Transcript DISORDERS OF THYROID AND PARATHYROID GLAND AND THEIR MANAGEMENT Prof. Dr. S. N. Ojha M.D.

DISORDERS OF THYROID
AND PARATHYROID
GLAND AND THEIR
MANAGEMENT
Prof. Dr. S. N. Ojha
M.D. (Ayu.) Phd.
Dean & Superintendent
Dr. D. Y. Patil College of
Ayurveda & Research Centre
Pimpri, Pune.
What is Thyroid?
The thyroid is a small gland, shaped like a butterfly, located
in the lower part of your neck. The main hormones released
by the thyroid are triiodothyronine, (T3) & thyroxine, (T4)
What Diseases and Conditions Affect the
Thyroid?
Hypothyroidism – An underactive thyroid.
Hyperthyroidism – an overactive thyroid.
Goiter – An enlarged thyroid.
Thyroid Nodules – Lumps in the thyroid gland.
Thyroid Cancer – Malignant thyroid nodules or tissue.
Thyroiditis – Inflammation of the thyroid.
Hyperthyroidism :
Hyperthyroidism is a condition where the
thyroid gland – the master gland of metabolism
– is overactive.
Causes of Hyperthyroidism
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Graves’ disease.
2.
Thyroiditis
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Autoimmune condition Hashimoto’s
disease, a temporary hyperthyroidism that
affects women
Risk of Graves’ Disease /
Hyperthyroidism
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Female gender
Personal and family history of thyroid
problems, autoimmune disease, or endocrine
disease
Age 20 and 40
Pregnancy – During pregnancy and the year
after childbirth
Current or former smoker
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Excessive intake of thyroid hormone
Exposure to or excess of iodine/iodine
drugs
Certain medical treatments
Trauma to the thyroid
Recently experienced major life stress
Holistic and nutritional factors
Common symptoms
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Goiter, thyroid enlargement, neck sensations
Weight and appetite changes
Pregnancy-related problems
Feeling warm all the time, sweating, thirst, fever
Heart and blood pressure changes, fast heart rate,
abnormal heart rhythms
Bowel problems, diarrhea
Fatigue, exhaustion
Muscle and join pain and fatigue
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Skin changes, blister-like bumps on the
forehead and face, hives, itching, vitiligo.
Skin patches on the shins and legs (Graves’
dermopathy / pretibial myxedema)
Hair loss and other hair changes.
Finger/nail changes, including swollen,
wider fingertips and separation of nail bed
from skin.
Eye problems, including bulging, dryness,
pain, redness, puffiness
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Thinking/cognition problems, including
difficult concentrating or making decisions,
memory problems, and racing thoughts.
Changes to mood and feelings, including
depression, mood swings, uncontrollable
anger, irrational anger.
Panic and anxiety, panic attacks
Fast reflexes, startling, tremors
Insomnia
Diagnosing Graves’ Disease
Clinical Exam.
• Feel (also known as “palpating”) neck
• Palpate for what’s known as “thrill”
• Listen for “bruit” during palpation
• Test reflexes-hyper responsive reflexes can
be a sign of hyperthyroidism
• Heart rate, rhythm & blood pressure
• Measure weight
• Measure body temperature
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Examine face and neck area
Examine skin for some possible signs of
hyperthyroidism
General quantity and quality of hair
Tremors
Nails and hands for thyroid signs
Evaluate legs
Examine eyes
Test results that confirm hyperthyroidism
include:
TSH Test – usually below normal, to undetectable
T4/Free T4 Test – Normal to High
T3/Free T3 Test – Normal to High
Radioactive Iodine Update (RAI-U) Test
Elevated Thyroid Receptor Antibodies (TRAb) /
Thyroid-Stimulating Immunoglobulin (TSI).
Hyperthyroidism – can be treated with three different
approaches:
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Drug treatment with antithyroid drugs
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Ablation of the thyroid gland with Radioactive Iodine (RAI)
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Surgery to remove all or part of the thyroid.
Antithyroid Drug Treatment
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Methimazole - Carbimazole
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Propylthiouracil
Radioactive Iodine Treatment
Radioiodine ablation
Radioactive iodine ablation
Thyroid ablation
Ablation therapy
Chemical thyroidectomy
Chemical surgery
Radioactive cocktail
Ayurvedic Treatment
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Kanchanar Guggulu
Aarogyavardhini Rasa
Sootshekhar Rasa
Dasha moolarishta
Hypothyroidism :
When the thyroid gland is underactive,
improperly formed at birth, surgically
removed all or in part, or becomes
incapable of producing enough thyroid
hormone, a person is said to the
hypothyroid.
Causes
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Iodine deficiency
Hashimoto’s thyroiditis
Lack of the thyroid gland
Deficiency of hormones from either the
hypothalamus or the pituitary.
Postpartum thyroiditis
Sporadic inheritance, sometimes autosomal
recessive
Wolff-Chaikoff effect
Lithium-based mood stabilizers
Type
Origin
Description
Primary
Thyroid gland
Hashimoto’s thyroiditis &
radioiodine therapy for
hyperthyroidism
Secondary
Pituitary gland
Occurs if the pituitary gland
does not create enough TSH
Tertiary
hypothalamus
Hypothalamus fails to produce
TRH
Symptoms
Early symptoms
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Poor muscle tone
Fatigue
Cold intolerance
Depression
Muscle cramps and joint pain
Arthritis
Goiter
Thin, brittle fingernails
Thin, brittle hair
Paleness
Dry, itchy skin
Weight gain and water retention
Bradycardia (low heart rate: less than sixty beats per minute)
Constipation
Late symptoms
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Slow speech and a hoarse, breaking voice.
Dry puffy skin, especially on the face
Thinning of the outer third of the eyebrows. (sign of
Hertoghe)
Abnormal menstrual cycles
Low basal body temperature
Less common symptoms
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Migraine headache
Impaired memory
Anxiety / panic attacks
Urticaria
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Impaired cognitive function and inattentiveness
A slow heart rate with ECG changes including low
voltage signals.
Reactive (or post-prandial) hypoglycemia
Pericardial effusions may occur.
Sluggish reflexes
Hair loss
Early greying of the hair
Anemia caused by impaired hemoglobin synthesis
Difficulty swallowing
Shortness of breath with a shallow and slow
respiratory pattern
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Hypercapnia & hypoxia
Increased sleep
Osteopenia or Osteoporosis
Irritability and mood instability
Yellowing of the skin
Impaired renal function
Thin, fragile or absent cuticles
Elevated serum cholesterol
Acute psychosis
Decreased libido
Decreased sense of taste and smell
 Puffy face, hands and feet
 Premature wrinkling on the face
Pediatric
 Short stature
 Mental retardation
 Short neck
 Delayed development
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Severity
 Cardiovascular & psychiatric
 Myxedema
Diagnostic testing
 Free triiodothyronine (fT3)
 Free levothyroxine (fT4)
 Total T3
 Total T4
 24 hour urine free T3
 antithyroid antibodies
 Serum cholesterol
 Prolactin
 Testing for anemia, including ferritin
 Basal body temperature
Treatment
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Levorotatory forms of thyroxin (L-T4)
Different treatment protocols in thyroid
replacement therapy:
T4 Only
T4 and T3 in Combination
Desiccated Thyroid Extract
Ayurvedic Treatment
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Laxmivilas Rasa
Punarnavadi Mandur
Agnitundi Vati
Ashwagandharishta
Amrtarishta
Shatavari
Chitrak
Chatusparni
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Autoimmune Thyroid Disease
In the case of autoimune thyroid disease, antibodies
either gradually destroy the thyroid, or make it
overactive.
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Goiter/Thyroid Nodules
When the thyroid become enlarged, this is known as a
goiter.
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Thyroid Cancer
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Thyroiditis
When the thyroid become inflamed, due to bacterial or
viral illness, this is known as thyroiditis
Treatments – Surgery, Thyroid drugs
Parathyroid gland
The parathyroid glands are small
endocrine gland in the neck that
produces parathyroid hormone.
 Most people have four parathyroid
glands, but some people have six or
even eight
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Hypoparathyroidism
It is decreased function of parathyroid
glands, leading to decreased levels of
parathyroid hormone (PTH).
Causes
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Removal of the parathyroid glands in thyroid surgery
(thyroidectomy)
Autoimmune.
Hemochromatosis
Chromosome 22q11 microdeletion syndrome (other
names: DiGeorge syndrome Schprintzen syndrome,
velocardiofacial syndrome).
Magnesium deficiency
DiGeorge syndrome, absence of the parathyroid
glands at birth.
Idiopathic, occasionally familial
Signs and Symptoms
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Tingling lips, fingers, and toes
Muscle cramps
Pain in the face, legs, and feet
Abdominal pain
Dry hair
Brittle nails
Dry, scaly skin
Cataracts
Weakened tooth enamel (in children)
Muscle spasms called tetany
Convulsions (seizures)
Additional symptoms
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Painful menstruation
Hand or foot spasms
Decreased consciousness
Delayed or absent tooth formation
Diagnosis
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Measurement of calcium
Serum albumin
PTH in blood.
E.C.G.
Differential diagnoses are:
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Pseudohypoparathyroidism
Pseudopseudohypoparathyroidism
Vitamin D deficiency or hereditary
insensitivity to this vitamin (X-linked
dominant).
Malabsorption
Kidney disease
Medication: Steroids, diuretics, some
antiepileptics.
Treatment
1. Intravenous calcium
Long-term treatment
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Calcium and Vitamin D 3
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Teriparatide
Possible Complications
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Tetany can lead to a blocked airway
Stunted growth, malformed teeth, slow mental
development
Overtreatment with vitamin D and calcium can
cause hypercalcemia
Pseudohypoparathyroidism
Pseudohypoparathyroidism is a condition
caused by resistance to the parathyroid
hormone.
Patients have a low serum calcium and high
phosphate, but the parathyroid hormone level
(PTH) is appropriately high.
Types
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Type 1 a pseudohypoparathyroidism
Type 1 b pseudohypoparathyroidism lacks the
physical appearance of type 1 a biochemically similar
Type 2 pseudohypoparathyroidism also lacks the
physical appearance of type 1 a.
Presentation
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Features of hypocalcaemia
Including; carpo-pedal spasm, tetany, muscle
cramps and seizures.
Type 1 a Pseudohypoparathyroidism is clinically
manifest by blunting of fourth and fifth
metacarpals, short stature, obesity, developmental
delay.
Biochemical Findings
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Hypocalcemia
Hyperphosphatemia
Elevated parathyroid hormone
Hypocalcemia
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Muscle spasm
Carpopedal spasm
facial grimacing
Layrngeal spasm
Convulsion
Respiratory arrest may occur
Increase intracranial pressure
Irritability
Depression
Psychosis
Arrhythmias
Intestinal cramps
Chvostek’s or Trousseaus Sign
Treatment
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Replacement with Vit. D or Calcitriol
High oral calcium intake
Thiazide diuretics
Ayurvedic Treatment
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Godanti
Praval Panchamruta
Hyperparathyroidism
Hyperparathyroidism is overactivity of the parathyroid glands
resulting in excess production of parathyroid hormone (PTH)
Classification
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Primary Hyperparathyroidism
It results from a hyper function of the parathyroid glands
themselves. There is over secretion of PTH due to adenoma,
hyperplasia or rarely, carcinoma of the parathyroid glands.
Secondary hyperparathyroidism
Secondary hyperparathyroidism is the reaction
of the parathyroid glands to a hypocalcemia
caused by something other than a parathyroid
pathology, e.g. chronic renal failure.
Tertiary Hyperparathyroidism
Tertiary hyperparathyroidism is a state of
excessive secretion of parathyroid hormone
(PTH) after a long period of secondary
hyperparathyroidism and resulting in
hypercalcemia.
Etiology
Primary hyperparathyroidism
1. benign parathyroid adenoma
2. multiple endocrine neoplasia
Secondary hyperparathyroidism
Due to excessive secretion of parathyroid
hormone (PTH) by parathyroid glands in
response to hypocalcemia and/or
hyperphosphatemia, usually due to chronic
renal failure.
Tertiary hyperparathyroidism
Caused by long lasting disorders of the calcium
feedback control system.
Symptoms and signs
Asymptomatic hyperparathyroidism
Coincidental finding of hypercalcemia
Symptomatic Hyperparathyroidism
Most of the symptoms of parathyroid disease are
“neurological”
weakness and fatigue,
depression, aches and pains,
decreased appetite,
feelings of nausea and vomiting,
constipation,
polyuria,
polydipsia,
cognitive impairment,
kidney stones and
osteoporosis.
Symptoms of hyperparathyroidism can be
remembered by the rhyme “moans, groans,
stones, bones, and psychiatric overtones” :
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“moans” (complaints of not feeling well)
“groans” (abdominal pain, gastroesophageal
reflux)
“stones” (kidney)
“bones” (bone pain)
“psychiatric overtones” (lethargy, fatigue,
depression, memory problems)
Laboratory tests
Serum calcium
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In cases of primary, tertiary hyperparathyroidism
increased PTH consequently leads to increased
serum calcium (hypercalcemia)
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In secondary hyperparathyroidism effectiveness
of PTH is reduced.
Serum phosphorus
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Primary hyperparathyroidism levels are
abnormally low
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Secondary hyperparathyroidism serum
phosphorus levels are generally elevated
Alkaline phosphatase
Alkaline phosphatese levels are not elevated in all types of
hyperparathyroidism
Diagnosis
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PTH immunoassay
PTH
Serum calcium
Likely type
high
high
Primary hyperparathyroidism
high
Low or normal
Secondary hyperparathyroidism
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Tertiary hyperparathyroidism has a high PTH and high serum
calcium.
Treatment and monitoring
Surgery
If surgery is not available, the following
should be monitored
 Calcium level
 Bone density
 Check for kidney stones
Prevention
 Exercise
 Vitamin D-Adequate amounts of vitamin D aid
in calcium absorption.
 Stay hydrated
 No smoking
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Hypercalcemia
Fatigue
Depression
Mental Confusion
Anorexia
Nausea
Vomiting
Constipation
Increased urination
Cardiac arrythmias
Treatment
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Restricted Dietary Calcium
Rehydration
Forced Diuresis
Calcitonin
Anti resorptive agents (bisphosphonates)
Phosphate therapy