Natural Treatment to get rid of Hypothyroidism

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. More here...

The Hypothyroidism Revolution Overview


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Hypothyroidism Caused by Iodine Therapy

Radioactive iodine (13'I) is one of the common methods of treating patients with Graves' disease. This treatment leads to the development of hypothyroidism in most patients. The dose of 131I administered affects the onset of hypothyroidism. Of patients who receive 370 MBq (10 mCi) or more (> 5.55 MBq g of thyroid tissue), about 50 of patients become hypothyroid 1 year after treatment and about 70 of patients are hypothyroid 10 years after treatment.4445 Euthyroidism can initially be attained by treatment with a low dose of radioactive iodine (1.48 to 2.59 MBq g of thyroid tissue delivered) however, most patients subsequently develop hypothyroidism by 10 years or later.46

Hypothyroidism Caused by External Radiation to the Neck

External radiation to the neck is known to cause thyroid disorders, including hypothyroidism.47 Radiation doses of 4500 cGy or more cause hypothyroidism by 20 years in approximately 50 of patients of all ages,48 and more cases occur thereafter. The effect of radiation therapy on the development of hypothyroidism is dose and duration dependent. The higher the dose and the longer the observation period, the higher the incidence of hypothyroidism. The timing of development of hypothyroidism after the initial radiation therapy can be 4 months to years, depending on the dose and duration received.49 Ionized radiation releases reactive oxygen species from the water molecule.50 This appears to be the mechanism of radiation-induced hypothyroidism. In addition to hypothyroidism, radiation therapy to the neck also predisposes to hyperthyroidism, thyroid cancer, Hashimoto's thyroiditis, and benign thyroid nodules.48 49 Lifelong observation is needed in patients who received external radiation...

Iodide Induced Hypothyroidism

Hypothyroidism caused by excessive iodine intake has also been observed in patients having the following conditions or underlying diseases history of postpartum thyroiditis, after a previous episode of subacute thyroiditis, and recombinant INF-a treatment.55 The hypothyroidism is transient, and thyroid function returns to normal 2 to 3 weeks after iodide withdrawal however, long-term follow-up is needed for these patients because some subsequently develop permanent primary hypothyroidism.55

Laboratory Testing for Detection of Hypothyroidism

The diagnosis of hypothyroidism is now focused on a single or most cost-effective test. A single TSH test was advocated for screening of thyroid dysfunction in 1993.62 Serum TSH measurements use highly sensitive second- and third-generation assays, based on lower limits of detection of 0.1 and 0.01 (xU mL, respectively. The TSH test accurately measures thyroid function and helps provide accurate thyroid hormone treatment. The limitation of the single TSH test is missing central hypothyroidism, since serum TSH concentrations in most patients with central hypothyroidism are normal.63 In addition, some patients have elevated serum TSH concentrations (immunologically active and biologically inactive TSH) despite the presence of central hypothyroidism.63 Using serum free thyroxine (FT4) alone as a diagnostic test of hypothyroidism detects hypothyroidism and monitors rapidly changing function better, but it cannot detect subclinical hypothyroidism. Also, low FT4 alone is not sufficient to...

Spectrum of thyroid disease

There are two general modes of presentation for thyroid disorders changes in the size or shape of the gland and changes in secretion of hormone from the gland. In some cases, structural changes can result in changes in hormone secretion. Thyroid nodules and goiters in euthyroid patients are common problems. Patients with a goiter who are biochemically euthyroid often require no specific pharmacotherapy, unless the goiter is due to iodine deficiency. In developing countries, iodized salt is the primary therapy in treating goiter. Thyroid nodules, seen in 4 to 7 of adults, may be malignant or may autonomously secrete thyroid hormones. A discussion of thyroid nodules is beyond the scope of this chapter however, thyroid cancer will be discussed briefly in the context of levothyroxine (LT4) suppressive therapy. Refer to other resources for a more extensive review of thyroid cancer management. Changes in hormone secretion can result in hormone deficiency or excess. While patients with overt...

Epidemiology of thyroid disease

A number of studies have assessed the epidemiology of thyroid hormone abnormalities. The 1999 to 2002 National Health and Nutrition Examination Survey (NHANES)1 reported the prevalence of thyroid hormone disorders in 4,392 people 12 years of age and over in a sample representing the geographic and ethnic distribution of the U.S. population. Hypothyroidism was found in 3.7 (3.4 mild) and hyperthyroidism in 0.5 of the sample. The prevalence of hypothyroidism was higher in older age groups and in whites and Hispanics, whereas blacks had a lower prevalence of hypothyroidism. The prevalence of hypothyroidism correlated with age. Compared to the total population, people of age 50 to 79 had an almost twofold higher prevalence, and those age 80 and older had a fivefold higher prevalence. Pregnant women also had a higher prevalence of hypothyroidism. The Colorado Thyroid Health Sur-2 vey assessed thyroid function in 25,862 subjects attending a health fair. The overall prevalence of an abnormal...

Screening for Hypothyroidism

Because the prevalence of hypothyroidism is high in certain populations, screening may be useful. Screening for hypothyroidism in women over age 35 is as cost effective as screening for breast cancer and hypertension,8 although some organizations recommend screening of adults over the ages of 50 or 60. Others advocate a case-finding approach, defined as performing a TSH determination in patients based on risk factors or the presence of signs and symptoms.9,10 Refer to Clinical Presentation and Diagnosis of Hypothyroidism for more information regarding screening and diagnosis.

Causes of Hypothyroidism

The most common causes of hypothyroidism are listed in Table 44-2 of patients with autoimmune thyroiditis have circulating anti-TPOAbs. The autoim Iatrogenic hypothyroidism can follow thyroid irradiation or surgery and excessive doses of antithyroid drugs. Several drugs can cause hypothyroidism, including iodine-containing drugs such as amiodarone and iodinated radiocontrast media, lithium, in-terferon-a, sunitinib, -aminosalicylic acid, ethionamide, sulfonylureas, valproic acid, and aminoglutethimide.13 Iodine deficiency is a common worldwide cause of hypothyroidism, including congenital hypothyroidism in newborns. Patients with hypo-thalamic or pituitary disease often have other signs of piuitary disease, such as hypo-gonadism, and the TSH level will be low. Table 44-2 Common Causes of Hypothyroidism

Signs and Symptoms of Hypothyroidism

Hypothyroidism can affect virtually any tissue or organ in the body. The most common symptoms, such as fatigue, lethargy, sleepiness, cold intolerance, and dry skin, are nonspecific and can be seen with many other disorders. The classic overt signs, such as myxedema and delayed deep tendon reflexes, are seen uncommonly now because more patients are screened or seek medical attention earlier. Patients with mild hypothyroidism may have subtle symptoms that progress so slowly that they are not noticed easily by the patient or family. The lack of overt or specific signs and symptoms emphasizes the importance of using the serum TSH level to identify patients with hypothyroidism.

Congenital Hypothyroidism

The hypothalamic-pituitary-thyroid axis is active by midgestation and mature by birth. Prior to midges-tation, fetal development relies on maternal thyroid hormones (Greenspan and Gardner 2004). Congenital hypothyroidism occurs in approximately 1 of 4,000 live births and is usually due to thyroid dysgenesis or deficits in thyroid hormone production. Congenital hypothyroidism is one of the most common causes of mental retardation however, because maternal thyroid hormones transfer across the placenta, early diagnosis and treatment with L-thyrox-ine can result in normal cognitive development of affected children (New England Congenital Hypothyroidism Collaborative 1990). Maternal hypothy-roidism alone, or in conjunction with fetal hypothy-roidism, leads to cognitive impairment in children despite postnatal therapy. This observation illustrates the importance of thyroid hormone exposure during early fetal development for subsequent cognitive function (Haddow et al. 1999 Morreale de...

Circulating Thyroid Hormones

Biosynthesis of thyroid hormone is unique among endocrine glands because final assembly occurs extracellularly in the fol-licular lumen. The source of thyroid hormones (T4 and triiodothyronine, or T3) is thyroglobulin (Tg), an iodoprotein produced by thyroid follicular cells. Thyroglobulin is the major portion of intraluminal colloid and is the most important protein of the thyroid gland (Kopp, 2005). Thyroglobu-lin provides a matrix for the synthesis of thyroid hormones and a vehicle for subsequent storage. Stored thyroglobulin is oxidized by thyroid peroxidase (TPO), adding an iodine molecule to tyrosine to form monoiodotyrosine (MIT) and diio-dotyrosine (DIT). MIT and DIT are then assembled into the final products, tetraiodothyronine (T4) and triiodothyronine (T3), which are stored in the follicular colloid for future use. When stimulated by serum thyrotropin (sTSH), thyroglobulin within the colloidal space is internalized by thyroid cells and enzymatically degraded to release T4...

Other Forms of Hypothyroidism

Central hypothyroidism is caused by pituitary failure and is rare. The diagnosis is suggested with low to nonexistent sTSH levels in a patient without symptoms of hypermetabolism (thyrotoxicosis) and with low circulating FT4. Generally, when presented with these data, further evaluation to determine the etiology of the hypothyroidism is not necessary. However, the patient should be evaluated for pituitary failure if not already done (see Pituitary Disorders). Depending on the degree of injury to the thyroid gland, thyroiditis (postpartum, sporadic, and subacute) can result in a transient hypothyroid state, with eventual recovery. Subacute thyroiditis is more likely to undergo this process, with insufficient T4 production for 3 to 6 months. Treatment is usually unnecessary, but low-dose thyroxine replacement can be used on a temporary basis for patients who become symptomatic. Other causes of hypothyroidism include dietary iodine deficiency, surgery, 131I radiation therapy, and...

Screening for Thyroid Disease

Screening for asymptomatic thyroid disease is controversial, although screening in specific populations may be beneficial. Women over age 50 have the highest incidence of spontaneous hypothyroidism compared with all males and mixed younger populations, approaching 5 per year. Thus, screening has a good chance of finding disease early. However, the evidence supporting benefit from early intervention is weak and probably does not justify cost. Patients who present with paroxysmal atrial fibrillation should be routinely screened for hyperthyroidism, although the incidence of positive findings is low (AACE, 2002). One area where screening is advantageous is patients with newly diagnosed dementia. This is especially true if the clinical course is atypical or accelerated. Both hypothyroidism (myxedema) and hyperthyroidism (apathetic thyrotoxicosis) can present with dementia-like symptoms, and in these patients, timely intervention can completely reverse the signs and symptoms of dementia or...

Treatment of Hypothyroidism

There are three major goals in the treatment of hypothyroidism replace the missing hormones, relieve symptoms, and achieve a stable biochemical euthyroid state. While these goals should not be difficult to achieve, 20 to 40 of treated patients are not receiving optimal pharmacotherapy. and T3, and animal-derived products. Despite the availability of a wide array of thyroid hormone products, it is clear that synthetic LT4 is the treatment of choice for almost all patients with hypothyroidism.11 12 Using LT4 mimics the normal physiology of the thyroid gland, which secretes mostly T4 as a prohormone. Peripheral tissues convert T4 to T3 as needed, based on metabolic demands. If T3 is used to treat hy-pothyroidism, the peripheral tissues lose their ability to control local metabolic rates. LT4 also has distinct pharmacokinetic advantages over T3. With a 7 to 10 day half-life, LT4 provides a very smooth dose-response curve with little peak and trough effect. In a small number of patients...

Patient Care and Monitoring Hypothyroidism

Use serum TSH to identify patients with hypothyroidism and to monitor LT4 replacement therapy. 2. Use synthetic LT4 as the treatment of choice for hypothyroidism. 3. Provide LT4 replacement to patients with overt hypothyroidism. 5. Provide the calculated full replacement LT4 dose (1.6 mcg kg day based on ideal body weight if obese) to patients with overt hypothyroidism who are older than 12 and younger than 65 years of age and who do not have cardiac disease. 6. Patients with mild hypothyroidism may be started at 25 to 50 mcg day of LT4. 9. The target TSH for patients on LT4 replacement therapy for hypothyroidism is 0.5 to 2.5 milliunits L. Most patients feel best at a TSH level in the low- to middle-normal range (i.e., 0.5-1.5 milliunits L).* 16. Check a TSH in pregnant women as soon as the pregnancy is diagnosed. In hypothyroid pregnant women, check the TSH monthly, and expect to raise the LT4 dose during the first trimester. Maintain the TSH in the low- to middle-normal range....

Sequelae of Hypothyroidism

Hypothyroidism is a chronic disease that may result in significant long-term sequelae. Hypercholesterolemia is associated with hypothyroidism, increasing the long-term risk of cardiovascular disease and cardiovascular mortality.14 Between 4 and 14 of patients with hypercholesterolemia are found to be hypothyroid. The Colorado Thyroid Health Study showed a direct correlation between the degree of TSH elevation and the rise in serum cholesterol. Hypothyroidism also may result in increased systemic vascular resistance, decreased cardiac output, and increased diastolic blood pressure. Hypothyroidism can cause significant neuropsychiatric problems, including a dementia-like state in the elderly that is reversible with LT4 therapy. Maternal hypothyroidism can have dire consequences for the developing fetus. The fetus is almost completely dependent on maternal thyroid hormones during the first trimester, a time crucial for development of the CNS. Inadequately treated maternal hypothyroidism...

Painful de Quervains Thyroiditis

Painful thyroiditis is a transient inflammatory thyroid disorder that was first described by de Quervain in 190421 and is the most common cause of a painful thyroid gland. Other eponyms for this condition include granulomatous thyroiditis, subacute granulomatous thyroiditis, or pseudogranulomatous thyroiditis. Painful thyroiditis is thought to be viral in origin or result from a post-viral inflammatory response. This theory is supported by the following observations The inflammatory process may involve the entire gland or a single lobe. On cut section, the involved areas are firm and yellow-white. Microscopically, the changes vary with the stage of the disease and may overlap. Microabscesses, which result from neutrophil replacement of disrupted follicles, are commonly seen during the early inflammatory stage. Later, lymphocytes, histiocytes, and plasma cells are seen to accumulate around damaged follicles. Colloid (or fragments thereof) are surrounded by multinucleated giant cells,...

Acute Suppurative Thyroiditis

Acute thyroiditis was first described by Bauchet in 1857 and accounted for approximately 0.1 of thyroid surgeries before the advent of antibiotic therapy.1 The thyroid gland has an innate resistance to infection due to its extensive blood and lymphatic supply, high iodide content, and fibrous capsule.2 Despite these protective mechanisms, acute thyroiditis may be caused by infectious agents that seed the thyroid gland (1) by the hematogenous or lymphatic route, (2) by direct spread from persistent pyriform sinus fistulas or thyroglossal duct cysts, or (3) as a result of penetrating trauma to the thyroid gland.3 Takai and associates first demonstrated that acute suppurative thyroiditis can result from persistent pyriform sinus fistulas.4 Since then, several investigators have demonstrated that pyriform sinus fistulas are responsible for a large proportion of cases of recurrent acute thyroiditis. These fistulas are commonly believed to be fourth branchial pouch remnants and originate at...

Thyroid Disease in Pregnancy

Pregnancy can exacerbate an already-existing thyroid disorder, thus requiring extra vigilance by the family physician. Careful monitoring and proactive clinical intervention are key. The majority of women with hypothyroidism, who are euthyroid on stable doses of thyroid replacement, will require increased doses of thyroxine replacement during their pregnancy. Being aware of this need and prepared to make dosage adjustments in a timely manner is important. Consulting an endocrinologist to help with the care of these patients is advised (Shankar et al., 2001). Silent (postpartum) thyroiditis during pregnancy is essentially a benign, short-term disease and requires only symptomatic treatment. Occasional checks of sTSH and FT4 levels are justified to monitor recovery.

Lymphocytic Hashimotos Thyroiditis

Lymphocytic thyroiditis was first described in four female patients by Hashimoto in 1912 as struma lymphomatosa a transformation of thyroid tissue to lymphoid tissue.55 Subsequently, Roitt and colleagues demonstrated thyroid autoantibodies in patients with this disease.56 Chronic autoimmune thyroiditis has two different clinical manifestations an atrophic form and a goitrous form. The latter is also known as Hashimoto's thyroiditis57 and is the most common inflammatory disease of the thyroid. Prevalence rates of chronic autoimmune thyroiditis vary depending on the criteria used for diagnosis. Autopsy studies demonstrate that 40 to 45 of women and 20 of men in the United States and United Kingdom have focal thyroiditis.58 59 Most autopsy and thyroid antibody studies document Hashimoto's thyroiditis in approximately 17 of women in the United States and Japan.60 However, a recent review of population-based studies with strict criteria for the diagnosis of Hashimoto's thyroiditis reported...

Hashimotos Thyroiditis

Hashimoto's thyroiditis, known as an autoimmune or chronic lymphocytic thyroiditis, is the leading cause of hypothyroidism. The pathogenesis of hypothyroidism is complex. Three mechanisms have been proposed (1) thyroid cell damage by the thyroid antibody-mediated complement attachment (2) T-cell-mediated cytotoxicity and (3) enhanced apoptosis (programmed cell death). The initial event is the formation of antibody in response to self-antigen such as thyroid peroxidase (TPO) and thyroglobulin this event does not normally happen. If self-antigen is falsely recognized by the immune system, antibody formation takes place to the specific self-antigen, creating organ-specific autoimmunity. This leads to immune complex deposition in the basement membrane of follicular cells and complement activation, as suggested in 1977.9 Weetman and associates confirmed the presence of terminal complement complexes around thyroid follicles.10 Thyrocytes attacked by complement through antibodies were shown...

Hypothyroidism after Subtotal or Total Thyroidectomy

Subtotal thyroidectomy is still an excellent form of treatment for patients with Graves' disease, particularly when antithyroid drugs and 1311 therapy are not suitable.51 Surgical approach has three advantages over radioactive iodine therapy. First, the incidence of overt hypothyroidism is considerably less than after radioactive iodine therapy. Second, the incidence of hypothyroidism does not increase as much in later years. Third, patients with Graves' ophthalmopathy are less likely to develop progression than after radioactive iodine therapy. Kuma and associates characterized the type of postoperative hypothyroidism after surgery in patients with Graves' disease who underwent subtotal thyroidectomy.52 Nearly 40 to 50 of patients experienced subclinical hypothyroidism during the first 4 years after surgery, and the incidence correlates inversely with the size of the thyroid remnant. Palit and colleagues reviewed 35 published papers regarding subtotal thyroidectomy for Graves'...

Central Hypothyroidism

Abnormalities of the pituitary gland, such as pituitary tumor, ischemic lesion (Sheehan's syndrome), and iatrogenic events (surgical removal or radiation therapy), can cause central hypothyroidism with decreased pituitary TSH secretion. Other rare causes of pituitary lesions include tuberculosis, syphilis, hemochromatosis, sarcoidosis, histiocytosis, and aneurysms of the internal carotid artery. Hypothalamic lesions, such as suprasellar extension of pituitary tumors or craniopharyngioma, meningioma, glioma, and metastatic tumors, can damage the hypothalamus and decrease thyrotropin-releasing hormone (TRH) secretion. This event leads to decreased TSH secretion and subsequent hypothyroidism. Chronic head trauma (e.g., in boxers) can also be the cause of hypothalamic dysfunction. Bexarotene, a retinoid X receptor-selective ligand used for treatment of T-cell lymphoma, has been shown to suppress TSH secretion and cause reversible central hypothyroidism.56 Hereditary central hypothyroidism...

Etiology of Iodine Deficiency

Iodine is an essential substrate in the synthesis of the thyroid hormones L-thyroxine (T4) and L-triiodothyronine (T3). The normal human thyroid gland releases about 65 (ig of hormonal iodine to the circulation per day, which represents the minimum daily requirement of iodine. Iodine requirements increase during puberty, pregnancy, and lactation. Low supply of dietary iodine is the main cause of development of endemic goiter. Because it is difficult to measure the iodine content of foods, the adequacy of dietary iodine is usually determined by the measurement of urinary excretion of iodine. This measurement represents the ratio between concentrations of iodine and creatinine in casual urine samples.13 Two or more casual urine samples from the same individual taken on consecutive days are recommended to allow for variation in creatinine content.14 Experience has shown that the iodine concentration in early-morning urine specimens adequately reflects an individual's iodine status. In...

Acquired Juvenile Hypothyroidism

Hypothyroidism occurs in either sex from infancy through adulthood but most commonly presents during pubertal development in girls (LaFranchi 1992). In pediatric populations, acquired hypothy-roidism typically results from autoimmune destruction of the thyroid gland. Classic symptoms of acquired hypothyroidism include poor growth, weight gain, poor concentration, depression, and fatigue. Similar to congenital hypothyroidism, acquired hy-pothyroidism is treated with levothyroxine (Fisher and Grueters 2008). Data from the Third National Health and Nutrition Examination Survey reveal that adolescents with subclinical hypothyroidism outperform their euthyroid counterparts on reading and block design tests (Wu et al. 2006). Subclinical hypothyroidism consists of mild elevation of thyroid-stimulating hormone with normal thyroid hormone levels (Biondi and Cooper 2008) (see Figure 19-1). The observation of Wu et al. (2006) agrees with an earlier report of decline in school performance...

Riedels Thyroiditis

Riedel's thyroiditis is a rare variant of thyroiditis that was initially described in two patients by Riedel in 1896 and subsequently in a third patient in 1897.103104 It is also known as Riedel's struma or invasive fibrous thyroiditis and leads to a wood-like thyroid gland. A review of the Mayo Clinic experience disclosed 37 cases in 56,700 thyroidectomies over a 64-year period.105 Riedel's thyroiditis is characterized by the replacement of thyroid parenchyma by fibrous tissue, which also invades into adjacent tissues. The etiology of this disorder is controversial and has not been resolved. This disorder has been reported to occur in patients with other autoimmune diseases such as pernicious anemia and Graves' disease. This association, coupled with the presence of lymphoid infiltration and response to steroid therapy, led some investigators to suggest a primary autoimmune etiology.106107 Riedel's thyroiditis is also associated with other focal sclerosing syndromes, including...


Hypothyroidism is the most common clinical disorder of thyroid function. It is the clinical syndrome that results from inadequate secretion of thyroid hormones from the thyroid gland. The vast majority of hypothyroid patients have primary gland failure, whereas rare patients have pituitary or hypothalamic failure. Most studies define hypothyroidism based on a serum TSH level above the upper limit of the laboratory reference range. In adults, 1.4 of women and 0.1 of men are biochemically hypothyroid. However, the incidence is highly age-dependent. In the Colorado Thyroid Health Study, by age 64, 12 of women and 5 of men were hypothyroid, and in the over 74 year age group, the incidence in men approached that of women. Most epidemiologic studies of hypothyroidism in the elderly show a prevalence of 6 to 12 . There is a strong correlation between the presence of anti-TPOAb or anti-TGAb and the risk of developing hypothyroidism. In patients with subclinical hypothyroid-ism and positive...


Forms of thyroiditis include postpartum (silent) sporadic, which is a variant of postpartum but outside the postpartum period subacute (granulomatous) chronic autoimmune (Hashimoto's) and other, which includes bacterial or pyogenic (Farwell, 2005 Lazarus, 2005). The forms usually encountered in primary care are postpartum, sporadic, and chronic autoimmune, which are all autoimmune diseases, and subacute, which is thought to be viral in etiology. The mechanism of injury to the thyroid gland is disruption of thyroid architecture caused by lymphocytic infiltration, resulting in leakage of colloid-stored thyroxine into the peripheral circulation. This nonphysiologically triggered leakage of stored T4 causes a spike in peripheral circulating T4 and transient hypermetabolic symptoms. Early testing in the disease can demonstrate an elevated FT4 level, although not necessarily outside the normal range. Depending on duration of the destructive process and degree of injury, sTSH may be normal,...

Iodine Deficiency

Iodine deficiency is a serious worldwide problem, particularly in Africa, China, southern Asia, and Europe. It is estimated that about 1 billion people are iodine deficient. About 20 million people have endemic goiter and 2 million people have endemic cretinism.53 To form adequate amounts of thyroid hormone, 100 to 150 ig day of iodine is needed.53 If iodine intake is less than 100 ig day, endemic goiter may develop. Further decrease in iodine intake of less than 25 ig day may cause endemic cretinism.53 Most patients with endemic goiter have normal thyroid function however, hypothyroidism develops when iodine deficiency is severe. Endemic cretinism is divided into two types neurogenic and myxedematous.54 The former is more common than the myxedematous type and is characterized by irreversible neurologic deficits such as deafness, gait abnormality, squint, and spasticity. Curiously, neurogenic cretins are euthyroid, despite severe iodine deficiency. Myxedematous cretinism is relatively...

Painless Thyroiditis

Painless thyroiditis is also known as lymphocytic thyroiditis with spontaneously resolving hyperthyroidism, subacute lymphocytic thyroiditis, painless lymphocytic thyroiditis, painless thyroiditis, or silent thyroiditis. Painless thyroiditis may occur sporadically or in the postpartum period. Both variations of subacute painless thyroiditis are considered to be autoimmune in origin. Like Hashimoto's thyroiditis, patients with painless thyroiditis have a high prevalence of anti-thyroid peroxidase (anti-TPO or antimicrosomal) antibodies and lymphocytic infiltration of the thyroid gland.30 Furthermore, painless thyroiditis is also associated with other autoimmune conditions such as Sjogren's syndrome,31 autoimmune Addison's disease,32 Graves' disease,33 and Hashimoto's thyroiditis.34 There is also evidence for a genetic predisposition with an association with HLA-DR3, -DR4, and -DR5 haplotypes.35 36 The evidence supporting an autoimmune origin for postpartum thyroiditis is much stronger....

Synthesis of Thyroid Hormone

After uptake into the follicular cells through the basal membrane (Fig. 1-2), inorganic iodide is rapidly oxidized. Thyroid hormones are then synthesized by the combination of iodine with tyrosyl residues within the protein thyroglob-ulin. This reaction is catalyzed by thyroperoxidase in two principal steps. In the first reaction, iodide reacts with tyrosyl residues in thyroglobulin to form monoiodotyrosine (MIT) and diiodotyrosine (DIT). In the second reaction, MIT and DIT condense to form 3,5,3'-triiodothyronine (T3) or the inactive 3,3',5'-triiodothyronine (rT3), whereas two molecules of DIT condense to form T4. T3 and rT3 are also formed by intrathyroidal deiodination of thyroxine, catalyzed by deiodinase enzymes.23 In conditions of iodine-sufficient intake, the predominant iodothyronine synthesized by the thyroid gland is T4.24 Once formed, the thyroid hormones, covalently bound to thyroglobulin, are stored in colloid within the center of the follicle. The thyroid gland contains...

Diencephalic Dysfunction

Disorders of the diencephalon may affect consciousness either directly, by interfering with reticular system function, or indirectly, by producing endocrine disorders. These conditions may develop slowly, as with anterior pituitary syndromes resulting in hypothyroidism or cortisol deficiency, or rapidly, as with osmoregulatory disorders. The lesions producing these problems may also affect the cerebral cortex, as in the case of neoplasms, and produce seizures or other focal neurological disorders. Patients with structural diencephalic lesions may have toxic downward eye deviation, small pupils, decorticate posturing, and Cheyne-Stokes respirations as an archetype, although varying combinations of signs may appear.

Pathophysiology of Endemic Goiter

Clinical euthyroidism is thus maintained, but biochemically the pattern of low serum T4, elevated TSH, and normal or supranormal T3 is often found.2224 In severe thyroid failure, such as that in endemic cretinism, serum T3 and T4 concentrations are low and serum TSH concentration is markedly elevated. In less severe thyroid endemism, serum T3 and T4 concentrations may remain normal. The serum TSH level may also be normal or moderately elevated, and there may be an exaggerated TSH response to thyrotropin-releasing hormone (TRH) simulation, implying an increase in the pituitary reserve of TSH and subclinical hypothyroidism.

Treatment and Prophylaxis

An increased incidence of thyrotoxicosis occurs after increased iodine consumption. This increase was observed in Tasmania after bread iodination in 1966 and was most evident in older people.44 The thyrotoxicosis was attributed to the presence of autonomous nodules or underlying hyperthyroidism in persons with long-standing endemic goiters. Overall, however, the long-term correction of iodine deficiency not only abolishes endemic goiter but also reduces the incidence of toxic nodular goiters. Therefore, the occurrence of thyrotoxicosis does not outweigh the enormous benefits of iodine prophylaxis in endemic regions. However, iodination does have some risk in individuals older than 45 years with goiter, because hyperthyroidism may develop. For the patient with hypothyroidism and endemic goiter, the functional and neurologic changes are irreversible.

Environmentally Induced Goiter

IODINE DEFICIENCY Endemic goiter is discussed in Chapter 3. An inadequate adaptive mechanism of the thyroid to protect from severe iodine deficiency results in the development of goiter. These adaptive mechanisms include increased iodide clearance, increased production of triiodothyronine (T3) relative to thyroxine (T4), and increased mass of thyroid follicular cells.1 Pregnancy increases the need for iodine and T4, which results from significant transfer of thyroid hormone from the mother to the fetus and also increased iodide loss in the urine.12 Iodine-deficient thyroid tissue is more growth responsive to thyroid-stimulating hormone (TSH) than is iodine-replete thyroid tissue.13 Thyroid cellular growth is also influenced by the higher human chorionic gonadotropin serum concentrations that occur during pregnancy.14 The development of sporadic goiter is influenced by many factors. Thiocyanate is a well-known goitrogen produced from cigarette smoke and vegetable foods such as cassava...

Associated Neurological Findings

The sensory examination is the most subjective part of the evaluation and can be difficult to interpret. The presence of a sensory abnormality triggers the same differential diagnosis as that used for a mentally normal person. It is important to test vibratory and position sensations in a patient with a mood or thought disorder. A sensory neuropathy should lead the clinician to assess nutritional problems (vitamin B 12 deficiency), infections (human immunodeficiency virus HIV and syphilis), hypothyroidism, or malignancy. The gait should also be checked. An obviously factitious gait may cast doubt on the organicity of an unexplained mood, emotion, or thought abnormality encountered during other parts of the examination. However, gait ataxia and mood disorders may occur in the context of alcoholism and multiple sclerosis, and more rarely with hypothyroidism. Assessment of vital signs, preferably performed prior to administration of medications, is very important. Fever should...

Control and Treatment of Contributing Disorders

All causes of HF must be investigated to determine the etiology of cardiac dysfunction in a given patient. Because the most common etiology of HF in the United States is ischemic heart disease, assessment for cardiac ischemia, which may include stress testing, echocardiography, and or coronary angiography is warranted in the majority of patients with a history suggestive of underlying CAD. Revascularization of those with significant CAD may help restore some cardiac function in patients with reversible ischemic defects. Aggressive control of hypertension, diabetes, and obesity is also essential because each of these conditions can cause further cardiac damage. Surgical repair of valvular disease or congenital malformations may be warranted if detected. Because clinical HF is partly dependent on metabolic processes, correction of imbalances such as thyroid disease, anemia, and nutritional deficiencies is required. Other more rare causes such as autoimmune disorders or acquired...

Intervention Versus Observation

Exposure to low or moderate doses of therapeutic radiation also dramatically increases the risk of thyroid cancer.32 Previous investigations document that exposure to as little as 6 cGy radiation increases the risk of thyroid cancer sixfold.33 The risk increases as the dose of radiation increases to 2000 cGy. Higher doses of radiation, such as 5000 to 6000 cGy, result in hypothyroidism, but thyroid cancer does not appear to increase appreciably, probably because the thyroid cells are destroyed.32 Younger children who receive radiation are most likely to develop thyroid cancer. A genetic predisposition to developing thyroid cancer after exposure to low-dose therapeutic radiation or radiation fallout may be present.3435

Clinical Assessment and Diagnosis

Routine laboratory testing of patients with AHF includes electrolytes and blood glucose, as well as serum creatinine and blood urea nitrogen to assess renal function. CBC count is measured to determine if anemia or infection is present. Creatine kinase and or troponin concentrations are used to diagnose ischemia, and hepatic transaminases are measured to assess hepatic congestion. Thyroid function tests are measured to assess hyperthyroidism or hypothyroidism as causes of AHF. A urinalysis is obtained in patients with an unknown history of renal disease to rule out nephrotic syndrome. Lastly, a toxicology screen is obtained in patients in whom use of illicit drugs is suspected.

Prevalence and Subclinical Forms

The prevalence rates of overt hypothyroidism and subclinical hypothyroidism in the general population are 0.4 and 9 , respectively, based on the Colorado Thyroid Disease Prevalence Study.1 The National Health and Nutrition Examination Survey (NHANES) III in the United States showed overt hypothyroidism of 0.3 and subclinical hypothyroidism of 4.3 in the general population in all ages.2 Thus, subclinical hypothyroidism is 16 to 20 times more common than overt hypothyroidism. The prevalence of subclinical hypothyroidism increases with age and is more common in women than in men. In groups older than 70 years of age, a steep increase in prevalence of subclinical hypothyroidism is apparent it reaches to 14 in the white population and 5 in the black population.2 Subclinical hypothyroidism, therefore, should always be suspected whenever elderly patients undergo surgical procedures. Most patients with subclinical hypothyroidism have either mild symptoms of hypothyroidism or nonspecific...

Professional healthcare

In the uterus, babies may be tested for genetic disorders such as Down's syndrome. Immediately after birth, a baby's appearance and responses are checked for abnormalities, and a few days later, a blood sample is taken from the heel to look for hypothyroidism (underactivity of the thyroid gland) and phenylketonuria (a metabolic defect that can cause brain damage). In early childhood, the acquisition of certain skills, known as Hypothyroidism and phenylketonuria (a rare metabolic disorder)

Class 3 antiarrhythmic drugs

Should be diluted and administered slowly (5 mg kg l over at least 5-10 min) to avoid bradycardia, hypotension (particularly if LV function is poor) and thrombophlebitis. It prolongs PR and QT intervals AV block may also occur. It is contraindicated in the presence of bradycardia or AV block, and should not be combined with diltiazem, verapamil or drugs which prolong the QT interval (e.g. phenothiazines, sotalol or class la antiarrhythmics). Bradycardia unresponsive to atropine, and hypotension have been reported during general anaesthesia in patients receiving amiodarone therapy. Oral amiodarone is absorbed slowly, is highly protein-bound, widely distributed in the tissues, and one of the hepatic metabolites is active. Its half-life is extremely prolonged (up to 50 days) but shows significant interpatient variation oral doses are reduced after initial loading. Long-term therapy produces reversible corneal microde-posits, cutaneous photosensitivity and pigmentation, pulmonary fibrosis...

Additional Neurological Findings

The general physical examination may reveal reversible memory disturbances, the most common causes of which are intracranial masses, normal pressure hydrocephalus, thyroid dysfunction, and vitamin B12 deficiency. Examination of the patient's general appearance, vital signs, skin and mucous membranes, head, neck, chest, and abdomen should reveal clinical signs that will aid in the differential diagnoses of dementia and amnesic syndromes. Fever, tachycardia, hypertension or hypotension, sweating, hypothermia, and impaired level of consciousness should suggest a systemic disease, anticholinergic intoxication, or withdrawal from ethanol or sedative drugs rather than an isolated memory disorder. Jaundice suggests hepatic disease glossitis, intestinal problems, and yellowish skin suggest a vitamin B12 deficiency hot, dry skin is often characteristic of anticholinergic drug intoxication. Hypothermia, hypotension, bradycardia, coarse dry skin, brittle hair, and subcutaneous edema are...

Evaluation Guidelines Table52

Vitamin B,2 deficieney, thyroid disease Infectious illnesses Fluid and Tissue Analysis. Memory impairment may occur secondarily to conditions such as drug and alcohol intoxication or withdrawal and to systemic diseases such as vitamin deficiencies, endocrine disorders (specifically thyroid disease), chronic infections, or carcinomas. These are often treatable conditions diagnosed by analysis of tissue (by biopsy) or fluids (by tests of blood and urine). When a treatable condition is found, further evaluation of memory need not be performed unless the memory impairment persists or becomes worse after the underlying disease has been treated. Some tests, such as the sedimentation rate, are nonspecific but lead the investigator toward other tests that may properly document a condition such as vasculitis or cerebritis. Choice of the biopsy site depends on the diagnosis being actively entertained--for example, amyloidosis is often diagnosed by rectal biopsy, while temporal arteritis is...

Thyroid Hormone Treatment

There are three thyroid hormone preparations l-thyroxine (T4), T3, and combined T4 and T3 (desiccated thyroid Thyrolar ). Synthetic levothyroxine (l-T4) is used most often and has distinct advantages long half-life of 7 days and efficient conversion to T3. Thus, this medication is given once a day, and missing a dose for 1 to 2 days is not harmful. l-T4 also generates T3 in the liver, the kidney, the brain and other tissues, providing tissue T3. The dose of l-T4 of 1.7 Jig kg (0.075 to 0.15 mg day) should normalize the serum TSH level in most patients with hypothyroidism.70 The daily requirement of T4 is 100 to 150 fig for adults, 50 to 100 Xg for children, and 50 Xg for infants. These are commonly used doses the dose may need to be adjusted for some patients depending on body weight and severity of hypothyroidism. Patients with myocardial ischemia or cardiac arrhythmia, such as atrial fibrillation, should be treated using a small starting dose of thyroxine (0.0125 to 0.025 mg once a...

Conditions that Affect the Maintenance Dose of T4

Several conditions require increasing the dose of T4. Pregnancy is the most important because more T4 is needed during pregnancy in patients with hypothyroidism based on serial serum TSH measurements.77 Similarly, patients with hypothyroidism who take estrogen require more thyroid hormone due to increased thyroid-binding protein by estrogen and subsequent decrease in available FT4.78 Medications to decrease T4 absorption include cholestyramine, sucralfate, ferrous sulfate, aluminum hydroxide, and calcium carbonate.79,80 Increased thyroid hormone replacement should be considered if patients are on these medications. Patients should also take these medications at a different time than when they take their thyroid hormone. Measurement of serum TSH levels is an excellent method to determine the appropriate T4 dose in patients with primary hypothyroidism. In contrast, some conditions require decreased thyroid hormone dose. Androgen therapy decreases T4-binding globulin and increases FT4...

Coronary Bypass Surgery

Similar to those seen with chronic hypothyroidism. In fact, diminished cardiac contractility altered gene expression similar to that seen in hypothyroidism developed in animals.96 Also, T3 treatment increased left ventricular function in patients with congestive heart failure who also exhibited the picture of nonthyroidal illness.97-98 There have been several investigations showing the beneficial effects of T3 treatment given before and after CABG in adults and children by demonstrating increased cardiac output.99103 Administration of T3 had no adverse effects in most studies99'100,102 and even lowered the incidence of atrial fibrillation after cardiac surgery.103 The dose of T3 administered intravenously by Klemperer and colleagues was 1.4 jag kg of body weight over a period of 6 hours (average total dose of 110 Xg) starting immediately after surgery.103 If hypothyroid patients need bypass surgery, the same strategy of intravenous T3 treatment should be considered, but such...

Physiology and Pharmacology

Pituitary and cerebral cortical T3 is, however, produced predominantly by local deiodinase II action, and thus central nervous system levels of active thyroid hormone depend on both circulating T3 and T4. Conversion of T4 to T3 in these tissues contributes equally to or even as much as 80 to levels of nuclear bound T3 Therefore, although most peripheral tissues depend primarily on circulating T3 levels, the central nervous system is sensitive to both circulating T3 and T4.2426 In thyrotropin suppression treatment, the aim is not principally the physiologic replacement of T4 (and T3) as in hypothyroidism (although this may well be necessary in patients rendered hypothyroid after total or near-total thyroidectomy), but the use of T4 is to induce a particular level of TSH suppression by supraphysiologic dosing without rendering the patient clinically hyperthyroid. In this setting, the benefit-risk equation for TSH suppression therapy must be assessed for each patient on the basis of the...

Thyroxine and Lipid Metabolism

There is an overall increase in hyperlipidemia in overt hypothyroidism, and there have been claims of higher mortality from ischemic heart disease in undertreated patients.63,64 In subclinical hypothyroidism the biologic efficacy of thyroid hormone replacement has been confirmed with observed changes in serum lipoprotein concentration, improvement in cognitive performance and indices of cardiac function, and reduction of subjective symptoms. The majority of patients show no fundamental changes in lipid profile during levothyroxine treatment for TSH suppression,65 but occasional reports of deleterious changes in relative high-density lipoprotein (HDL)-low-density lipoprotein (LDL) cholesterol concentration have been documented.6668 Franklyn and colleagues69 have argued that supraphysiologic levothyroxine may be distinctly beneficial because of its effects on LDL cholesterol in reducing the number of cardiac events in those so treated, but it may not be possible to extrapolate the...

Thyroid Stimulating Hormone Suppressive Treatment of the Multinodular Goiter

No clear response association exists with patient's age, duration of goiter, family history of thyroid disease, pretreatment thyroid volume, or preliminary radioactive iodine uptake.99122'125 The mechanism in the patients who respond is unknown, but T4 has been shown to influence thyrocyte growth synergistically in the presence of other growth-stimulating factors.126 Many questions remain concerning this type of treatment. What constitutes response Is complete regres-sion necessary, and is uniform regression ever possible Considering that a significant proportion of patients are never submitted for surgery, what is the true underlying incidence of carcinoma

Thyroid Stimulating Hormone Suppression and the Post Thyroidectomy Patient

Levothyroxine may prevent clinical hypothyroidism after bilateral or subtotal thyroidectomy and occasionally after unilateral lobectomy.139 In three randomized, controlled trials comparing levothyroxine with placebo, there was no demonstrable difference in nodular recurrence after a range of thyroid operations in the TSH-suppressed patients.140142 Miccoli and colleagues142 demonstrated an advantage for suppressive as opposed to substitutive T4 dosing on echographic follow-up at 3 years, but this was in an area of endemic goiter in northern Italy, where the rate of nodular recurrence postoperatively is normally relatively high. The particularly high early recurrence of echographically demonstrable postoperative recurrence after thyroidectomy in the latter article (78 on substitutive T4 therapy) may not be indicative of the general Western experience. Large, uncontrolled, retrospective series, however, with prolonged follow-up over periods ranging from 5 to 8 years, have failed to...

Thyroid Stimulating Hormone Suppression and Miscellaneous Benign Goiters

Given that there is an increased incidence of hypothyroidism and thyroid nodules in children exposed to head and neck irradiation for such conditions as Hodgkin's disease, neuroblastoma, Wilms' tumor, and leukemia, as well as in adults irradiated for breast cancer and lymphoma, the role of TSH suppressive therapy in an expanding population of patients needs to be defined.167168 The question remains whether patients who have been exposed should have suppressive treatment in the absence of nodules as well as the correct management of ultrasonographically demonstrable impalpable nodules. It should also be recognized that the rate of false-negative fine-needle aspiration cytology is significantly higher in the inradiated gland.169 What is also unknown is the role of TSH suppressive treatment during the time of neck irradiation. T4 may also be of value in the treatment of transient goitrous hypothyroidism in infants exposed to the transplacental passage of thyrotropin receptor antibodies...

Associated Medical Findings

Because one of the most common causes of orbital infiltration is thyroid disease, patients with orbital signs such as proptosis, chemosis and conjunctival injection together with abnormal ocular motility should be examined for goiter, pretibial myxedema, smooth moist skin, and loss of lateral eyebrows. y In thyroid disease, the extraocular muscles can develop edema, lymphocytic infiltration, and fibrosis, resulting in loss of elasticity more than loss of contractile strength. The diplopia that results from this restrictive feature is due to the tethering of the eye in an abnormal position by one or more shortened inelastic extraocular muscles.

Incidence and Prevalence

Autopsy studies have demonstrated the prevalence of unrecognized follicular thyroid neoplasms. In a detailed evaluation of 300 whole thyroid glands from people with no known thyroid disease, 13 had follicular adenomas (4.3 overall, 5 of men and 3 of women).4 Follicular carcinoma was found in four thyroids (1.3 overall, 0.5 of men and 3 of women). In a separate study that evaluated only grossly evident lesions in 625 thyroid glands, only two follicular carcinomas, both in men, were identified (0.3 overall).5 The difference between these studies probably lies in the thoroughness of evaluation of each thyroid gland unsuspected follicular cancer probably exists in approximately 1 of the population.

Sequelae Complications And Their Management

The majority of wound complications will heal with aggressive cleansing and infection control. Management of co-morbidities, such as diabetes mellitus, malnutrition and hypothyroidism, in order to maximize wound healing is critical. Poor healing or a persistent oral cutaneous fistula may result from the presence of a foreign body such as hardware, non-absorbable suture or sequestered bone. Persistent or recurrent tumor must be ruled out by biopsy in any non-healing wound after oral cancer surgery. The frequency, complexity and duration of wound complications are greater in the irradiated patient.

General Considerations

The World Health Organization estimates that more than 200 million people in the world have enlarged thyroid glands, a condition known as goiter. Asians first described goiter around 1500 bce. Even at that time, they recognized that seaweed in the diet tended to make goiters smaller. Iodine was not discovered until the 19th century, but it is now believed that those goiters were related to an iodine deficiency that was partially corrected by the iodine in the seaweed.

Clinical Characteristics

Hurthle cells are large polygonal, eosinophilic cells with pleomorphic, hyperchromatic nuclei and fine granular, acidophilic cytoplasm, representing an abundance of mitochondria (Fig. 14-1). The individual cells are 10 to 15 pm in diameter and can vary in shape and size from small dumbbells to bizarre giant cells. Hurthle cell neoplasms are encapsulated collections of Hurthle cells (Fig. 14-2). Therefore, the presence of nonencapsulated Hurthle cells does not signify a neoplastic process, because they are commonly associated with Hashimoto's thyroiditis, Graves' disease, and nodular goiters as well as with well-differentiated thyroid cancers.

Importance of LThyroxine Suppressive Therapy

Both the function and the growth of some metastatic thyroid tumors are under TSH control. It is a common observation that bone or lung metastases increase in size and take up radioiodine during periods of T4 withdrawal, whereas a reduction in size and lack of uptake are observed during periods of T4 therapy. Serum Tg, a marker of cell function, increases dramatically during hypothyroidism (see Fig. 17-1), whereas Tg levels return to low values during treatment with T4. In the classic article by Mazzaferri,30 thyroid hormone therapy significantly influenced both recurrence rate and survival as an independent variable. In this regard, suppression of endogenous TSH to undetectable levels is to be regarded as a true antineoplastic therapy and should never be omitted in patients with active disease.

Concluding Comments

Injury, and thyroid disease may be associated with anxiety symptoms for pediatric patients. In addition, a range of medications and substances should be considered as potential contributors to anxiety symptoms presenting in the medical setting. The evaluation of anxiety in the pediatric setting should be approached in a systematic fashion that takes into account the role of preexisting primary anxiety disorders as well as anxiety symptoms arising as a result of a psychological or physiological reaction to an organic condition. Treatment of anxiety disorders in the medical setting follows many of the same principles as treatment occurring in other settings, although a brief problem-focused approach is often necessary. Strong empirical evidence supports the use of individual and group CBT for anxiety as a first-line treatment however, patients in the inpatient medical setting often require pharmacological treatment of anxiety, at least temporarily, to help alleviate acute distress while...

Clinical Case 3 Atlantoaxial Instability

Figure 13-3 presents images from a CT scan of an 85-year-old woman with severe neck pain and occipital neuralgia. The pain had been progressively worsening during the past 12-month period despite analgesia. Past medical history included hypertension, hypothyroidism, and osteoarthritis resulting in bilateral knee arthroplasties. On physical exam no weakness or evidence of myelopathy was detected. Dynamic imaging revealed a C1-C2 atlantodens interval of 4 mm in neutral, increasing to 5 mm in flexion and in extension. CT imaging (see Figure 13-3) demonstrated gross evidence of atlantoaxial instability including pannus. The patient received temporary relief with a greater occipital nerve block. Because of the overwhelming disability attributable to her neck pain and occipital neuralgia, the patient was considered for surgical intervention.

Pathology of Tumors of the Thyroid Gland

This chapter concentrates on the epithelial tumors of the thyroid gland. The discussion centers on the pathology and cytopathology of carcinomas of the thyroid gland. Controversies involving criteria to determine histologic diagnoses and classification of thyroid tumors are described. Descriptions of nonepithelial tumors are included when appropriate. Nodular goiters, thyroiditis, hyperplastic changes in the thyroid gland, and other non-neoplastic changes are discussed in the context of the diagnosis and treatment of thyroid neoplasms.

Follicular Carcinomas

A confounding factor is the presence of Hiirthle cell nodules in benign diseases of the thyroid gland, notably in nodular goiters and Hashimoto thyroiditis. Hiirthle cell metaplasia of follicular cells is common in nodular goiters and is an integral part of autoimmune thyroiditis. Histologically, such nodules are usually not problematic. However, extensive Hiirthle cell changes in a goitrous nodule can suggest a Hiirthle cell neoplasm. A more troublesome lesion is the solid nodule composed entirely of Hiirthle cells in autoimmune thyroiditis. It may be encapsulated, and a Hiirthle cell neoplasm becomes a serious consideration. To determine definitively which of such lesions is malignant can be pathologically difficult.

Structural Abnormalities

Lesion deficit correlation studies demonstrate that certain disorders are more likely to be associated with a major depression than others (a) discrete brain lesions, as seen with trauma, surgery, stroke, tumors, and certain types of epilepsy (b) neurodegenerative diseases with regionally confined pathologies such as Parkinson's, Huntington's, and Alzheimer's diseases (c) disorders affecting diffuse or multiple random locations such as multiple sclerosis and (d) system illness with known central nervous system effects such as thyroid disease, cancer, and acquired immunodeficiency syndrome (AIDS) (Table 7.1). Hypothyroidism,

Environmental Radiation Exposure

The risk of thyroid cancer after diagnostic iodine 131 thyroid scans giving an estimated dose of 50 rad. The standardized incremental risk is shown for the total population, for subgroups based on sex, and for subgroups based on the category of thyroid disease for which they were being studied. (Adapted from Holm LE, Wiklund KE, Lundell GE, et al. Thyroid cancer after diagnostic doses of iodine 131 A retrospective cohort study. J Natl Cancer Inst 1988 80 1132.)

Sensorineural Hearing Loss

The cause of presbycusis is likely multifactorial, but ultimately the loss of cochlear hair cell function is thought to be the cause in most cases. Hair cell damage or loss can result from chronic noise exposure, genetic predisposition, and ototoxic medications. The hearing loss may also be caused by neurovascular injury from chronic conditions such as hypertension or diabetes, which can affect the cochlea or cochlear nerve. Hormonal conditions such as hypothyroidism should be considered, as should unusual conditions such as tertiary syphilis. Central auditory problems might be the cause, from dementia, cerebrovascular disease, or cerebrovascular accident (CVA, stroke).

Clinical Application of Indicators of Thyroid Tumor Aggressiveness

The ready application of a variety of risk group definitions (AMES, AGES, MACIS) indicates that all patients should be so characterized before initial surgery and again at completion of surgery. Age and tumor size can be determined preoperatively, whereas local invasion, distant metastases, resectability, and tumor histology or grade are usually determined postoperatively. By characterizing the risk group, the surgeon can make an initial preoperative estimate of the need for and extent of thyroid and regional lymph node resection and, postoperatively, the need for RAI treatment. When the risk of recurrence is only 3 and the risk of death only 1 in the low-risk MACIS, AMES, or AGES risk definition categories, it is impossible to prove the advantage of total thyroidectomy with RAI in contrast to a more limited or unilateral operation. Although no randomized trial has been conducted because of the infrequency of thyroid carcinoma even in young patients, studies addressing the issue of...

Obstructive Sleep Apnea

Common characteristics of OSA include snoring, choking, gasping for air, nocturnal reflux symptoms, and morning headaches. A bed partner or roommate may observe these characteristics and witness episodes where the patient stops breathing during sleep. Obesity predisposes to and can worsen OSA. Patients with large neck sizes (greater than 45 cm about 18 in. neck circumference) and a body mass index (BMI) of 30 kg m or greater are at higher risk for OSA. Hypertension, depression, and hypothyroidism are found frequently in patients with OSA.

Direction the viva may take

You are likely to be asked about the anaesthetic implications of thyroid disease. Overt thyrotoxicosis and myxoedema are rare, but anaesthetic mismanagement of either condition may be disastrous. So even though the viva may have concentrated on basic endocrinology, make sure that you know the principles of clinical management. Airway problems All forms of thyroid disease may be associated with large goitres, which may extend retrosternally and cause airway problems. Hypothyroidism Hypothyroid patients, in contrast, need much smaller doses of anaesthetic drugs. The BMR is greatly reduced, and with it cardiac reserve. Uncorrected myxoedema may be associated with amyloidosis, with accompanying cardiac and renal impairment. The opposite of thyroid storm is myxoedema coma, which is characterised by obtunded cerebration, marked hypothermia, alveolar hypoventilation and bradycardia. Correction of hypothyroidism is usually undertaken slowly, giving oral thyroxine, although intravenous T3 can...

Further direction the viva could take

You may be asked, almost as an aside, why patients with thyrotoxicosis develop proptosis, and why hypothyroidism is known as myxoedema. It will have (almost) no bearing on whether you pass or fail, but there is no point in becoming unnecessarily dejected by not knowing the answer to the final question of the section. Skin contains various proteins combined with polysaccharides, hyaluronic acid and chondroitin sulphuric acid. In hypothyroidism these complexes accumulate, and so promote water retention along with a characteristic coarsening of the skin, which becomes puffy. When treated with thyroid hormone these complexes are metabolised with resolution of the 'myx'-oedema.

Upon completion of the chapter the reader will be able to

Discuss the prevalence of thyroid disorders, including subclinical (mild) and overt (typical signs and or symptoms present) hypothyroidism and hyperthyroidism. 3. Discuss the relationship between serum thyroid-stimulating hormone (TSH) levels and primary thyroid disease and the advantages for the use of TSH levels over other tests such as serum T4 (thyroxine) and T3 (triiodothyronine) levels. 4. Identify the typical signs and symptoms of hypothyroidism and the consequences of inadequate treatment. 6. Describe the clinical use of LT4 in the treatment of hypothyroidism. 7. Describe the management of hypothyroidism and hyperthyroidism in pregnant women.

Patient assessment and monitoring

The assessment of patients for thyroid disorders entails a history and physical examination. In many patients with subclinical or mild thyroid disease, there may be an absence of specific signs and symptoms, and the physical examination may be normal. Various diagnostic tests can be used, including serum thyroid hormone(s), TSH, thyroid antibody levels, and imaging techniques to evaluate patients for thyroid disorders. Reference ranges for selected laboratory tests are given in Table 44-1.

Other Diagnostic Tests

Global tests of thyroid gland function can be performed to assess the rate of hormone synthesis. The radioactive iodine uptake (RAIU) will be elevated in hyperthyroidism and can aid in identifying thyrotoxicosis owing to nonthyroid gland sources. Radi-onuclide thyroid scans are used in the evaluation of thyroid nodules. Because many thyroid disorders are autoimmune, measurement of various serum antithyroid antibodies can be performed. Antithyroid peroxidase (anti-TPOAb) and antithyroglobulin antibodies (anti-TGAb) are present in many patients with hypothyroidism. Most patients with Graves' disease will have TSH receptor-stimulating antibodies (TSHR-SAb) as well as elevated anti-TPOAb and antimicrosomal antibodies.

Therapeutic Use of LT4

LT4 is indicated for patients with overt hypothyroidism. However, the need for treatment is controversial in patients with mild or subclinical disease (TSH less than 10 milliunits L or 10 microunits mL and normal free T4). There is some evidence that mild or subclinical hypothyroidism is associated with increased cardiovascular mor- bidity and mortality, ' though there are conflicting data. There are no large clinical trials that show an outcome benefit with treating these patients, and the therapeutic decision must be individualized. Many patients with subclinical hypothyroidism do, in fact, have subtle symptoms that improve with LT4 replacement. In patients without symptoms who have high cardiovascular risk, goiter, positive anti-TPOAb, and or are

Nonthyroidal illness euthyroid sick syndrome

A number of changes in the hypothalamic-pituitary-thyroid axis occur during acute illness.46,47 These changes are termed nonthyroidal illness or euthyroid sick syndrome. The type and degree of abnormalities depend on the severity of illness. Mild to moderate medical illness, surgery, or starvation causes a decrease in serum T3 levels owing to decreased peripheral conversion of T4 to T3. The reduced T3 levels do not correlate with ultimate mortality and are thought to be an adaptive response to stress. Patients with more severe illness, especially those in the intensive-care unit, frequently have reduced total T4 levels, although FT4 levels usually are normal. In the critically ill, there is a correlation between the degree of serum T4 reduction and mortality. In most acutely ill patients who are euthyroid, the TSH level is normal. However, administration of dopamine, octreotide, or high doses of glucocorticoids can reduce TSH levels. During recovery from acute illness, the TSH level...

Preconception Counseling

During pregnancy, maternal illness can adversely affect the fetus and lead to adverse neonatal outcomes. Maternal hypertension, preeclampsia, alcohol and tobacco use, illicit drug use, and autoimmune diseases can cause intrauterine growth restriction (IUGR) and preterm birth. Children born to women with diabetes mellitus or gestational diabetes are at risk for shoulder dystocia, operative delivery, hypoglycemia, and birth trauma (American College of Obstetricians and Gynecologists ACOG , 2005). Maternal hyperglycemia at delivery also puts the infant at risk for hypoglycemia. Poorly controlled maternal hypothyroidism and hyperthyroidism are associated with low birth weight (LBW) and preterm delivery (ACOG, 2005). Fetal alcohol syndrome is directly caused by maternal alcohol use and abuse, and other illicit drug use is associated with preterm birth, congenital abnormalities, neurobehavioral abnormalities, and neonatal drug withdrawal syndromes (ACOG, 2005). Box 22-1 lists the more...

Regulation of NIS Gene Expression and Function

The NIS protein is targeted to the basolateral membrane of follicular cells. Although the mechanism of this targeting is not fully elucidated, several sorting signals in the COOH terminus have been identified including the PDZ, dileucine, and acid-based motifs.2123 Localization of NIS at the basolateral plasma membrane is important not only for iodide transport in the thyroid gland but also for effective treatment of thyroid disease with radioactive iodine. Impaired targeting is one mechanism by which thyroid cancers have decreased iodide uptake.24,25 Therefore, it is important for the treatment of thyroid cancer to determine the mechanisms that regulate the subcellular distribution of NIS. Iodide has also been shown to be a major regulator of iodide uptake by the thyroid gland. In 1923, Plummer27 noted that high doses of iodide block thyroid function in patients with hyperactive thyroid disease. However, it was Wolff and Chaikoff who, in 1948, reported that the binding of iodide in...

Vital Signs Heart Rate

And should be evaluated for conditions such as sepsis, anemia, hypoxemia, hypovolemia, and hyperthermia. Persistent bradycardia is abnormal and may be associated with sepsis, asphyxia of the fetus, hypoxemia, congenital heart block, increased intracranial pressure, and hypothyroidism (Hoekelman, 2001, Thureen et al., 2005).

Epidemiology and Etiology

Approximately 10,000 to 15,000 children have growth failure owing to GH deficiency. Children may present with GH deficiency at any time during their developmental stages. The evaluation for GH deficiency in a short child should be deferred until appropriate exclusion of other identifiable causes of growth failure, such as hypothyroidism, chronic illness, malnutrition, genetic syndromes, and skeletal disorders. Also, several medications, such as methoxamine, iso-

Classification And Clinical Presentation

These tumors do not secrete active hormones, and therefore signs of hormone excess are absent. Prolactin levels may be mildly elevated because of the stalk effect, resulting from loss of tonic inhibition from the hypothalamus caused by compression or distortion of the pituitary stalk. Varying degrees of hypopituitarism may also be seen, and a full panel of hormone levels should be drawn. Signs of hormone insufficiency include decreased libido, fatigue, weakness, and hypothyroidism. It is essential to draw thyroid hormone levels in addition to thyroid-stimulating hormone (TSH) levels, because the patient with hypothyroidism of pituitary etiology will likely have a low TSH. Symptoms diminished libido, fatigue, weakness, hypothyroidism Thyrotrophic adenomas are rare and account for only 1 of pituitary adenomas. They occur with equal frequency in all age groups, without male or female predominance. Two types of these tumors are commonly noted those producing excessive TSH, causing...

Patient Encounter Part 1

BW, a 50-year-old woman with a history of osteoarthritis and hypothyroidism, presents to the clinic complaining of hot flashes, vaginal dryness, and insomnia. She states that she experiences approximately two hot flashes per day and is awakened from sleep at least three to four times a week in a pool of sweat requiring her to change her clothes and bed linens. Her symptoms began about 3 months ago, and over that time, they have worsened to the point where they have become very bothersome. On questioning, she states her last menstrual period was 1 year ago.

Outcome evaluation

If abnormal or heavy bleeding occurs, refer the woman to her primary care provider. Monitor subjective parameters such as adverse effects and adherence to the therapy regimen, as well as monthly breast self-examinations. In addition, monitor objective parameters, including blood pressure, at every outpatient visit encourage yearly clinical breast examinations, mammograms, and thyroid-stimulating hormone (TSH) determination, particularly for women with hypothyroidism on thyroid therapy, and conduct a BMD test every 5 years. Also perform endometrial studies, as necessary, in women with undiagnosed vaginal bleeding. Lastly, evaluate the patient's overall QOL. Because the management of menopause is largely symptomatic, it is important to document symptoms at the beginning of therapy and monitor symptom improvement and potential adverse effects at each visit. Frequent follow-up, proper monitoring, and education will help to ensure that the woman achieves...

What Other Psychiatric Symptoms May Develop In Epilepsy

Anxiety is an important and common condition associated with epilepsy and can have various causes. In addition to the direct anxiety produced by a seizure during the ictal phase, anxiety symptoms can develop during the postictal and interictal periods. Seizures can produce autonomic effects resulting in symptoms that mimic anxiety or panic, including increased heart rate, increased blood pressure, and flushing. In patients with epilepsy, anxiety may also develop as a response to anticipating a seizure, which could result in the development of secondary phobia. Certain medications (such as stimulants), medication withdrawal from barbiturates or benzodiazepines, and alcohol and substance abuse may also result in anxiety states. Various medical conditions, including thyroid disease, asthma, hypoglycemia, and adrenal dysfunction, may also produce anxiety. In summary, the clinician should consider all these potential causes when evaluating a patient with epilepsy in whom an anxiety...

Risk Factor Modification

Control of dyslipidemia and diabetes is also very important in the management of patients with CHF. Screening for sleep apnea and thyroid disease and aggressively treating these conditions need to be done. The avoidance of alcohol, illicit drug use, and smoking is strongly advised. Losing weight and establishing a routine exercise program are also important preventive measures in the CHF patient. Patients with a history of heart palpitations need to be evaluated for tachycardia because this is a well-established risk factor for cardiomyopa-thy and CHF. If patients have daily palpitations, a 24-hour Holter monitor is sufficient to help establish the type of arrhythmia. On the other hand, if palpitations occur infrequently (a few times per month), an event care monitor is more useful because patients can keep this type of monitor with them at home for a month and record the arrhythmia as it occurs. If palpitations are very infrequent, it is unlikely that they will be contributing to...

History and Geography

The next important reports were presented by John Fraser and Arthur Mitchell in 1875 at the Royal College of Physicians in Edinburgh. Mitchell pointed out the similarities between the syndrome and cretinism (congenital hypothyroidism). Reports by W. W. Ireland and G. E. Shuttleworth followed during the 1870s and 1880s. Shuttleworth suggested that children with the condition were actually unfinished, representing the persistence of anatomy characteristic of a particular phase in fetal development. He specifically cited the already recognized association between the syndrome and advanced maternal age, pointing out the large number of children with Down syndrome who were the last-born in large families. During the end of the nineteenth and beginning of the twentieth centuries, many reports appeared, expanding the description of the syndrome's phenotypic manifestations. Important among these were the extensive neuropathologi-cal descriptions by A. W. Wilmarth presented in reports from...

Noninvasive Preoperative Methods

The most common cause of false-positive results is the coexistence of benign thyroid disease (adenomas or multinodular goiter) (Fig. 46-3).85 Also, the presence of follicular,86 papillary,87 and HUrthle cell thyroid carcinomas,88 primary thyroid lymphomas,89 and lymph nodes79 account for false-positive sestamibi results (see Fig. 46-3). False-negative results, as in our own experience, are related more to the smaller size of the gland. Intrathyroid, mediastinal (Fig. 46-4), or deep cervical parathyroids can be localized using technetium 99m sestamibi (i.e., its accuracy is not

Clinical Manifestations and Pathology

Failure of both ventricles simultaneously usually accompanies a strain common to both sides of the heart, as in constrictive pericarditis, beriberi, hypothyroidism, or anemia so severe that the heart rate increases markedly to compensate for the reduced number of red blood cells delivering oxygen to the tissue.

Bone Marrow Transplantation

Children undergoing bone marrow transplantation are exposed to high levels of chemotherapy and radiation and are thus at high risk for many of the physical sequelae, including neurocognitive impact (Wilkins et al. 2007). Typical problems encountered by over 25 of survivors in the first 10 years after transplant include infections, cataracts, bone and joint complications, hypothyroidism, learning disabilities, and psychological problems (Ferry et al.

Results of Unilateral Parathyroidectomy Original Approach

When patients are considered for unilateral parathyroidectomy, it is important to exclude familial HPT because these patients usually have multiple abnormal parathyroid glands. Patients who had previous operations in their neck for either parathyroid disease or thyroid disease are not candidates for unilateral parathyroidectomy because the functional parathyroid reserve cannot be evaluated.

Hypopituitarism Simmonds disease

Causes include chromophobe adenoma, tumours of surrounding tissues (e.g. craniopharyngioma), skull fractures, infarction following postpartum haemorrhage and infection. Clinical features include loss of axillary and pubic hair, amenorrhoea, features of hypothyroidism and adrenal insufficiency, including hypotension, but with a striking pallor, in contrast to the pigmentation of Addison's disease (see p. 447).

Prevention and Treatment

In many other parts of the world, both rich (Scriba et al. 1985) and poor (Prevention 1986), goiter remains endemic (World Health Organization 1960 Stan-bury and Hetzel 1980) with its attendant disfigurement, cretinism, and hypothyroidism. It is worth noting that persons in an endemic area could have any of the diseases that cause sporadic goiter, which is one reason why goiter prevalence never falls to zero even with iodine repletion. For some areas this endemia is a major public health problem, and millions of people remain at risk. The disease, when endemic, is almost always associated with low iodine intake and iodine deficiency, and while there remains no good explanation as to why some do not develop goiter in areas of low dietary iodine, iodine does prevent the disease. The issue then becomes a social and political one of providing iodine to those in deficient areas and then getting them to take it. As Marine wrote, Endemic goiter will be prevented only when society decides to...

Lobar Hemorrhage in Cerebral Amyloid Angiopathy

An 82-year-old man is brought to the emergency room by his family because of a severe headache and complaint that he cannot see to the right. He was reported to be well early that morning. After breakfast, he developed an occipital headache. He noticed he could not see the right-hand side of the newspaper he was reading so he called to his wife. Previous medical history was significant for hypertension, atherosclerotic cardiovascular disease, a left hemiparesis secondary to a right lenticulostriate territory lacunar infarct, and hypothyroidism. He has no allergies and takes aspirin, lisinopril, and levothyroxine. He does not drink alcohol but has a 50 pack-year smoking history.

Arthritis of Systemic Disease

Lyme arthritis caused by Borrelia burgdorferi can cause migratory monoarthritis or oligoarthritis in the knees or shoulders weeks to months after the rash of erythema chron-icum migrans has developed. Poorly controlled diabetes (affecting foot, ankle, and knee), hyperthyroidism (affecting fingers and toes), hypothyroidism (causing noninflammatory effusions in knees, wrists, and hands), and parathyroid disease (causing chondrocalcinosis) are all endocrine disorders that can cause arthritis.

Juvenile Rheumatoid Arthritis

There are no specific laboratory tests to diagnose JRA. Other causes for arthritis must be excluded, including reactive arthritis from extra-articular infection, septic arthritis, neoplastic disorders, endocrine disorders (thyroid disease, type 1 diabetes mellitus), degenerative or mechanical disorders, and idiopathic pediatric joint pain. Diagnosis of JRA

Resistance to Thyroid Hormone

RTH is a rare disorder that results from target cell in-sensitivity to thyroid hormones. Newborn screening for congenital hypothyroidism can detect RTH if both T4 and thyroid-stimulating hormone are measured. The incidence of RTH is the same for males and females. Clinical presentation varies in individuals affected by RTH, and some people are asymptomatic. Behavioral characteristics (and their overall frequency) associated with RTH include emotional disturbances (73 ), attention-deficit hyperactivity disorder (70 ), hyperactivity (19 -42 ), learning disabilities (21 -32 ), and hearing deficits (25 ) (Hauser et al. 1993 Weiss and Refe-toff 2000). Limited data indicate that supraphysio-logical treatment with fast-acting thyroid hormone reduces the expression of both hyperactivity and im-pulsivity in children with RTH (Weiss et al. 1997).

Acquired Juvenile Hyperthyroidism

Acquired hyperthyroidism in childhood results primarily from Graves' disease, an autoimmune disorder that occurs most often in adolescent girls. Hyperthyroidism results from thyroid-stimulating antibodies that affect overproduction and secretion of thyroid hormones. Symptoms of Graves' disease include agitation, hyperactivity, poor memory, and poor concentration (Fisher and Grueters 2008). Treatment options for Graves' disease include anti-thyroid medications, radioiodine, and surgery (Glaser and Styne 2008). Adults affected by Graves' disease report more symptoms of depression and anxiety than unaffected individuals, but they do not exhibit impaired cognitive function as measured by standard neuro-psychological assessments (Samuels et al. 2008 Vogel et al. 2007). Furthermore, affective symptoms resolve following medical treatment for Graves' disease (Vogel et al. 2007). Similar to the case of acquired hypothyroidism, most information regarding affective and cognitive impairment...

Emergency Department Treatment and Disposition

Core temperature measurement is best made with an esophageal probe. Rectal temperature is less accurate without the use of a special low-reading thermometer. Gentle handling and appropriate warming methods are the mainstays of ED treatment. Cardiovascular instability often complicates rewarming Advanced Cardiac Life Support (ACLS) guidelines for hypothermia provide guidance. If not obvious, a cause should be sought (eg, hypothyroidism, hypoglycemia, sepsis), as should associated pathology. Most patients require admission for observation or to treat associated injuries or comorbidities.

Long Term Followup of Thyroid Disorders

For patients receiving long-term thyroid therapy for hypothyroidism, monitoring is through sTSH unless there is hypotha-lamic-pituitary disease. It takes 2 to 4 weeks after initiating treatment (or changing dose) before clinically significant change occurs in sTSH level. In most patients, checking sTSH once monthly is sufficient until steady state is reached. After the patient is stabilized, sTSH can be checked annually unless the patient develops new symptoms or dosing changes. Patients with benign nodules should be followed annually with careful palpation of the thyroid gland. Unless there is a change in size, no additional testing is required. Ultrasound of the thyroid is not recommended for follow-up of nodules less than 1.0 cm. Repeat ultrasound is required in patients with an enlarging nodule, evidence of a new thyroid mass, or who complain of pain or pressure. Unless the patient is experiencing symptoms of hyperthyroid or hypothyroid, repeat testing of sTSH or FT4 is not...

Sick Euthyroid Syndrome Thyroid Hormone Adaptation Syndrome

(sTSH, T4, thyroglobulin), but there is no clear evidence this reflects a disease state (Chopra, 1997). Because these changes appear to have no direct adverse effect on the patient's overall clinical state, this condition is labeled sick euthyroid syndrome. In broad terms, sick euthyroid syndrome is more of academic interest than clinical. Administration of T4 to a seriously ill individual does not improve outcome for most patients, although evidence suggests that high doses of T3 immediately after cardiac surgery may be beneficial (Wiers-inga, 2005). The physician should remember the rare patient whose thyroid disease is uncovered by serious illness. If a seriously ill patient is not responding as expected (e.g., difficulty in weaning from ventilator support), checking thyroid function may be appropriate, although any interpretation of results should be reviewed by a clinician experienced in interpreting thyroid tests in seriously ill patients before intervention. Patients with...

Etiology and Immunology

The overwhelming evidence is that myasthenia gravis is due to an immune system dysfunction that produces an autodirected antibody against the acetylcholine receptor in the postsynaptic membrane of the neuromuscular junction. The evidence is clinical, laboratory, serologic, and therapeutic. The clinical evidence that myasthenia is an autoimmune disease is based on the association of myasthenia with vaccination, insect sting, infection, or trauma and its association with autoimmune diseases such as hypothyroidism, systemic lupus, and polymyositis. Many laboratory abnormalities point to the immune system dysfunction in myasthenia gravis. These include serologic abnormalities, increased incidence of a specific human leukocyte antigen (HLA-B8) in certain types of disease, histologic abnormalities of thymus and skeletal muscle, and abnormal responsiveness of lymphocytes to mitogens. Antinuclear antibodies are positive in uncomplicated myasthenia in about 18 percent of cases and in 54...

Tibial Stress Fracture

Most patients present with a characteristic history. The leg pain is of insidious onset, associated with repetitive activities, and relieved by rest. Running and jumping sports are most often affected, including track, basketball, volleyball, dance, and football. While the cause is not completely clear, there is an obvious association with overuse. Thus, the athlete may describe an increase in training frequency or intensity, a change of shoes or practice surface, or another variation that could lead to excess biomechanical stresses. At the time of presentation, most often the pain has been present for weeks to months and sometimes even years. The pain may initially occur only after strenuous exercise, later becoming present even with simple walking. It may fluctuate with athletic seasons or gradually worsen with time until the athlete can no longer participate in sports. The examiner should obtain a history regarding amenorrhea in the female, thyroid disease, nutritional deficits, or...

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