Dharma Lindarto Div. Endokrin-Metabolisme dan Diabetes. Dep Ilmu Penyakit Dalam FK USU / RSUP !M MedanHYPERTHYROIDISMHYPERTHYROIDISMAnatomy of the Thyroid Gland "iroid DiseaseAspectfunction morphologyeutiroid,hypertiroid, hypotiroidnormal, atrophic, nodule, difus Hypothalamus-Hypothalamus-Pituitary- Thyroid AxisPituitary- Thyroid AxisTypical Thyroid Hormone Levels in Thyroid Disease TSH T4T3Hypothyroidism HighLow LowHyperthyroidism Low High HighSubclinical Hypothyroidsm HighnormalnormalSubclinical HyperthyroidsmLow normalnormalThyrotoxicosis and HyperthyroidismDefinitionsThyrotoxicosis

The clinical syndrome of hypermetabolism that results when the serum concentrations of free T!" T#" or both are increasedHyperthyroidism

Sustained increases in thyroid hormone biosynthesis and secretion by the thyroid glandThe $ terms are not synonymous%raverman L&" et al' Werner & Ingbars The Thyroid. A Fundamental and Clinical Tet' (th ed' $)))'"#yroid Storm*are complication of hyperthyroidism where manifestations of thyrotoxicosis become life threatening' Also may be termed "#yroto$i% &risis'!pat#eti% "#yroto$i%osis*are form usually occurring in the elderly' +ften presents as single organ failure ,-H./' 0atient may develop thyroid storm without the typical manifestations'0revalence of Thyrotoxicosis1n a cross2sectional study of urban and rural adults" the prevalence of thyrotoxicosis ranged from

3'45 to $'65 in women

)'375 to )'$#5 in menTunbridge 89G" et al' Clin !ndocrinol' 3466:6;!(32!4#'ypert#yroidism Etiolo'y(raves) diseaseMultinodular 'oiter!utonomous noduleE$o'enous t#yroid #ormone"ransient*suba%ute t#yroiditis+ postpartum t#yroiditisDru's*amiodarone&auses o, "#yroto$i%osisDivided by De'ree o, Radioiodine Uptakei'# I-./ UptakeGraves< diseaseToxic nodular goiterTSH2mediated thyrotoxicosis0ituitary tumor0ituitary resistance tothyroid hormoneH-G2mediated thyrotoxicosisHydatidiform mole-horiocarcinoma+ther H-G2secreting tumorsThyroid carcinoma ,very rare/I1230o1 I-./ UptakeSubacute thyroiditisHashitoxicosisDrug2induced1odideThyroid hormoneStruma ovarii.actitiousI123-ommon Signs and Symptoms of ThyrotoxicosisSymptoms Signs=ervousness Hyperactivity.atigue Tachycardia 8ea>ness Systolic hypertension1ncreased perspiration 8arm" moist" or smooth s>inHeat intolerance Stare and eyelid retractionTremor Tremor Hyperactivity Hyperreflexia0alpitations 9uscle wea>nessAppetite?weight changes9enstrual disturbances%raverman L&" et al' Werner & Ingbars The Thyroid. A Fundamental and Clinical Tet' (th ed' $)))'S@ST&91- &..&-TS*&S01*AT+*@Dyspnea" panting" hyperventalationrespiratory muscle wea>nessincreased tissue carbon dioxide levelsA?2 congestive heart failureS@ST&91- &..&-TS-A*D1+BAS-CLA*Thyrotoxic cardiomyopathy

Hypermetabolic state

Systemic hypertension

Direct T# and T! action on heart muscleLB hypertrophy" 1BS hypertrophy" *A and aortic dilation" enhanced contractility3' Graves< Disease ,Toxic Diffuse Goiter/ The most common cause of hyperthyroidism

Accounts for 7)5 to 4)5 of cases

1ncidence in the Cnited States estimated at )')$5 to )'!5 of the population

Affects more females than males" especially in the reproductive age rangeGraves disease is an autoimmune disorder possibly related to a defect in immune toleranceGraves DiseaseAutoimmune disorder

0roduction of TSH receptor autoantibodies

Stimulate thyroid hormone overproduction-haracteriDed by the presence of %2 and T2lymphocytes in thyroid tissue

TSH receptor activation

Thyroglobulin and thyroid peroxidase antibodies

Sodium?iodide cotransporter ,=1S/ activity enhanced ,increased *A1/

AutoantigensAbbott Laboratories Diagnostics Division 8eb site'Available at; et al' Werner & Ingbars The Thyroid. A Fundamental and Clinical Tet' (th ed' $)))'Graves' DiseaseGoiterHyperthyroidismExophthalmosLocalized myxedemaThyroid acropachyThyroid stimulatin immunolo!ulins"linical "haracteristics o# Goiter in Graves$ DiseaseDi##use increase in thyroid land size%o#t to slihtly #irm&on'nodular(ruit and)or thrill*o!ile&on'tender+ithout prominent adenopathyGraves$ Disease ' Localized *yxedema*arins sharplydemarcatedThic,ened s,in&odularity*arins sharplydemarcatedGraves< +phthalmopathy -lass one; spasm of upper lids with thyrotoxicosis -lass two; periorbital edema and chemosis -lass three; proptosis -lass four; extraocular muscle involvement -lass five; corneal involvement -lass six; loss of vision due to optic nerve involvementD1AG=+ST1-S&ndocrine Testing

Total T!; E23)5 will be normal

Total T#; #)5 will be normal

.ree T!; false negative with =T1 and shipping

fT!d better

T# supression

T*H stimulation and TSH responseD1AG=+ST1-S*AD1+=C-L1D& 19AG1=G0ertechnetate imagingextent of involvementdetect metastasis to other glandno palpable enlargement ,within thorax/-arcinoma metastasis$' Toxic 9ultinodular Goiter9ore common in places with lower iodine inta>e

Accounts for less than E5 of thyrotoxicosis cases in iodine2sufficient areas&volution from sporadic diffuse goiter to toxic multinodular goiter is gradualThyrotropin receptor mutations and TSH mutations have been found in some patients with toxic multinodular goitersSurgery or 3#31 is recommended treatment%raverman L&" et al' Werner & Ingbars The Thyroid. A Fundamental and Clinical Tet' (th ed' $)))'Toxic 9ultinodular Goiter 9=G is an enlarged thyroid gland containing multiple nodules

The thyroid gland becomes more nodular with increasing age

1n 9=G" nodules typically vary in siDe

9ost 9=Gs are asymptomatic9=G may be toxic or nontoxic

Toxic 9=G occurs when multiple sites of autonomous nodule hyperfunction develop" resulting in thyrotoxicosis

Toxic 9=G is more common in the elderly#' Toxic AdenomaAutonomously functioning thyroid nodule hypersecreting T# and T! resulting in thyrotoxicosis ,0lummerg loading " infusion of )')E2)'3 mcg?>g?min / 'AdPunctive Therapy for Thyroid Storm Treat fever aggressively with acetaminophen '1B fluid containing 3)5 dextrose are recommended 'Administer vitamin supplements " including thiamine 'Treat -H. with conventional methods 'AdPunctive Therapy for Thyroid Storm , continued /1dentify the precipitating event " including infection '-onsider plasmapheresis " hemodialysis or peritoneal dialysis for removal of metabolically active hormone 'Thyrotoxic 0eriodic 0aralysis 9ost common cause of hypo>alemic periodic paralysis.laccid paralysis Lower extremities affected most often +cular and bulbar muscles uninvolved" respiratory muscles rarely involved 9ost often starts during sleep 0recipitated following exercise" high salt inta>e or high carbohydrate diet Hypo>alemia during the paralysisTHA=M @+CQQQQQ