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EUTHYROID mutatation in TBG, TTR and Albumin


HYPERTHYROXINEMIA ↓
inc binding affinity for T4 and/or T3
FAMILIAL DYSALUBMINEMIC
HYPERTHYROXENIEMIA

THYROID HORMONE RESISTANCE
 TSH: inc or inaapproprite NORMAL



(AD)
TH: inc

pregnancy, TBG nephrotic syndrome TBG➡


OCP androgen
SERM
inflammatory liver disease

HYPOTHYROID

HYPOTHYROID RAIU, THYROID SCANNING GOAL: TSH at lower half of N range.

PRIMARY: TSH use monitor Tx For NO RESIDUAL FX:


SECONDARY: TSH: low, N/ T4: low; TSH NOT USE
LEVOTHYROXINE
IDA
 FF-up TSH: q 1 yr or 2-3 yrs
-mc worldwide POOR ADHERENCE: >=200 mcg STILL HIGH TSH.

HASHIMOTO

-mc in iodine sufficient areas

IATROGENIC HYPOTHYROIDISM
 T4 better than TSH


-mc in iodine sufficient areas

CONGENITAL HYPOTHYROIDISM NEONATAL SCREENING

T4 


-Permanent (MC)

-TG dysgenesis (MC)

HASHIMOTO MARKERS: ANTIBODY to TPO and Tg Same: hypothyroid



(AUTOIMMUNE )
HYPOTHYROIDISM HISTOPATH:
-lymphocytic
-germinal center
-atrophy
-oxyphil metaplasia
- (-)colloid
-fibrosis

SUBCLINICAL HYPOTHY (-) CM
 TSH: inc TREAT LEVOTHY IFFFFFFF!


but POSITIVE
T3/T4: NORMAL
BIOCHEMICAL EVIDENCE

MYEXEDEMA COMA Independent to T4 and TSH


LEVOTHY
Alt: Liothyronine (T3)

Alt: Levo + Lio

IMPAIRED ADRENAL RESERVE:


HYDROCORT

HYPETHYROIDISM

GRAVE
 diffuse enlarge THYROID
 THIONAMIDES



 
 -PTU 

-Stress: impt factor
 NOSPECS for eval of Ophthalmopathy -with Indication
-SMOKING- minor RF BUT MAJOR -CARBIMAZOLE
RF in dvt ophthalmopathy 
 METHIMAZOLE


SINUS TACHY- (MC) CV mx


TSH: supp
 EVAL:
Total/ unbound: increased
 TFT q 4-6 wks

 TITRATE base on unbound T4
-T3 TOXICOSIS: T3 only inc

-T4 TOXICOSIS: T4 only, n T3
 REMISSION: 12-18 mos
-usually d/t EXCESS iodine
OTHERS:

TRAb and TPO: if dx unclear, not routine PROPANOLOL- for adrenegic sx

ANTICOAG (WARFARIN)- for AF
LAB:
 RAI

-inc liver enzymes, Bilirubin, Ferritin
 -w/ a-ad bockers, ATD

-Microcytic, Thrombocytopenia -w/ Prednisone (for OPHTH)

SURGERYL SUBTOTAL/ NEAR TOTAL THRYOIDECTOMY



-very large Goiter

-PreOp: ATD then SSKI (ctrl thyrotoxicosis, dec vascu;arity)

THYROID STORM DIAGNOSTIC CRITERIA: PTU (via NGT/rectum)



≥45: TS
25-44: impending
 ALT: Methimazole
<25: unlikely (1hr p ATD)

 SSKI (WOLFF CHAIKOFF)

-Temp
-CNS
-GI dysfx
 PROPANOLOL
-CV (Tachy, CHF, AF)
 HYDROCORT
-Precipitating Antibiotics, Cooling, O2, IVF
DESTRUCTIVE THYROIDITIS LOW RAIU

(SUBACUTE/SILENT T) INCREASED Circulaing Tg

F- Factitia

E- Excess

LOW OR ABSENT RAIU
F- Functional

E- Ectopic
THYROTOXIC FACTITIA

IODINE EXCESS
ECTOPIC THYROID TISSUE

-Struma Ovarii

-Ovarian Teratoma
FUNCTIONAL METASTATIC FOLLICULAR CARCINOMA

THYROIDITIS HISTOPATH:
-patchy inflammatory infiltration
-disruption of thyroid follicles
-multinucleated giant cells (inside follicles)
-granuloma -> fibrosis

ACUTE THYROIDITIS
-Bacterial (SES)
-Staph

-Entero

-Strep

-Fungal (CCHAP)
-Candida
-Coccidiodes

-Histo
-Asperg
-Pneumocystis

-Amiodarone (subac/chr)

SUBACUTE THYROIDITIS
 3 PHASES: ASA


-DQ
 1. THYROTOXICOSIS 

-Granulomatous
 ALT: NSAID
-Viral (MICAE)
 - supp TSH, Elev T4/T3

-Mumps
 -High ESR, Low RAIU
 IF inadequate:
-Influenza

-Coxsackie -Inc WBC, (-) TH Ab GLUCOCORTICOID

-Adenovirus -Prednisone
-Echovirus
2. HYPOTHYROID-
3. RECOVERY BB- for adrenergic
ATD- if prolonged hypothy phase, BUT LOW DOSE.

EVAL: TFT (TSH and FT4)



-q 2-4 wks

SILENT THYROIDITIS TPO Ab BB for SEVERE THYROTOXICOSIS


(PAINLESS THYROIDITIS) Normal ESR
NO Glucocort

THYROXINE- at hypothyroid phase

ANNUAL ff-up

DRUG INDUCED THYROIDITIS


-Amiodarone

CHRONIC: (PRAT) TPO Ab SURGERY- relief compression


-Autoimmune. (FAH)

-Focal Thyroiditis HISTOPATH: Dense Fibrosis that EXTEND outside Thyroid capsule TAMOXIFEN
-Atrophic

-Hashimoto -MC clinically apparent
(-)THYROID DYSFX
Reidel’s

Parasitic. (CES)
-Cysticercosis
-Echinococcosis
-Strongylodiasis

Trauma (palpate)

SICK EUTHYROID SYNDROME TSH, T4- Normal AVOID ROUTINE TEST OF THYROID during acute Ilness

T3 (unbound and Total) LOW


Fluctuation TSH:

<0.1 in very ill (Dopa/GC tx)
>20 recovery phase

PREGNANT IODINE intake 250 mcg

(HYPER) Fluid replacement

If using LEVOTHYROXINE: increase 50%

NODULAR CLASSIFICATION
0: NO Goiter
1a: PALPABLE
1b. PALPABLE, VISIBLE (head TILT)
2. VISIBILE (Head NORMAL position)
3. VISIBLE AFAR

SIMPLE GOITER (-) NODULES AND HYPERTH IODINE REPLACEMENT

(DIFFUSE NONTOXIC G) SURG: (for Compression)


-THYROIDECTOMY (SubTotal/ Near Total)
NON-TOXIC MULTINODULAR AVOID IODINE AND CONTRAST
 RADIOIODINE (dec size, selective ablate regions of autonomy)

-JOD BASEDOW EFFECT

LEVOTHYROXINE
-start low
T4 suppression RARE EFFECTIVE

-risk: subclinical/overt THYROTOX

SURGERY/ GC: (compression)

TOXIC MULTINODULAR THYROID SCAN:
 RADIOACTIVE IODINE



-heterogenous uptake with multiple areas of increase/decrease uptake -TOC

ULTRASOUND: areas of decreased uptake (COLD NODULE)
 ATD


-if +, Do FNA
SURGERY (if Thyrotox)

-DEFINITIVE

HYPERFUNCTIONING SOLITARY RADIOACTIVE IODINE



NODULE -TOC

-10- 29.9 mci
(TOXIC ADENOMA)
ATD & BB (not for long Term)

SURGERY: LOBECTOMY

BENIGN NEOPLASM I-defecient: IODINE & LEVOTHY

(VERY LOW risk of Mal)


-MACROfollicular Adenoma

-NORMOfollicular Adenoma

(HR)
MICROfollicular
Hurthle
Trabecular

THYROID CA

PAPILLARY THYROID CA LYMPHATIC HISTOPATH:
 early: Good prog


-Psammoma

(WELL DIFFERENTIATED -Orphan Annie (cleaved nuclei, large
THYROID CA) nucleoli)
-Papillary structures

FOLLICULAR THYROID CA POOR Prog FActors
 POOR prog


-distant mets

HEMATOGENOUS ->50
 SURGERY: NEAR TOTAL THYROIDECTOMY

(WELL DIFFERENTIATED >4cm
 -preferred in ALL
THYROID CA) -Hurthle cell
 -then RAI Ablation after surg (EXCEPT ST. 1, T1)
-marked vascular invasion
LEVOTHYROXINE

TK INHIBITORS (Sorafenib)

ANAPLASTIC THYROID CANCER VERY POOR PROG (6mos only)

POORLY DIFFERENTIATED Chemo



RadioTX

THYROID LYMPHOMA EXTERNAL RADIATION



-highle sensitive
Diffese Large Cell Lymphoma- MC
type AVOID: RESECTION

MEDULLARY THYROID CA MARKER: CALCITONIN



-if residual or recurrent

PLEASE REFER TO LONGER VERSION FOR ADDITIONAL INFO.

NAPAKRAMING IMPORTANTE NAWALA DITO LALO MGA CLINICAL MANIFESTATION.