HYPOTHYROIDISM

UNIVERSITY OF HEALTH SCIENCES

FACULTY OF MEDICINE
2016
IM BUNTHOEUN
 OBJECTIVES

• Explain pathophysiology of hypothyroidism

- Describe physiologic effects of thyroid hormones

- Describe etiology of hypothyroidism

- Explain mechanism related to clinical

manifestations of hypothyroidism
 Hypothalamus
TRH

feedback Pituitary

TSH
Thyroid gland

T3, T4
 EFFECT OF THYROID HORMONE
Target tissue Effect Mechanism
Heart Increased number and affinity of β-
adrenergic receptors.
Enhance response to circulating
catecholamine
Adipose tissue Catabolic Stimulate lipolysis
Muscle Catabolic Increase protein breakdown
Bone Developmental Promote normal growth and skeletal
development
Nervous system Developmental Promote normal brain development
Gut Metabolic Increase rate of carbohydrate
absorption
Lipoprotein Metabolic Stimulate formation of LDL receptors
Other Calorigenic Stimulate oxygen consumption
 ETIOLOGY

Classification Pathogenetic mechanism

CONGENITAL Aplasia or hypoplasia of thyroid gland
Defects in hormone biosynthesis or
action
ACQUIRED
Hashimoto’ s thyroiditis Autoimmune destruction

Severe iodine Hormone synthesis, release

deficiency
Lymphocytic thyroiditis Hormone synthesis, release
 ETIOLOGY

Etiologic classification Pathogenetic mechanism

Thyroid ablation Hormone synthesis, release

Drugs Hormone synthesis, release

Hypopituitarism Deficient TSH secretion

Hypothalamic disease Deficient TRH secretion
 PATHOGENESIS

• Low serum T4 and T3 levels, serum TSH level elevated

• Primary hypothyroidism (end organ failure): the noctunal

TSH surge intact

• Pituitary or hypothalamic hypothyroidism: low level of

serum TSH and the normal noctural TSH surge is
absent
 Hypothalamus
TRH

feedback Pituitary

TSH
Thyroid gland

T3, T4
HASHIMOTO’S THYROIDITIS
 PATHOLOGY

• In the early stage:

the gland enlarged,
firm, and nodular

• In the late stages:

the gland is smaller,
atrophic and fibrotic
 PATHOGENESIS

• It is possible that a defect in suppressor T lymphocytes

allows helper T lymphocytes to interact with specific
antigens on the thyroid follicular cell membrane

• Thyroid autoantibodies:
- The thyroglobulin antibody (Tg Ab),
- Thyroidal peroxidase antibody (TPO Ab) and
- The TSH receptor blocking antibody (TSH-R [block] Ab)
 PATHOGENESIS

• Serum level of these antibody do not correlate with

severity of disease
- High antibody titers ( Hashimoto’s thyroiditis),
- moderate titers (Graves’ disease, multinodular goiter,
and thyroid neoplasm)

• Associated with other autoimmune diseases

 CLINICAL MANIFESTATIONS

• Hypothermia, cold intolerance, weigh gain

• In children ,
- myelination defective and mental retardation,
- bone growth slowed and skeletal maturation delayed

• In adult,
- forgetfulness, decreased hearing, ataxia, mental
symptoms,
- tendon reflexes (low), paresthesia.
 CLINICAL MANIFESTATIONS

• Muscle weakness, and cramps

• In acute hypo thyroiditis:

- Decreased cardiac output, stroke volume, diastolic
volume at rest and
- Increased peripheral resistance
 CLINICAL MANIFESTATIONS

• In chronic hypo thyroiditis:

- Cardiomyopathy, fiber degeneration, decreased
contractility, low cardiac output, cardiac enlargement,
and heart failure

- Pericardial effusion
 CLINICAL MANIFESTATIONS

• Decreased ventilatory responses to hypercapnia and

hypoxia

• Increased the plasma cholesterol and triglyceride levels

• A normochromic, normocytic anemia

• Constipation
 CLINICAL MANIFESTATIONS

• The skin:
- Dry and cool;
- Myxedema: face puffy, with coarse features
• In larynx: hoarseness
• The hair: brittle, loss of body hair
• Carotenemia: decreased hepatic conversion of carotene
to vitamin A
 CLINICAL MANIFESTATIONS

• In women:
- menorrhagia, menses scanty or disappear
- hyperprolactinemia: galactorrhea and amenorrhea
• In men: infertility and gynecomastia
• Decreased glomerular filtration rate
• Myxedema coma: myxedema facies and skin,
bradycardia,hypothermia,alveolar hypoventilation and
coma
 Clinical finding in adult hypothyroidism

- Symptoms
• Slow thinking

• Lethargy

• Dry skin, thickness hair, hair loss, broken nails

• Diminish food intake; weight gain

• Menorrhagia; diminish libido

• Cold intolerance
 Clinical finding in adult hypothyroidism

- Signs
• Round puffy face, slow speech, hoarseness

• Hypokinesia, generalized muscle weakness, delayed

relaxation of deep tendon reflexes

• Cold, dry, scaling skin; dry, coarse, brittle hair,

longitudinally ridged nails.

• Periorbital edema

• Bradycardia
Hypothalamus Anterior pituitary Thyroid glands T3 & T4

Abnormality of Abnormality of Abnormality of

hypothalamus anterior pituitary thyroid glands

TRH TSH Production of antibody

TSH T4 Destruction of
thyroid cells
T4 Clinical
manifestations T4

Hypothermia Hyperlipidemia Periorbital edema Constipation

RR Anemia Pericardial effusion Fatigue
Coma Galactorrhea Ascites Weight gain
Dementia Infertility Myxedema Cold intolerance
Psychosis Menstrual Hoarseness Hair loss
irregularity Cardiomyopathy Reflexes
Neuropathy HR, CO
 REFERENCES

• S Silbernagl Florian LANG (2000), Atlas de poche de

physiopathology.
• Stephen J. McPhee et al (2014), Pathophysiology of
disease: an introduction to clinical medicine
• Thomas J. Nowak, et al, 2014. Essentials of
Pathophysiology. Concepts of Altered Health States.