MEDICINA

ENDOCRINOLOGA Dr. Luis Villar

M. Internista HNERM
luisvillar_65@yahoo.com
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 Hypothalamic stimlatory hormones Pituitary hormones
HIPOPITUITARISMO Corticotropin-releasing hormone - 41
Adrenocorticotropic hormone - basophilic corticotrophs
represent 20 percent of cells in anterior pituitary; ACTH is
amino acids; released from
ASPECTOS GENERALES paraventricular neurons as well as
product of POMC gene
Melanocyte-stimulating hormone - alternate product
Hypothalamic diseases PREVALENCIA: supraoptic and arcuate nuclei and
of POMC gene
45/100,000 limbic system
Mass lesions - Benign (craniopharyngiomas) INCIDENCIA: 4.2/100,000 Endorphins - also products of POMC gene
and malignant tumors (metastatic from lung, CAUSAS: Tumor
breast, etc) Growth hormone-releasing hormone - Growth hormone - acidophilic somatotrophs represent 50
61%/43%, tumor two forms, 40 and 44 amino acids percent of cells in anterior pituitary
Radiation - For CNS and nasopharyngeal extrapituitario 9%/7%, no
malignancies tumora 30%/50% Gonadotropin-releasing hormone - 10 Luteinizing hormone and follicle-stimulating hormone -
amino acids; mostly released from gonadotrophs represent about 15 percent of anterior
Infiltrative lesions - Sarcoidosis, Langerhans preoptic neurons pituitary cells
cell histiocytosis Gene
Thyrotropin-releasing hormone - three
Infections - Tuberculous meningitis GH1 Thyroid-stimulating hormone - thyrotropes represent
amino acids; released from anterior
GHRHR about 5 percent of anterior pituitary cells
Other - Traumatic brain injury, stroke FSHB hypothalamic area
TSHB
Pituitary diseases LHB Prolactin-releasing factors - include
Prolactin - lactotrophs represent 10 to 30 percent of
TRHR serotonin, acetylcholine, opiates, and
PROK2 anterior pituitary cells
Mass lesions - Pituitary adenomas, TPIT estrogens
other benign tumors, cysts GnRHR PROKR2
Hypothalamic inhibitory hormones
PC1
AVP-NPII
Pituitary surgery Somatostatin - 14 amino acids Inhibits the release of growth hormone
POU1F1
Pituitary radiation POMC Prolactin-inhibiting factors - includes dopamine Major prolactin control is inhibitory
PROP1
Infiltrative lesions - Hypophysitis, DAX1 HESX1
hemochromatosis CRH LHX3
Infection/abscess KAL1 LHX4
Infarction - Sheehan syndrome FGFR1
SOX3
Apoplexy GLI2
Leptin
Leptin-R SOX2
Genetic mutations
GPR54 GLI3
Empty sella
PITX2
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HIPOPITUITARISMO
GH Estmulo con GHRH
Estimulo con L-arginina o L-dopa
Estimulo con insulina (prueba de
hipoglucemia). MEJOR PRUEBA
PARA Dx DEFICIT DE GH
GINECOLOGA
ACTH
DIAGNSTICO
Estimulo con insulina (prueba
de hipoglucemia).
Prueba mas fiable para
valorar la reserva de ACTH
Estmulo con ACTH (prueba de
la cosintropina ACTH 1-24)
Prueba mas segura para
conocer el estado del eje
HPF-SPR
Test de la metirapona (inhibidor
de la 11-beta-hidroxilasa)
Medir 11-desoxicortisol en
plasma y 17-hidroxicorticoides
en orina
TSH Estimulo con TRH PRL
LH/FSH Estmulo con LH-RH Test de luforn
Test del Clomifeno
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 HIPOPITUITARISMO
TRATAMIENTO
MANEJO DE CADA HORMONA.
ACTH hidrocortisona
TSH levotiroxina (primero ver reservas de ACTH). No
fiarse de TSH. Dar 1.6mcg/kg, ajustar segn T4 o T4L
(mitad de rango).
Hombres: Testosterona (no frtil). FSH/LH o GNRN
Mujer: E + P (no frtil). GNRH pulsos. Andrgenos no
esta claro.

Terapia de reemplazo hormonal se ajusta de acuerdo

con la vigilancia de la hormona en suero.
Si no se trata la Crisis adrenal puede conducir a
severa hiponatremia, hipotiroidismo, anomalas
metablicas y la muerte.
Complicaciones: dficit visual, crisis suprarrenal,
susceptibilidad a infeccines y otros factores de
estrs.
Pronstico: los pacientes estables tienen un
pronstico favorable con la terapia hormonal de
reemplazo.
Los pacientes con descompensacin aguda estn en
estado crtico con una alta tasa de mortalidad.
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 Extensiones laterales
ADENOMA HIPOFISIARIO Principal defecto campimtrico AFECTANDO EL SENO
HEMIANOPSIA BITEMPORAL CAVERNOSO III PAR (+fr)
EPIDEMIOLOGA

Causa ms frecuente de los sndrome de hipo

e hipersecrecin de hormonas hipofisarias en
el adulto.
Suponen 15% de los tumores Intracraneales;
50-80% de tumores hipofisarios.
MICROADENOMAS MACROADENOMAS
Por orden de frecuencia: Mas frecuente en mujeres 95% Mas frecuentes en varones
Prolactinomas en mujeres Prolactinomas en varones
1. Adenoma lactotropo Adenomas corticotropos en Adenoma somatotropo en ambos sexos
2. Adenoma no funcionante (de cells gonadotropas pero ambos sexos Adenomas secretores de hormonas
solo sub alfa o beta) No producen hipopituitarismo glucoproteicas
Adenomas no funcionantes
3. Adenoma somatotropo
4. Adenoma corticotropo
5. Adenoma mixto GH + Prolactina
6. Adenoma secretores de TSH
7. Adenomas secretores de LH/FSH cursan
con hipogonadismo
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 HIPERPROLACTINEMIA

FISIOLOGICAS EMBARAZO
CAUSAS PATOLOGICAS
(+fr) y
lactancia

FARMACOS Mas frecuente y < 100ug/L

1. Antagonistas de receptores dopaminergicos: Fenotiacinas (corpromacina),
butirofenonas (haloperidol), benzamidas(metroclopramida), tioxantenos.
2. Frmacos que producen deplecin dopaminica: Reserpina y alfa-metildopa
3. Frmacos con accin directa sobre las cells lactotropicas: TRH, estrgenos
en altas dosis.
4. Otros: antagonistas H2, antidepresivos tricclicos, fluoxetina,
benzodiacepinas, antiandrgenos, opiceos(morfina), cocana(largo plazo),
verapamilo.

LESIONES HIPOTALAMICAS O DEL LESIONES HIPOFISIARIAS

TALLO < 100ug/L 1. Adenomas lactotropos (>100)
1. Tumores o mixtos
2. Enfermedades granulomatosas 2. Adenomas cromfobos no
3. Irradiacin craneal funcionantes que produzcan
4. Otras (seccin quirrgica del
distorsin del tallo hipofisario
tallo, silla turca vaca)
 CLINICA

MUJER VARN

1. GALACTORREA + OLIGO-AMENORREA + Infertilidad 1. La clnica es 10 a 15 aos mas tarda que en la mujer.

2. Amenorrea primaria 2. Clnica local por compresin CEFALEA Y DFICIT
3. Disminucin de la libido CAMPIMETRICO
4. Aumento de peso e hirsutismo leve 3. Impotencia y disminucin de la libido
5. Los prolactinomas son + fr en mujeres en edad frtil 4. Oligospermia
5. Infrecuente la galactorrea
 DIAGNOSTICO

ANALTICA PRUEBAS DE IMAGEN

Cifras matutinas basales de
prolactina en ayunas con 90
de reposo previo Rx lateral de
1. Valores Normales < 20mg/L crneo y TC de
2. Seguimiento teraputico silla turca
3. Valores > 100mg/L macroadenoma
4. Valores < 100mg/L microadenoma,
lesiones de silla turca que disminuyan la
inhibicin de la Dopamina o a causas no
neoplsicas de hiperprolactinemia.
5. Ante valores muy variables toma seriada

Pruebas dinmicas
1. Respuesta mnima al TRH.
2. Esto no posee valor diagnostico RNM con gadolinio
Gonadotropinas basales
Disminuidas por la accin
antigonadotropa de la PRL
 TRATAMIENTO

Normalizar los niveles de PRL para:

1. Aliviar sus efectos supresores de la funcin gonadal
OBJETIVO 2. Detener la galactorrea y
3. Conservar la densidad mineral sea.

OPCIONES TERAPEUTICAS
BROMOCRIPTINA
1 TTO
MDICO
CABERGOLINA

Preferible la va transesfenoidal
2 CIRUGA
Alta tasa de recidivas

COADYUVANTE de la Qx o tto medico

3 RADIOTERAPIA Reservado para hiperprolactinemias persistentes
despus de tto medico a dosis mximas o Qx.
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 INDICACIONES DEL TTO
MICROPROLACTINOMA
MACROPROLACTINOMA
MUJER VARON

1. Deseo de embarazo 1. Hipogonadismo

2. Disminucin de la libido 2. Disminucin de 1 TRATAMIENTO MEDICO
o galactorrea molesta la potencia BROMOCRIPTINA O CARBEGOLINA
3. Amenorrea(debido a alto sexual o la libido
riesgo de osteoporosis), 3. Esterilidad
acn o hirsutismo
2 Considerar Ciruga/Radioterapia en Pacientes
1 TRATAMIENTO MEDICO con hiperprolactinemia persistente sintomtica
BROMOCRIPTINA O CARBEGOLINA o con alteraciones visuales que no responden
rapidamente al tto medico
2 Ciruga
Solo al rechazo o intolerancia el tto medico
Despues de la Qx se suele dar
Bromocriptina por largo tiempo.
3 Abstencin al tto

4 Radioterapia
 ACROMEGALIA
ETIOLOGA CLINICA
1 causa ADENOMAS HIPOFISARIOS DE CELLS
SOMATOTROPAS. SINTOMAS Y SIGNOS LOCALES
Son ms fr los MACROADENOMAS
Cefalea, hemianopsia bitemporal, rinorrea
2 lugar en los adenomas hipofisarios
La acromegalia secundaria por exceso de GHRH es + o afeccion de los pares craneales IV o VI
frecuentemente causada por CARCINOIDES torcico o
abdominal

FISIOPATOLOGA

Sigue con su ritmo pulsatil, pero sin bajar a valores normales.

Se pierde el pico del sueo.

EPIDEMIOLOGA

EDAD MEDIA DE DX 40 en hombres y 45 en mujeres

Igual fr en mujeres y varones

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 SISTEMA NERVIOSO SISTEMA MUSCULOESQUELETICO
SINTOMAS Y SIGNOS GENERALES
MANIFESTACIONES GENERALES
PIEL Y TEJIDO CELULAR SUBCUTANEO

APARATO GENITOURINARIO

APARATO DIGESTIVO

SISTEMA ENDOCRINO

APARATO RESPIRATORIO

APARATO CARDIOVASCULAR

MANIFESTACIONES NEOPLASIAS
PSIQUIATRICAS ASOCIADAS
 DIAGNOSTICO

ANALITICA PRUEBAS DE SCREENING

1. HIPERGLICEMIA TEST DE SOBRECARGA DE GLUCOS (SOG) 75g. tras la SOG la GH > 10 mcg/L, en
2. HIPERINSULINEMIA sanos llega solo a 0.05-1ug/L
3. HIPERPROTEINEMIA
4. HIPERCALCIURIA CONCENTRACION PLASMATICA DE SM-C buena correlacin con grado de actv de enfermedad
5. HIPERFOSFATEMIA OTRAS PRUEBAS DIAGNOSTICAS
6. Fosfatasas alcalinas
normales o elevadas TEST DE TRH elevacin de GH superior a 100% tras dar TRH
7. Aumento de
HIDROXIPROLINURIA TEST DE GnRH en acromegalicos sube la GH pero en sanos no
8. GH SERICO
EFECTO PARADOJICO DE LOS AGENTES DOPAMINERGICOS en
AUMENTADOS
sanos aumentan la GH, en acromegalicos lo disminuyen
DURANTE LAS 24
HORAS
DIAGNOSTICO DE LOCALIZACION
9. AUMENTO DE LA [ ]
BASAL DE SM-C
ndice de actividad de la Rx y TC de la silla turca 90% SON ANORMALES
enfermedad
RNM Necesaria para decidir estrategia teraputica

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 TRATAMIENTO

CIRUGA
TRATAMIENTO DE ELECCION
1. TRANSESFENOIDAL
2. TRANSFRONTAL

TRATAMIENTO
FARMACOLOGICO
1. ANALOGOS DE LA SOMATOSTATINA
DE ACCION PROLANGADA
(OCTEOTRIDE via s.c. o i.m.)
2. AGONISTAS DE LA DOPAMINA
(Bromocriptina, cabergolina)
3. ANTAGONISTAS DEL RECEPTOR DE
LA GH

TRATAMIENTO
RADIOTERAPICO
IRRADIACION ESTEREOTAXICA
 POLIURIA
DIABETES
INSIPIDA

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 SIHAD

CRITERIOS
DIAGNSTICOS:
Descartar deficiencia de tiroides
o cortisol.
Osmolaridad <270 mOsm/kg.
Uosm >100 mosmol/kg.
Euvolemia.
Na orina >40mmol/l con ingesta
normal de sal.
SUPLEMENTARIOS:
Test anormal de sobrecarga de
agua.
Vasopresina elevada en plasma.
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 TRATAMIENTO
HIPOGONADISMO
INDUCCION DE LA PUBERTAD
DEFECTO EN LA SECRESION DE
DEFINICIN LOS PRINCIPALES ESTEROIDES NIOS 1. Enantato de Testosterona i.m. 1
SEXUALES POR LAS GONADAS dosis mensual/3 meses
(TESTOSTERONA Y ESTRADIOL). 2. hCG i.m.
NIAS Dosis bajas de estrgenos en
Etiologa funcional VARON: Retraso
puberal simple o ciclos de 21 das /3 meses
constitucional
HIPOGONADISMO HIPOGONADISMO HIPOGANADOTROPICO
HIPOGONADOTROPOS MUJER: Perdida
de peso Sustitucin con andrgenos si no
desea fertilidad.
1. Deficit de gonadotropinas (Sd. De VARON
Etiologa orgnica Kallman) Si desea fertilidad: gonadotropinas
2. Hiperprolactinemia tumoral o terapia pulstil
3. Sd. De Sheehan
4. Tumores hipofisarios MUJER Tto hacia la etiologa.
Si desea fertilidad tto inductor de
VARON: Sindrome de ovulacin
Klinefelter
HIPOGONADISMO
HIPOGONADISMO HIPERGONADOTROPICO
HIPERGONADOTROPO MUJER: Sindrome de
Turner VARON Testosterona i.m., implante
ETIOLOGA subcutneo o parche drmico
MUJER Anticonceptivos orales
 CLINICA
HIPOGONADISMO MASCULINO HIPOGONADISMO FEMENINO
No se modifican las caractersticas
PRENATAL PREPUBERAL POSPUBERAL PERIODO PRENATAL de los genitales externos.
PERIODO PRENATAL PERIODO PREPUBERAL PERIODO POSTPUBERAL
Pseudohermafroditis 1. Infantilismo sexual 1. Disminucin de la libido EDAD ADULTA
mo masculino (46XY con habito y de la potencia sexual
con organos sexuales corporal 2. Diminucin de 1. Oligo-amenorrea
con tendencia a ser eunucoide caracteres sexuales 2. Disminucin o perdida de la libido y
femeninos) 2. Voz aguda secundarios dispareunia
3. Micropene 3. Infertilidad por 3. Perdida o disminucin del vello pubiano, de la
azoospermia grasa corporal y atrofia mamaria.
4. A largo plazo, 4. Sntomas vasomotores, sntomas psquicos
osteoporosis, anemia y 5. A largo plazo osteoporosis y eliminacin del
disminucin de la efecto protector de los estrgenos sobre
fuerza muscular coronariopatias.

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 HIPOGONADISMO HIPERGONADOTROPOS
HIPOGONADISMO MASCULINO
Congenital abnormalities
HIPOGONADISMO HIPOGONADOTROPOS Klinefelter syndrome
Congenital Other chromosomal abnormalities
Isolated gonadotropin deficiency Mutation in the FSH and LH receptor genes
Kallmann's syndrome Cryptorchidism
Prader Willi Varicocele
Gonadotropin subunit mutation Disorders of androgen synthesis
Idiopathic Myotonic dystrophy
Acquired Acquired diseases
Suppression of gonadotropins Infections, especially mumps
Hyperprolactinemia Radiation
Gonadal steroid administration Alkylating agents
Glucocorticoid treatment Suramin
Critical illness Ketoconazole
Chronic systemic illness
Glucocorticoids
Opiates
Environmental toxins
Diabetes mellitus
Trauma
Idiopathic
Testicular torsion
GnRH analogs
Autoimmune damage
Damage to gonadotroph cells
Chronic systemic illnesses
Tumores
Infections Hepatic cirrhosis
Pituitary apoplexy Chronic renal failure
Trauma Qx - Rx AIDS
Idiopathic
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 Physical abnormalities % Characteristic Neonatal Childhood Adolescence Adulthood
Skeletal growth disturbances Check anti-Mllerian hormone
Short stature 100 Look for (AMH) before initiating hormone-
Discuss
mosaicism. replacement therapy around 12
Short neck 40 Gonadal reproductive Continue hormone
Look for Y- years of age.
Abnormal upper to low segment ratio 97 abnormalities options when replacement.
chromoso Begin therapy with low doses of
SD. TURNER Cubitus valgus 47 me
appropriate.
estradiol, and gradually increase
Short metacarpals 37 during the next two to four years.
Physical abnormalities Incidence, percent Madelung deformity 7.5 Continue to
Check thyroxine
Plot monitor growth.
Unknown factors Scoliosis 12.5 and thyrotropin
growth on Check thyroxine
Strabismus 17.5 levels.
Genu valgum 35 growth and thyrotropin
Stop growth hormone when bone Check thyroid
Ptosis 11 Characteristic facies with micrognathia 60 Growth curve levels. Check for
age exceeds 14 years or growth antibodies
failure specific for obesity. [1]
Multiple pigmented nevi 26 High arched palate 36 velocity drops below 2 cm/year. every three to five
those with Institute dietary
Physical abnormalities years.
Physiologic abnormalities Turner counseling.
Continue dietary
Growth failure 100 Growth failure 90 syndrome. Start growth
counseling.
Gonadal dysgenesis 90 hormone therapy.
Otitis media 73
Inverted, widely spaced nipples 74 Ensure adequate
Germ cell chromosomal defects calcium intake (1.2
Gonadal failure 90 Webbed neck 74 Watch for g/day).
Check for
Infertility 95 Nail dysplasia 74 Skeletal scoliosis. Watch for scoliosis, lordosis, and Encourage weight-
dislocated
Defective dental development 74 abnormalities Watch knee for kyphosis. bearing exercise.
Gonadoblastoma 5 hips.
tibial problems. Check bone mineral
Renal dysgenesis 53
Unknown factors - embryogenic density every three
Cardiac malformation 53 to five years.
Cardiovascular anomalies 55
Skeletal abnormalities 53 Review Continue to
Hypertension 7 Otitis is common
Otitis media 53 Craniofacial results of monitor hearing.
Renal and renovascular 39 and should be
Edema of hands and feet 41 malformati newborn Continue to monitor hearing. Audiogram
treated
anomalies on hearing every three to five
Eye deformities 41 aggressively.
screen. years.
Unknown factors - metabolic
Lymphatic obstruction
Hashimoto thyroiditis 34 Annual fasting
Webbed neck 25 glucose and lipid
Hypothyroidism 10 Low posterior hairline 42 Abnormal profile.
Alopecia 2 Rotated ears carbohydrat Glucose-tolerance

Vitiligo 2 e test may be
Edema of hands/feet 22 metabolism abnormal.
Gastrointestinal disorders 2.5 Severe nail dysplasia 13 Insulin resistance
Carbohydrate intolerance 40 Characteristic dermatoglyphics 35 is common.
 TRANSTORNOS DEL DESARROLLO SEXUAL 46XX (VIRILIZADA)
HIPERPLASIA SUPRARRENAL CONGNITA
DESARROLLO SEXUAL NORMAL Deficit clsico de 21 hidroxilasa.
Deficit de 11 hidroxilasa.
Deficit de 3B-OH-esteroide deshidrogenasa.
HIPERANDROGENISMO GESTACIONAL.

TRANSTORNOS DEL DESARROLLO SEXUAL 46XY (SUBVIRILIZADO)

HSC (con dficit de andrgenos).- Fx. Testicular anormal. Sx. Anormal de
andrgenos. Respuesta anormal a los andrgenos.

PUBERTAD PRECOZ: CENTRAL PERIFRICA

RETRASO PUBERAL
 GINECOMASTIA

GINECOMASTIA FISIOLOGICA

RECIEN NACIDO ADOLESCENTE SENIL

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 GINECOMASTIA
GINECOMASTIA PATOLOGICA

DEFICIENCIA EN LA PRODUCCION O ACCION DE LA TESTOSTERONA

Anorquia congnita Traumatismo

Sndrome de Klinefelter Castracin
Resistencia androgenica Enfermedades neurolgicas y granulomatosas
Orquitis viral Insuficiencia renal

AUMENTO EN LA PRODUCCION DE ESTROGENOS

Aumento de secrecin estrogenica tumores testiculares de Leydig y de Sertoli

Aumento de sustrato (androsteridona) de la aromatasa extraglandular

tumores suprarrenales feminizantes, hiperplasia suprarrenal congenita.
Aumento de aromatasa extraglandular tumores hepticos o suprarrenales
FARMACOS Estrgenos anticonceptivos, fitoestrogenos.
Frmacos que aumentan la secrecin endgena de estrgenos gonadotropinas, clomifeno
Inhibidores de la sntesis o la accin de la testosterona
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 GINECOMASTIA PATOLOGICA: GINECOMASTIA PATOLOGICA:
DIAGNOSTICO TRATAMIENTO
Solo en un 50% o menos de pacientes se llega a un Dx etiolgico positivo.
El estudio sistemtico depende de 3 cosas: Historia farmacolgica
negativa, mama dolorosa y masa mamaria > 4cm. CIRUGA
ESTUDIO DE LA GINECOMASTIA
RADIACION PROFILACTICA
HISTORIA CLINICA

MEDICION Y EXPLORACION DE LOS TESTICULOS

Testidulos de tamao reducido CARIOTIPO TRATAMIENTO ANTIESTROGENICO

Testiculos asimetricos buscar TUMOR TESTICULAR (TAMOXIFENO)
ANALISIS DE FUNCION RENAL Y HEPATICA

ESTUDIO ENDOCRINOLOGICO

Androsteridona srica o de los 17-cetosteroides en orina

INHIBIDORES DE LA AROMATASA
de 24 horas
Medicin del estradiol y hCG
LH y testosterona plasmtica
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 HIPERTIROIDISMO
DIAGNOSTICO
Hyperthyroidism with a normal or
high radioiodine uptake
Autoimmune thyroid disease
Graves' disease
Hashitoxicosis
Autonomous thyroid tissue
(uptake may be low if recent
iodine load led to iodine-induced
hyperthyroidism)
Toxic adenoma
Toxic multinodular goiter
TSH-mediated hyperthyroidism
TSH-producing pituitary adenoma
Non-neoplastic TSH-mediated
hyperthyroidism
Human chorionic gonadotropin-
mediated hyperthyroidism
Hyperemesis gravidarum
Trophoblastic disease
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Hyperthyroidism with a near absent
radioiodine uptake
Thyroiditis
Subacute granulomatous (de Quervain's)
thyroiditis
Painless thyroiditis (silent thyroiditis,
lymphocytic thyroiditis)
Postpartum thyroiditis
Amiodarone (also may cause iodine-induced
hyperthyroidism)
Radiation thyroiditis
Palpation thyroiditis
Exogenous thyroid hormone intake Antitiroideos: Metimazol, carbimazol, PTU
Excessive replacement therapy + Beta bloqueadores (propranolol)
Intentional suppressive therapy Radioyodo
Factitious hyperthyroidism Cirugia
Ectopic hyperthyroidism
Struma ovarii TRATAMIENTO
Metastatic follicular thyroid cancer
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 SKIN caliente, sudorosa, onicolisis, hiperpigmentacion,
prurito, vitiligo, alopecia areata, cabello fragil. EYES.
CARDIOVASCULAR aumenta GC, FC. RVP reduce. HTA
sistolica. FA 20%.
METABOLIC/ENDOCRINE: Serum lipids Patients with
hyperthyroidism tend to have low serum total and high-density
lipoprotein (HDL) cholesterol concentrations and a low total
cholesterol/HDL cholesterol ratio. These values increase after
treatment [].
Hyperglycemia
RESPIRATORY disnea por: aumento de consume de O2,
debilidad muscular, obstruccion traqueal, exacerba asma, HTP
GASTROINTESTINAL Weight loss hyperdefecation and
malabsorption; hyperphagia, Vomiting [] and abdominal pain,
rarely: Dysphagia due to goiter. Abnormalities in liver function
tests, particularly high serum alkaline phosphatase
concentrations and, rarely, cholestasis
THYMIC ENLARGEMENT In patients with Graves disease,
thymic enlargement due to hyperplasia has been reported [].
HEMATOLOGIC Anemia normocitica normocromica. Serum
ferritin concentrations may be high. Graves PTI, perniciona.
Protrombotico.
GENITOURINARY Urinary frequency and nocturia are
common in hyperthyroidism. Enuresis oligomenorrhea, and
anovulatory infertility []. Amenorrhea In men, gynecomastia,
reduced libido, and erectile dysfunction []. Spermatogenesis is
often decreased or abnormal, eg, more spermatozoa are
abnormal or non-motile [36
BONE The net effect is osteoporosis and an increased
fracture risk in patients with chronic hyperthyroidism.
NEUROPSYCHIATRIC Patients with thyrotoxicosis may
experience behavioral and personality changes, such as
psychosis, agitation, and depression.
GERIATRIC HYPERTHYROIDISM Hyperthyroidism in older
patients may be apathetic, rather than having hyperactivity,
tremor, and other symptoms of sympathetic overactivity [].
 Serum TSH Serum free T4 Serum T3 Assessment
HIPOTIROIDISMO Normal hypothalamic-pituitary function
Normal Normal Normal Euthyroid
Euthyroid
Normal Normal or high Normal or high
hyperthyroxinemia
Euthyroid
Normal Normal or low Normal or low
hypothyroxinema
DX Euthyroid: T3
Normal Low Normal or high
therapy
TRATAMIENTO Normal Low-normal or low Normal or high
Euthyroid: thyroid
extract therapy
Levotiroxina vo: iniciar c/ 50ug/dia
Primary
Levotiroxina ev + Hidrocortisona: En coma High Low Normal or low
hypothyroidism
mixedematoso
Subclinical
High Normal Normal
hypothyroidism
Low High or normal High Hyperthyroidism
Subclinical
Low Normal Normal
hyperthyroidism
Abnormal hypothalamic-pituitary function
TSH-mediated
Normal or high High High
hyperthyroidism
Central
Normal or low* Low or low-normal Low or normal
hypothyroidism

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 Symptoms Signs
Fatigue and
weakness
Cold intolerance
Slow movement
Dyspnea on
and slow speech
exertion
Slowing of Delayed
Weight gain
metabolic relaxation of
Cognitive
processes tendon reflexes
dysfunction
Bradycardia
Mental retardation
Carotenemia
(infantile onset)
Constipation
Growth failure
Coarse skin
Puffy facies and
Accumulati
Dry skin loss of eyebrows
on of
Hoarseness Periorbital
matrix
Edema edema
substances
Enlargement of
the tongue
Decreased hearing Diastolic
Myalgia and hypertension
paresthesia Pleural and
Other Depression pericardial
Menorrhagia effusions
Arthralgia Ascites
Pubertal delay Galactorrhea
TIROIDITIS
Multinodular goiter
Iodine-deficiency goiter
Autoimmune/thyroiditis
Chronic autoimmune (Hashimoto's)
Painless thyroiditis
Subacute thyroiditis
Postpartum thyroiditis
Infectious thyroiditis
Ingestion of goitrogens
Iodine
Lithium carbonate
Foodstuffs (cassava, millet)
Thyroid infiltrative disease
Riedel's thyroiditis
Amyloid goiter
Histiocytosis
Cystinosis
Sarcoidosis
Toxic goiter
Graves' disease
Autonomously functioning thyroid adenoma
Thyroid cysts
Thyroglossal duct cysts
Thyroid adenomas
Thyroid carcinoma
EVALUACIN DEL BOCIO

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 METASTASICOS (x melanomas, pulmon, mama, esofago) - LINFOMAS (tipo B el +fr)
MEDULARES (de las cells C parafoliculares calcitoninca): 80% esporadicos 20%
CANCER DE TIROIDES familiares(Aislado, MEN2A y MEN2B)
EPITELIO FOLICULAR (el ms fr)

PAPILAR FOLICULAR MEDULAR ANAPLASICO LINFOMA

EPID. El +fr(70%) El 2 en fr (15-20%) Esporadico 80%, El 3 en fr (5-10%) Mujeres 75.
Frecuencia bimodal (2-3d/5d) Frecuente en edad avanzada MEN2A, MEN2B, Frecuente en 6-7d 5% de turmores.
Frecuente en areas ricas en I Frecuente en zonas deficiente de familiar no MEN. Relacionado con
Es el +relacionado con la radiacion I Hashimoto,
craneo-cervical en la niez AcAPx+

PAT. Papilar recubiertas de cells atipicas, Semejante a epitelio tiroideo No deriva del epitelio Deriva del epitelio folicular, Linfoma difuso
Calcificaciones en grano de arena o normal, capsulado, puede invadir folicular. Acumulo de clulas gigantes fusiformes. de clulas B
cuerpos de psamoma capsula o vasos clulas C con amiloide. Existe confusion con grandes.
linfoma o sarcomas.

EVOL. Crecieminto lento Propagacion rapida por via Adenopatias calcificadas Crecimiento rapidisimo, -
Propagacion por la capsula a hematica (meta + a pulmon, y metstasis a SNC y invade y comprime hasta
estructuras vecinas (+ganglios) hueso (osteoliticas) o SNC hueso. puede ulcerar piel
[NO hematica]

MRK TG TG Calcitonina/CEA - -

I-131 SI SI No No No

PX MUY BUENO Tiene un subtipo agresivo Malo Tiene pronostico muy Variable.
(carcinoma de Hurthle, mas malo! Incluso postQx
invasor y menos radiosensible). (viven meses nomas)
En general tbn es mas agresivo
que el papilar.

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ESTADIAJE DE RIESGO
Primary tumor (T)*
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tumor 2 cm or less in greatest dimension, limited to the
T1
thyroid
T1a Tumor 1 cm or less, limited to the thyroid
Tumor more than 1 cm but not more than 2 cm in
T1b
greatest dimension, limited to the thyroid
Tumor more than 2 cm but not more than 4 cm in
T2
greatest dimension, limited to the thyroid
Tumor more than 4 cm in greatest dimension limited to
the thyroid or any tumor with minimal extrathyroid
T3
extension (eg, extension to sternothyroid muscle or
perithyroid soft tissues)
Moderately advanced disease
Tumor of any size extending beyond the thyroid capsule
T4a
to invade subcutaneous soft tissues, larynx, trachea,
esophagus, or recurrent laryngeal nerve
Very advanced disease
T4b Tumor invades prevertebral fascia or encases carotid
artery or mediastinal vessels
All anaplastic carcinomas are considered T4 tumors
T4a Intrathyroidal anaplastic carcinoma
T4b Anaplastic carcinoma with gross extrathyroid extension
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Low risk
Papillary thyroid cancer with all of the following present:
No local or distant metastases - All macroscopic tumor has been resected
No invasion of locoregional tissues
Tumor does not have aggressive histology (eg, tall cell, insular, columnar cell carcinoma,
Hrthle cell carcinoma, follicular thyroid cancer, hobnail variant)
No vascular invasion
131
No I uptake outside the thyroid bed on the post-treatment scan, if done
Clinical N0 or 5 pathologic N1 micrometastases (<0.2 cm in largest dimension)*
Intrathyroidal, encapsulated follicular variant of papillary thyroid cancer*
Intrathyroidal, well-differentiated follicular thyroid cancer with capsular invasion and no or
minimal (<4 foci) vascular invasion*
Intrathyroidal, papillary microcarcinoma, unifocal or multifocal, including BRAF
V600E mutated (if known)*
Intermediate risk
Any of the following present:
Microscopic invasion into the perithyroidal soft tissues
131
Cervical lymph node metastases or I avid metastatic foci in the neck on the post-treatment
scan done after thyroid remnant ablation
Tumor with aggressive histology or vascular invasion (eg, tall cell, insular, columnar cell
carcinoma, Hrthle cell carcinoma, follicular thyroid cancer, hobnail variant)
Clinical N1 or >5 pathologic N1 with all involved lymph nodes <3 cm in largest dimension*
Multifocal papillary thyroid microcarcinoma with extrathyroidal extension and BRAF V600E
mutated (if known)*
High risk
Any of the following present:
Macroscopic tumor invasion
Incomplete tumor resection with gross residual disease
Distant metastases
Postoperative serum thyroglobulin suggestive of distant metastases
Pathologic N1 with any metastatic lymph node 3 in largest dimension*
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