. cystic nodules

Identifies MNG

May aid FNA

Does not exclude malignancy

Diagnostic approach - other tests

Calcitoninvery high results diagnostic for MTCrisk of borderline false positivesnot for routine use

Thyroglobulinnot helpful for exclusion of carcinoma : overlap with benign diseasebest for follow-up after thyroidectomy

Thyroid noduleThyroid nodule

MixedMixed

FNACFNAC

L-T4 L-T4 Follow upFollow up Surgery Surgery

BenignBenign SuspeciousSuspecious

EchographyEchography

Malignant Malignant

Follow-upFollow-up

Echography Echography ScanScan

Normal TSHNormal TSH Low TSHLow TSH

Hot Hot Cold Cold

131131 I /surgery I /surgery

Cystic Cystic Solid Solid

Evacuation Evacuation

Management of the solitary nodule

N o

W atch ?

B en ig n

S u rg ery

M a lig n an t

In d ete rm in ate

S u rg ery

R ep eat F N A C

In d ete rm in ate

S u rg ery

F o llicu la r

F N A C

Y es

Tru e s o lita ry n od u le?

TreatmentTreatment• Thyroidectomi• Jodium 131Radioactive• Thyroxine supression