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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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...

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...

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...

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...

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...

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.

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

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.

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...

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...

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...

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

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...

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


This may result from primary thyroid failure, Hashimoto's thyroiditis, as a consequence of thyroid surgery, or secondary to pituitary failure. The diagnosis is suggested by tiredness, cold intolerance, loss of appetite, dry skin and hair loss. It may be confirmed by the finding of a low serum thyroxine concentration, associated, in primary thyroid failure, with a raised serum TSH concentration. Basal metabolic rate is decreased. Cardiac output is decreased, with little myocardial reserve, and hypothermia may be present. Treatment is with thyroxine, which should be started in a small dose of 25-50 pg daily. Rapid correction of hypothyroidism may be achieved using i.v. T3, but this is inadvisable in elderly patients and those with ischaemic heart disease, which is common in hypothyroidism, as the sudden increase in myocardial oxygen demand may provoke infarction. ECG monitoring is advisable during treatment. Elective surgery should be avoided in myxoede-matous patients, but if emergency...

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....


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,...

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...

Primary Insufficiency

PGA-I syndrome usually arises in childhood or early adulthood. In PGA-II syndrome, Addison's disease occurs in association with autoimmune thyroiditis and insulin-dependent diabetes but without hypoparathyroidism or chronic mucocutaneous candidiasis. PGA-II syndrome occurs in older patients, generally between the second and fifth decades of life.5 Both of these entities may occur in the familial form. PGA-II syndrome is more common and accounts for more than 50 of patients with Addison's disease.6 Young women with spontaneous premature ovarian failure should also be suspected of having autoimmune adrenal insufficiency.7 Discoveries in genetics have provided valuable insights into the development of these syndromes and adrenal function.8

Thyroid Eye Disease Thyroid Orbitopathy

Graves' ophthalmopathy occurs in approximately 95 of patients with Graves' thyroid disease, but is only rarely seen with Hashimoto's thyroid disease. The diagnosis of euthyroid Graves' ophthalmopathy is primarily a clinical diagnosis, confirmed with orbital CT imaging. Clinical characteristics include hypotropia, esotropia, or a combination of vertical and horizontal strabismus. Many patients are euthyroid at diagnosis, but there may be a history of previous thyroid dysfunction. Thyroid myopathy is a common cause of acquired vertical deviation in adults but relatively uncommon in children. Werner has classified eye involvement in Graves' disease by the NO-SPECS mnemonic no signs of symptoms, only signs of lid retraction or gaze palsy with or without lid

Endocrine Abnormalities

Monal abnormalities occur in 43 to 90 of patients at diagnosis.48 All of the adenohypophyseal hormones can be affected, including growth hormone luteinizing hormone (LH) or follicle-stimulating hormone (FSH) adrenocorticotropic hormone (ACTH) and thyroid stimulating hormone. Deficiencies in LH and FSH lead to delayed or arrested puberty in adolescents, loss of libido, or secondary amenorrhea in adults. Low growth-hormone levels will result in growth retardation and delayed bone age. Hypothyroidism leads to poor growth, weight gain, cold intolerance, and fatigability. Forty percent of children demonstrate decreased height velocity or short stature at diagnosis, either from growth-hormone deficiency, central hypothy-roidism, delayed puberty, or a combination of these three. Impingement on the pituitary stalk leads to decreased amounts of prolactin inhibitory factors such as dopamine. This stalk effect results in hyperprolactinemia. In Fahlbusch's reported data, pre-operative endocrine...

Hypothalamic Pituitary Dysfunction

Priate secretion of antidiuretic hormone, and cause hypofunctioning of any component of the hypothalamic-pituitary axis caused by direct injury. The incidence varies from approximately 4 in patients presenting with symptoms during rehabilitation to 60 in an autopsy series.44 Just how common occult and late endocrinopathies may be is uncertain. A self-limited salt-wasting syndrome is one of the most frequent complications of TBI. The hyponatremia often persists at the time of admission for rehabilitation, especially in patients who required a craniotomy. Salt wasting must be managed with salt tablets, 4-8 grams daily, and fludrocortisone, 0.1-0.2 mg twice a day, then tapered over a week to see if the syndrome has abated. Hypothyroidism can contibute to hyponatremia.

Hypoactive Sexual Desire Disorder

Female sexual desire is a complex interaction among biologic, psychological, social, interpersonal, and environmental components. Ovarian function, especially ovarian androgens, may play an important role. In women age 20 to 49, HSDD is almost threefold more likely in surgical postmeno-pausal women than premenopausal women. However, no significant difference in HSDD exists between naturally or surgical postmenopausal women over age 50 (Leiblum et al., 2006). Medical illnesses, such as thyroid disease, chronic pain conditions, urinary incontinence, and depression anxiety, may negatively impact sexual desire. Medications can affect sexual drive, especially selective serotonin reuptake inhibitor (SSRI) antidepressants, antihypertensives, antipsy-chotics, and narcotics. Fear of pregnancy or sexually transmitted infection and discord or communication difficulty in a couple's relationship may diminish sexual desire. The clinician must explore all aspects of the biopsychosocial model when...

Which Other Hormonal Systems Are Affected By Aeds

Thyroid Hormones Thyroid function test results are frequently abnormal in patients who are given CBZ or DPH. Thyroxine (T4) and free thyroxine (FT4) are often lowered, down to 70 of their normal values (see Refs. 85 and 86 for reviews). TSH- and TRH-stimulating test results usually remain normal, however, and the patients remain clinically euthyroid. Only two patients given CBZ and CBZ plus DPH have been reported to have overt hypothyroidism.8'1 The observed changes may be due to increased conversion of T4 to T3, induction by the hepatic enzyme-inducing AEDs of peripheral metabolism of the thyroid hormones,83 and competition by CBZ and thyroid hormones for thyroid-binding globulin.83 In clinically asymptomatic patients, the changes are of little clinical importance and require no treatment. In thyroxine-substituted hypothyroid patients, the increased peripheral metabolism of thyroid hormones with CBZ may necessitate adjusting upward the dose of thyroxine used.83

Diagnosis of Mood Disorders

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

Screening Tools for Depression

Manage depressed patients over time (Trivedi et al., 2006). Self-report measures obviate the need for trained office personnel to administer tests. Depression screening measures do not diagnose depression but do provide critical information regarding symptom severity within a given period. Almost all measures have a statistically predetermined cutoff score at which depression symptoms are considered significant. When a depression screen is positive, an interview is necessary because screening will not include many confounding diagnostic variables (e.g., substance abuse, hypothyroidism, bereavement), and physician judgment is required. Screening measures do not address important clinical features of psychiatric illnesses (e.g., total duration of symptoms, degree of impairment) from other comorbid psychiatric conditions.

Differential Diagnosis

Many medical conditions may cause or mimic depression. Physical disorders that have been associated with depression include Addison's disease, acquired immunodeficiency syndrome (AIDS), coronary artery disease (especially in those with myocardial infarction), cancer, multiple sclerosis, Parkinson's disease, anemia, diabetes, acute infection, temporal arteritis, hypothyroidism, and especially dementias. It is imperative that the physician complete a neurologic evaluation to rule out an underlying disorder as the cause of the patient's depression. In addition, many medications may worsen depression, especially cardiovascular drugs, hormones, typical antipsy-chotic agents, anti-inflammatory agents, and anticonvulsants.

Physical Examination

Perform a routine evaluation, including orthostatic changes in pulse and blood pressure. Be careful if the patient complains of dizziness or chest discomfort. If this occurs, have the patient lie down immediately. Obtain body temperature. If the patient is hypometabolic, as happens in hypothyroidism or in exposure hypothermia, the temperature may be less than 36 C. In the geriatric population, a normal temperature is commonly found in patients with severe infections. Accurate weights should be documented and observed over time.

A102 Thyroidstimulating hormone and the thyroid gland

The thyroid-stimulating hormone acts on the thyroid gland in the neck and stimulates the release of the thyroid hormones thyroxine and tri-iodothyronine. The thyroid hormone stimulates metabolism by acting on the cells to speed up the rate at which food is used up and converted to heat and energy. The thyroid gland is unique in that it stores its hormones as a colloid in small vesicles in the gland. The other glands store their secretions in the cells themselves. The formation of the thyroid hormone requires iodine ingested in the diet. In regions where populations may encounter a deficiency of iodine in their diets, the addition of iodine to salt (iodized salt) has helped in the prevention of thyroid disease, particularly the enlargement of the thyroid gland known as goitre. Deficiency of the thyroid hormone (also called hypothyroidism) in a child causes cretinism, where the development of the nervous system is affected and the child is mentally retarded. In an adult, deficiency of...

Alzheimers Disease and Alzheimers Dementia

Other purported risk factors are weaker and some are more controversial in that not all well-controlled epidemiological studies have found them to be significant. These risk factors include limited education, depression, gender, estrogen replacement therapy, use of vitamin E, head trauma, use of anti-inflammatory drugs, and a history of thyroid disease. severity, severe electroencephalographic abnormalities, visual hallucinations, tremulousness, or unsteadiness, or it may be accompanied by non-neurological symptoms as well. Such symptoms may occur within the context of another disease process known to cause neurological problems sometimes, such as hypothyroidism, or may occur under specific circumstances such as immunosuppression. Irreversible forms of dementia are generally more slowly progressive (more than a year or two), fluctuate much less, do not occur within the context of another potentially causative disease, have recognizable clinical and cognitive profiles, and are not...

Plummers Disease Toxic Multinodular Adenomatous Goiter

Adenomatous Goiter With Cystic Change

Radioactive iodine therapy in large multinodular goiters extending substernally puts patients at risk for radiation-induced thyroiditis that can, although rare, cause acute thyroid enlargement and airway compression.28 A follow-up study assessed solitary autonomous thyroid nodules treated with iodine.52 In this study of 23 patients, 54 of nodules were still palpable, 9 had increased in size, and 36 were hypothyroid. Goldstein and Hart concluded that iodine does not eradicate the nodule. The incidence of hypothyroidism in that study was not related to gland size, thyroid function, or total dose of radiation. Radioactive iodine is an effective therapy for hyperthyroidism caused by a single hot nodule, since the suppressed normal extranodular tissue should be protected via its inability to concentrate radioactive iodine. It is also suitable for patients with mild hyperthyroidism or those considered at high risk for surgical management.50

Diagnostic Procedures

Most patients (about 95 ) with distant metastases have an elevated serum Tg concentration when measured after withdrawal of thyroid-stimulating hormone (TSH) suppressive therapy. While patients are receiving l-thyroxine (L-T4), their serum Tg concentrations are often relatively low, but these levels are usually higher than in patients with nodal metastases (Fig. 17-1).212 The best time to determine the serum Tg level is when the patient is hypothyroid in preparation for a radioscan. Radioiodine uptake by metastatic tumor increases as TSH stimulation increases. To increase serum TSH levels, total or near-total thyroidectomy is required before it is possible to detect or ablate local or distant metastases. It is important to withdraw thyroid hormone therapy for a long enough period of time to induce a state of hypothyroidism sufficient to elicit high endogenous serum levels of TSH.1617 The minimum level of serum TSH required for adequate incorporation of 13II in neoplastic tissues is...

Bradycardia and tachycardia

Bradycardia is defined as a heart rate < 50 beats per minute, and becomes symptomatic only when the rate drops significantly. Bradycardia may be due to cardiac and non-cardiac causes. Non-cardiac causes comprise side-effects of drugs, and disorders such as hypothyroidism, hypothermia, electrolyte disturbances and increased parasympathetic tone. Furthermore, the brain may be involved in cardiovascular regulation, and the insular cortex is assumed to play a role in rhythm control 17 . Cardiac causes of bradycardia include acute or chronic coronary heart disease, valvular heart disease, and degenerative primary electrical disease. Performing a standard electrocardiogram enables one to diagnose more precisely the type of bradycardia as sinus bradycardia, atrioventricular block, sinus arrest, or AF, and to look for signs of acute myocardial ischemia and to assess whether QT prolongation is present, which is a potentially life-threatening situation 18 .

Primary Sensory Neuropathy Pure Sensory Distal Nerve Lesions

Hypothyroid neuropathy Examples of causes of diffuse sensory neuropathy include a dysproteinemic state (IgM monoclonal gammopathies with antimyelin-associated glycoprotein), amyloidosis (generally small fiber), hereditary, diabetes mellitus, uremia, hypothyroidism, immunological (scleroderma, sarcoid), and toxins. A generalized peripheral neuropathy can show selective involvement of certain fiber types such as large myelinated fibers. In these circumstances there will be a dissociated sensory loss with a deficit of vibration and proprioception while sparing pain and temperature on sensory examination. Examples of these conditions include Friedreich's ataxia, Charcot-Marie-Tooth disease, uremia, and Guillain-Barre syndrome.

Identification of Sperm Oxidative Stress from Clinical History

Male Infertility Causes Mnemonics

Thyroid dysfunction may also be an endocrine cause of sperm oxidative stress as both hyperthyroidism and hypothyroidism have been linked with systemic oxidative stress 30-32 . This systemic state of oxidative stress appears to extend to the testicle, since animal studies using experimentally induced hyperthyroidism and hypo-thyroidism have shown increased levels of lipid peroxidation products and reduced antioxidant status within the testicle tissue 33, 34 . Furthermore, a recent study examining the link between thyroid hormones and antioxidant capacity in seminal plasma of infertile men reported a significant positive correlation between seminal plasma antioxidant capacity and serum free thyroxin levels 35 . Therefore, screening of infertile men for thyroid dysfunction may be useful, especially since returning thyroid hormone status to normal has been shown to reduce systemic levels of oxidative stress within 1-2 months 30 .

Mecanism Of Centripetal Lipid Accumulation Supraclavicular Fat And Face

Dopamine receptor antagonist Inhibitors of dopamine synthesis and release Estrogens Neurogenic Chest wall spinal cord lesions Breast stimulation Suckling Physical stress Others Primary hypothyroidism Renal failure Pregnancy Idiopathic Treatment of hyperprolactinemia depends on the cause. Normalization of PRL levels results in immediate restoration of menstrual function and fertility in women and libido and potency in men, assuming the residual normal gland remains functional. In cases of drug-induced hyperprolactinemia, cessation of the offending drug is often sufficient to return PRL levels to normal. In patients with psychosis, administration of antipsychotics that do not induce hyperprolactinemia should be instituted. For hypothyroid-related hyperprolactinemia, treatment of the hypothyroidism with thyroxine will result in normalization of PRL. In patients with a tumor or mass lesion, primary treatment should focus on the appropriate treatment for the tumor. For microprolactinomas,...

Patient Encounter 1 Part 2

Congenital hypothyroidism is still seen in the United States, and all newborns in the United States undergo screening with a TSH level. As soon as the hypothyroid state is identified, the newborn should receive the full LT4 replacement dose. The replacement dose of LT4 in children is age-dependent. In newborns, the usual dose is 10 to This is a life-threatening condition owing to severe, long standing hypothyroidism and has a mortality rate of 60 to 70 . These patients are given 300 to 500 mcg IV LT4

Definition Advantages and Disadvantages of Hemithyroidectomy

The advantages of this surgical approach are that, when compared with total thyroidectomy, surgical complications including permanent hypoparathyroidism and bilateral recurrent laryngeal nerve palsy are lower, even when an inexperienced surgeon performs the operation. In patients treated in this manner, only one of the two recurrent nerves and two or three of the four parathyroid glands are at risk. Most patients are also euthyroid postoperatively, so that lifelong thyroid hormone replacement therapy is unnecessary. When we recently examined thyroid function by measuring serum thyroxine (T4), triiodothyronine (T3), and TSH concentrations in 150 patients who had hemithyroidectomy, 95 (63 ) of all patients examined were euthyroid, 31 (21 ) had subclinical hypothyroid (low T4 and normal T3 with abnormally high TSH), and 24 (16 ) were hypothyroid.

Specific Complications

The recurrent laryngeal nerve is involved in most claims concerning complications of thyroid surgery.1 Morbidity related to this injury ranges from minimal changes in voice quality to recurrent tracheal aspiration and or severe dyspnea requiring tracheostomy. The incidence of injury to the recurrent laryngeal nerve(s) during thyroid surgery is influenced by many factors. The risk is higher in more extended thyroid resections, in patients with malignant thyroid disease, in patients in whom the recurrent laryngeal nerves could not be identified, and in re-operations due to recurrent thyroid disease.1117 Although it is recognized that experience reduces complication rates in surgery in general and reoperations on thyroid disease specifically, reports concerning this topic in primary thyroid surgery are conflicting and emphasize the importance of individual surgical skill and performance.12'14161819 Use of a harmonic scalpel reduces operating time but was not shown in small studies to be...

Anesthesia Anesthesiology Consultation

We recommend a consultation before the day of surgery if possible, especially if there are any medical issues that could affect the administration of anesthesia. If you have a history of a significant medical illness or are under treatment for a medical disease, you should schedule a preoperative anesthesiology evaluation at least two working days ahead of your admission to the hospital for the surgery. Such illnesses include heart disease (coronary artery disease, valvular disease excluding mitral valve prolapse, arrhythmias), severe asthma, chronic obstructive pulmonary disease, emphysema, diabetes, thyroid disease, sleep apnea, and morbid obesity. In addition, any woman over the age of 50 should have preoperative clearance from her primary care physician or have a preoperative anesthesia evaluation. Even if you don't fit into any of these categories, if you are more comfortable with an anesthesia evaluation before you go into the hospital, you should ask for a consultation....

Thyroid and Parathyroid Tumors

Thyroid Berry Ligament

Diseases of the thyroid gland represent a common medical and surgical problem. A variety of inflammatory lesions and neoplasms are noted by endocri-nologists and surgeons interested in thyroid pathology. Various pathologic conditions include Hashimoto's thyroiditis, nodular goiter, solitary thyroid nodule, adenomas and thyroid cancer. Although thyroid disease is extremely common, thyroid cancer is relatively uncommon and forms less than 2 percent of all human cancers. Approximately 19,500 new patients with thyroid cancer will be seen in the United States during the year 2001, while approximately 1,300 patients will die of thyroid cancer.1 The prevalence of nodular goiter has decreased considerably in the United States due to the routine use of iodized salt. However, it is still quite prevalent in other parts of the world, particularly in certain European countries around the Alps, and in Asia near the Himalayas. The routine use of ultrasonography has shown a very high incidence of...

Median Neuropathy Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is one of the most common mononeuropathies. It typically occurs within the confines of the carpal tunnel in the wrist. The median nerve can also be entrapped in the forearm as a pronator or interosseous syndrome. The entrapment can be caused by anything that causes a decrease in the size of the carpal tunnel (e.g., Colles' fracture, rheumatoid arthritis, congenital carpal tunnel stenosis), enlargement of the median nerve (e.g., diabetes, amyloidosis, thyroid disease, neuroma), or an increase in the volume of other structures within the carpal tunnel (e.g., tenosynovitis, ganglion, gout, urate deposits, lipoma, hematoma, fluid retention in pregnancy).

Chronic Inflammatory Demyelinating Polyradiculoneuropathy

There is no conclusive evidence that CIDP patients have a higher incidence of other medical conditions, including autoimmune disorders. However, associated disorders, including systemic lupus erythematosus, Hashimoto's thyroiditis, thyrotoxicosis, chronic active hepatitis, inflammatory bowel disease, urticaria, eczema, and psoriasis do occur in some CIDP patients.y A CIDP-like disorder may occur in the setting of monoclonal gammopathies of uncertain significance (MGUS), as well as with multiple myeloma, osteosclerotic myeloma and other lymphoproliferative disorders. These disorders are discussed as distinct entities in the following sections. Differential Diagnosis. On purely clinical grounds, CIDP may be confused with a wide variety of chronic sensorimotor polyneuropathies, including those related to diabetes, uremia, hypothyroidism, acromegaly, toxins, and alcoholic-nutritional mechanisms. Although CIDP may produce distinguishing clinical features, such as predominant motor symptoms...

Thyroxine and Ischemic Heart Disease

Clearly, T4 replacement is necessary to prevent the development of overt hypothyroidism in postsurgical patients. There is also an annual conversion rate of 3 from subclinical to clinical hypothyroidism after 131I therapy and slightly less than 1 per year after thyroidectomy. Post-thyroidectomy hypothyroidism is more likely in elderly patients and in those who have circulating thyroid autoantibodies.74,75 Myocardial infarction and angina are both recognized complications of levothyroxine therapy in hypothyroid patients, even in dosages as small as 25 j.g day. Forty percent of patients with a history of angina are unable to tolerate fully suppressive doses of T4.76 Patients with known cardiac disease who are older than 65 years should, therefore, be treated with caution. Substantial increases in both heart rate and left ventricular contractility tend to increase myocardial oxygen consumption, although slight reductions in ventricular afterload may offset this effect.77 It is likely...

Hyperprolactinemia and Prolactinomas

Laboratory tests include serum prolactin and thyroid function. Primary hypothyroidism is associated with hyperpro-lactinemia secondary to elevated TRH that induces prolactin secretion. Testing should also seek systemic illnesses with increased prolactin levels, such as liver or renal failure. MRI is the imaging modality of choice for the anatomic evaluation of the hypothalamus and pituitary gland. Complete pituitary hormone evaluation should be performed when an adenomatous mass is noted in the region of the pituitary.

Recommendations for the Use of Levothyroxine in Thyroid Cancer

It can be seen that radioiodine scanning and ablation are not trivial undertakings. The need to stop replacement therapy and to render the patient at least subclinically hypothyroid, along with the precautions necessary in the use of radiopharmaceuticals, must be coordinated by a nuclear medicine physician with a specific interest and experience in thyroid tumor treatment. The timing of the first scan, the indications for remnant removal or ablation, and the interval between scanning are all matters of controversy. patients with differentiated carcinoma. Thyroglobulin is a large glycoprotein synthesized by thyroid follicular cells and stored in colloid, providing the tyrosyl groups for iodi-nation and coupling to form both T3 and T4. TSH stimulates thyroglobulin release, and thus serum thyroglobulin is elevated in any disease associated with an increased mass or activity of the gland. As a result, it is elevated in endemic and sporadic goiter, thyroiditis, and benign and malignant...

Surgical Anatomy of the Thyroid and Parathyroid Glands

Ligament Berry

The normal thyroid is soft, dark wine-red in color, and covered with a thin capsule. It is loosely attached to neighboring structures. The variations in fixation of the gland may arouse suspicion of pathologic change, particularly when the history suggests acute thyroiditis or cancer. Normally, the gland adheres only to the cricoid cartilage and the upper tracheal rings. This is the posterior suspensory, or Berry's, ligament.

Differentiated Thyroid Cancer of Follicular Cell Origin

Thallium 201 (201T1) was first used in the early 1980s for detecting metastases from both well-differentiated thyroid cancer and recurrent medullary cancer in 1980s.3944 It accumulates in the tumor and gives a positive image by contrasting with the negative image by radioiodine and remains in the tumor longer than it does in normal thyroid (Fig. 16-6). Tc 99m sestamibi became available around 1987, and many investigators compared the results of 20IT1 scintigraphy to Tc 99m sestamibi. Although these two imaging isotopes gave comparable results, Tc 99m sestamibi results were slightly better and clearer than those with 20'T1 in patients with differentiated thyroid cancer.45-46 For patients with medullary cancer 99mTc(V)-dimercaptosuccinic acid (Tc 99m DMSA) appeared to be somewhat more accurate than 201T1 for routine clinical use 47 20IT1 imaging is most useful after total or near-total thyroidectomy and 131I ablative therapy in patients with rising or elevated serum thyroglobulin...

Familial Amyloid Polyneuropathy

The differential diagnosis of FAP varies with the presentation and is wider when there is no family history. Presentation with a painful, distal, and mainly sensory neuropathy of small-fiber type poses a differential diagnosis of leprosy, diabetes, vasculitis, or paraneoplastic associated neuropathies. Familial small-fiber neuropathies include type 1 hereditary sensory neuropathy and the neuropathy associated with Tangier's disease. Presentation with carpal tunnel syndrome requires differentiation from hypothyroidism, diabetes, osteoarthritis, and acromegaly. Carpal tunnel syndrome may also occur in patients undergoing hemodialysis, in whom there is deposition of beta-microglobulin derived amyloid. Presentation with prominent autonomic symptoms may require differentiation from other hereditary diseases such as familial dysautonomia (Riley-Day syndrome), dopamine beta-hydroxylase deficiency, and Fabry's disease.

Levocarnitinein Libido

In tuberculosis, 1262 in urinary tract infections, 1311 , 1312 Levofloxacin resistance, 1194 Levomethadyl, arrhythmia with, 179 Levonorgestrel, 843, 845 , 849, 851, 853, 875 Levorphanol dosage of, 575 in pain, 575 Levothyroxine (T4), 828 anxiety with, 694 dosage of, 769 drug interactions of, 771 in hypothyroidism, 769-771, 771 a-Linolenic acid, in intravenous lipid emulsions, 1684, 1684t Liothyronine dosage of, 769t in hypothyroidism, 769t Liotrix dosage of, 769t in hypothyroidism, 769t Lipase hypothyroidism with, 679, 767, 767 , 779

Thyroid Stimulating Hormone Suppression and Thyroid Cancer

Thyroid tumors vary markedly in prognosis, and the natural history of differentiated tumors is long. The control of thyroid cell growth is complex and is influenced by many hormones and growth factors operating through distinctly different cell signal transduction systems. Classically, TSH is considered the major thyroid growth hormone, and, although there is no dispute about its role in stimulating thyroid gland function, its effects on thyroid growth and particularly abnormal growth are in question. TSH stimulates differentiated thyroid functions, most notably iodine uptake and organification as well as thyroglobulin synthesis, by activating a membrane-bound adenylate cyclase system and increasing intracellular cyclic adenosine monophosphate this results in cytoplasmic protein phosphorylation and increased nuclear transcription.177 In general, follicular thyroid neoplasms have enhanced adenylate cyclase activity in response to TSH stimulation and tend to have an inverse correlation...

Compressive Neuropathies

Entrapment neuropathies. 1 Although nonspecific tenosynovitis is the most common cause of rising canal pressure, other causes may be relevant amyloidosis may infiltrate the tendon sheaths, rheumatoid arthritis may cause synovial tissue to invade the canal, or hypothyroidism may cause tissue edema. In about 75 percent of patients, CTS is accompanied by nonspecific tendinitis in the flexor tendons. Hypothyroidism, atypical mycobacterial infection, diabetes, rheumatoid arthritis, and acromegaly are also associated with CTS. Pregnancy accounts for about 1 percent of CTS cases. In half the patients with symptomatically unilateral CTS, NCV in the opposite extremity is delayed. Additional ulnar nerve compression, cervical radiculopathy, bursitis, tendinitis, and osteoarthritis often occur in CTS patients, as well as an array of rheumatological complaints.

Pharmacological Agents Nifedipine

Amiodarone Blue Skin

Patients on long-term high-dose amiodarone (600 mg d for 2 yr) may develop a blue-gray dermal melanosis ofthe face, especially ofthe areas exposed to the sun (131). It may take several months for the skin discoloration to resolve after stopping the drug because of its long half-life (132,133) (Fig. 17). A lupus-like syndrome has also been reported with amiodarone (134). Hyperthyroidism, hypothyroidism, liver dysfunction, and pulmonary fibrosis are other side effects of amiodarone (131).

Physiologic Classification

Aplastic anemia Anemia of inflammation Chronic renal insufficiency Hypothyroidism Mild iron deficiency Another pathologic process resulting in inadequate EPO stimulation is hypometabolism, particularly hypothyroidism. The anemia may reflect a reduced need for oxygen-carrying capacity because of the reduced metabolic load resulting from the thyroid hormone deficiency.

Persistent Recurrent Hyperparathyroidism in MEN 1 Patients

The combination of oblique planar images and singlephoton emission CT yields the most sensitive information (Figs. 76-3A and 76-4A).102 Sensitivities in the range of 70 to 85 have been reported.98102 SPS falls short in patients with multigland disease (but less so when only one or two glands remain) and in patients with nodular thyroid disease. It is particularly helpful in patients with mediastinal and ectopic glands.64

Thyroxine Suppressive Therapy and Diffuse Goiter

The most common cause of adult diffuse nontoxic goiter in nonendemic areas is chronic autoimmune thyroiditis. Both microsomal cytoplasmic and thyroid peroxidase autoantibodies are evident in 10.3 of adult women and 2.7 of adult men in clinical surveys of sporadic goiter. Conversely, about one third of patients with detectable antibodies have clinical goiters.1 Chronic autoimmune thyroiditis is also the most common cause of sporadic childhood and adolescent goiter, of which there is a spectrum of illness ranging from focal thyroiditis to Hashimoto's thyroiditis. Such patients typically have high titers of antimicrosomal antibodies and are often hypothyroid, either clinically or subclinically. Levothyroxine is given to both euthyroid and hypothyroid patients with chronic goitrous thyroiditis of this type and has been shown to be associated with a mean reduction in palpable thyroid volume.130 The natural history of autoimmune thyroiditis, however, is in general toward inexorable...

Evaluation Guidelines Table173

Metabolic disorders (e.g., lipid, mitochondrial and storage disorders, Refsum's and Wilson's diseases, hypothyroidism) should be excluded in early-onset chronic progressive ataxia and in adult-onset forms of the disorder, which are not dominantly inherited. Lipids, vitamin E, lactate, very long-chain fatty acids, adrenocorticotropic hormone (in males), phytanic acid, ceruloplasmin, and thyroxine should be analyzed. Alpha-fetoprotein is increased and immunoglobulins are decreased in ataxia-telangiectasia. A muscle biopsy should be performed in cases of suspected mitochondrial myopathy. Poisoning or drug intoxication has to be excluded. Anemia, macrocytosis, and raised gamma-glutamyltranspeptidase suggest alcoholic cerebellar degeneration. In children, neuroblastoma may be associated with paraneoplastic cerebellar degeneration leading to opsoclonus. Urinary catecholamine levels are increased. Diabetes mellitus should be excluded in Friedreich's ataxia. Genetic testing is available for...

Diseases of the Premodern Period in Japan

In addition to the plentiful information on diseases supplied by court histories, literature, and other records, medical texts and an encyclopedia called the Wamyo ruiju sho also list medical terminology (Hattori 1945). Among the infections included are idiopathic cholera (shiri yori kuchi yori koku yamai, kakuran), leprosy (raibyd), elephantiasis igeju), bronchitis (shiwabuki yami), hepatitis (kibamu yamai), dropsy (harafukuru yamai), asca-rids (kaichu), threadworms (gyochu), meningitis (fubyo), infantile dysentery (shoji kakuran), diphtheria (bahi), bronchial asthma (zensoku), epilepsy (tenkari), chronic nephritis (shokatsu), tonsilitis (kdhi), osteomyelitis (fukotsuso), thyroiditis (ei), erysipelas (tandokuso), ringworm (senso), gastritis (iso), palsy (kuchi yugamu), and scabies (kaiso). Records from the era 700-1050 also have led scholars to infer the existence of cancer, pneumonia, tapeworms, rheumatoid arthritis, and hookworms.

Nonthyroidal Illness as a Diagnostic Dilemma

Nonthyroidal illness is an alteration of serum thyroid hormone levels due to the presence of medical illness or fasting or after surgery. The nature of this disorder and a practical approach to this disorder have been well described.65,66 Initially, these patients present with low serum triiodothyronine (T3) levels due to decreased deiodinase 1 activity that converts T4 to T3. As the disease progresses, total T4 concentrations are reduced. When FT4 was measured by equilibrium dialysis, FT4 levels were usually normal,67 whereas FT4 measured by the analog method is low.68 The analog method is used in automated thyroid testing in most clinical laboratories and is significantly altered by high or low serum protein levels.68 Serum TSH levels vary depending on the stage of nonthyroidal illness. During the recovery stage of illness, serum TSH levels tend to be elevated. This causes difficulty in determining whether patients are hypothyroid. History of medical illness, careful physical...

Medical and Surgical Treatment of Endemic Goiter

Endemic goiter is a preventable disease caused by iodine deficiency. According to statistics from the World Health Organization (WHO) in 1999, a total of 740 million people about 13 of the world's population are affected by endemic goiter alone.1 The occurrence of endemic goiter is preventable by an adequate supply of iodine in the diet. Universal salt iodina-tion is the goal of WHO in an attempt to eliminate the disease by the year 2000. Data from WHO in 1999 showed that 68 of the total population in countries affected by iodine deficiency disorders (IDDs) have access to iodized salt. Existing endemic goiters are currently treated with iodine supplementation to reverse hypothyroidism and to reduce the size of the goiters. For long-standing goiters, the treatment is the same as that for sporadic goiter T4 therapy and thyroidectomy are used for treatment radioiodine therapy is used selectively. Goiter, an enlargement of the thyroid gland, is conventionally called an endemic goiter when...

Osteosclerotic Myeloma

One or more additional features of the POEMS syndrome often are observed, but in many cases, these are not prominent and must be carefully sought. Hepatomegaly may be found in up to 50 percent of patients, whereas lymphadenopathy and splenomegaly are less common. Manifestations of endocrinopathy include diabetes mellitus, hypothyroidism, impotence, gynecomastia, testicular atrophy, amenorrhea, hyperprolactinemia, and hyperestrogenemia. Skin changes include hyperpigmentation, thickening of the skin, hypertrichosis, skin angiomas, clubbing, and white nails. Some skin changes are suggestive of scleroderma. Peripheral edema, ascites and pleural effusions may also be seen. POeMs syndrome, sometimes referred to as Crow-Fukase syndrome, is not unique to osteosclerotic myeloma. It has been observed in multiple myeloma, Waldenstrom's macroglobulinemia, and angiofollicular lymph node hyperplasia, also referred to as Castleman's disease.y

Clinical Manifestations of Thyrotoxicosis

Many of the signs and symptoms seem to be related to autonomic hyperactivity. As with hypothyroidism, the clinical manifestations may be subtle initially and slowly progressive. Screening of patients for thyroid disease may identify patients with sub-clinical or mild thyrotoxicosis. Patients may seek medical attention only after a long period of thyrotoxicosis or owing to an acute complication such as atrial fibrillation. The clinical manifestations of thyrotoxicosis in the elderly may be blunted or atypical.

Clinicopathologic Correlations

Superior Vena Cava Thrombosis

Although iodine deficiency is still a worldwide cause of thyroid enlargement, other important causes of goiter are infection, autoimmune disease, cancer, and isolated nodules. An enlarged thyroid may be associated with hyperthyroidism, hypothyroidism, or a simple or multinodular goiter of normal function. As indicated in the quotation at the beginning of this chapter, hyperthyroidism may manifest with a variety of generalized symptoms and signs. It has been said, ''To know thyroid disease is to know medicine,'' because there are so many generalized effects of thyroid hormone excess. Table 9-1 lists the variety of clinical symptoms related to thyroid hormone excess.

Lymphoma of the Thyroid

Primary lymphomas of the thyroid are rare, accounting for only 1 to 2 of thyroid malignancies and less than 2 of extranodal lymphomas.26 126128 Most thyroid lymphomas are non-Hodgkin's lymphomas of B-cell origin, although Hodgkin's disease of the thyroid has been described.126129 In a large proportion of cases, thyroid lymphomas are associated with Hashimoto's thyroiditis and histologically may be difficult to distinguish from this chronic lymphocytic disease.25 130 Follow-up studies have estimated the relative risk of thyroid lymphoma in patients with chronic lymphocytic thyroiditis to be 70 to 80 times higher than in controls.131 The actual relationship between Hashimoto's thyroiditis and thyroid lymphomas remains obscure. Whether the presence of lymphocytes in the thyroid provides the tissue in which the lymphoma can develop or whether the chronic stimulation of the lymphocytes predisposes the cells to develop malignant clones has not been defined. Most patients present with a...

Hypokinetic Movement Disorders

Other parathyroid abnormalities, hypothyroidism, hepatocerebral degeneration, brain tumor, paraneoplastic diseases, normal pressure hydrocephalus, noncommunicating hydrocephalus, syringomesencephalia, hemiatrophy-hemiparkinsonism, peripherally induced tremor and Parkinsonism, and psychogenic disorders

Iodide Metabolism and Uptake

Iodine usually enters the body as the result of dietary and water uptake, but it can also be found in various drugs, such as cough medicines, and in diagnostic agents. Dietary iodine intake varies widely throughout various parts of the world. The relationship between iodine intake and thyroid disease was first demonstrated by Chatin in 1852, but the practice of iodine supplementation of food and water, which he recommended, fell into disrepute and was not revived until the large-scale experiments of Marine and Kimball in Ohio in 1917.14 Even in areas where endemic goiter is not a problem, iodine intake and excretion vary considerably with urinary excretion, ranging from as little as 40 j,g day up to 400 j,g day.15 Iodine deficiency is associated with nodular goiter, hypothyroidism, and cretinism16 as well as the development of follicular thyroid carcinoma.17 In areas of the world where iodine deficiency is still a problem, a variety of measures are being introduced to increase iodine...

Diagnosis of Recurrence

Measurement of Tg levels in patients receiving suppressive doses of T4 provides useful information about the presence of thyroid cancer but is not as sensitive as Tg levels after recombinant TSH or after thyroid hormone withdrawal, resulting in hypothyroidism.41 Tg levels in patients with residual thyroid cancer usually increase when serum TSH levels increase (e.g., when the patient is not receiving thyroid hormone in preparation for a radioiodine scan). Elevated antithyroglobulin antibody levels can produce inaccurate Tg levels in 8 to 22 of patients 42 However, measuring messenger RNA transcripts of Tg in peripheral blood may solve this problem.43 Tumor-associated glycoprotein antigen CA 50 has also been used as a marker for patients with persistent thyroid cancer.44 For patients with MTC, determining serum CT and carcinoembryonic antigen levels helps determine tumor persistence or recurrence. Radioiodine can be given as soon as 6 weeks after total or near-total thyroidectomy. The...

Androgen deficiency states in women

Estrogen And Androgen Over Time Women

A core precept of endocrinology is that of an endocrinopathy, defined as a hormonal deficiency state with clearly defined adverse sequelae. This paradigm is best illustrated by hypothyroidism and subsequent replacement, or by male hypogonadism with testosterone replacement. In the previous section, we have hypothesized that a clear androgen deficiency state does not exist in women undergoing natural menopause, but there are several conditions that are associated with decreased levels of androgens in women. These include the use of postmenopausal hormone replacement therapy (HRT), (particularly orally administered), oral contraceptive use, pre-or postmenopausal oophorectomy, and adrenal suppression. Combined, these iatrogenic causes are prevalent enough to makeandrogen deficiency in women an extremely common condition.

Morphologic Changes in Endemic Goiter

An increase in thyroid gland mass often accompanies the physiologic changes in response to iodine deficiency. Generalized epithelial hyperplasia occurs, with cellular TABLE 3-5. Relation Among Prevalence of Goiter and Cretinism and Severity of Iodine Deficiency IDD - iodine deficiency disorder. hypertrophy and reduction in follicular spaces. In chronic iodine deficiency, the follicles become inactive and distended with colloid accumulation. These changes persist into adult life, and focal nodular hyperplasia may develop, leading to nodule formation.31 Some nodules retain the ability to secrete thyroid hormone and form hot nodules. Others do not retain this ability, become inactive, and form cold nodules. Necrosis and scarring result in fibrous septa, which contribute to the formation of multinodular goiter.

Endocrine and Metabolic Factors

Hypothyroidism Although rarely found in children, hypothyroidism is associated with slow statural growth and developmental delay. More common among adults and more often seen in women, hypothyroidism is a relatively rare cause of obesity. If undiagnosed, it is typically accompanied by other symptoms of thyroid deficiency, such as cold intolerance, decreased energy, obstipation, and increased thinning of the scalp.

Affective Disorder Syndromes

The differential diagnosis of depression includes primary psychiatric syndromes other than major depression such as behaviors associated with schizophrenia, generalized anxiety disorder, and obsessive-compulsive neuroses. Medical and neurological disorders either associated with or mimicking depression include malignancy, infections, medications (steroids, reserpine, levodopa, benzodiazepines, propranolol, anticholinesterases), endocrinological dysfunction (Cushing's disease, hypothyroidism, apathetic hyperthyroidism, diabetes), pernicious anemia, and electrolyte and nutritional disorders (inappropriate secretion of antidiuretic hormone, hyponatremia, hypokalemia, hypercalcemia). Depression is also associated with multiple sclerosis, Parkinson's disease, head trauma, stroke (particularly of the left frontal lobe), and Huntington's disease. Interictal changes in temporal lobe epilepsy may mimic depression, particularly with right-sided epileptic foci. Patients with diencephalic and...

Sex Chromosomal Abnormalities

Turner's syndrome, a form of gonadal dysgenesis resulting from a 45,X karyotype (X-chromosomal monosomy), is characterized by female phenotype, short stature, a shieldlike chest, a short and sometimes webbed neck, low- set ears, high-arched palate, small mandible, and sexual infantilism. y The frequency of 45,X in female live births is 0.1 to 0.6 per 1000. A variety of other malformations can be associated, including congenital lymphedema, particularly of the hands and feet, cardiac and renal defects, skeletal anomalies, and abnormalities of the nails. An increased number of pigmented nevi has also been reported. Other disorders have been associated with this disorder, including Hashimoto's thyroiditis, obesity, inflammatory bowel disease, and rheumatoid arthritis. Nerve deafness occurs in approximately half the patients, and olfactory as well as taste deficits have been described. Eighteen percent of patients studied in one series were mentally retarded, although this high prevalence...

NIS and Thyroid Cancer

Since the discovery of the NIS gene, much attention has been focused on the symporter because it is a marker for differentiation and also the mechanism by which radioactive iodide therapy works. Thyroid diseases directly affect the function of the NIS symporter. Three mechanisms, as previously stated, have been proposed for poor iodide uptake in thyroid carcinoma (1) NIS gene mutations,39 (2) suppression of the NIS gene expression,6,3944 and (3) post-transcriptional modifications of the NIS protein.24'26 Congenital ITD is an infrequent autosomal recessive condition caused by mutations in the NIS gene. The clinical picture consists of hypothyroidism, goiter, low thyroid iodide uptake, and low saliva-to-plasma iodide ratio. The incidence of ITD is 1 per 4000 neonates. It has an irreversible effect on the growth and development of the neonate, leading to cretinism. Mutations in thyroid-specific molecules such as thyroid peroxidase, thyroglobulin, and TSHR have been identified.4547 NIS...

Treatments Independent of Differentiated Thyroid Function

High expression of VEGF was found in both chronic lymphocytic thyroiditis and DTCs but not in poorly differentiated cancers.131132 Although it is controversial, there is considerable evidence that VEGF overexpression in DTCs is associated with aggressive clinical features, such as a larger

Ecology of Nutritional Deficiency Diseases

Some of the nutritional deficiency diseases have a clear regional prevalence. Goiter, for example, has a high rate of endemicity in a sub-Himalayan belt extending from Arunachal Pradesh and other states in northeast India through Bhutan, West Bengal, Sikkim, Bihar, Nepal, Uttar Pradesh, Himachal Pradesh, Jammu, and Kashmir. Goiter is also found in parts of Gujarat, Madhya Pradesh, and Maharashtra (India 1987). Endemic goiter is primarily due to a dietary iodine deficiency, resulting in enlargement of the thyroid gland. At one time considered only an unsightly inconvenience, goiter is now known to be a possible precursor of cancer of the thyroid, and is associated with below normal mental and physical development. It is also possible that very high infant mortality in these regions is related to regional iodine deficiency (Hutt and Burkitt 1986). The government of India in 1983 launched a major program, through both private and public channels, of iodizing salt, in an effort to combat...

Polly SY Cheung Mb Bs Hk

Professor of Surgery, Department of Surgery, University of California, San Francisco, School of Medicine, San Francisco, California Sporadic Nontoxic Goiter Thyroiditis Papillary Thyroid Carcinoma Rationale for Total Thyroidectomy Potentially New Therapies in Thyroid Cancer Diagnosis of Primary Hyperparathyroidism and Indications for Parathyroidectomy Parathyroid Hyperplasia Parathyroidectomy

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...

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...

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...

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...

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).

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

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.

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.

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...

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.

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

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...

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