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General Characteristics a. Onset of sx is insidious & can go undetected for yrs i. Myxedema coma 1. Presents w/depressed state of consciousness, profound hypothermia, respiratory depression 2. Can develop after yrs of severe untreated hypothyroidism 3. Precipitating factors: trauma, infection, cold exposure, narcotics 4. Medical emergency w/high mortality rate even w/tx 5. Supportive therapy to maintain BP & respiration 6. Give IV thyroxine & hydrocortisone while monitoring hemodynamic state Causes a. MC is primary hypothyroidism: thyroid cant make enough thyroid hormone i. MCC of primary hypothyroidism is Hashimotos disease (chronic thyroiditis) 1. Also assoc. w/other autoimmune disorders (lupus, pernicious anemia) 2. At increased risk of thyroid carcinoma & thyroid lymphoma ii. Next cause is iatrogenic 1. Due to prior tx of hypothyroidism (radioiodine therapy, thyroidectomy, meds, i.e. Li) b. Secondary hypothyroidism (due to pit disease, i.e. def of TSH) & tertiary hypothyroidism (due to hypothalamic disease, i.e. def of TRH) i. For < 5% cases ii. Assoc. w/low FT4 & low TSH level Clinical Features a. Sx i. Heavy weakness, lethargy ii. Heavy menstrual periods (menorrhagia), slight weight gain but pts not obese iii. Cold intolerance iv. Constipation v. Slow mentation, inability to concentrate (mild dementia), dull expression vi. Muscle weakness, arthralgias vii. Depression viii. Diminished hearing b. Signs i. Dry skin, coarse hair; thickened puffy features ii. Hoarseness iii. Nonpitting edema (due to GAG in interstitial tissues not water & salt) iv. Carpal tunnel syndrome v. Slow relaxation of DTRs vi. Loss of lateral portion of eyebrows vii. Bradycardia viii. Goiter

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1. Hashimotos: rubbery, nontender and even nodular 2. Subacute thyroiditis: tender & enlarged, not always symmetric ix. Hx of URI & fever (subacute thyroiditis) Subclinical Hypothyroidism a. Thyroid fn is inadequate but increased TSH prod maintains T4 level w/in ref range of normalcy TSH is elevated & T4 is normal b. Look for nonspecific or mild sx of hypothyroidism & elevated serum LDL c. Tx w/thyroxine if pt develop goiter, hypercholesterolemia, sx of hypothyroidism or sig elevated TSH (> 20) Dx a. High TSH level is MOST SENSITIVE INDICATOR OF HYPOTHYROIDISM b. Low TSH level secondary hypothyroidism c. Low FT4 level (or FT4 index) in pts w/clinically overt hypothyroidism; FT4 may be normal in subclinical cases d. Increased antimicrosomal Abs (Hashimotos thyroiditis) e. Elevated LDL & decreased HDL f. Anemia, MC mild normocytic g. TSH is primary test; also order lipid profile & CBC Tx a. Levothyroxine (T4) is treatment of choice b. Effect seen in 2-4 wks; very effective in achieving euthyroid state c. Convenient 1x daily morning dose d. Tx continued indefinitely e. Monitor TSH level & clinical state periodically