Thyroid

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Thyroid

• ???????? Thyroid Hormone
• ????????????????????
• Peroxidase Peroxidase
• Iodide Iodine MIT T4
  T4. T3
• DIT T3
  ????????????
• Thyroglobulin

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Metabolism of TH

• 5 monodeiodination
• T4
• 5 monodeiodination

T3 - 80 T3 ????????????, active form Reverse T3
(inactive form)
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Hypothalamus
TRH

-
Peripheral Tissue
Pituitary
-
TSH

Thyroid
TBG - T3 TBG - T4
T4,T3 TBG
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Thyroid disorder
I. ????????????????????????????? thyroid -
Thyrotoxicosis / Hyperthyroidism -
Hypothyroidism II. ???????????? thyroid
????????? ??????????????? - Diffuse euthyroid
goiter - Solitary thyroid nodule - multinodular
goiter III. ?????????????? thyroid function test
?????????? thyroid ???????????? -
Euthyroid hyperthyroxinemia - Euthyroid sick
syndrome - Euthyroid hypothyroxinemia
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Thyrotoxicosis
- ??????? thyroid hormone ??????????
- ????????? hormone ??? -
?????????????? ???????? thyroid H. ???
????? ???????, ??????, ??.??, ???????,
???????, ???????????? ???????, ????????,
??????, ????????, ?????????????????
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?????????
Fine tremor, moist skin warm
tachycardia, hyperactive Plummers Nails
Staring eyes, Lid retraction, Lid Lag Localized
myxedema (pretibial)
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??????
- Graves disease - Toxic multinodular
goiter - Toxic Adenoma - Thyroiditis -
Struma Ovarii - Functioning metastatic thyroid
CA - Thyrotoxic factitia - Hydatidiform
mole Diagnosis TH , TSH (lt0.1)
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???????? 3 ??????????????????????? TBG ???????
TBG ????????? TBG ???? ????????? ??????????
??? (major systemic illness) ???????????? ????
?????????????? ??????????????????????? ??????????
????? ???????????????? active
acromegaly ????????????????? ???????????????????
????????????????????? tamoxifen ????????????????
????????????????? ???????? perphenazine ????????
L-asparaginase ???????????????? ????????? Chro
nic active hepatitis Biliary cirrhosis Acute
intermittent porphyria ?????????
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???????? 1 ??????????????????????????????????????
???????????????????? ???????????????????????
??????????????????????????????????? ?????????????
??????? associate with hyperthyroidism
????? radioactive iodine uptake(RAIU)
??? Graves disease ???????????????????????
?????????????? bruit, ophthalmopathy,
dermopathy Toxic multinodular goiter ????????
radioiodine ??? nodule ???????? Toxic
adenoma ???????? radioiodine ???
nodule Hashimoto disease (Hashitoxicosis) ??????
?????? TPOAb ???/???? TgAb ?????????? Thyrotropin
producing pituitary tumor ????????????????????????
????, ??????????? T4 ??? ??????????????????
TSH ??????????? Hydatidiform mole ??????????????
??? HCG ???????????
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??????????????????????????????????? ?????????????
???????
???????????????????????????? ????? RAIU
??? Thyroid hormone therapy ???????????
thyroglobulin ??? Thyrotoxicosis factitia
??????????? thyroglobulin ??? Subacute
thyroiditis ???????????????????????????????
??, ????? ESR ??? Lymphocytic
(silent) thyroiditis ???????????????????????
????????????? ????????? TPOAb
Postpartum thyroiditis ????????????????????
???????????????? ????????? TPOAb ??????
6 ???????? ????????????
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???????? 3. ??????????????????????????????????????
?
?????? radioactitive iodine uptake (RAIU) RAUI
??????????? Graves disease Toxic
multinodular goiter Toxic adenoma Hydratidifor
m mole TSH producing tumor Pituitary
resistance ??? thyroid hormone
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RAUI ??? Transient painless thyroiditis subacute
painful thyroiditis Hashimotos
thyroiditis Strum ovarii Thyrotoxic
factitia Iodine induce thyrotoxicosis Funcfioning
metastatic follicular carcinoma
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????????
1. Medication 2. I131 therapy 3.
Surgery Medication - ???????? -
??????????? - ???????????????? Thionamide -
propylthiouracil (PTU) - Methimazole
(MMI)
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Action
1. inh. oxidation ??? iodine ???????????
tyrosine residues ?? thyroglobulin 2. inh.
???????????? MIT, DIT 3. inh. ?????????? T4
???? T3 ??? peripheral tissue 4. ???????
TSI MMI ??? CBZ ????? 3. Dose PTU 150- 300
mg/d MMI 15- 30 mg/d Duration 1 1/2
-2 yrs.
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PTU MMI
- Pregnancy, lactation PTU - Thyroid
crisis PTU - Surgery MMI , PTU rectal
suppository
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???????? 4 ??????????????????????
???????????????????????????????????
PTU MMI
Serum protein binding 75 nil Serum
half-life 75 ???? 4-6 ??????? Volume of
distribution 20 ???? 40 ???? Metabolism of
drug illness Severe liver disease ???? ???? Se
vere kidney disease ???? ????
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PTU MMI
Transplacental passage ???? ??????? Levels in
breast milk ???? ??????? Potency 1 10 Inh
ibition of peripheral - ????? conversion of T4
to T3 All adverse reactions 7.1 3.3 Magor
adverse reactions Agranulocytosis
0.4(idiosyncrasy) 0.1(dose related) Hepatotoxi
city hepatocellular damage cholestasis Vasculiti
s ?????????? ??????????
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SE
rash, itching alopecia, arthralgia,
fever agranulocytosis hepatitis,
thrombocytopenia vasculitis, pneumonitis
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Hypothyroidism
- ?????????????? thyroid H. ?????????? ????? ??
??????, ????????, ?????????, ???????,
??????? ???????????, ????????????????? ?????????
Bradycardia, Slow reflex relaxation coarse
skin dry hoarseness, edema Lab T4
TSH - 1O Hypothyroidism
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????????? 1 Hypothyroidism
O
- ??? iodine - ?????? goitrogen -
Hashimotos thyroiditis - ??????????????
enzyme ?????????? TH ???????? - Na - L -
thyroxine 0.1 - 0.15 mg/d oral form - iodine
supplement
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Multinodular goiter
???? TH, TSH ???? 10-20 yrs. TH ????,
TSH. (autonomous hyperfunction) Toxic
Multinodular goiter Treatment - Surgery -
I131 Therapy
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Solitary Thyroid Nodule
- Benitgn or Malignancy - HX PE - FNA
Biopsy - Other thyroid Scan - cold
nodule - hot nodule ultrasound -
Treatment - FNA - Benign Na-L-thyroxine
Suppressive dose

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Diffuse Euthyroid goiter
?????? 1. Hashimatos thyroiditis 2. Iodine
deficiency 3. ?????? goitrogen 4.
?????????????? enzyme 5. physiologic -
puberty - pregnancy 6.
Idiopathic Diagnosis TH TSH ???? Treatment
Na-L-thyroxine suppressive dose 0.15-2.0
mg/d
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DIFFUSE ENLAEGEMENT OF THYROID GLAND
??????? ???????????
????????????? hyperthyroidism
????????????? hypothyroidism ???? euthyroid
T3 (???? FT3) TSH
T4 (???? FT4) TSH
T3 ??? TSH ???
T4,T3 ???? TSH ????
T4 ??? TSH ???
EUTHYROID GOITER
HYPOTHYROIDISM
HYPERTHYROIDISM
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HYPERTHYROIDISM
Multinodular
Nodule
Diffuse
Hot nodule ???? GRAVES ??????? cold nodule
Toxic multinodular goiter
??????? ????? eye sign ?????????
??????? exophthalmos ???? localized myxedema
?????????????? thyroid nodule
131I uptake
?????
??????
???
GRAVES
Low normal
Thyroiditis (probably Hashimatos
Transient painless thyroiditis
?????
??????????? - blocker

• .

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Thyroid Nodule
solitary
multinodular
FNAB
TFT
cystic
solid or mixed
hyperthyroidism
Euthyroid
Surgery or I131
FNAB
malignant neoplasm
follicular benign
benign
inadequate
repeat FNAB US-FNAB
malignant
suspicious
benign
-L-T4 -observe
scanTSH
benign
Warm/cold
hot
surgery
surgery
Symptom compatible winh malig- nant
No symptom
reaspirate L-T4?
Hyperthyroid (old patient, nodulegt2.5 cm.)
euthyroid (young patient, nodulelt2.5 cm.)
L-T4 or observe
Surgery of I131 Rx
Observe/follow up