Cure Hypothyroidism Forever

The Hypothyroidism Revolution

During Phase 1 of the Hypothyroidism Revolution Program, the magic begins to happen as you begin to notice many positive changes occurring. You will begin your progressive transition towards the ideal thyroid healing diet that will give your thyroid the big boost that it needs to help your cells produce more than enough energy for you. By the end of Phase 1, your energy levels will be rapidly on the rise and you will feel amazingly satisfied with zero food cravings. You will feel in control again as your mood drastically improves and any sign of depression and anxiety begin to disappear. Your family and friends are going to notice some major positive changes in you. You will also begin to experience many of the outer changes that come with improved thyroid function. Youre skin will begin to clear up and glow while your hair and nails will begin to look healthy again. As you ease into the thyroid healing diet, you will progressively remove the foods that suppress your thyroid, disrupt your hormone pathways, cause digestive upset and irritation, and cause toxic byproducts that congest your liver. At the same time, you will be progressively adding the foods that will be supplying your cells with the right balance and combination of nutrients that they need to thrive and produce endless amounts of energy. Read more...

The Hypothyroidism Revolution Summary


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Hypothyroidism and Weight Loss

Weight loss is uncommon in hypothyroidism, although appetite is usually reduced. Most patients manifest a gain in weight due to retention of fluid by hydrophilic glycoprotein deposits in the tissues. The effect of hypothyroidism on energy metabolism is opposite to that of hyperthyroidism and is characterised by a general decrease of energy metabolism and heat production. This is reflected in a reduced BMR, decreased appetite, cold intolerance, and slightly lower basal body temperature 18 . Some cases of weight loss associated with hypothyroidism have been reported, most frequently in elderly patients. In these cases, weight loss can also be induced by malabsorption 18,24 or hypothalamic or pituitary insufficiency in the case of central hypothyroidism. In these cases, the hyposecretion of TSH is accompanied by a decrease in the secretion of other pituitary hormones, with combined gonadal and corticoid insufficiency.

Nodular Thyroid Disease

Thyroid nodules, both solitary and multiple, are common and are often found incidentally on physical examination, ultrasonography, or computed tomography. They are more prevalent in women and increase in frequency with age. Although their pathogenesis is not clear, nodules are known to be associated with iodine deficiency, higher gravidity, and the ingestion of goitrogens. Further work-up of identified nodules is indicated, as the incidence of malignancy in solitary nodules is estimated at 5-6 . The incidence of malignancy is higher in children, adults younger than 30 or older than 60 years, and patients with a history of head or neck irradiation. Other historical risk factors include a family history of thyroid cancer, the presence of cervical lym-phadenopathy, and the recent development of hoarseness of the voice, progressive dysphagia, or shortness of breath. 15.2 Primary hypothyroidism is generally treated using 15.41 When the diagnosis of primary hypothyroidism is made in a...

Levothyroxine for hypothyroidism

The main indication for levothyroxine is treatment of deficiency (cretinism, and adult hypothyroidism) from any cause. The adult requirement of hormone is remarkably constant, and dosage does not usually have to be altered once the optimum is found. Patients should be monitored at annual intervals. Monitoring needs to be more frequent in children, who may need more as they grow. Similarly, pregnant women should be monitored monthly, and require 50-100 increase in their normal dose of levothyroxine. Early treatment of neonatal hypothyroidism (cretinism) (1 5000 births) is important if permanent mental defect is to be avoided. It must be lifelong. Hypothyroidism due to panhypopituitarism requires replacement with adrenocortical as well as with thyroid hormones. Use of levothyroxine alone can cause acute adrenal insufficiency.

Treatment of hypothyroidism

Hypothyroid patients tend to be intolerant of drugs in general owing to delayed metabolism. Liothyronine Tabs. Liothyronine is the most rapidly effective thyroid hormone, a single dose giving maximum effect within 24 h and passing off over 24 48 h. It is not used in routine treatment of hypothyroidism because its rapid onset of effect can induce heart failure. Its main uses are in myxoedema coma and psychosis, both rare conditions. A specialised use is during the withdrawal of levothyroxine replacement (to permit diagnostic radioiodine scanning) in patients with thyroid carcinoma. Myxoedema coma follows prolonged total hormone deficiency and constitutes an emergency. Intravenous therapy is mandatory because of impaired absorption of drugs in this condition. Liothyronine 5-20 micrograms is given every 12 hours. Hydrocortisone i.v. is also needed, as prolonged hypothyroidism may be associated with adrenocortical insufficiency. Subclinical hypothyroidism. This term refers to patients...

And Autoimmune Thyroiditis

This chapter describes four murine models of autoimmune diseases two related to autoimmune myocarditis and two related to autoimmune thyroiditis. The first model, Coxsackie virus B3 (CB3)-induced myocarditis, results in the development of acute myocarditis in susceptible as well as resistant mouse strains, whereas chronic myocarditis develops only in genetically susceptible mice. CB3-induced myocarditis closely resembles the course of human myocarditis, which is believed to be initiated by viral infection. Mouse cardiac myosin heavy chain has been identified as the major antigen associated with the late chronic phase of viral myocarditis. The second model is cardiac myosin-induced experimental autoimmune myocarditis (EAM) and, in a modification, cardiac a-myosin heavy chain peptide-induced myocarditis. In the EAM model, cardiac myosin or the relevant peptide in Freund's complete adjuvant (FCA)is injected subcutaneously into mice. The immune response, the histological changes, and the...


Patients with hypothyroidism can present with a wide range of symptoms, including lethargy, weight gain, hair loss, dry skin, slowed mentation or for-getfulness, constipation, intolerance to cold, and a depressed affect. In older patients, hypothyroidism can be confused with Alzheimer disease and other conditions that cause dementia. In women, it is often confused with depression. Physical findings that can present in hypothyroid patients include low blood pressure, bradycardia, nonpitting edema, hair thinning or loss, dry skin, and a diminished relaxation phase of reflexes. Several different conditions can cause hypothyroidism. The most common noniatrogenic condition causing hypothyroidism in the United States is Hashimoto thyroiditis, an autoimmune thyroiditis. Iatrogenic causes include post-Graves disease thyroid ablation and surgical removal of the thyroid gland. Another cause is secondary hypothyroidism related to hypothalamic or pituitary dysfunction. These conditions are...

Late Effects In Survivors

As noted earlier, patients who survive the first five years after HCT are likely to survive long-term with mortality rates eventually approaching that of the general population (5). However, some survivors experience late complications of HCT. Baker et al. (67) studied the long-term risks and benefits of HCT for CML. Two hundred forty-eight recipient of HCT for CML who had survived at least two years post-HCT were compared to 317 normal siblings. Subjects completed a 238-item survey on medical late effects. When compared with sibling controls, survivors had higher risks of ocular, oral health, endocrine, gastrointestinal, musculo-skeletal, neurosensory, and neuromotor impairments. Multivariate analysis of the allograft recipients identified chronic GVHD as a major risk factor for hypothyroid-ism, osteoporosis, cardiopulmonary, neurosensory, and neuromotor impairments. These data show the need for continued monitoring and medical intervention in these patients. The CIBMTR and EBMT...

CD4CD25 Regulatory T Cells

That using the 'S-word' became a certain way of having one's paper rejected. However, during the mid-1990s this slowly began to change when Sakaguchi and co-workers described a subset of immunosuppressive T cells capable of preventing autoimmune disease in mice. These cells were characterized by the expression of CD4 and CD25, the interleukin-2 (IL-2) receptor a chain 10 . Rather than calling them suppressor T cells, these cells are now referred to as CD4+CD25+ regulatory T cells (Tregs). When stimulated in vitro, the CD4+CD25+ Tregs were found to be anergic and suppressive 11 . In vivo depletion of this subset by day-3 thymectomy resulted in the spontaneous development of organ-specific autoimmunity such as gastritis and thyroiditis, and reconstitution of the mice with CD4+CD25+ Tregs prevented disease 10, 12, 13 . Since then, many groups have investigated the presence and function of these cells in both rodents and humans, and this is accompanied by a steep increase in the number of...

Thymic Generation of CD4CD25 Regulatory T Cells

Sakaguchi and co-workers demonstrated that CD4+CD25+ regulatory T cells could be detected in the thymus as well as in peripheral lymphoid organs 10, 12, 13 . Thymectomy on day 3 led to the spontaneous development of organ-specific autoimmunity such as gastritis and thyroiditis however, thymectomy at day 0 or day 7 did not result in disease. This was explained either by a lack of peripheral CD4+CD25- effector T cells at day 0, or by sufficient influx of suppressive CD4+CD25+ T cells into the periphery at day 7. Importantly, reconstitution of the mice with CD4+CD25+ Tregs from either the thymus or peripheral lymphoid organs such as spleen or lymph nodes prevented disease 10, 12, 13 . These data demonstrated that CD4+CD25+ Tregs can be found in both the thymus and the periphery. Furthermore, these studies provided evidence for thymic generation but did not exclude the possibility that CD4+CD25+ Tregs can be generated in the periphery. A later study by the same group showed that CD4+CD25+...

Comprehension Questions

Hashimoto thyroiditis 12.4 A 35-year-old woman who was diagnosed with hypothyroidism 4 weeks ago presents to your office complaining of persistent feelings of fatigue and sluggishness. After confirming your diagnosis with a measurement of the TSH. you started her on levothyroxine 50 jjg daily. She has been reading about her diagnosis on the Internet and wants to try desiccated thyroid extract instead of the medicine you gave her. On examination, she weighs 175 lb. her heart rate is 64 bpm at rest, and her blood pressure is normal. What is the best next step

Clinical Approach

Amenorrhea can ensue for 2 to 3 months after a term delivery breast-feeding may inhibit hypothalamic function and lead to a greater duration of amenorrhea. However, in a nonlactating woman in whom menses does not resume by 12 weeks after delivery, then pathology must be suspected. Overall, the most common cause of amenorrhea in the reproductive years is pregnancy. Hence, a pregnancy test is the appropriate initial test. If the patient does not have a history of postpartum hemorrhage, pursuit of hypothalamic causes, such as hypothyroidism or hyperprolactinemia, often is fruitful. If the patient is somewhat obese or has a history of irregular cycles, then a diagnosis of polycystic ovarian syndrome (PCOS) would be entertained. Findings consistent with PCOS include a positive progestin withdrawal bleed (vaginal bleeding after ingestion of a progestin, such as medroxyprogesterone acetate or Provera). PCOS is characterized by estrogen excess without progesterone, obesity, hirsutism, and...

Thyroid Disorders Thyrotoxicosis

Thyrotoxicosis factitia Chronic thyroiditis Subacute thyroiditis Celiac disease may occur more frequently in patients with autoimmune thyroid disease and represents an associated cause of malabsorption and weight loss 24 . Recent evidence suggests that the association between autoimmune thyroid diseases and celiac disease is quite similar to that between diabetes mellitus type 1 and celiac disease 24 . In an earlier series, about 5 of patients with celiac disease were found to suffer from hyper- or hypothyroidism even though the percentages are highly variable, with clinical hyperthyroidism in celiac disease ranging from 0 up to 7 in different studies 24 . Moreover, gastric achlorydria and autoantibodies against gastric parietal cells are detectable in about one-third of patients with Graves' disease 18,24 . Hepatic dysfunction also occurs, particularly when TS is severe hypoproteinaemia and increase of AST and ALP may be present 18 .

TABLE 524 Thyroid Enlargement and Function

A diffusely enlarged gland includes the isthmus and the lateral lobes, but there are no discretely palpable nodules. Causes include Graves' disease, Hashimoto's thyroiditis, and endemic goiter (related to iodine deficiency, now uncommon in the United States). Sporadic goiter refers to an enlarged gland with no apparent cause.

Toxicities of radioimmunotherapy

The major complications of radioimmunotherapy are infusional reactions during the administration of the cold antibody, especially the rituximab, and myelo-suppression that occurs around 7-9 weeks after therapy. Febrile neutropenia or infections that require hospitalization are uncommon events. There is little in the way of alopecia, nausea, vomiting, or mucositis. Because of the radioactive iodine, I-131 tositumomab therapy is associated with hypothyroidism in fewer than 10 of patients.

Extranodal Marginal Zone Lymphoma Of Malt

Autoimmune processes Helicobacter pylori gastritis, Hashimoto's thyroiditis, and Sj gren syndrome.8 Sequence analysis of the immunoglobulin genes expressed by the MALT lymphoma B cells shows a pattern of somatic hypermutation and intraclonal variation, suggesting that the tumor cell has undergone antigen selection in germinal centers and that they continue to be at least partially driven by direct antigen stimulation.9-12

Creatine kinase myocardial band

CK-MB 27 served us well for many years, and facile assays exist that are reasonably sensitive. The percentage of CK-MB depleted from the heart that ends up in the blood, however, is modest (15 in the absence of reperfusion and 30 with reperfusion), limiting its sensitivity compared with troponin. In addition, because there is CK-MB in skeletal muscle, individuals have a circulating constitutive level and CK-MB elevations can be diagnosed only when that broad normal range is exceeded. This further limits sensitivity, but it also has implications for specificity. Elevations can occur as a result of skeletal muscle damage in patients with renal failure and abnormalities in clearance associated with hypothyroidism. In addition, re-expression of the B-chain gene in skeletal muscle when damage to muscle occurs can increase the percentage of CK-MB and confound diagnosis. The use of the relative index, which relies on the percentage of CK-MB with respect to total CK, improves specificity, but...

Causes Of Hyponatremia

Hypothyroidism the free water excretion is impaired (urine not maximally concentrated, 150-200 mOsm kg). If the urine is maximally dilute, it is handling free water normally but its capacity for excretion has been overwhelmed, as in central polydipsia. More commonly, free water excretion is impaired and the urine is not maximally dilute as it should be. Two important diagnoses must be considered at this point hypothyroidism and adrenal insufficiency. Thyroid hormone and Cortisol both are permissive for free water excretion, so their deficiency causes water retention. Isolated Cortisol deficiency can mimic SIADH. In contrast, patients with Addison disease also lack aldosterone, so they have impaired ability to retain sodium. Patients with adrenal insufficiency are usually hypovolemic and often present in shock. B. Hypothyroidism

The Autoreactive Repertoire Is An Important Component Of The Normal Bcell Repertoire

In 1956, Witebsky and Rose 9 induced for the first time, an experimental autoimmune disease mediated by autoantibodies autoimmune thyroiditis. They succeeded in inducing the disease by injecting thyroglob-ulin in the presence of Freund's adjuvant. Since they were able to produce autoantibodies, the precursor B cells producing these should exist. More recently, considerable data have accumulated raising doubts concerning the clonal deletion theory as an unique explanation for tolerance since (1) autoimmune diseases can be induced by injecting organ extracts 9 (2) numerous autoantibodies have been demonstrated under normal conditions 10-12 and (3) autoantibodies have been induced from normal B lymphocytes upon mitogenic stimulation 13, 14 ,

CD137 and Regulatory T Cells Treg

Consistent to these findings, Morris et al., also found that CD137 signaling interferes with CD4+CD25+ Treg-mediated tolerance in an experimental autoimmune thyroiditis (EAT) mouse model (Morris et al., 2003). In vivo depletion of CD25+ cells could abrogate established tolerance, indicating that CD4+CD25+ Treg cells are essential for the tolerance induction. Administration of CD137 mAb inhibited the tolerance induction and interfered with the established tolerance to EAT. In vitro CD137 signals also inhibited the suppression of mouse thyroglobulin-specific T cell proliferation by CD4+CD25+ Treg cells. In addition, CD137 stimulation did not increase Treg cells to proliferate. Thus, the authors suggested that signaling through CD137 on the autoreactive T cells directly overcomes suppression by CD4+CD25+ Treg cells.

Endocrinologically Silent Pituitary Adenomas

Hormonally inactive pituitary tumors (up to one third of all pituitary tumors) can with growth and displacement of surrounding tissues result in a hormonal deficit, hypopituitarism with a loss of gonadal function (often the first clinical sign) and hypothyroidism, weakness of the muscles, loss of body hair or with symptoms of hypothalamic disease, including diabetes insipidus, and disorders of sleep, body temperature, and poor motivation.

Nonhodgkin Lymphoma Eatl Enteropathyassociated Tcell Lymphoma

Coeliac patients have a higher incidence of non-Hodgkin's lymphoma than that of the general population 7, 34-39 , Malignancy develops in 8-13 of patients. EATL is slightly more frequent in males and has its peak in the sixth decade of life. An interesting recent finding shows that the incidence of lymphoma in CD diagnosed in elderly patients (over 60 years) was much higher (23 ) than that in younger population (8 ). Moreover, other autoimmune diseases, dermatitis herpetiformis and autoimmune thyroiditis, were common in this group of patients 10 . The relationship between EATL and CD is underlined by the finding of the CD associated DQA1 0501, DQB1 0201 phenotype in EATL patients.

Thyroid And Gonadal Dysfunction

Subclinical and clinical thyroid disease is common after treatment of HL. In a series of 151 patients, 26 cases of subclinical, 12 cases of manifest clinical hypothyroidism, and 2 cases of hyperthyroidism were documented.14 Thyroid dysfunction was more frequent in patients who underwent mantle or neck radiotherapy. Hypothyroidism was often revealed after the sixth year of follow-up. A high incidence of thy-roiditis was also reported in this group of patients. Annual monitoring of thyroid function should be incorporated in follow-up patients with HL, particularly in those treated with radiation involving neck.

The Team Approach

Neonatal thyroxine levels are generally elevated at birth when compared to adults, such as 11.8 to 22.6 g dL for ages 1 to 3 days, due to maternal estrogen-induced thyroid-binding globulin (TBG) levels. The medical decision limit for detecting neonatal hypothyroidism is less than 7.5 g dL.5 However, synthesis of thyroid hormones require adequate intake of proteins, so the thyroid screen should occur after adequate feedings. In preterm infants, thyroxine level is also lower and tends to rise up to typical reference ranges when term birth weight is reached. Thy-roxine levels gradually decline to the adult reference range by age 10, with some fluctuations in the values at onset of puberty. Free thyroxine is generally near adult levels but generally is tested only after repeat thyroxine levels and TSH are determined to be abnormal.

Cigarettesmoking Transition From Immunity To Autoimmunity

The breakdown of immune surveillance is considered as the initiator of autoimmunity development. The exact mechanisms contributing to this process have not been defined, yet it appears that they are not limited to a single arm of the immune system. Polyclonal T-cell activation has been suggested to play an important role in occurrence of autoimmune disease 32 , Accordingly, cancer patients treated with high doses of IL-2, a T-cell stimulator, are more prone to the development of autoimmune thyroiditis or anti-red blood cell autoantibodies 33 . By analogy, thymectomized mice develop autoimmune disease following stimula

Mhc Class Ii Expression On Autoimmune And Malignant Thyroid Cells

Many investigators have used the thyroid gland as a model for research of autoimmune processes. Autoimmune thyroid diseases are the archetype of organ specific autoimmune disorders, and shares with them T-cell dependency as a common characteristic. Inappropriate MHC class II expression has been first observed on thyroid cells derived from patients with Graves' autoimmune thyroid disease 40 , and lead to the hypothesis that such expression would result in antigen presentation of thyroid autoantigens to T cells, thereby starting an autoimmune response 41 . Expression of MHC class II molecules was found to be common also on malignant thyroid cells 42 , and has been recently suggested to represent local antitumor response, which prevents metastatic spread of the malignant cells 43 . We and others have shown that T and inflammatory cell products, such as IFN-Y alone or synergistically with TNF-a, induced class II expression on normal and malignant thyrocyte cell lines derived from patients...

Diagnostic Confirmation Of Metastatic

As TSH is the best stimulus for Tg production a baseline Tg level should be obtained just prior to 13'i scanning when the patient is hypothyroid following total thyroidectomy. Thyroglobulin levels may then be monitored routinely at regular intervals in patients who have undergone total thyroidectomy or checked when recurrent or metastatic disease is suspected clinically. Rising Tg levels are suggestive of recurrent or metastatic disease and 13'i scanning should then be performed (21,22). Tg measurement has

Guide To Further Reading

Cooper D S 2001 Subclinical hypothyroidism New Lindsay R S, Toft A D 1997 Hypothyroidism. Lancet 349 413-417 Mandel S J et al 1990 Increased need for thyroxine during pregnancy in women with primary hypothyroidism. New England Journal of Medicine 323 91-96 Pashke R, Ludgate M 1997 The thyrotropin receptor in thyroid diseases. New England Journal of Medicine 337 1675-1681 Surks M I, Sievert R 1995 Drug therapy drugs and thyroid function. New England Journal of Medicine 333 1688-1694 Toft A D 1994 Thyroxine therapy. New England

Hypothalamus and anterior pituitary

Is a tripeptide formed in the hypothalamus and controlled by free plasma T4, T3 concentration. It has been synthesised and can be used in diagnosis to test the capacity of the pituitary to release thyroid stimulating hormone (TSH), e.g. to determine whether hypothyroidism is due to primary thyroid gland failure or is secondary to pituitary disease or to a hypothalamic lesion. TRH is also a potent prolactin-releasing factor. Antithyroid drugs, by reducing thyroid hormone production, cause increased formation of TSH which is the cause of the thyroid enlargement that sometimes occurs during antithyroid drug therapy. GHRH and somatostatin both regulate growth hormone secretion. Prolactin is secreted by the lactotroph cells of the anterior pituitary gland. Its control is by tonic hypothalamic inhibition through prolactin inhibitory factor (PIF), probably dopamine, opposed by a prolactin releasing factor (PRF) in both women and men and, despite its name, it influences numerous biological...

Interferon And Autoimmunity

Given the possible effects of interferons on the immune system it is perhaps not surprising that autoimmune disorders have been reported as a consequence of interferon-a therapy. For example, autoimmune haemolytic anaemia, autoimmune thyroid disorders and thrombocytopenic purpura have all been described 18 . Interferon-a therapy is also associated with autoantibody production including antibodies to nuclear antigens 19 , thyroid antigens and epithelial cells. Ronnblom et al. 20 described a patient with a malignant carcinoid tumour who developed SLE during interferon-a therapy. Interestingly, this patient had a further course of interferon-a therapy which resulted in the recurrence of anti-DNA antibodies and clinical evidence of active lupus. This report stimulated the authors to prospectively study 135 patients with malignant carcinoid tumours treated with interferon-a and they found 25 patients who developed clinical evidence of autoimmune disorders 18 . This included 18 patients...

Signs and Symptoms of Pituitary Tumors

A primary deficit of a pituitary end organ's hormonal production (e.g., primary hypothyroidism) could cause a secondary swelling of the pituitary gland of sufficient size to make contact with the chiasm. In such cases, simple replacement of the missing hormone will lead to a reversal of the syndrome.

Definition and Diagnosis

Cachectic heart-failure patients are weaker and fatigue earlier, which is due to both reduced skeletal muscle mass and impaired muscle quality. A simple and fast applicable definition of 'clinical cardiac cachexia' is the following in CHF patients without signs of other primary cachectic states (e.g. cancer, thyroid disease, or severe liver disease), cardiac cachexia can be diagnosed when weight loss of 6 of the previous normal weight is observed over a period of 6 months 4 . The previous normal weight of a heart-failure patient would be the average weight prior to the onset of heart disease (before the diagnosis). It is important to document dry weight loss measured in a non-oedematous state to prove the diagnosis.

Approach To Diabetes Mellitus Definitions

Glycosylated hemoglobin or hemoglobin A c (HGA c) is not recommended for diagnosis. This test is used to estimate the average glucose over the past 3 months in those who are diagnosed with diabetes. Measurement of C-peptide and insulin levels can be used to distinguish type 2 from type 1 diabetes when the history, physical examination, and other tests, such as serum ketones and osmolality, are not enough. Other tests recommended by the American Diabetes Association are fasting lipid profiles (at the time of diagnosis and. at least, annually thereafter), serum creatinine, urinalysis, urine microalbuminxreatinine ratios (at time of diagnosis in type 2 diabetics and annually thereafter in type 1 diabetics who have had disease for 5 years and annually thereafter), annual dilated eye examinations, regular foot examinations, EKG (in adults), and, in type 1 diabetics. thyroid disease screening with a thyroid-stimulating hormone (TSH).

Approach To Hirsutism

The appearance and cosmetic changes associated with hirsutism depend on the number of follicles present, ratio of growth to resting phases, asynchrony of growth cycles, and thickness and degree of pigmentation of individual hairs. The history should focus on the onset and duration of symptoms (faster growth is associated with tumors of adrenal and ovary, whereas slow onset since menarche more likely is PCOS). The severity of symptoms should be characterized (e.g., virilization is rare and usually is associated with androgen-secreting tumors). The regularity of the menses and symptoms of thyroid disease should be sought. Physical examination should focus on the location of hair growth and its severity, thyromegaly. body shape and habitus, presence of breast discharge, skin changes (acanthosis or abdominal striae), adnexal or abdominal masses, and external genitalia. Helpful laboratory tests include assays for serum testosterone, DHEA-S, 17-hydroxyprogesterone (which is elevated with...

Testing For Thyroid Disorders

The American Thyroid Association recommends a testing decision pathway for thyroid disorders in adult patients. Total thyroxine hormone levels should not be assessed in healthy or asymptomatic patients. In other words, total thyroxine level should not be used as a screening test to investigate for thyroid disease. If signs and symptoms of thyroid disorder are clear, the first laboratory test that should be ordered is TSH.37 If the results are abnormal compared to age- and gender-adjusted reference ranges, thyroid disease is likely present. For example, if TSH is less than 0.1 U mL in the adult, primary hyperthyroidism is most likely present.5 Free T4 (or free T4 index) can be analyzed if TSH results do not correlate with symptoms. However, due to the severe consequences of untreated thyroid disease in the neonate, particularly hypothyroidism, asymptomatic neonates are typically screened for T4 (total thyroxine) and followed up with TSH testing if abnormal results are obtained.

Dimension of the Nutritional Problem in the World

Severely Undernourished People

Superimposed upon the energy intake spectrum is the global problem of micronutrient malnutrition. Iron deficiency anaemia affects approximately 1.5 billion people, mostly women and children. Iodine deficiency disorders affect about 740 million people worldwide. Vitamin A deficiency-

The Spectrum of Malnutrition

Nearly 30 of humanity - infants, children, adolescents, adults and older persons in the developing world - are currently suffering from one or more of the multiple forms of malnutrition. This remains a continuing travesty of the recognised fundamental human right to adequate food and nutrition, and freedom from hunger and malnutrition, particularly in a world that has both the resources and knowledge to end this catastrophe. The tragic consequences of malnutrition include death, disability, stunted mental and physical growth and as a result, retarded national socioeconomic development. Some 49 of the 10.7 million deaths each year among children aged under 5 in the developing world are associated with malnutrition. Iron-deficiency anaemia affects 2 billion people, especially women and children. Iodine deficiency is the greatest single preventable cause of brain damage and mental retardation worldwide 740 million are affected. PEM affects 150 million children aged under 5. Intrauterine...

Investigating the pathogenesis of problematic hypoglycaemia

Pathogenesis Nsclc

It is important to avoid carrying out hypoglycaemia studies on people with ischaemic heart disease, epilepsy, hypertension, untreated hypothyroidism, hypoadrenalism or unstable diabetic retinopathy. It is crucial not to carry out studies on women of childbearing age if radioisotopes or potentially teratogenic or fetotoxic drugs are to be used, because of the potential risk to any future fetus.

Approach To Diseases Of The Breast Palpable Breast Mass

Galactorrhea is an inappropriate discharge of breast milk or milky fluid. It is not associated with breast cancer. Galactorrhea may be associated with hypothyroidism. hyperprolactinemia, or the use of certain medications (contraceptives, phenothiazines. others). Offending medications should be discontinued, if possible. Prolactin and thyroid-stimulating hormone levels should be drawn to evaluate for endocrine abnormalities. Imaging of the pituitary with a head computed tomography (CT) scan or magnetic resonance imaging (MRI) is indicated if the prolactin level is elevated, to evaluate for a pituitary adenoma.

Ghb With Synthetic Glycogen For Cancerous Cells

Half-life (t1 2), of drugs, 506 Hallucinogens, 528 Haptens, 131 Haptoglobin, 21, 253t Hartnup disease, 553t Hashimoto's thyroiditis, 402, 410t hCG. See Human chorionic gonadotropin (hCG) hormones of, 389t, 438 Hypothyroidism, in neonates, 398-399, 402, 403 463-464 Leucine, diagnostic use of, 553t Levey-Jennings chart, 56, 56f, 58, 59f Levothyroxine, for hypothyroidism, 402 Leydig cells, 442

TABLE 1712 Diagnostic Facies in Infancy and Childhood

Fetal Alcohol Syndrome Congenital Syphilis Congenital Hypothyroidism Facial Nerve Palsy The child with congenital hypothyroidism (cretinism) has coarse facial features, a low-set hair line, sparse eyebrows, and an enlarged tongue. Associated features include a hoarse cry, umbilical hernia, dry and cold extremities, myxedema, mottled skin, and mental retardation. It is important to note that the majority of infants with congenital hypothyroidism have no physical stigmata this has led to screening of all newborns in the United States and in most other developed countries, for depressed thyroxin or elevated thyroid-stimulating hormone levels.

Antitumor Immunity And Autoimmune Disease

Further evidence to the coexistence of antitumor immunity and autoreactivity was brought about through observations by Rosenberg and coworkers that in patients with metastatic melanoma who were treated with high-dose interleukin-(IL)-2 immunotherapy, vitiligo, which is a manifestation of normal melanocyte destruction, developed in 15 of those patients who showed significant tumor regression, whereas none of the patients who did not receive the treatment developed vitiligo 103 . Furthermore, autoimmune-related thyroiditis was also observed to associate with an antitumor response in melanoma patients given IL-2, with the incidence of hypothyroidism positively correlating with a favorable antitumor response. 104 , Studies aiming at defining the molecular targets of antimelanoma cytotoxic T lymphocytes showed that those CTLs recognized a series of HLA class-I-restricted antigenic peptides having self-sequences 105 . These findings suggested the existence of a mechanism, shared by...

The Many Functions Of Atpdependent Chromatin Remodelling Factors

SNF5 (INI1), a core subunit of SWI SNF is inactivated in malignant rhabdoid tumours, a highly aggressive cancer of early childhood (reviewed in Roberts and Orkin, 2004). Specific mutations in the mammalian SWI2 SNF2 homologue BRG1 have been identified in pancreatic, breast, lung and prostrate cancer cell lines (Wong et al., 2000). SWI SNF also directly interacts with tumour suppressors and proto-oncogenes such as RB, BRCA1, c-Myc and MLL (Bochar et al., 2000 Cheng et al., 1999 Dunaief et al., 1994 Nie et al., 2003). However, the mechanisms by which the remodelling complex contributes to tumour suppression are yet to be fully understood. Mutations in other ATP-dependent chromatin remodelling factors have been linked to disease, such as in ATR-X, causing X-linked mental retardation syndromes. The phenotypes include facial dysmorphism, urogenital defects, and alpha-thalassaemia (resulting from reduced alpha-globin expression (Xue et al., 2003 and references...

Autoimmune Manifestations Of Viral Hepatitis

Chronic viral hepatitis, both type B (3) and type C, has been associated with a spectrum of autoimmune phenomena. McMurray and Elbourne (4) summarized many of the reported autoimmune complications of HCV hepatitis (Table 1). Some of these HCV-related entities, such as membranous glomerulonephritis (GN) (5), cryoglobulinemia, and associated vasculitis (6-9), tend to improve following successful treatment and viral eradication. Among HBV-associated autoimmune phenomena, the HBV-related proteinuria (10) and polyarteritis nodosa (11-16) usually improve, following successful IFN antiviral therapy. Nevertheless, the opposite may also occur Worsening of cryoglobulinemic neuropathy and fatal bleeding secondary to vasculitic gastritis occurred when IFN-a was given to a hepatitis C patient with highly symptomatic cryoglobulinemia (17), in whom steroids had not been tried before IFN. It is not clear whether corticosteroids should be started before, or along with, IFN in the patient with...

Approach To Dementia Alzheimer Disease

Treatable, a screening test for depression should be performed when dementia is evaluated. Similarly, hypothyroidism and vitamin B,, deficiency are common and treatable conditions that can cause cognitive problems. Thyroid-stimulating hormone (TSH) and vitamin Bp levels should be performed as a routine part of the work-up. Neurosyphilis could present in this fashion, but is such an uncommon diagnosis that routine screening would not be recommended. Evaluation for neurosyphilis would be warranted if there were identified high-risk factors, history of the disease, or if the patient lived in an area with a high prevalence of syphilis. Neuroimaging with either a noncontrast CT scan or an MRI of the brain is recommended to rule out other confounding diagnoses. Other testing, such as positron emission tomography (PET), genetic testing, and spinal fluid analysis are not routinely recommended. prescription and over-the-counter medications can cause memory disturbances. Chief among these are...

Balancing the risk and Benefits of RT in adolescent and young adult Patients

Spinal RT (CrSp) in this group are considerable, and include secondary hypothyroidism, growth hormone deficiency, and in girls, either precocious puberty or incomplete pubertal development, as well as risking infertility from irradiation of the hypothalamus, pituitary, and ovaries. Irradiation to the vertebrae will result in failure of these bones to grow during the adolescent growth spurt, causing loss of up to 5 cm in height this is unresponsive to growth hormone therapy.

Suppression of Autoimmune Disease by Regulatory Cells from Donors with or Without the Relevant SelfAg

In view of differential suppression of autoimmune prostatitis (AIP) and autoimmune thyroiditis by T cells from Ag-positive vs Ag-negative cell donors (described below), how do we explain their equal suppression of AOD Our interpretation is that even if the regulatory capacities of male and female CD4+CD25+ T cells for AOD suppression are different, they are equalized when the cells encounter the endogenous ovarian Ag in the young d3tx host. Indeed, we have shown that ovarian Ags (mater and ZP3) are expressed from birth and have the capacity to stimulate T cells on day 3 (Alard et al. 2001). This is also exemplified by the process of diversified autoAb response that depends on de novo B cell response to endogenous ovarian Ag. Immunized female mice with a ZP3 peptide that contains T but not native B epitope (in CFA) elicited Ab response to a distant native ZP3 B cell epitope within 7 days, 2 days after detectable response to the ZP3 T cell epitope (Lou et al. 1996). Other examples of...

Treatment of intercurrent illness

Viral infections contracted during steroid therapy can be overwhelming because the immune response of the body may be largely suppressed. This is particularly relevant to immunosuppressed patients exposed to varicella herpes zoster virus, which may cause fulminant illness they may need passive protection with varicella zoster immunoglobulin, VZIG, as soon as practicable. Continuous use of prednisolone 20 mg day (or the equivalent) is immunosuppressive. But a corticosteroid may sometimes be useful in therapy after the disease has begun (thyroiditis, encephalitis) and there has been time for the immune response to occur. It then acts by suppressing unwanted effects of immune responses and excessive inflammatory reaction. Vomiting requires parenteral administration. In the event of surgery being added to that of adrenal steroid therapy the patient should receive hydrocortisone 100-200 mg i.m. or i.v. with premedication. If there is any sign suggestive that the patient may collapse, e.g....

Clinical features

Chromophobe adenoma is the commonest pituitary tumour. As it enlarges it expands the pituitary fossa (sella turcica) and this may be demonstrated radiologically. Compression of the optic chiasma produces the very rapid typical bitemporal hemianopia (see 'The optic nerve', pages 365 and 366). The tumour itself is non-secretory and gradually destroys the normally functioning gland. The patient develops hypopituitarism with loss of sex characteristics, hypothyroidism and hypoadrenalism. In childhood there is an arrest of growth. As the tumour extends there may be involvement of the hypothalamus with diabetes insipidus and obesity.

Adverse effects on reproduction

Directly (thalidomide, cytotoxic drugs, antithyroid drugs, aromatic retinoids, e.g. isotretinoin) any drug affecting cell division, enzymes, protein synthesis or DNA synthesis, is a potential teratogen, e.g. many antimicrobials. Late pregnancy. Because the important organs are already formed, drugs will not cause the gross anatomical defects that can occur when they are given in early pregnancy. Administration of hormones, androgens or progestogens, can cause fetal mascu-linisation iodide and antithyroid drugs in high dose can cause fetal goitre, as can lithium tetracyclines can interfere with tooth and bone development, angiotensin-converting enzyme inhibitors are associated with renal tubular dysgenesis and a skull ossification defect. Tobacco smoking retards fetal growth it does not cause anatomical abnormalities in man as far as is known.

Other Conditions That Increase Natriuretic Peptides

Concentrations of BNP and NT-proBNP may be elevated in settings other than acute heart failure. Such increases do not represent analytic false positives but may cause false positive clinical diagnostic results, if other etiologies for abnormal BNP results are not considered. Disease processes other than heart failure (e.g., renal and thyroid function) have been shown to influence the concentration of natriuretic peptides (37). As an example, hyperthyroidism increases and hypothyroidism decreases natriuretic peptide concentrations (38). Renal impairment has been shown to increase NT-proBNP concentrations substantially and BNP to a lesser extent (39,40). In severe renal impairment (glomerular filtration rate of

Causes Of Cancers In

In another study, 19 of 135 patients with malignant carcinoid, developed autoimmune diseases including autoimmune thyroid disease, SLE, pernicious anemia and vasculitis 59 , The data indicate that interferon therapy may trigger the development of autoimmunity and should not be used in patients with clinical and laboratory features suggesting autoimmune diseases.

Therapeutic Challenges

131I tositumomab is a radioimmunoconjugate comprising a murine anti-CD20 MoAb covalently linked through tyrosine amino acids in the immunoglobulin protein to iodine-131. Tositumomab does not require a linker due to direct covalent bonding between the MoAb and the radionuclide. 131I is more readily available than 90Y and is relatively inexpensive. However, 131I emits both p- and 7-irradiation, necessitating special radiation precautions for patients receiving this compound. Dehalogenation (cleaving of the radionuclide from the compound) can occur as well this results in potential uptake of free iodine by the thyroid and stomach. Oral thyroid blockade is recommended beginning 24 h before therapy and continuing for 14 days in order to prevent iodine uptake and subsequent hypothyroidism.47 The rate of dehalogenation varies significantly among patients, resulting in fluctuating rates of urinary clearance. Thus, dosimetry calculations incorporating total-body distribution and tissue uptake...

The Antigen Specificity of Naturally Arising TR

The presence of the corresponding organ, as adoptive transfer of T cells from male mice were more effective at preventing neonatal thymectomy-induced autoimmune prostatitis than oophoritis, and vice versa for T cells from female mice (Taguchi et al. 1994). Studies from Mason's group extended this observation by demonstrating that ablation of the thyroid gland resulted in the selective functional loss of T cells within the CD4+ population capable of preventing radiation-induced autoimmune thyroiditis, but not diabetes (Seddon and Mason 1999). Curiously, thyroid ablation did not result in the loss of protective thymic CD4+ T cells. Although the CD4+ T cell population was not fractionated in these studies to ensure that the suppressing cells were indeed CD25+ TR, these data support the hypothesis that tissue-specific antigen recognition by TR is necessary for their survival, development, and or expansion in the periphery, as the tissue-protective CD4+ T cell population is functionally...

Positive Autoantibodies but Without Symptoms of Autoimmune Disorders

The report by Okanoue et al. (28), which followed 677 patients with chronic hepatitis C virus during therapy, found that autoimmune side effects were more frequent among those individuals who had pre-existing autoantibodies. Of 24 patients with pretreatment antimicrosomal antibodies, for example, four individuals (16 ) developed hypothyroidism during therapy, compared to 2 653 (0.32 ) without antimicrosomal antibodies, who developed this problem. Likewise, Custro et al. (29) found that HCV patients with pretreatment thyroid autoantibodies (antimicrosomal thyroid peroxidase and antithyroglobulin antibodies) were 3x more likely to develop hypothyroidism during therapy than HCV patients who were seronegative. Bell et al. (30) studied a group of patients with HCV hepatitis, including 20 patients who had one or more pre-existing autoantibody, and 20 patients without any pre-existing autoantibodies. During treatment with IFN-a, 6 20 patients (30 ) with autoantibodies developed new...

Clinical Correlation

Coronary artery disease, increased cholesterol concentration may be the result of hypothyroidism, liver disease, renal disease, or diabetes. Decreased cholesterol concentration may be the result of hyperthyroidism, digestive malabsorption, or impaired liver function. Factors that increase HDL-C include increased estrogen in women, increased exercise, and the effects of certain blood pressure medicines. Factors that decrease HDL-C include increased progesterone, obesity, smoking, and diabetes. Increased triacylglycerol may be the result of pancreatitis, diabetes mellitus, acute alcohol consumption, or certain liver diseases. In addition, triacylglycerol may be increased artifactually in nonfasting blood samples.


Hypothyroidism Headache, bitemporal hemianopsia, galactorrhea, medications. hypothyroidism place hypothyroidism at the top of the list. Because of the lack of headaches or visual field changes, a prolactinoma is less likely however, a prolactin level that is very high would direct investigation toward this entity, given the history of galactorrhea. In the workup of secondary amenorrhea, these two diagnoses are the easiest to start with because the tests are minimally invasive and relatively inexpensive, and the treatment is straightforward. Hypothyroidism is defined as the insufficient production of thyroid hormone. Secondary hypothyroidism as a result of dysfunction of hypothalamic and pituitary hormone secretion are much less common but should be suspected in a patient with a history suggestive of Sheehan syndrome or with symptoms or signs of a tumor in the region of the sella. Ninety-five percent of cases of hypothyroidism are caused by primary thyroid gland failure, resulting in...


Iodine deficiency is one of the most common nutritional deficiencies. Worldwide, it is estimated that nearly 1 billion people are at risk of iodine deficiency disorders (IDD).1 Iodine deficiency, both in utero and during early childhood, can impair mental development and is the most prevalent cause of preventable


Two proteins identified in the survey, termed ALMS1 and OFD1, have previously been identified genetically as being linked to human diseases. In particular, the C-terminal half of ALMS1 was localized to the centrosome by tagging 21 and, independently, antibodies to OFD1 have been shown to decorate the centrosome 31 . Both proteins need further investigation to confirm their association with the cen-trosome but their identification as candidate centrosome components is intriguing. The diseases caused by defects in these genes are relatively rare and poorly understood. Patients with Alstrom syndrome (ALMS1) display a complex set of symptoms. Childhood obesity starts at the early age of 6 months and many patients develop type 2 diabetes. The disease is also associated with neurosensory defects and subsets of patients show dilated cardiomyopathy, hepatic dysfunction, hypothyroidism, male hypogonadism, short stature and mild developmental delay 32, 33 . The symptoms of oral-facial-digital...


Include degenerative neurological illnesses (e.g. Parkinson and Huntington diseases), stroke, metabolic conditions (e.g. vitamin B12 deficiency), endocrine conditions (e.g. hyper- and hypothyroidism, hyper- and hypoadrenocorticism), autoimmune conditions (e.g. systemic lupus erythematosus), viral or other infections (e.g. hepatitis, mononucleosis, human immunodeficiency virus), and certain cancers (e.g. carcinoma of the pancreas). The associated physical examination findings, laboratory findings, and pattern of prevalence or onset reflect the aetiolog-ical general medical condition, the management of which is more complex and the prognosis less favourable if major depressive disorder is present.

Animal Models

Finally, hyperthyroidism is associated with sinus tachycardia, and several laboratories have investigated the regulation of HCN subunits by thyroid hormone. Pachucki and colleagues identified a thyroid hormone consensus site in the HCN2 promoter and demonstrated that thyroid hormone administration to hypothyroid rats increased HCN2 message levels (Pachucki et al. 1999). Another group also found a correlation between whole-heart HCN2 message level and thyroid state, as well as HCN4 level, but when they studied atrial tissue, only HCN2 levels decreased with hypothyroidism (Gloss et al. 2001). This same study also reported that knocking out one of two isoforms of the thyroid hormone receptor in the mouse heart resulted in sinus bradycardia and reduced message levels of HCN2 and HCN4.


The differential diagnosis of depression includes many other psychiatric and medical disorders. The psychiatric disorders include dysthymic disorder, bereavement, and bipolar disorder. Numerous medical conditions can cause depressive symptoms. Common among these are hypothyroidism and anemia. The role of pharmacologic agents and substance use. abuse, or dependence also should be investigated, as these can cause significant mood changes. This is especially true of alcohol, sedatives, narcotics, and cocaine.

Thyroid Dysfunction

Thyroid dysfunction is a common occurrence in patients receiving IFN, with an incidence of 3-5 in patients treated for HCV (31-33), but higher incidences associated with therapy of malignancy. Both the dosage and duration of therapy with IFN are associated with an increased incidence of thyroid problems (34). Patients with antithyroglobulin or antithyroid peroxidase antibodies, prior to the start of IFN therapy, are at the highest risk of developing thyroid disease (35,36). These antibodies are present in 16 of U.S. women and 1.5-3 of U.S. males, and are also the characteristic autoantibodies seen in Hashimoto's thyroiditis (35). IFN causes an autoimmune destructive thyroiditis, which causes proteolysis and release of thyroid hormones, resulting in a clinically mild thyrotoxic state. As the gland is depleted of thyroid hormones, the persistent inflammation prevents further uptake of iodine and synthesis of thyroxine, resulting in hypothyroidism. Therefore, the commonest clinical...

Growth Hormone

Neonatal Hypothyroidism Repeat Thyroid Testing on a Baby ROLE OF ENDOCRINE GLANDS IN THYROID FUNCTION Thyroid-Stimulating Hormone Pituitary Hormone Thyroid Hormone Metabolism Hypothyroidism Case Scenario 11-5. Graves Disease The Woman With Prominent Eyeballs TESTING FOR THYROID DISORDERS Thyroid Function Testing

Laboratory Features

Endocrine abnormalities were found in two-thirds of our patients at presentation. Hypogonadism was the most common abnormality, and 71 of males had erectile dysfunction. Twenty-four of 28 patients who had serum testosterone levels measured had a reduction. Gynecomastia was found in 17 men. Prolactin levels were not increased. Hypothyroidism was found in 14 of patients. An additional 12 had a mild increase in the thyroid-stimulating hormone level but had normal thyroxin levels. Abnormalities of the adrenal-pituitary axis were present in 16 . In five additional patients, adrenal insufficiency developed during follow-up.


Other diseases that are important to consider in the perimenopausal woman include hypothyroidism, diabetes mellitus, hypertension, and breast cancer. Women in this stage of life may also experience depression, whether spontaneous in onset or situational due to grief or midlife adjustments. The practitioner should advocate aerobic exercise at least three times per week, with weight-bearing exercise advantageous for preventing osteoporosis. Bone mineral density (BMD) testing, such as dual-energy x-ray absoiptiomelry (DEXA), is useful in the early identification of osteoporosis and osteopenia. 4.21 F. Both hypothyroidism and hyperprolactinemia may cause hypothalamic dysfunction, which inhibits gonadotropin-releasing hormone pulsations, which in turn inhibit pituitary FSH and LH release. The lack of gonadotropins leads to hypoestrogenic amenorrhea.


Protein have both been proposed as important genes in brain development. Crystalline a is linked to both a dominant and recessive form of cataract. Interferon-a and p, w receptors 1 and 2, 7 receptor 2 (integrin p-2), and an autoimmune regulator responsible for autoimmune polyglandular disease are all also found on chromosome 21. How might these genes interact to bring about immune suppression or the excess of thyroid disease seen in DS The answers are not yet available in the literature.

Immunomodulation Of

Roubata et al. 18 have described the protective immunity against experimental autoimmune thyroiditis induced by a thyroglobulin (Tg)-specific cytotoxic T cell clone and showed that this down-regulation occurred through the generation of anti-Id antibodies (Ab2 Beta) which recognized the paratope of anti-Tg mAb (Abl) specific to the pathogenic epitope of the Tg molecule 18 . Protection from experimental allergic encephalomyelitis (in Lewis rats) was conferred by a monoclonal antibody directed against a shared idio-type on rat T cell receptors specific for myelin basic protein (MBP) 75 ,

Thyroid Hormone

BMD at the distal and 8-mm sites on the radius was measured with SPA (Nuclear Data ND 1100A) in 78 postmenopausal women who had been on thyroid hormone replacement for a minimum of 5 years (165). The average age of the women was 64 years. Hypothyroidism in these women was initially caused by idiopathic hypothyroidism or primary autoimmune hypothyroidism. Forty-four of these women had persistently suppressed thyroid stimulating hormone (TSH) values, whereas 34 did not. One hundred two women served as controls. The women with nonsuppressed TSH values had z-scores at the 8-mm and distal radial sites of -0.07 and -0.03, whereas the women with suppressed TSH had z-scores of -0.25 and -0.20, respectively. The differences between the three groups were not statistically significant. The authors estimated that a suppressed TSH was associated with at most a 5 decrease in BMD. Affinito et al. (166) also measured BMD at the distal radius in a study of 54 postmenopausal women with primary...

Radioiodine 131i

In hyperthyroidism the beneficial effects of a single dose may be felt in one month, and patients should be reviewed at 6 weeks to monitor for onset of hypothyroidism. The maximal effect of radioiodine may take 3 months, -adrenoceptor blockade and, in severe cases, an antithyroid drug (but see footnote 1) will be needed to render the patient comfortable whilst waiting this is more likely when radioiodine is used for treatment of patients with relapsing thyrotoxicosis. Very rarely radiation thyroiditis causes excessive release of hormone and thyroid storm. Repeated doses are sometimes needed. In the first year after treatment 20 of patients will become hypothyroid. After this 5 of patients become hypothyroid annually, perhaps because the capacity of thyroid cells to divide is permanently abolished so that cell renewal ceases. Patients must therefore be followed up indefinitely after radioiodine treatment, for most are likely to need treatment for hypothyroidism eventually. Because such...

Thyroid storm

Encies or operations, radiation thyroiditis, toxaemia of pregnancy or parturition. Treatment is urgently required to save life. The cause may be related to an immunoglobulin that attacks the external ocular muscles and retrobulbar tissue. Antithyroid drugs do not help. TSH secretion is not responsible (it is high in primary thyroid gland failure in which exophthalmos rarely occurs). The patient should be rendered euthyroid. Mild to moderate cases regress spontaneously. Artificial tears (hypromellose) are useful when natural tears and blinking are inadequate to maintain corneal lubrication. In severe cases, high systemic doses of prednisolone, alone or in combination with another immunosuppressive (azathioprine) may help. A course of low-dose orbital radiation achieves rapid regression of ophthalmopathy, and may take the place of prolonged immunosuppressant treatment. In urgent cases orbital decompression by surgery is necessary.


Treatment of thyroiditis (Hashimoto's thyroiditis, subacute thyroiditis of de Quervain). Where hyperthyroidism is a feature, treatment is by a adrenoceptor blocking drug. Antithyroid drugs should not be used. Where there is permanent hypothyroidism, the treatment is thyroid hormone replacement. Hypothyroidism is readily treated by oral administration of levothyroxine 50 200 micrograms daily.This needs to be continued indefinitely. The treatment of hyperthyroidism due to Graves' disease is either I 2 months treatment with cafbimazole or propylthiouracil or a single diagnosis of ' 'I.These drugs do not have a place in the 5 10 of patients in whom thyrotoxicosis is due to a toxic adenoma or to subacute thyroiditis. The natural history of Graves' disease is of alternating emission and relapse. Progression to hypothyroidism can occur, especially after fill treatment. Such patients should have long-term follow-up. and are likely to require thyroid hormone replacement therapy.

Ets2 208

Experimental allergic encephalomyelitis (EAE) 338, 339 Experimental autoimmune encephalomyelitis 366 Experimental autoimmune myasthenia gravis (EAMG) 370 Experimental autoimmune thyroiditis 373 Experimental autoimmune uveoretinitis (EAU) 370 Extramammary Paget's disease 125 Hashimoto thyroiditis (HT) 312, 319 Hashimoto's thyroiditis 5


Principle 131i Treat Hyperthyroidism

This patient has symptoms and signs consistent with hyperthyroidism, including warm, moist skin caused by excessive sweating and cutaneous vasodilation a resting tremor an enlarged thyroid gland weight loss and tachycardia. Her irregular heart beat may be a manifestation of atrial fibrillation, which occurs in approximately 10 of hyperthyroid patients. Eye abnormalities are common in hyperthyroid states. Retraction of the upper lid, resulting in the thyroid stare is common. Graves disease has a unique ophthalmopathy that may cause a prominent exophthalmos (Fig. 15-1). The most common cause of noniatrogenic hyperthyroidism is Graves disease, an autoimmune thyroid disorder. Autoantibodies to the TSH receptors on the thyroid gland result in hyperfunctioning of the gland, with the result that the thyroid gland functions outside the usual control of the hypothalamic-pituitary axis. Graves disease commonly occurs in reproductive-age females and is much more common in women than men. The...

Cd And Autoimmunity

(2) Associated autoimmune diseases It has been reported that insulin-dependent diabetes mellitus (IDDM) occurs in 1-10 of adult coeliac patients and the prevalence of CD in patients with IDDM has been 2-7 . Similarly, 2-4 of coeliacs suffer from autoimmune thyroid disease and serological screening for CD in patients with autoimmune thyroid disease gives a coeliac prevalence of approximately 4 . The association between Sjogren's syndrome and CD was recently shown 3-5 of adult coeliac patients had Sjdgren's syndrome and 14 of patients with Sjogren's syndrome had CD 1,13 .

Clinical Pearl

Any illnesses such as hypertension, hepatitis, diabetes mellitus, cancer, heart disease, pulmonary disease, and thyroid disease should be elicited. If an existing or prior diagnosis is not obvious, it is useful to ask exactly how it was diagnosed that is, what investigations were performed. Duration, severity, and therapies should be included.


Thyroid disorders occur more frequently in women than in men, occurring in up to 10 of all women. Tests for levels of TSH, free thyroxine, and free triiodothy-ronine are need by clinicians to make the diagnosis. Generally, high TSH values suggest primary hypothyroidism, while suppressed levels indicate primary hyper-thyroidism. Signs and symptoms of hyperthyroidism include goiter (enlarged thyroid gland), optic changes including exophthalmos, proximal muscle weakness, tachycardia, atrial fibrillation, hyperthermia, and weight loss or inability to gain weight. Among women, the most common etiology of thyroid disease is thyroid autoimmunity, with Graves' disease more common than Hashimoto's thyroiditis. Other causes of primary hyperthyroidism include thyroid adenoma, toxic multinodular goiter, and thyroid carcinoma. Table 11-8 summarizes the typical laboratory findings in thyroid diseases.


Each state requires screening of all newborns for specified congenital diseases however, the specific diseases for which screening is done vary from state to state. All states require testing for phenylketonuria (PKU) and congenital hypothyroidism, as early treatment can prevent the development of profound mental retardation. Diseases for which testing commonly occurs include hemoglobinopathies (including sickle cell disease), galactosemia, and other inborn errors of metabolism. This screening is done by collecting blood from newborns prior to discharge from the hospital. In some states, newborn screening is repeated at the first routine well visit, usually at about 2 weeks of age.

Chd Risk Factors

One should exclude a secondary cause of lipid disorder, either by clinical or laboratory evaluation. Underlying disorders include diabetes, hypothyroidism, obstructive liver disease, chronic renal failure nephrotic syndrome, and medication side effects (progestins, anabolic steroids, corticosteroids). High cholesterol levels in young patients in the absence of secondary causes suggest familial hypercholesterolemia, a condition caused by defective or absent LDL surface receptors and subsequent inability to metabolize LDL particles. Homozygotes for this condition may develop atherosclerotic disease in childhood and usually require intensive lipid-lowering drug therapy.


Women with medical conditions such as diabetes, asthma, thyroid disease, hypertension, lupus, thromboembolism, seizures should be referred to providers with experience in managing high risk pregnancies. Women with psychiatric disorders should be comanaged with a psychiatrist and counselor therapist so that the patient can benefit from pharmacologic and behavioral therapy. These patients may require more frequent visits. Patients who have drug, tobacco, or alcohol dependence should be educated about the risks and referred to rehab treatment centers to quit the drug prior to conception. Women should also be educated about proper nutrition and exercise during pregnancy. Preconception counseling may also address issues such as financial readiness, social support during pregnancy and the postpartum period, and issues of domestic violence.

Longterm Followup

(Table 14.5) would be to follow the patients monthly during the first year, every 2 to 3 months during the second and third years, and then at least every 6 months during the next 3 years. At 6 years and thereafter, patients can be monitored annually with history and physical examination, complete blood count with differential, and careful attention for second malignancies, heart failure, sterility, avascular necrosis, and hypothyroidism all potential sequelae of therapy. Assessment of minimal residual disease should preferably be associated with clinical trials.

Graves Disease

A history of prior problems with hyper- or hypothyroidism may suggest an acquired restrictive mechanism, and if Graves' disease has been active in the past, there should be some evidence of proptosis, conjunctival erythema, che-mosis, or lid retraction. Forced duction testing (see above) will demonstrate restriction of movement, the intraocular pressure will rise with attempts to move the eye into the restricted field of gaze, and CT MRI ultrasound testing will confirm the presence of rectus muscle thickening (see Chap. 9).


Following total or completion thyroidectomy (if the initial surgery entailed only a lobectomy), the patient is rendered hypothyroid with plans to administer RAI therapy 4-6 weeks later. This treatment is based upon studies in adults that demonstrate a lower recurrence rate and subsequent lower cancer-related mortality rate in patients treated with 131I 51 . Although RAI therapy in low-risk patients is controversial, it is generally recommended that all patients less than 15 years who have been treated surgically for PTC or FTC receive additional therapy with 131I, both to ablate the normal thyroid gland remnant (hence making long-term follow up easier) and to treat any remaining thyroid cancer or metastases 52 . Although short-term triiodothyronine therapy (Cytomel 1-2 p,g kg day divided twice daily to three times daily) is used frequently in adolescents and young adults, younger children are often quite tolerant of hypothyroidism. Therefore, it is also reasonable to give no thyroid...

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