Quick Hypothyroidism Cure
In Hashimoto's thyroiditis, which is most frequently seen in middle-aged women, an individual produces auto-antibodies and sensitized TH1 cells specific for thyroid antigens. The DTH response is characterized by an intense infiltration of the thyroid gland by lymphocytes, macrophages, and plasma cells, which form lymphocytic follicles and germinal centers (Figure 20-1). The ensuing inflammatory response causes a goiter, or visible enlargement of the thyroid gland, a physiological response to hypothyroidism. Antibodies are formed to a number of thyroid proteins, including thyroglobulin and thyroid peroxidase, both of which are involved in the uptake of iodine. Binding of the auto-antibodies to these proteins interferes with iodine uptake and leads to decreased production of thyroid hormones (hypothyroidism).
Some clinically important autoantibodies are directed against hormone receptors, for example thyrotoxicosis in Basedow's disease is caused by autoantibodies that stimulate the TSH receptor, and myasthenia gravis is caused by blockage of the acetylcholine receptor by specific autoantibodies. Other antibody-induced diseases mediated by antibodies, directed against hormones and other cellular self antigens, include Hashimoto thyroiditis (induced by anti-thyroglobulin and anti-mitochondrial autoantibodies), pernicious anemia (anti-intrinsic factor), pemphigus vulgaris (anti-desmosome) Guillain-Barre syndrome (ascending paralysis caused by specific myelin auto-antibodies), and scleroderma (involving anti-collagen antibodies). Other immunopathologies involving autoantibodies include transplant rejection as a result of endothelial damage (especially in xenogeneic transplants), and tumor rejection caused by antibodies against tumor-associated antigens present on neoplastic cells (especially...
The next hormones to become deficient are usually the gonadotropins. Prepubertal children have no effects from gonadotropin deficiency, but adults develop oligoamenorrhea, impotence, and or infertility. Deficiencies of TSH, which leads to hypothyroidism, and ACTH, which leads to hypoadrenalism, are less common, even with large tumors. Deficiency of prolactin (PRL) is also uncommon and only presents in the postpartum period as a failure to lactate. Diabetes insipi- The clinical presentation of a patient with hypopituitarism is nonspecific and thus may lead to confusion. Many of the symptoms of hypopituitarism are vague, and patients can be misdiagnosed with chronic fatigue or psychiatric illness before the true diagnosis is known. In addition, symptoms of one hormone deficiency may mask those of another hormone deficiency. For example, weight gain is expected with hypothyroidism and weight loss with hypoadrenalism. If a patient has both TSH and ACTH deficiencies, weight may be...
Carpal tunnel syndrome is produced by compression of the median nerve at the wrist. As the nerve passes through the unyielding carpal tunnel, it is at risk for compression by the transverse carpal ligament. In most patients, no specific etiology can be determined, but thickening and proliferation of the peritendinous synovium is seen. This condition is very common in RA, in diabetes, during or after pregnancy, and after wrist fracture. It is also seen in postmenopausal women and in patients with the myxedema of thyroid disease.
Weight loss chronic cough change in bowel habits night pain or other constitutional symptoms may suggest an underlying
Similar pain or morning stiffness in other areas of the body would increase the suspicion that this represents a more generalized rheumatologic condition (e.g., ankylosing spondylitis, psoriatic arthritis, or endocrine disorder, such as hypothyroidism, hyperthyroidism, or hyperparathyroidism).
2.5 A Radioisotope Used in Medicine The thyroid gland takes up iodine and uses it to make thyroid hormone. A patient suspected of having thyroid disease can be injected with radioactive iodine, which allows the thyroid gland to be visualized by a scanning device. 2.5 A Radioisotope Used in Medicine The thyroid gland takes up iodine and uses it to make thyroid hormone. A patient suspected of having thyroid disease can be injected with radioactive iodine, which allows the thyroid gland to be visualized by a scanning device.
The treatment of HCV-associated lymphomas does not differ substantially from that of idiopathic B-cell NHL (97). However, the occurrence in the same subject of chronic viral infection and cancer and, in some cases, of other HCV-related disorders may be a conditioning factor for an optimal therapeutic strategy (Fig. 3). In all patients with B-cell NHL the detection of HCV-related markers (anti-HCV and HCV RNA) is obviously mandatory, together with histologic classification and staging of the disease. Before the treatment and during the patient's clinical follow-up, in HCV-positive NHL patients should be carefully evaluated for chronic hepatitis, cirrhosis, hepatocellular carcinoma, mixed cryoglobulinemia syndrome, and other HCV-related disorders, such as thyroiditis and glomerulonephritis. To date, there is not sufficient information on specific complications of cancer chemotherapy in HCV-positive NHL. In a series of patients with lymphoplasmocytoid lymphoma immunocytoma, the presence...
As discussed before, the liver converts vitamin D3 to 25-hy-droxy vitamin D3, an essential step before conversion to the active hormone 1,25-hydroxy vitamin D3 in the kidneys. The liver is also a major site of conversion of the thyroid hormone thyroxine (T4) to the biologically more potent hormone triiodothyronine (T3). The regulation of the hepatic T4 to T3 conversion occurs at both the uptake step and the conversion step. Due to the liver's relatively large reserve in converting T4 to T3, hypothyroidism is uncommon in patients with liver disease. In advanced chronic liver disease, however, signs of hypothyroidism may be evident.
Most forms of congenital deafness are caused by genetic factors, but environmental factors may also interfere with normal development of the internal and middle ear. Rubella virus, affecting the embryo in the seventh or eighth week, may cause severe damage to the organ of Corti. It has also been suggested that poliomyelitis, erythroblastosis fetalis, diabetes, hypothyroidism, and toxoplasmosis can cause congenital deafness.
Autoimmune Thyroid Disease Postpartum Thyroiditis Certain diseases affecting the function of the thyroid gland occur when an individual's immune system fails to recognize particular thyroid proteins as self and reacts to the proteins as if they were foreign. This usually triggers both humoral and cellular immune responses. As a result, antibodies to these proteins are generated, which then alter thyroid function. Two common autoimmune diseases with opposite effects on thyroid function are Hashimoto's disease and Graves' disease. In Hashimoto's disease, the thyroid gland is infiltrated by lymphocytes, and elevated levels of antibodies against several components of thyroid tissue (e.g., antithyroid peroxidase and antithyroglobulin antibodies) are found in the serum. The thyroid gland is destroyed, resulting in hypothyroidism. In Graves' disease, stimulatory antibodies to the TSH receptor activate thyroid hormone synthesis, resulting in hyperthyroidism (see text for details). A third,...
For increasing growth (height) with the child's parents or guardians. If the drug is to be given at bedtime and not in the outpatient clinic, the nurse instructs the parents on the proper technique to administer the injections. The parents are encouraged to keep all clinic or office visits. The nurse explains that the child may experience sudden growth and increase in appetite. The nurse instructs the parents to report lack of growth, symptoms of diabetes (eg, increased hunger, increased thirst, or frequent voiding) or symptoms of hypothyroidism (eg, fatigue, dry skin, intolerance to cold).
Thyroiditis A 35-year-old woman is seen in the Endocrine Clinic for evaluation of thyroid disease. The patient complains of weight loss, irritability, and restlessness. Physical examination reveals enlargement of the thyroid gland, weakness in maintaining the leg in an extended position, warm moist skin, and tachycardia. Family history indicates that the patient's mother had hypothyroidism after the birth of the patient's brother and an aunt had Hashimoto's disease. 1. The physical findings, including the presence of goiter, suggest that the patient may be hyperthyroid. However, goiter can also occur in hypothyroidism. Since autoimmune thyroid disease runs in families, the family history suggests that the thyroiditis might be due to an autoimmune response.
The glucocorticoids are administered with caution to patients with renal or hepatic disease, hypothyroidism, ulcerative colitis, diverticulitis, peptic ulcer disease, inflammatory bowel disease, hypertension, osteoporosis, convulsive disorders, or diabetes. The glucocorticoids
Liable than those obtained later in the day. In women, prolactin levels vary with time of menstrual cycle, with the peak at day 12 of the cycle and the nadir during the follicular phase. In addition, the number of live births plays a role in premenopausal women, with prolactin levels varying inversely with parity. In premenopausal women, high intake of saturated fats is associated with elevated prolactin levels (Wang et al. 1992 Wennbo and Tornell 2000). Primary hypothyroidism can also cause hyperprolactine-mia, but values seldom exceed 50 ng mL. The upper limit of normal prolactin levels is 23-25 ng mL in women (obtained at day 3 of the cycle in premenopausal women) and 20 ng mL in men.
Thyroid hormones are used as replacement therapy when the patient is hypothyroid. By supplementing the decreased endogenous thyroid production and secretion with exogenous thyroid hormones, an attempt is made to create a euthyroid (normal thyroid) state. Levothyroxine (Synthroid) is the drug of choice for hypothyroidism because it is relatively inexpensive, requires once-a-day dosages, and has a more uniform potency than do other thyroid hormone replacement drugs. Myxedema is a severe hypothyroidism manifested by lethargy, apathy, memory impairment, emotional changes, slow speech, deep coarse voice, thick dry skin, cold intolerance, slow pulse, constipation, weight gain, and absence of menses. Thyroid hormones are also used in the treatment or prevention of various types of euthyroid goiters (enlargement of the thyroid gland), including thyroid nodules, subacute or chronic lymphocytic thyroiditis (Hashimoto's), and multinodular goiter and in the management of thyroid cancer. The...
Thyroid hormones are administered once a day, early in the morning and preferably before breakfast. An empty stomach increases the absorption of the oral preparation. Levothyroxine (Synthroid) also can be given intravenously and is prepared for administration immediately before use.
Entrapment neuropathy secondary to nerve compression by mechanical or dynamic forces may be a cause of upper extremity pain and weakness in the athlete. Anatomically narrow passages predispose individual nerves to entrapment neuropathies. Dynamic changes within these narrow tunnels during repetitive athletic activity can produce further compression of a nerve with only minimal anatomic variation 1 . Nerve compression may also be produced by space-occupying lesions such as tumors, cysts, inflammatory processes or by post-traumatic conditions such as hematoma, myositis ossificans, and scar formation. Other causes for nerve compression are associated with hormonal alterations and systemic diseases, such as pregnancy, oral contraceptive ingestion, diabetes mellitus, and hypothyroidism.
Excludes congenital hypothyroidism with or without goitre ( E03.0-E03.1 ) dyshormogenetic goitre ( E07.1 ) Pendred's syndrome ( E07.1 ) Transitory neonatal hypothyroidism P72.8 Other specified transitory neonatal endocrine disorders P72.9 Transitory neonatal endocrine disorder, unspecified
From its introduction in 1997, HAART has become the cornerstone of HIV therapy 84 . Lipodystrophy, hyperlipidemia, hypertriglyceridemia, insulin resistance 85 , hyperglycemia, cardiovascular symptoms 86 , and hypothyroidism have been described as long-term side effects of HAART. From
Although many nutritional deficiencies, particularly vitamin deficiencies, have been proven to be teratogenic in laboratory animals, the evidence in humans is sparse. Thus, with the exception of endemic cretinism, which is related to iodine deficiency, no analogies to animal experiments have been discovered. However, the evidence suggests that poor maternal nutrition prior to and during pregnancy contributes to low birth weight and birth defects.
Increased incidence of infections (ear. respiratory) Endocrine (diabetes, hypothyroidism) Orthopedic (atlantoaxial instability, hip dislocation) Dental (delayed missing dentition) Increased risk of leukemia Hearing loss hypothyroidism) Obesity Constipation (hypotonia, hypothyroid, fluid loss) Delayed oral motor skill development Delayed feeding skill development Selective intake
CVID usually becomes manifest in patients between 20 and 30 years of age and only occasionally in childhood. Most patients manifest recurrent infections of the sinopul-monary tract. They are also prone to develop noncaseating granulomas of the skin, gut, and other organs. These patients are predisposed to develop autoimmune disorders such as immune thrombocytopenic purpura (ITP), systemic lupus erythe-matosus (SLE), and thyroiditis.
Thyroid-stimulating hormone (TSH) from the anterior pituitary stimulates the thyroid to secrete thyroxine however, it also exerts a trophic (growth-stimulating) effect on the thyroid. This trophic effect is evident in people who develop an iodine-deficiency (endemic) goiter, or abnormal growth of Figure 11.24 Endemic goiter is caused by insufficient iodine in the diet. A lack of iodine causes hypothyroidism, and the resulting elevation in TSH secretion stimulates the excessive growth of the thyroid. People who have inadequate secretion of thyroid hormones are said to be hypothyroid. As might be predicted from the effects of thyroxine, people who are hypothyroid have an abnormally low basal metabolic rate and experience weight gain and lethargy. A thyroxine deficiency also decreases the ability to adapt to cold stress. Hypothyroidism in adults causes myxedema accumulation of mucoproteins and fluid in subcutaneous connective tissues. Symptoms of this disease include swelling of the...
ISSD is a rare disorder, presenting in the neonatal period with coarse facial features, hepatospleno-megaly, and often ascites or hydrops. Cardiomegaly and heart failure may also be present. The patients usually display generalized hypotonia. The subsequent clinical course is invariably characterized by failure to thrive and grossly delayed development. Most patients have hypopigmented skin and fair hair. Albinoid fundi and optic atrophy may be present. Mild hypertrophy of the tongue and gums may be seen. A nephrotic syndrome may complicate the course of the disease. Spastic tetraparesis develops with increased muscle tone and hyperactive tendon reflexes. Seizures may occur. There are recurrent respiratory tract infections. Hypothyroidism has been reported infrequently. The age at death varies from soon after birth to 5 years of age.
Lid retraction, with widening of the palpable aperture, is obvious when sclcra is visible above and below the iris (Fig. 7.4). It occurs in hyperthyroidism, usually with a lag of Ihe upper lid on looking down (lid-lag) and when the eye is pushed forward (proplosed) by retrobulbar tumours or inflammation. Proptosis is also called exophthalmos. It is common in auto-immune thyroid disease. The periorbital (issues are loose and the lids swell easily. Periorbital oedema occurs commonly in congestive heart failure, glomerulonephritis, hypersensitiviiy reactions and thyroid
Growth and weight gain, activity pattern, psychosocial economic issues, smoking, medical history (celiac disease, nephropathy, hyperllpidemia, eating disorder, high blood pressure, asthma, attention deficit disorder, hypothyroidism, and other autoimmune diseases), insulin regimen, oral glucose-lowering medications, blood glucose monitoring schedule
Of migraine, which contains both an analgesic and an anti-emetic. Similarly, some nonprescribed herbal or alternative remedies contain constituents that cause PRL elevation. Thus, a comprehensive drug history is essential. With regard to pathologic causes of hyperprolactinemia, it is important to exclude primary hypothyroidism. Modest hyperprolactinemia is present in 40 ofpatients, although only 10 have levels 600 mU L (24 g L). Nevertheless, some young women with hypothyroidism may present with menstrual disturbance and galactorrhea, together with few typical hypothyroid symptoms. Once venipuncture stress, pregnancy, interfering drugs, and primary hypothyroidism are excluded, significant hyperprolactinemia is usually associated with a pituitary adenoma (Table 2).
Assessment of baseline pituitary function before Gamma Knife radiosurgery is mandatory to determine the need for any hormone replacement therapy. Because radiation therapy is expected to cause damage to the normal pituitary gland, patients should be evaluated at least every 6 mo for development of secondary hypothyroidism, secondary hypogonadism, secondary adrenal insufficiency, and GH deficiency. Radiation therapy does not usually cause diabetes insipidus (DI), but patients should be asked about excessive urination and thirst. Patients should be educated about the symptoms of hypothyroidism, adrenal insufficiency, and hypogonadism and instructed to return earlier should such symptoms develop. New hormone deficiency or deficiencies are identified by obtaining a thorough clinical history and physical examination and measurement of appropriate hormone concentrations. Fatigue, weight gain, decreased mental alertness, and constipation suggest hypothyroidism. Fatigue, orthostatic symptoms,...
Approximately 99.96 of the thyroxine in the blood is attached to carrier proteins in the plasma the rest is free. Only the free thyroxine and T3 can enter target cells the protein-bound thyroxine serves as a reservoir of this hormone in the blood (this is why it takes a couple of weeks after surgical removal of the thyroid for the symptoms of hypothyroidism to develop). Once the free thyroxine passes into the target cell cytoplasm, it is en-zymatically converted into T3. As previously discussed, it is the T3 rather than T4 that is active within the target cells.
Several other spontaneous autoimmune diseases have been discovered in animals that have served as models for similar human diseases. Among these are Obese-strain chickens, which develop both humoral and cell-mediated reactivity to thyroglobulin resembling that seen in Hashimoto's thyroiditis.
These are rare tumors, representing approx 2 of all pituitary adenomas (28). Typically, the presentation is with features of hyperthyroidism, often a mass lesion is present, and these tumors may cosecrete GH or prolactin (29). Most TSH-secreting adenomas produce an excess of the a-subunit, and an elevated molar ratio of a-subunit to intact TSH is present in the serum. Treatment of TSH-secreting tumors is directed at both correction of hyperthyroidism and therapy for the tumor. Antithyroid drugs are usually indicated before surgery. The initial management should be surgical, but data regarding the usefulness of operation are scanty. Success, defined as normalization of thyroid function, has been reported to be approx 40 (30) therefore, postsurgical follow-up is essential. If TSH a-subunit levels remain elevated, radiation therapy should be considered. Dopamine agonist drugs and somatostatin analogs have also been used, with particularly positive reports after octreotide use (29).
_ Congenital iodine-deficiency syndrome Includes endemic conditions associated with environmental iodine deficiency either directly or as a consequence of maternal iodine deficiency. Some of the conditions have no current hypothyroidism but are the consequence of inadequate thyroid hormone secretion in the developing fetus. Environmental goitrogens may be associated. Excludes subclinical iodine-deficiency hypothyroidism ( E02 ) E00.0 Congenital iodine-deficiency syndrome, neurological type Endemic cretinism, neurological type E00.1 Congenital iodine-deficiency syndrome, myxoedematous type hypothyroid E00.2 Congenital iodine-deficiency syndrome, mixed type E00.9 Congenital iodine-deficiency syndrome, unspecified Congenital iodine-deficiency hypothyroidism NOS Endemic cretinism NOS _ Iodine-deficiency-related thyroid disorders and allied conditions Excludes congenital iodine-deficiency syndrome ( E00.- ) subclinical iodine-deficiency hypothyroidism ( E02 ) E01.0...
Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes constitute the MELAS acronym. The disease shows maternal inheritance with considerable intrafamilial variation in expression of the disease. The age at onset varies between 3 months and 40 years, but in most cases first signs and symptoms occur before adulthood. Early development is normal in the majority of patients. The first manifestations of disease usually belong to the group of general features of encephalomyopathies. Growth disturbance and epileptic seizures are the most frequent first symptoms. The disease is progressive with increasing symptomatology. Learning disabilities, cognitive regression, exercise intolerance, and limb weakness are frequent manifestations of the disease. The myopathic features are rarely very prominent in MELAS. Stroke-like episodes are rarely early signs of the disease but have occurred before the age of 40 years in almost all patients. The stroke-like events give rise...
Certain drugs, such as barbiturates, alcohol, and phe-nothiazines, and certain diseases, such as hypothyroidism, hypopituitarism, congestive heart failure, and septicemia, may impair the defense against cold. (Septicemia, especially in debilitated patients, may be accompanied by hypothermia, instead of the usual febrile response to infection.) Furthermore, newborns and many healthy older adults are less able than older children and younger adults to maintain adequate body temperature in the cold. This failing appears to be due to an impaired ability to conserve body heat by reducing heat loss and to increase metabolic heat production in the cold.
The most commonly recognized endocrine myopathy occurs as a feature of hypothyroidism it may antedate the diagnosis of hypothyroidism by several months. Symptoms and signs of this entity range from mild aches and pains, muscle cramps, and proximal weakness to apparent muscle hypertrophy and the mounding phenomenon, or myoedema (a transient focal ridging of muscle in response to percussing or pinching the muscle). In the usual form, proximal weakness may be observed, although atrophy is rare. 1. Laboratory studies. Serum CK is often markedly elevated. A variety of EMG changes have been noticed, most of which indicate a myopathic process. Muscle biopsy may show focal necrosis, regeneration, and vacuolization of fibers, but findings are usually normal. Fiber size is quite variable. Sarcolemma nuclei are numerous, enlarged, and centrally placed. Mucoprotein deposits occur in one-third of patients. Histochemical staining has shown a decrease in type 2 fibers that...
Radiation of the head for treatment of primary central nervous system (CNS) tumors or brain metastases may cause the gradual onset of hypothalamic-pituitary failure. The most frequent endocrine abnormalities after cranial radiotherapy are hypothyroidism (65 ), hypogonadism (61 ), and mild hyperprolactinemia (50 ). Although the mechanism of radiation damage to the hypothalamus and pituitary gland is not known, it must involve a direct injury to the secreting cells or to the stroma or its microvasculature or damage the vascular channels that transfer the hypothalamic hormones to the pituitary (93).
Deterioration of endocrine function in the elderly is also important.24 Diabetes mellitus predisposes to increased morbidity from cardiovascular and infectious complications. Maintenance of good control in diabetics is critical in preparing them for major surgery and anaesthesia. Hypothyroidism has a prevalence of approximately 10 in the elderly who are hospitalized. The consequence of this in the metabolism of various drugs and responsiveness to surgery needs to be taken into account in planning for a safe perioperative course.
Of thyroid hormone deficiency include heritable diseases that affect certain steps in the biosynthesis of thyroid hormones and hypothalamic or pituitary diseases that interfere with TRH or TSH secretion. Obviously, radioiodine ablation or surgical removal of the thyroid gland also causes thyroid hormone deficiency. Hypothyroidism is the disease state that results from thyroid hormone deficiency. Metabolism is also reduced in thyroid hormone-deficient individuals. Basal metabolic rate is reduced, resulting in impaired body heat production. Vasoconstriction occurs in the skin as a compensatory mechanism to conserve body heat. Heart rate and cardiac output are reduced. Food intake is reduced, and the synthetic and degradative processes of intermediary metabolism are slowed. In severe hypothyroidism, a substance consisting of hyaluronic acid and chondroitin sulfate complexed with protein is deposited in the extracellular spaces of the skin, causing water to accumulate osmotically. This...
Thyroid carcinoma occurs in 1-2 of FAP patients 138 . The relative risk of thyroid cancer has been estimated to be 7.6 (95 CL 2.5-17.7) in FAP 139 compared with the general population. FAP-associat-ed thyroid cancer is typically characterized by female predominance, young age at tumor diagnosis (usually 30 years or below), papillary differentiation, and multifocal involvement 140 . Therefore, several authors have advocated periodic thyroid evaluation in young women with FAP 139,140 . An association between FAP and thyroiditis has also been reported 141 .
Mutations in the gonadotropin subunit genes appear to be extremely rare, perhaps because of their deleterious effects on reproduction (see Table 1 26-39). Probably for the same reason, not a single patient with a germline mutation in the common a-sub-unit gene has been noted. Such mutations would lead to defective hCG, LH, FSH, and TSH function, a condition that would probably be lethal, particularly because of lack of hCG. Nevertheless, a-subunit Knockout mice are viable, though hypogondal and hypothyroid (26), but because this species does not produce chorionic gonadotropin, the gestation regulation may be under differential hormonal control. Only one somatic a-subunit point mutation (Glu56Ala) in the ectopically produced hCG of a carcinoma
Hyponatremia with hypoosmolality can occur in the presence of a decreased, normal, or even increased total body Na+. Hyponatremia and decreased body Na+ content may be seen with increased Na+ loss, such as with vomiting, diarrhea, and diuretic therapy. In these instances, the decrease in ECF volume stimulates thirst and AVP release. More water is ingested, but the kidneys form osmotically concentrated urine and plasma hypoosmolality and hyponatremia result. Hyponatremia and a normal body Na+ content are seen in hypothyroidism, cortisol deficiency, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). SIADH occurs with neurological disease, severe pain, certain drugs (such as hypoglycemic agents), and with some tumors. For example, a bronchogenic tumor may secrete AVP without control by plasma osmolality. The result is renal conservation of water. Hyponatremia and increased total body Na+ are seen in edematous states, such as congestive heart failure, hepatic...
A goiter is an enlarged thyroid gland, which causes a pronounced bulge on the front and sides of the neck. Goiter can be associated with either hyperthyroidism (very high levels of thyroxine) or hypothyroidism (very low levels of thy-roxine). The negative feedback loop whereby thyroxine controls TSH release helps explain how two very different conditions can result in the same symptom, but it is also necessary to understand how the thyroid makes, stores, and releases thyroxine. Hypothyroid goiter results when there is not enough circulating thyroxine to turn off TSH production. The most
Many conditions can be identified at first glance. Some arc very obvious, such as gross obesity others less so. such as the increased arterial ncck pulsation in aortic incompetence or the blue sclera of osteogenesis imperfecta (Fig. 2.1 A). Other examples of 'spot diagnoses' are shown in Figure 2.1B-D. Skills of making these observations can be tested on the general public First impressions are often invaluable. For example, hypothyroidism may be identified on first sight but overlooked by somebody in regular contact with the patient who has failed to appreciate the insidious onset of the changes in voice and facial appearance.
A complete blood count with differential, urinalysis, and tests for ESR, ANA, and RF can help identify an underlying systemic disorder in the initial evaluation. Additional tests should be ordered accordingly. Evaluation for the presence of a hypercoagulable state, cryoglobulins, hypothyroidism, and anti-centromere and anti-topoisomerase antibodies may be necessary. Chest radiography might reveal a bony cervical rib or basal lung fibrosis. Echocardiography is useful for exclusion of thromboemboli or septic emboli, and nerve conduction studies for nerve compression syndromes.
Ticularly and disproportionately in the amount of myelin produced per oligodendrocyte. Thyroid hormone also has an effect on myelinogenesis. Hypothyroidism during early development leads to hy-pomyelination, whereas hyperthyroidism accelerates myelination. Steroids have a complex influence. None of the myelin protein genes is transcriptionally regulated by steroids,but steroids probably act at the post-translational level, stimulating the translation of MBP and PLP mRNAs and inhibiting the translation of CNP mRNA.
These include weight gain and constipation, apathy and forgetfulness, gruffness of voice and cold intolerance. In the elderly, symptoms tend to develop insidiously and may be unrecognised or wrongly attributed to the ageing process. Goitre. Significant enlargement of the thyroid gland (goitre) is common. By definition, the lateral lobes of the thyroid have a volume in excess of the terminal phalanges of the thumbs of the subject. Goitre may be noted by the patient or by relatives and friends, but many subjects are unaware of its presence. The vast majority are asymptomatic. Tenderness may be associated with various forms of thyroiditis and acute pain may occur following bleeding into a thyroid cyst. Dysphagia is rare cxccpt when there is marked swelling of the gland. Its presence suggests a malignant process.
Diseases associated with CPPD include hyperparathyroidism, hemochromatosis, hypophosphatasia, hypomagnesemia, gout, neuropathic arthropathy, and osteoarthritis. The association of CPPD with hypothyroidism is controversial. Diabetes has been shown not to be linked with pseudogout.
Corticotropin is used for diagnostic testing of adreno-cortical function. This drug may also be used for the management of acute exacerbations of multiple sclerosis, non-suppurative thyroiditis, and hypercalcemia associated with cancer. It is also used as an anti-inflammatory and immunosuppressant drug when conventional glucocorti-coid therapy has not been effective (see Display 50-1).
The measurement of serum prolactin is a useful blood test in diagnosing seizure disorders. Prolactin is a polypeptide hormone produced by the anterior pituitary, involved in milk production and endocrine function. Unlike most pituitary hormones, prolactin is under negative hypothalamic control via prolactin inhibiting factor. When seizure activity influences the hypothalamic-pitu-itary axis, prolactin inhibiting factor is presumed to be inhibited itself, and prolactin is released into the circulation. Trimble (105) first showed that serum prolactin rises with generalized epileptic seizures, but not with psy-chogenic seizure-like episodes. Complex partial seizures can also raise serum prolactin. Sensitivity is approximately 90 for tonic-clonic seizures and 70 for complex partial seizures (106). Complex partial seizures originating in the frontal lobes rarely elevate serum pro-lactin (89,90), again emphasizing the difficulty in diagnosis of frontal lobe epilepsy. Several conditions can...
Normal newborn Increased erythropoiesis* Post splenectomy Liver disease1 Obstructive jaundice1 Aplastic anemia Hypothyroidism Megaloblastic anemias Down syndrome Syndromes with elevated Hgb F Disseminated intravascular coagulation (and other MAHA) Postsplenectomy or hyposplenic state Vitamin E deficiency Hypothyroidism
HYPOTHYROID Fig. 2.47 Features of hyper- and hypothyroidism. Tenderness. Diffuse tenderness usually implies thyroiditis localised tenderness may occur following bleeding into a cyst. Vascular bruit. This indicates an abnormally large blood flow and is sometimes associated with a palpable thrill. Increased blood flow occurs in hyperthyroidism, but the use of antithyroid drugs may also increase the vascularity of the gland sufficiently to produce a murmur. A thyroid A14-year-old schoolboy presented with increasing lethargy over the previous 12 months. Over Ihe past 2-3 years, his performance at school has been noted to deteriorate. Or examination he had the characteristic lacia) features ol primary hypothyroidism (Fig, 2.48A), Biood tests confirmed primary hypothyroidism with a normochromic normocyte anaemia (haemoglobin 8 g dl). The facial change disappeared within 6 months of starting treatment with thyroxine (Fig. 2.48B). Because the facial and other features of thyroid disease...
Kearns-Sayre syndrome (KSS) is a rare, sporadic disorder that affects males and females equally. Disease onset is before the age of 20 years. The sequence of manifestations is not constant, but the signs and symptoms in themselves are consistent. Early development is normal. Ptosis and chronic progressive external ophthalmoplegia are usually the initial signs. Apart from progressive external ophthalmoplegia the typical clinical triad includes pigmentary degeneration of the retina and cardiac conduction block. The fine salt-and-pepper type of atypical retinitis pigmentosa is usually associated with good visual function and follows a benign course. Incidentally, choroi-deremia is present instead of pigmentary retinopathy. The most common cardiac conduction blocks are complete atrioventricular block, bundle branch blocks, and fascicular blocks. Other frequently noted signs are short stature due to progressive growth failure, delayed psychomotor development, sensorineur-al hearing loss,...
Each patient with a clinically nonfunctioning pituitary tumor should have a free-T4 level measured. A low free-T4 level indicates the need for l-thyroxine replacement therapy. The goal of therapy is a midnormal free-T4 level. As mentioned, it is not helpful to follow TSH levels. Free T4 should be measured before surgery to provide necessary l-thyroxine replacement before the induction of general anesthesia, because hypothyroid patients may have problems with clearance of anesthetic agents and other postoperative complications. If possible, surgery should be delayed for at least 1 wk. In dire
There are many possible causes for a delay in myelination hypoxia-ischemia, congenital infections, congenital malformations, chromosomal abnormalities, congenital heart failure, postnatal infections, hydrocephalus, hypothyroidism, hypercorti-solism,hypocortisolism, fetal intoxications, malnutrition, and inborn errors of metabolism. The delay is usually bilateral and symmetrical,but unilateral delay is seen in cases with hemimegalencephaly, unilateral porencephalic cysts, cerebral hemiatrophy, or unilateral periventricular leukomalacia.
Measurement of serum prolactin (PRL) is mandatory. This is required to identify hyperprolacinemia attributable to a prolactinoma that usually responds to medical treatment with a dopamine agonist and spares the patient an operation. Thyroid function must also be assessed. It is dangerous to operate on a hypothyroid patient (see next paragraph). Also, rarely, a large pituitary lesion, apparently a tumor, may result from thyrotroph hyperplasia secondary to primary hypothyroidism. The MRI appearances in Fig. 1 were seen in such a case and resolved after thyroid replacement. In pregnancy and during the teenage growth spurt, the gland enlarges and it is quite possible to extend into the suprasellar space and even touch the chiasm. Hypertrophy from other causes also occurs rarely, for instance in primary hypothyroidism (Fig. 1). The gland may also be squeezed up into the suprasel-
Fibrosis, depending on the chronicity of the condition. Several lines of evidence suggest that this process has an autoimmune basis (177-180). First, the cellular infiltrate present in affected glands is similar to other autoimmune reactions occurring in other organs. Antipituitary antibodies have been identified in the serum of some patients with the condition. Finally, patients with lymphocytic hypophysitis frequently have a concurrent or prior history of other autoimmune diseases (Hashimoto's thyroiditis, idiopathic adrenalitis, pancreatitis, and others), thus suggesting that lymphocytic hypophysitis is but one component of a generalized polyglandular autoimmune disorder.
Occur (e.g., headaches, seizures, altered personality, cranial nerve palsies, symptoms related to the deficiencies of other pituitary hormones, and hydrocephalus). With long-standing hypogonadism, the testes are usually soft but of normal size and the semen analysis frequently reveals low semen volume, oligospermia, or azoospermia (14-16). Most men with hyperprolactinemia have low-normal serum levels of LH, testosterone, and DHT, and low-frequency and low-amplitude spontaneous LH secretory episodes (17), together with a normal increase in serum LH levels after GnRH administration (10). The identification of high PRL levels is the beginning of the diagnostic process however, hyperprolactinemia should be correctly identified and other causes should be excluded. PRL levels in patients with PRL-secreting adenomas are usually higher than 100 ng ml and are proportional to the size of the tumor. Lower values may be associated with drugs, pituitary stalk compression, renal failure, cirrhosis,...
Iodine daily requirement derives from vegetable, rice or fish. For some people living in the most impoverished areas in high altitude or far from the sea this in not possible. Iodine once present in the soil has long since leached away, causing catastrophic effects for public health. Iodine deficiency can lead to neurological disorders, deafness, psychomotor retardation, brain damage, mental defi ciency, and retarded growth. In Tibet raw salt is freely available in salt lakes, but it is the main cause of the nation's high level of retarded growth, goitre, and neurological impairments, because it is non-iodised salt. The Australia's Overseas Aid Program has provided over 2 million to support the elimination of iodine deficiency in Tibet, distributing iodised oil capsules to vulnerable groups'' (Focus-AusAID 2006, p. 11).
Brown algae also produce a number of other useful substances. Many seaweeds, but particularly kelps, build up concentrations of iodine to as much as 20,000 times that of the surrounding seawater. Although it is cheaper to obtain iodine from other sources in North America, dried kelp has been used in the treatment of goiter, which results from iodine deficiency, in other parts of the world. Kelps are relatively high in
Many members of the Ephedra family have been used medicinally (ie, E. sinica and E. intermedia). Ephedra preparations have traditionally been used to relieve cold symptoms, improve respiratory function, as an adjunct in weight loss, and to treat a variety of conditions from headaches to sexually transmitted disease. Large doses may cause a variety of adverse reactions, such as hypertension, irregular heart rate, tremors, epigastric pain, nausea, vomiting, sweating, weakness, and possible dependence. Ephedra is contraindicated in patients with hypertension, glaucoma, hypertrophy of the prostate, urinary tract problems, clotting disorders, anxiety, anorexia, colitis, thyroid disease, or diabetes. Ephedra should not be used with the cardiac glycosides, halothane, guanethi-dine, MAOIs, oxytocin, and in patients taking St. John's wort. Weight loss preparations containing ephedra should be avoided.
Because thyroid hormone affects the growth and function of many tissues, a deficiency of this hormone in infancy causes physical and mental retardation as well as other symptoms that together constitute congenital hypothyroidism, formerly called cretinism. In the adult, thyroid deficiency causes myxedema, in which there is weight gain, lethargy, rough, dry skin, and facial swelling. Both of these conditions are easily treated with thyroid hormone. Most U.S. states now require testing of newborns for hypothyroidism. If not diagnosed at birth, hypothyroidism will lead to mental retardation within 6 months. The most common form of hyperthyroidism is Graves disease, also called diffuse toxic goiter. This is an autoimmune disorder in which antibodies stimulate an increased production of thyroid hormone. There is weight loss, irritability, hand tremor, and rapid heart rate (tachycardia). A most distinctive sign is a bulging of the eyeballs, termed exophthalmos, caused by swelling of the...
Hypothyroidism Enlargement of the thyroid gland. May be toxic or nontoxic. Simple (nontoxic) goiter is caused by iodine deficiency. A condition caused by hypothyroidism in an adult. There is dry, waxy swelling most notable in the face. A chronic thyroiditis of autoimmune origin
Galactorrhoea is characterised by a milky discharge from multiple ducts in both breasts and is a feature of hyperprolactinaeinia. There is usually associated Montgomery tubercle hyperplasia. Spontaneous milk production is uncommon and often galactorrhoea is found only by trying to express milk. The causes of hyperprolactinaeinia include physiological processes (pregnancy, postpartum), drugs (dopamine antagonists, dopamine-depleting agents), pituitary tumours, hypothalamic and stalk lesions, primary hypothyroidism and renal failure.
Stain with fluorescein and look for an ulcer - diffuse staining may be related to exposure secondary to thyroid disease. 1. An afferent pupillary defect (see p. 7) may indicate optic nerve compression secondary to thyroid disease. 1. Fundal appearance is usually normal although small folds in the retina can occasionally be seen in thyroid disease.
In 1958, Nelson and colleagues (110) reported the rapid enlargement of ACTH-secreting pituitary adenomas after bilateral adrenalectomy. Historically, these patients develop hyperpigmentation by excessive ACTH elevation (the ACTH molecule contains a-MSH) and radiologic demonstration of pituitary enlargement (129). Although the incidence of Nelson's syndrome has been reported to be as high as 38 in patients with CD who underwent bilateral adrenalectomy (109,130133), it is encountered only rarely these days, because bilateral adrenalectomy is now reserved for patients who did not respond to pituitary surgery and or radiotherapy. Because many ACTH-secreting pituitary adenomas respond to CRH stimulation, it is conceivable that, in analogy to some patients with severe hypothyroidism (TSH 100 U mL, TRH elevation unknown) and subsequent pituitary enlargement, in patients after bilateral adrenalectomy the CRH stimulus causes enlargement of some but not all ACTH-secreting adenomas, with a...
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