Hipertiroidisme

Kepaniteraan ilmu penyakit dalam RSUD CILEGON UNIVERSITAS YARSI

DEFINISI (Sudoyo,W Aru,dkk.2006)

Manifestasi klinis kelebihan hormon tiroid yang beredar dalam sirkulasi

TIROTOKSIKOSIS

HIPERTIROID

Tirotoksikosis yang diakibatkan hiperaktifitas dari kelenjar tiroid

Tirotoksikosis vs hipertiroidisme
Apapun sebabnya, manifestasi klinisnya sama Efek ini disebabkan ikatan T3 dengan T3-inti makin penuh

(Sudoyo,W Aru,dkk.2006)

THE THYROID GLAND

www.univ-st-etienne.fr/lbti/Mednucl/AtlasEnd/thyroide/

THYROID HORMONES

OH I I I O I O

OH I I O

NH2
OH

I O

NH2 OH

Thyroxine (T4)

3,5,3-Triiodothyronine (T3)

FEEDBACK REGULATION
THE HYPOTHALAMIC-PITUITARY-THYROID AXIS
Hormones derived from the pituitary that regulate the synthesis and/or secretion of other hormones are known as trophic hormones.

Key players for the thyroid include:

TRH - Thyrophin Releasing Hormone

TSH - Thyroid Stimulating Hormone

T4/T3 - Thyroid hormones

PITUITARY-THYROID AXIS

HM Goodman, BASIC MEDICAL ENDOCRINOLOGY 3rd Ed.

Negative Feedback Loop

Thyroid Disease Affects Many Body Systems and Overall Health

Thyroid
Thyroid Disease Can Have Widespread Effects

Brain
Depression Decreased Concentration General Lack of Interest

Liver
Increased LDL Cholesterol Elevated Triglycerides

Heart
Decreased Heart Rate Increased/Decreased Blood Pressure Decreased Cardiac Output

Intestines
Constipation Decreased GI Activity

Reproductive System
Decreased Fertility Menstrual Abnormalities May Harm Development of Infant

Kidneys
Decreased Function Fluid Retention and Edema

Hormon tiroid berfungsi untuk mengendalikan kecepatan metabolisme tubuh. Hormon tiroid mempengaruhi kecepatan metabolisme tubuh melalui dua cara : 1. Merangsang hampir setiap jaringan tubuh untuk menghasilkan protein. 2. Meningkatkan jumlah oksigen yang digunakan oleh sel. (fitriani,2010)
http://yosefw.wordpress.com/2008/06/10/penggunaan-obat-antitiroid-pada-pasien-hipertiroidisme/

etiologi

Etiologi
Hipertiroidisme primer : penyakit Graves, struma multinodosa toksik, adenoma toksik, metastasis karsinoma tiroid fungsional, struma ovarii, mutasi reseptor TSH, obat kelebihan yodium (fenomena Jod Basedow).2 Tiroiditis silent, destruksi tiroid (tanpa amiodarone, radiasi, infark adenoma), asupan hormon tiroid yang berlebihan (tirotoksikosis factitia)2 Hipertiroidisme sekunder: adenoma hipofisis yang mensekresi TSH, sindrom resistensi hormon tiroid, tumor yang mensekresi HCG, tirotoksikosis gestasional2

Lebih dari 90 % hipertiroidisme adalah akibat penyakit graves dan nodul tiroid toksik.

Signs and Symptoms Of Hyperthyroidism

Nervousness Irritability Difficulty Sleeping

Hoarseness or Deepening of Voice Persistent Sore or Dry Throat

Difficulty Swallowing Rapid or Irregular Heartbeat Infertility Weight Loss Heat Intolerance Increased Sweating First-Trimester Miscarriage

Bulging Eyes/Unblinking Stare Swelling (Goiter) Menstrual Irregularities or Light Period Frequent Bowel Movements

Warm, Moist Palms Excessive Vomiting in Pregnancy Family History of Thyroid Disease or Diabetes

Common Signs and Symptoms of Hyperthyroidism

May Include:

Nervousness Irritability Difficulty Sleeping Bulging Eyes Unblinking Stare Goiter Rapid Heartbeat

Increased Sweating Heat Intolerance Unexplained Weight Loss Scant Menstrual Periods Frequent Bowel Movements Warm, Moist Palms Fine Tremor of Fingers

TABLE1.MAJOR SYMPTOMS AND SIGNS OF HYPERTHYROIDISM AND OF GRAVES DISEASE AND CONDITIONS ASSOCIATED WITH GRAVES DISEASE 5 Manifestations of hyperthyroidism Symptoms Hyperactivity, irritability, altered mood, insomnia Heat intolerance, increased sweating Palpitations Fatigue, weakness Dyspnea Weight loss with increased appetite (weight gain in 10 percent of patients) Pruritus Increased stool frequency Thirst and polyuria Oligomenorrhea or amenorrhea, loss of libido Signs Sinus tachycardia, atrial fibrillation Fine tremor, hyperkinesis, hyperreflexia Warm, moist skin Palmar erythema, onycholysis Hair loss Muscle weakness and wasting Congestive (high-output) heart failure, chorea, periodic Paralysis (primarily in Asian men), psychosis*

Manifestations of Graves disease Diffuse goiter Ophthalmopathy A feeling of grittiness and discomfort in the eye Retrobulbar pressure or pain Eyelid lag or retraction Periorbital edema, chemosis, scleral injection Exophthalmos (proptosis) Extraocular-muscle dysfunction Exposure keratitis Optic neuropathy Localized dermopathy Lymphoid hyperplasia Thyroid acropachy Conditions associated with Graves disease Type 1 diabetes mellitus Addisons disease Vitiligo Pernicious anemia Alopecia areata Myasthenia gravis Celiac disease Other autoimmune disorders associated with the HLA-DR3 Haplotype

Diagnosis
Diawali oleh kecurigaan klinis. Berdasarkan indeks klinis Wayne and Newcastle yang didasarkan anamnesis dan pemeriksaan klinis yang teliti. Dilanjutkan dengan pemeriksaan penunjang untuk konfirmasi diagnosis anatomis, status tiroid dan etiologi

diagnosis
Untuk fungsi tiroid diperiksa kadar hormon beredar TT4, TT3, dalam keadaan tertentu sebaiknya fT4 dan fT3, dan TSH Untuk fase awal penentuan diagnosis, perlu T4, T3, dan TSH Namun pada pemantauan hanya T4 saja.

Investigations
Thyroid function test: TSH- Undetectable T4 - Raised T3 - Raised RAIU- Raised TSH-receptor antibodies(TRAb)-elevated in Gravess disease Isotope scanning- Increased uptake

Treatment of Hyperthyroidism
HYPERTHYROIDISM Type title here

MEDICAL

SURGICAL

IODINE

Anti thyroid drugs Beta blockers

Sub total thyroidectomy

Radio active iodine Lugol's solution

Anti thyroid drugs

Chemically block hormone synthesis Enhance evolution to remission Best indicated for children,adolescents,young adults and pregnant women. Propylthiouracil-100-150mg every 6or 8 hrs Carbimazole- 40-60mg daily initially for 3 weeks,then reduce to 20-40mg for another 8 weeks and maintain at 5-20mg daily for 18-24 months. Methimazole-active metabolite of Carbimazole

Duration of treatment
18-24 months Side effects- Rash Leukopenia Agranulocytosis

Control of adrenergic symptoms

Adrenergic antagonists: Propranolol-40-120mg/day

Ablative therapy(Surgery & Iodine)

Indications: Relapse or recurrance following drug therapy A large goiter Failure to follow medical regimen. Radioactive iodine is simple,effective and economical

Complications of ablative therapy

Immediate complications of surgery: Bleeding,injury to recurrant laryngeal nerve and thyroid crises. Other complications Hypothyroidism Radiation thyroiditis

Complications of thyrotoxicosis
1)Cardiac- Heart failure Atrial fibrillation 2)Thyrotoxic crises: or storm: Fulminating increase in signs and symptoms of thyrotoxicosis. Occurs in medically untreated or inadequately treated patients.May be precipitated by surgery or sepsis The syndrome is characterized by extreme irritability,delirium or coma,fever 41C or more,tachycardia,restlessness,hypotension,vomiti ng and diarrhea.

Treatment of thyroid crisis

Provide supportive care; Treat dehydration Administer glucose and saline Vitamin B complex and glucocorticoids Digitalization is required in those with atrial fibrillation Immediate and large doses of anti thyroid agents(Eg-propylthiouracil 100mg every 2h) Iodine intravenously or by mouth Propranolol 40-80mg every 6h Dexamethasone(2mg every 6h) and to be tapered later.

Treatment of ophthalmopathy and Dermopathy

Methylcellulose eye drops Tinted glasses Persistant diplopia can be corrected by surgery Papilloedema,loss of visual field or acuity requires urgent treatment with prednisolone 60 mg daily. Majority of patients require no treatment other than reassurance. Dermopathy of Graves rarely requires treatment