Most Effective Hypothyroidism Treatment
Autoimmune thyroid diseases are characterized by the presence of autoantibodies to multiple thyroid antigens 1 including thyroglobulin (TG), thyroid peroxidase (TPO), and the TSHR. As mentioned above, these proteins play essential roles in the production of thyroid hormone. With respect to specific diseases, Over 90 and 80 of patients with GD have anti-TSHR and anti-TPO autoantibodies, respectively, while over 90 of patients with HT have anti-TPO and or anti-TG autoantibodies. Unlike anti-TSHR antibodies, anti-TPO and anti-TG antibodies do not play a significant role in the pathogenesis of either HT or GD. However, they are helpful in the differential diagnosis and may serve as predictors of ensuing thyroiditis. The Whickam study, an extensive population-based study, showed that after a 20-year follow-up, the odds ratio (with 95 confidence) of developing thyroiditis in individuals with thyroid autoantibodies and elevated TSH but normal free T4 was 38 (22-65) for men and 173 (81-370)...
Hypothyroidism may be primary, or secondary Autoimmune thyroiditis is the commonest primary cause, whilst the sequelae of surgical or radioiodine treatment of thyroid disease are also common. Deficiency of circulating thyroid hormone results in retardation of all body functions. After successful treatment, both TSH and T4 levels should be normal. Replacement therapy must be cautious so as not to precipitate myocardial ischaemia or heart failure. In severe, untreated hypothyroidism, elective surgery must be postponed. If emergency surgery has to be undertaken, the mortality is high. Since thyroxine is an inotropic agent and a vasodilator, its routine use in cardiac surgery in patients without thyroid disease has been suggested. However, there is no evidence to show that it is of benefit (Bennett-Guerrero et al 1997).
Thyroid disease is associated with changes in the skin, which may sometimes be the first clinical signs. There may be evidence of the effect of altered concentrations of thyroxine on the skin, with changes in texture and hair growth. Associated increases in thyroid stimulating hormone concentration may lead to pretibial myxoedema. In autoimmune thyroid disease vitiligo and other autoimmune conditions may be present.
Thyroiditis, pemphigus vulgaris and bullous pemphigoid. Noteworthy, some of these disorders are exclusively mediated by circulating autoantibodies such as the hemolytic anemias, thrombocytopenia, pemphigus, and pemphigoid while others, such as allergic autoimmune encephalomyelitis and autoimmune thyroiditis require the transfer of immunocompetent cells in addition to auto-antibodies.
Persistent thyroglossal duct anomalies. In some patients, the epithelium of the thyroglossal cyst may persist as a fistula or a blind-ended cyst usually located above the thyroid cartilage. Thy-roglossal duct cysts, however, may present as midline structures from the base of the tongue to the suprasternal notch. Excision of the fistula or cyst should include resection of the midsection of the hyoid bone to avoid recurrence (Sistrunk operation). About 1 of thyroglossal duct cysts contain a focus of papillary thyroid cancer and about 25 of these patients have thyroid cancer elsewhere in the thyroid gland. The thyroid may also fail to descend and may result in a sublingual thyroid gland. Some patients with sublingual thyroids are hypothyroid, and the thyroid tissue may become calcified (Figure 1-1). The pyramidal lobe hypertrophies in patients with Graves' disease, multinodular goiter, or Hashimoto's thyroiditis and can usually be palpated in the central neck at the level of the...
In the presence of normal renal function, magnesium retention and hypermagnesemia are relatively uncommon. Hypermagnesemia inhibits magnesium reabsorption in both the proximal tubule and the loop of Henle. This inhibition of reabsorption leads to an increase in magnesium excretion and prevents the development of dangerous levels of serum magnesium, even in the presence of above-normal intake. However, in familial hypocalciuric hypercalcemia, there appears to be an abnormality of the thick ascending limb of the loop of Henle that prevents excretion of calcium. This abnormality may also extend to Mg. In familial hypocalciuric hypercalcemia, mild hypermagnesemia does not increase the renal excretion of magnesium. A similar abnormality may be caused by lithium 1,2,6,10 . The renal excretion of magnesium also is below normal in states of hypomagnesemia, decreased dietary magnesium, dehydration and volume depletion, hypocalcemia, hypothyroidism, and hyperparathyroidism 1,2,6,10 .
An increased TSH, and decreased T4 and sometimes T3. It should be remembered that depression ofT4 alone often occurs in ill patients who are not hypothyroid. Acute hypothyroidism has been been described in a severely ill surgical patient (Mogensen & Hjortso 1988). 3. Hypothyroidism is associated with bradycardia and AV conduction blocks. Diastolic hypertension may occur and is associated with increased systemic resistance (Gammage & Franklyn 1997).Ventricular systolic and diastolic function are impaired.The ECG is of low voltage with flattened or inverted T waves, and CXR may show mild cardiac enlargement. 7. Patients occasionally develop hypothyroidism during pregnancy and this is associated with thyroid antibodies, preeclampsia, preterm delivery, and subsequent impairment of IQ of the child (Montoro 1997, Haddow et al 1999).
As would be expected, stallions with low circulating testosterone levels have depressed DSO as well as decreasing libido. As mentioned previously, testosterone, hCG and GnRH therapy have been used with mixed success to address this problem. The lack of success may well be due to the fact that depressed pituitary function is the cause of infertility in only 1 of cases (Boyle et al., 1991 Roger and Hughes, 1991). Abnormal hormone levels may be associated with hypothyroidism, resulting in delayed puberty, smaller testes, decreased spermatozoan production and decreased libido. Feminization of the genitalia may also be observed. It has been postulated that changes in thyroid function may be the cause of stallion summer infertility associated with elevated environmental temperatures (Brachen and Wagner, 1983).
Unfortunately, to date, no good therapy exists to manage fatigue in patients with PBC. There are many anecdotal reports that UDCA improves fatigue, and pilot studies of methotrexate (MTX) suggested that it may be effective for this purpose as well. Although targeted therapy may not markedly affect fatigue in PBC, it is important to ensure that there are no other contributing factors. Hypothyroidism is commonly associated with PBC and should be excluded. Fatigue is extremely common in the general population and is often multifactorial. It is important to take a good sleep history and to identify and correct any bad habits that may be worsening fatigue. Some common problems include hypothyroidism In addition to the specific symptoms of PBC, it is also worthwhile to consider associated diseases. Rheumatoid arthritis Raynaud's phenomenon with or without scleroderma calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia (CREST syndrome) thyroiditis and...
Pathogenic autoantibodies to the TSHR disturb normal hypothalamus-pituitary-thyroid regulation of thyroid function 8-10 (Fig. 14.1). GD is characterized by hyperthyroidism, which often leads to tachycardia, anxiety, excessive sweating, and acute weight loss. On the other hand, autoimmune PM is characterized by hypothyroidism that can lead to physical and mental lethargy, bradycardia, and weight gain. Pathogenic antibodies (TSAbs) from patients with GD bind to TSHR and stimulate thyroid, but in PM, pathogenic antibodies (TSBAbs) block either the binding of TSH or TSH-mediated activation of thyroid cells. Unlike in HT, the primary cause of thyroid dysfunction in GD and PM is not due to glandular destruction but rather to physiological perturbation of thyroid function mediated by anti-TSHR antibodies. The important question is how one develops pathogenic antibodies against the thyroid. Since self-tolerance prevents development of autoimmune responses, breakdown in self-tolerance must...
Patient from T4 are complex and require individual judgment. After the first negative post-131I therapy scan, and if the basal serum Tg is undetectable, we recommend the use of rhTSH for the second and subsequent scans to eliminate the need for T4 withdrawal and the attendant morbidity associated with hypothyroidism. Patients will continue on T4 treatment but will have to follow a low-iodine diet for 1 week prior to the study (Table 2-2). A positive scan or a rise in serum Tg to 2 ng mL is indicative of metastatic disease, which would require high-dose 131I therapy.24 For 131I ablative therapy, the patient would require routine T4 withdrawal preparation.
In a subsequent study, this same group stratified the patients by age and found a strong and progressive effect on all laboratory parameters. In other words, as the patients became older, there was an increased incidence of cobalamin deficiency, as shown in Table 3.8. Patients with autoimmune gastritis-associated IDA had many features overlapping with classic pernicious anemia (e.g., coincident thyroiditis, diabetes mellitus, Sjogren's syndrome, etc.). This raises the question of whether H. pylori gastritis represents an early phase of a progressive disease in which an infectious disease is
Clinical course of patients with MTC. Some patients may survive several decades with persistent disease, whereas some will have rapidly progressive tumors and will die within months of presentation. Only early diagnosis and at least a total thyroidectomy with central neck node clearance give the patient the best chance of disease-free survival. A number of clinical, biochemical, and molecular factors have been reported to predict outcome in patients with MTC (Table 3-2). The most important prognostic factors consistently observed are the age of the patient and the stage of MTC.10 Some studies, but not all, have also suggested that male gender is associated with a worse prognosis. The presence of diarrhea, cervical node metastasis, large tumor size, extrathyroidal tumor extension, and elevated stimulated serum calcitonin levels ( 10,000 pg mL) at the time of diagnosis have also been shown to adversely influence survival.33 Deoxyribonucleic acid (DNA) ploidy (aneuploid tumors),...
The majority of the clinically useful autoantibody tests have been cleared by the FDA for in vitro use to help diagnose autoimmune diseases. These include those to help diagnose connective tissue diseases such as RA, SLE, SS, SSc, and PM DM gastrointestinal diseases such as celiac disease, Crohn's disease, and ulcerative colitis autoimmune liver diseases such as PBC and autoimmune hepatitis types I and II autoimmune vasculitides such as Wegener's granuloma-tosis and Goodpasture's syndrome autoimmune endocrine diseases such as Hashimoto's thyroiditis and Graves' disease and autoimmune coagulation disorders such as antiphospholipid syndrome. Examples of clinically useful autoantibody tests that have not been cleared by the FDA include antibodies to help diagnose pernicious anemia, autoimmune skin-blistering diseases such as pemphigus and pemphigoid, and some autoimmune neurological diseases. Auto-
In sporadic MTC, a large unifocal tumor is usually found, whereas in the hereditary forms of MTC, the tumors are usually bilateral and multicentric, with or without CCH present. CCH in hereditary MTC is generally regarded as a premalignant lesion, but this is less clear for sporadic MTC (Figure 3-2). CCH is usually of monoclonal cell origin and may have a diffuse or nodular pattern. CCH usually develops where the greatest number of C cells reside in the thyroid gland. To identify CCH or microscopic MTC, it is important to take thin (1 to 5 m) sections of the thyroid and perform a systematic complete histologic examination of the entire thyroid gland (Figure 3-3). Microscopic MTC is distinguished from CCH by invasion through the basement membrane of the thyroid follicle. Young patients undergoing preventive thyroidectomy, based on a positive genetic screening test, may only have CCH or no pathologic abnormality.9 Nonspecific CCH may occur with chronic lymphocytic thyroiditis,...
In this condition there is a loss of pigment as a result of antibodies developing against melanocytes in the skin in a limited area. However, the areas affected tend to gradually increase. There may be other autoimmune diseases in the same patient, causing, for example, pernicious anaemia, and thyroid disease.
Characteristic antibodies of AIH type 2 are liver kidney microsomal antibodies (LKM-1) directed against cytochrome P450 (CYP)2D6 and, with lower frequency, against UDP-glucuronosyltransferases (UGT) 35 . In 10 of cases, LKM-3 autoantibodies against UGTs are also present 36, 37 . In contrast to AIH type 1, additional organ-specific autoantibodies are frequently present, such as anti-thyroid, anti-parietal cell, and anti-Langerhans' cell autoantibodies. The number of extrahepatic autoimmune syndromes such as diabetes, vitiligo, and autoimmune thyroid disease is also more prevalent compared to AIH type1 34 .
Ever, the molecular characterization of target antigen specificity does not supply important additional information to increase the diagnostic precision of AIH type 1. Although organ-specific autoantibodies are usually not observed, an association of AIH type 1 with other autoimmune syndromes is observed in 48 of cases, with autoimmune thyroid disease, synovitis, and ulcerative colitis as leading associations 18, 19 .
The etiology of autoimmune thyroid disease (AITD) is unclear. Similar to other autoimmune diseases, genetic, environmental, and other endogenous factors contribute to the initiation of the disease. Increased incidence of GD among members of a family and a higher degree of disease concordance among identical twins indicate that genetic factors may play an important role in determining susceptibility to GD 15-17 . As in most other autoimmune diseases, the strongest bias in developing GD is gender women are 5-10 times more likely than men to develop the disease. Two recent reviews on genetic susceptibility to GD have summarized and discussed the implications of a large number of stud
It usually takes 6 to 12 months after initial therapy for 131I to achieve maximal effects. Serum TSH and Tg concentrations may be measured every 3 months during this period. The 131I diagnostic scan is repeated at the end of the year after adequate thyroid hormone withdrawal and dietary iodine restriction. If there is uptake in the neck or the body or if serum Tg is 5 ng mL when the patient is hypothyroid, a repeat treatment with 100 to 200 mCi of 131I should be given.
Women with symptoms caused by another illness, but without demonstrable PMS, should receive reassurance and clarity about possible sources of their discomfort. Accurate information about sexual health, experiences normally associated with the menstrual cycle, and symptom patterns may be tremendously helpful. Treatment of a previously unrecognized or poorly controlled physical illness (e.g., hypothyroid-ism, diabetes mellitus) may eliminate the premenstrual complaints. New or more intensive treatment of a psychiatric disorder such as depression may lead to improvement in symptoms attributed to the premenstrual phase. Doses of psychotropic medication may need to be increased during the late luteal phase and early follicular phase to control symptoms. It should be made explicit that women who are thought not to have PMS will receive continued health care and will not be abandoned to cope with their symptoms alone.
A state of thyroid overactivity, which should be controlled before elective surgery, to avoid precipitating a thyroid crisis (Pronovost & Parris 1995). If antithyroid drugs are used,preparation for thyroid surgery may take up to 2 months. With beta adrenoceptor blockers and potassium iodide alone, control can be achieved within 2 weeks, but not all are agreed on the adequacy of this method for patients who need surgery. Beta blockers only block the peripheral effects of the hormones.They do not affect their synthesis or release, and may obscure a crisis (Eriksson et al 1977). Since they are short acting, their omission in the perioperative period may lead to an unexpected crisis. Occasionally a thyrotoxic patient requires urgent surgery. Alternatively, surgery may be unwittingly undertaken in a thyrotoxic patient, because the diagnosis is obscured by other pathology. Thyrotoxicosis may also be precipitated by infections, labour, trauma, acute medical illness, and stress (Smallridge...
Often restrict themselves to a liquid diet, which is tolerated better than solids. Bezoars are common and are seen in up to 12 of postgastrectomy patients (14). Gastric atony (Fig. 9) is a major complication of gastric surgery. This may be further exacerbated by diabetes, hypothyroidism, and neurologic disorders. It is important to determine whether the impedence to gastric outflow is mechanical or functional. Endoscopy, contrast radiography, and scintigraphy usually allow differentiation.
In infants with neonatal Marfan syndrome, the thumb may extend beyond the fifth finger when the infant fists its hand. This infant with Marfan syndrome had an upper lower segment ratio of 1.52. The normal upper lower segment ratio in the neonate is 1.69 to 1.7. It is much reduced in Marfan syndrome and increased in short-limbed dwarfism and hypothyroidism. Note that the fingers are long, tubular, and relatively slender.
This is another example of long feet and toes in an infant with Marfan syndrome. Note the bilateral congenital curly toes. This infant had a birth length of 53 cm and an upper lower segment ratio of 1.41. The normal upper lower segment ratio at birth is 1.69 to 1.70. In short-limbed dwarfism and hypothyroidism it averages 1.8 or more, and in Marfan syndrome it averages 1.45.
This is another example of long feet and toes in an infant with Marfan syndrome. Note the bilateral congenital curly toes. This infant had a birth length of 53 cm and an upper lower segment ratio of 1.41. The normal upper lower segment ratio at birth is 1.69 to 1.70. In short-limbed dwarfism and hypothyroidism it averages 1.8 or more, and in Marfan syndrome it averages 1.45.
Calcification of the basal ganglia occurs with many medical conditions, including TORCH and other infectious diseases, vascular disorders (birth anoxia,hemorrhage),toxic and metabolic disorders (carbon monoxide intoxication, lead encephalopathy, radiation therapy, hypopara-thyroidism, pseudohypoparathyroidism, hyperpara-thyroidism, hypothyroidism, and lipoid proteinosis) (Kauffman et al. 1992 Fulup and Zeifer 1991 Kowd-ley et al. 1999 McLeod et al. 1989 Lee and Suh 1977 Margolin et al. 1980 Reyes et al. 1986) (Fig. 1.45 a,b). In addition, it occurs with several genetic disorders, including Cockayne syndrome, oculo-dento-osseous
This figure shows the growth arrest lines in the long bones of a term infant with severe intrauterine growth retardation. Note the lack of the distal femoral and proximal tibial ossification centers, normally appearing at 36 and 38 weeks respectively, also caused by growth retardation. Hypothyroidism is also a consideration. Figure 1.4. This figure shows the growth arrest lines in the long bones of a term infant with severe intrauterine growth retardation. Note the lack of the distal femoral and proximal tibial ossification centers, normally appearing at 36 and 38 weeks respectively, also caused by growth retardation. Hypothyroidism is also a consideration.
Passive transfer of immunoglobulins from GD patients to experimental animals caused increased thyroid hormone production 39 . The discovery that autoantibodies were the cause of Graves' disease began the quest to detect, quantify, and characterize these antibodies. Two main assays are used to detect and characterize anti-TSHR autoantibodies. One measures the inhibition of TSH binding (TBII) to the TSHR, while the other measures the stimulatory activity (TSAb) of the antibody through cAMP production by TSHR-expressing cells. The latter assay can be readily modified to detect blocking activity (TSBAb) by measuring the ability of a given antibody to prevent cAMP production in the presence of a known amount of TSH. Although there is considerable agreement between results from TBII and TSAb assays, such agreement is lacking between the antibody titer activity in the serum and the severity of the disease 40-43 . It is interesting to note that the TBII assay can detect both TSAb and TSBAb...
This chapter explores the interactions of anemia and aging that are of interest for at least three reasons. First, incidence and prevalence of anemia increase with aging (6-8). Second anemia may represent the early sign of an underlying serious disease such as cancer, hypothyroidism or malabsorption (6). Third, anemia itself is associated with increased mortality and disability (7). It is reasonable to expect that prompt and effective management of anemia may help compress the aging-related morbidity.
There are several ways in which medical conditions may be related to mental disorders. First, the medical condition may be the direct cause of the mental condition. For example, hypothyroidism (Axis III) can lead to a syndrome of depressed mood known as Mood Disorder due to Hypothyroidism (Axis I). Similarly, Alzheimer's Disease (Axis III) produces Dementia of the Alzheimer's type (Axis I), and systemic infections (Axis III) can produce a Delirium (Axis I).
The TBII activity present in the sera of patients with GD is most likely due to TSAbs, and they primarily bind to epitopes in the N-terminus of TSHR as demonstrated by using LH CGR-TSHR chimeras. In contrast, the TBII activity found in the sera of patients with HT or PM most likely represents TSBAb activity, and they predominantly bind to epitopes in the C-terminus of the TSHR ECD. This indicates that the TSBAb activity, however, does not always correlate with the TBII activity and vice versa. Epitopes involved in TSBAb binding are primarily located on the C-terminal portion of the TSHR ECD, probably within residues 261-395. This is in contrast to TSAb epitopes (TSAbl), which are primarily located at the N-terminal portion of the TSHR ECD (Fig. 14.3). Evidence to date suggests that these N-terminal and C-terminal areas come together due to protein folding and that the function of the receptor is critically maintained by proper three-dimensional structure. Another study, in which...
Diabetes is probably one of the best investigated endocrine diseases concerning olfactory disorders 121, 166-168 . Most studies reveal slight olfactory deficiencies in diabetic patients especially at threshold levels indicating a peripheral patho-mechanism compatible with a possible diabetic micro-angiopathy or peripheral polyneuropathy. However, olfactory impairment in diabetes is relatively mild. Two recent studies conducted with identification tests in large study samples did not find that diabetic patients exhibit a decreased ability to identify odors compared to healthy controls 121, 122 . Several other endocrine diseases such as hypothyroidism 169, 170 , adre-nocortical insufficiency (Addison's disease) 171 or pseudohypoparathyr-oidism 172 , have been reported to cause olfactory disorders. Many endocrine diseases have been reported to cause hyposmia but rarely lead to anosmia.
The abrupt onset of symptoms of a severe hypermetabolic state, associated with the output of thyroxine, in a patient with pre-existing thyroid disease.This is a clinical, not a bichemical, diagnosis, and biochemically it is difficult to distinguish between the two. However, serum free T4 concentrations are significantly higher in a thyroid crisis compared with thyrotoxicosis. It may occur in a patient with occult thyroid disease, in whom a crisis may be precipitated by an acute medical, traumatic or surgical event. It can also occur in treated thyrotoxic patients following thyroidectomy, either if there is inadequate preoperative control (Jamison & Done 1979, Knighton & Crosse 1997), or if antithyroid therapy has been discontinued too early in the postoperative period.Thyrotoxicosis may be difficult to diagnose during pregnancy, and a thyroid crisis may be precipitated by delivery or Caesarean section (Clark et al 1985, Halpern 1989).
Congenital hypothyroidism is thyroid hyposecretion present from birth it was formerly called cretinism, now regarded as an insensitive term. Severe or prolonged adult hypothyroidism can cause myxedema (MIX-eh-DEE-muh). Both syndromes are described in table 17.8, and both can be treated with oral thyroid hormone. Figure 17.25 Endemic Goiter. The thyroid gland has hypertrophied as a result of iodine deficiency, leading to TSH hypersecretion. Figure 17.25 Endemic Goiter. The thyroid gland has hypertrophied as a result of iodine deficiency, leading to TSH hypersecretion. iodine deficiency. There is little iodine in soil or most foods, but seafood and iodized salt are good sources. Without iodine, the gland cannot synthesize TH. Without TH, the pituitary gland receives no feedback and acts as if the thyroid were understimulated. It produces extra TSH, which stimulates hypertrophy of the thyroid gland. In the earlier-described toxic goiter, by contrast, the overgrown thyroid produces...
A very small percentage of women (1 ) experience natural menopause before the age of 40. It is not known why these people stop having their periods. Idiopathic ovarian insufficiency or premature ovarian failure is a condition that usually occurs in women under the age of 40 and causes menopause. Idiopathic ovarian insufficiency is usually caused by autoimmune and genetic disorders, Addison's disease (disorder of the adrenal glands, which manufacture steroid hormones), or hypothyroidism (an underactive thyroid gland).
Anti-brain antibodies solely to a unique characteristic of the brain, rather than to the incorporation of heat-killed Mycobacterium tuberculosis into the inoculum of complete Freund's adjuvant (Kopeloff and Kopeloff 1944 Freund et al. 1947). Confronted with Witebsky et al.'s 1957 report that thyroiditis could be induced in rabbits by immunization with extracts of the rabbits' own thyroids in complete Freund's adjuvant, he assumed that thyroglobulin was also segregated from the immune system in some way (Burnet 1959). We now know that virtually any autologous tissue can be used to raise antibodies by immunization in the presence of killed bacteria it is not the tissue that is special, it is the adjuvant.
Important metabolic causes of parkinsonism include hypothyroidism and parathyroid dysfunction. Patients with hyperparathyroidism have clinical presentation identical to that of idiopathic PD, but the syndrome is levodopa resistant. The symptoms, however, may be relieved after resolution of the parathyroid dysfunction by surgical removal of the parathyroid adenoma. Hypoparathyroidism may also cause levodopa unresponsive parkinsonism (69,70).
Thyroiditis Thyroiditis Abbreviations GVHD graft-versus-host disease GMB glomerular basement membrane EAT experimental autoimmune thyroiditis EMG experimental myasthenia gravis C1q component of serum complement Dnasel deoxyri-bonuclease 1 SAP serum amyloid P component c-mer tyrosine kinase.
Patients with acute colonic pseudo-obstruction are usually postoperative or critically ill. The numerous conditions associated with pseudo-obstruction include recent surgery, trauma, metabolic disturbances, electrolyte imbalance, sepsis, infections, narcotics and other medications, hypothyroidism, diabetes, renal failure, myocardial infarction, inflammatory processes, and prolonged bed rest. It is more predominant in males and is most commonly reported in the sixth decade of life. It is almost always temporary and reversible. Acute pseudo-obstruction is believed to result from an imbalance between neurotransmitters of the sympathetic and the parasympathetic neurons.
On the other hand, many illnesses common to the elderly, as well as prescribed medications, may have concomitant symptoms of depression and anxiety. For example, elders are at increased risk for hypothyroid-ism, cardiovascular disease, and chronic obstructive pulmonary disorder, which may cause fatigue, sleep disturbances, and negative affect. Other disorders, such as myocardial infarctions, vitamin deficiencies, anemia, pneumonia, and hyper- and hypothyroidism, may present with symptoms of anxiety. Further, many medications commonly prescribed in the elderly, such as antihypertensives, may also create symptoms of depression. Thus, physical, mental, and social health are often tightly intertwined in the elderly, and multi-pronged assessment techniques may be necessary to adequately establish the etiology of symptoms of depression and anxiety in the elderly.
Autoimmunity to thyroid antigens is the most common cause of thyroid diseases including Hashimoto's thyroiditis (HT), Graves' disease (GD), and primary myxedema (PM). Different autoimmune diseases of the thyroid share similar immunological characteristics and are thought to be interrelated. However, particular thyroid antigens, immunological abnormalities, symptoms, and clinical courses are associated with specific thyroid diseases. For example, it is well known that anti-thyroid antibodies circulate in the serum of patients that suffer from HT and GD, but it is generally accepted that HT is primarily a T cellmediated disease in which thyroglobulin-specific T cells infiltrate the thyroid and cause glandular destruction that results in hypothyroidism. In contrast,
The north Indian belt is also known as the stone belt (due to the deficient nutritional factors in the diet) and also for the iodine deficiency in the water there. The land is very fertile and the pesticides are used liberally in the fields. The population is mainly vegetarian and consume lot of fresh vegetables in the diet. In addition, most of the population with ARM in this region have a low socioeconomic status. All of these factors suggest environmental factors affecting or precipitating the anomaly at a window time after conception when the hindgut is developing and differentiating into urinary and intestinal tracts.
Nikki reports that she was diagnosed 8 years ago as having Grave's disease (hyperthyroidism with one or more of the following goiter, exophthalmos, pretibial myxedema). The disease is not controlled at the present time, although she has had isotope therapy, which resulted in the reverse condition (hypothyroidism). Side effects of the disease and or treatment, according to Nikki, include memory problems and emotional side effects such as nervousness and irritability.
Differential diagnosis Skew deviation, a disparity in the vertical positioning of the eyes of supranuclear origin, can mimic trochlear palsy. Myasthenia gravis, disorders of the extraocular muscles, thyroid disease, and oculomotor palsy that affects the superior rectus can also cause similar effects.
Cutis marmorata is a common finding in normal infants. This fine reticulated mottled appearance is due to vasomotor instability and thus is more commonly seen in premature infants, but should also alert one to the possibility of sepsis, hypothyroidism, and central nervous system pathology. Figure 1.20. Cutis marmorata is a common finding in normal infants. This fine reticulated mottled appearance is due to vasomotor instability and thus is more commonly seen in premature infants, but should also alert one to the possibility of sepsis, hypothyroidism, and central nervous system pathology.
This is dependent on the specific disorder, but if appropriate therapy is institut- Prognosis ed the prognosis is usually good for the endocrine disorders such as hypothyroidism, hyperthyroidism, hyperparathyroidism, acromegaly, and diabetes. Horak HA, Pourmand R (2000) Endocrine myopathies. Neurol Clin 18 203-213 Madariaga MG (2002) Polymyositis-like syndrome in hypothyroidism review of cases reported over the past twenty-five years. Thyroid 12 331-336
The thyroid gland produces the thyroid hormone that is required to maintain normal metabolism of the body. A highly regulated feedback loop controls thyroid function and helps maintain the euthyroid status (Fig. 14.1). Thyroid-stimulating hormone (TSH) is produced in the anterior pituitary in response to stimulation by thyroid-releasing hormone (TRH) produced in the hypothalamus. The TSH binds to the thyrotropin receptor (TSHR), which then activates adeny-lyl cyclase and phosphatidyl inositol pathways and leads to the production of thyroid hormone. Hormone production begins when tyrosine residues of the thyroglobulin (Tg) are iodinated and then coupled through the catalytic action of the thyroid peroxidase (TPO), leading to the formation of the thyroid hormone precursor T4. The T4 undergoes deiodination and results in the formation of the thyroid hormone triiodothyronine (T3). The T3 binds to its cognate receptor in cells throughout the body and forms a complex, which is translocated...
The history should also include questions to help rule out endocrine causes of obesity, such as hypothyroidism, hyperadrenalism, and neuroendocrine tumors, though in adults even the most common of these, hypothyroidism, is rarely a significant factor in causing obesity. Also inquire about drugs that may be associated with weight gain, such as sulfonylureas, insulin, steroids, most psychotropics, and antiseizure medications. Also assess for symptoms suggestive of diseases that often complicate obesity, such as type 2 diabetes, coronary artery disease, hypertension, and sleep apnea. Symptoms and signs of depression should also be sought, as depression is a common accompaniment of severe obesity and may require additional treatment. Childhood or later sexual or physical abuse is also common, and is usually not volunteered, so it needs to be specifically elicited after rapport has been established. Individual or group counseling may be helpful when sexual or other abuse is detected. The...
Premenstrual syndrome differs from other endocrine-related mood disorders, such as depression induced by diabetes or hypothyroidism, in that blood hormone levels are essentially normal. These findings suggest that PMS may have special psychobiological features, and these should raise questions about the relationship of PMS to childhood health and nurturing. Early evidence indicates that tactile stimulation before weaning, for example, leads to antibody production, thought to be essential for proper functioning of the immune system in infancy and for immune and pituitary - adrenal activation in adulthood. Research should thus focus on the impact of early development on immunological and neuroendocrinological patterns that may permanently influence the person's susceptibility to or immunity from illness. As these complex issues become clarified, clinical attention should focus on the quality of the caregiver-infant relationship to ensure optimal maturation and enhanced neuroendocrine...
Described elsewhere 17 , Metabolites of ATC, i.e., alpha-tocopheryl quinone and hydroquinone, are able to exert potent anti-oxidant activity, albeit in the presence of ATC 80 , Due to the practical difficulties involved in directly obtaining organ biopsies, plasma levels of ATC are frequently used to indirectly reflect tissue levels. It is important to note that with regards body distribution, the most abundant reservoir source of alpha-tocopherol is skeletal muscle by virtue of the fact that this organ is a major component of the body (i.e., contributing to 40 ofbody weight 81 ). Highest concentrations are in adipose and adrenal tissue. ATC circulates in plasma bound to beta-lipoprotein and in red cells (20 of plasma level). Levels increase in hypothyroidism, diabetes mellitus and hypercholestero-laemia, and are reduced in liver disorders and malnutrition. Dietary requirements are in the order of 15-30 IU day.
Soy however should not be viewed as a panacea. Excessive use of soy derivatives or concentrates might have deleterious effects since there is evidence that soy isoflavones possess antithyroid properties. In addition to inhibition of the thyroid peroxidase-catalyzed reaction essential to thyroid hormone synthesis, soy diets and derivatives can apparently induce goiter, hypothyroidism, and thyroid neoplasms in humans and rodents.79-82
Nal fibrosis, sclerosing cholangitis, Riedel's thyroiditis, and fibrous pseudotumor of the orbit. In the clinical setting, patients with idio-pathic retroperitoneal fibrosis exhibit systemic symptoms such as malaise, anorexia and weight loss, and abdominal or flank pain. Renal insufficiency is often seen and is caused by bilateral ureteral obstruction. Laboratory test results usually demonstrate anemia and an elevated sedimentation rate. The treatment is directed to the release of the ureteral obstruction, which initially can be achieved by placement of ureteral stents. Administration of corticosteroids is helpful to control the systemic manifestations of the disease and
Three histologic variants of anaplastic carcinoma include giant cell, spindle cell, and squamoid. Studies have clearly demonstrated that ATC labeled small cell in the past was, in fact, thyroid lymphoma (TL) or medullary thyroid carcinoma (MTC).9,13-15 TL represents an extranodal variant of non-Hodgkin's lymphoma. It is typically seen in patients with a prior history of Hashimoto's thyroiditis. It is less aggressive than true ATC, with an overall 5-year survival of 50 and a median survival of 2 years. Although most anaplastic tumors exhibit mixed morphology, the most common histologic pattern is the giant cell variant, with abundant eosinophilic, granular cytoplasm, multiple hyper-chromatic nuclei, and occasional acidophilic intracy-toplasmic hyaline globules. The spindle cell variant has spindle-shaped cells with a fascicular architecture that can mimic fibrosarcoma, occasional inflammatory infiltrates resembling malignant fibrous histiocytoma, and pronounced vascularization...
The discovery of preferred cytokine secretion profiles from in vitro CD4 T-cell clones nearly two decades ago has led to a great deal of work on T-cell subset differentiation 87 . Generally, based on their ability to produce distinct cytokines, T cells can differentiate into two subsets called Th1 and Th2. Although more complicated, one can functionally categorize Th1 cells as those producing IL-12 and IFN-y and supporting cell-mediated immune responses, while Th2 cells can be characterized as those producing IL4 and supporting antibody production. Modulation of immune responses where one type of response is enhanced at the expense of the other has had a significant impact on both onset of disease in animal models and our understanding of disease progression. For example, infection of susceptible BALB c (H-2d) mice with the intracellular parasite Leishmania major induces predominantly a Th2-type T-cell response that leads to death, but the resistant B10.D2 (H-2d) strain of mice...
Collagenous and lymphocytic colitis are clinicopatho-logic syndromes that represent distinct, possibly autoimmune, forms of idiopathic inflammatory colonic bowel disease. Both disorders present as chronic, watery, noninfectious diarrhea in middle-aged patients with negative radiographic and endoscopic studies. Collagenous colitis predominantly occurs in women lymphocytic colitis is found equally in both genders. Often there is intermittent, diffuse abdominal pain, and, not surprisingly, some patients have a previous diagnosis of irritable bowel syndrome (IBS). Routine blood studies generally show normal results, but elevations in the Westergren sedimentation rate and eosinophil count are not uncommon. Abnormalities in complement levels, serum immunoglobulins (Igs), and pANCA (antineutrophil cytoplasmic antibodies) may be found. Although stool studies are negative for pathogens and blood, up to 55 of patients have white blood cells in stool samples. Other medical conditions reported to...
The high risk of AD in DS is also associated with early mortality, with an average life expectancy at birth of only 56 years (Baird and Sadovnick,1988). Karyotypic analysis of adults aged over 70 years with DS can provide an opportunity to identify genetic factors associated with longevity. While these cases are rare, they are highly informative and suggest that karyotypes that decrease pAPP load are associated with improved survival and reduced risk of AD. Prasher and colleagues determined the clinical and molecular correlates of partial trisomy 21 in a 78-year-old woman with DS 46,XX,rec(21)dup q, inv(21) (p12q22.1) (Prasher et al., 1998). Although she did not display the full range of stigmata associated with the DS phenotype, she developed several of the characteristic age-related medical conditions, including hypothyroidism, cataracts, hypotonia, and hearing impairment. Analysis of gene sequences on chromosome 21 using fluorescent in situ hybridization showed that the partial...
As already pointed out above, the case history is the basis of the clinical examination. Before assessing the patient in detail, the general examination may give clues to underlying disease (e.g., diabetes, thyroid disease, toxic or nutritional problems). The family history may suggest genetic diseases. Changes of the skeletal system (e.g., kyphosis, scoliosis, atrophy, hypertrophy, and abnormal muscle movements) may indicate neuromuscular disease. Skin changes to watch for include signs of vasculitis, cafe-au-lait spots, patchy changes from leprosy or radiation, and the characteristic changes associated with dermatomyositis. - Myoedema occurs after percussion of a muscle and results in a ridge-like mounding of a muscle portion, lasting 1-3 seconds. It is a rare finding and can be seen in hypothyroidism, cachexia, or rippling muscle disease.
Interferon-a is given by subcutaneous injection and most patients can be taught to self-administer the drug. The usual dose in chronic HBV infection is 5 MU daily or 10 MU thrice weekly for a duration of 16 weeks. I find that the daily dosing schedule is usually better tolerated by patients. Interferon almost always causes flu-like symptoms, which may vary from mild to debilitating. Usually these symptoms improve after the first few weeks of treatment despite continued therapy. Interferon is myelosup-pressive and patients must be monitored for neutropenia and thrombocytopenia. Autoimmune disorders can be exacerbated or unmasked by interferon and the treatment is generally contraindicated in patients with autoimmune diseases with the exception of stable hypothyroidism. Depression may occur, especially in patients with a prior history. This treatment should not be used in patients with a history of major depression, suicidal attempts or ideation, or major affective disorders. As...
Thyroiditis 5-25 Thyroiditis factitia Uncommon sent with normal-size thyroid glands. Some patients present with apathetic thyrotoxicosis and appear to be clinically hypothyroid rather than hyperthyroid. Apathetic hyperthyroidism is more A classic triad of tachycardia with palpitation, weight loss, and heat intolerance is usually diagnostic of Graves' disease in a patient with a diffuse goiter. The goiter is usually symmetrically enlarged, with a smooth rubbery consistency. Elevated T3 and T4 and reduced TSH levels confirm the diagnosis and establish a baseline for follow-up. High antibody titers against TSH, also called TSI, are present in about 80 of patients with Graves' disease. A radionuclide uptake scan may be unnecessary, but it is essential if one suspects subacute thyroiditis the scan would reveal increased uptake in Graves' patients (Figure 1-17) and low uptake in the thyroid bed in patients with thyroiditis. Furthermore, Plum-mer's disease and toxic adenoma have a...
The alteration of cardiac gene expression in cocaine-induced cardiomyopathy has recently been investigated using a rat model 88 , Specifically, the effects of acute as well as prolonged administration of cocaine were studied with respect to the transcription of atrial natriuretic factor (ANF) mRNAs as a marker of acute mechanical overload 89-91 , Acute and prolonged dosing with cocaine was also investigated with respect to the encoding of myosin heavy chain mRNAs as markers of prolonged mechanical overload 90,92-94 , Additionally, the study also sought to determine the effect of acute and prolonged administration of cocaine in terms of the transcription of type I and III procollagens as markers of active fibrosis 91,95 , The study found that acute injection of cocaine induced ANF gene expression. Cocaine treatment during 28 days resulted in left ventricular hypertrophy (+20 after 24 days) with normal blood pressure, associated with an accumulation of mRNAs encoding ANF and type I and...
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