Hypothyroidism : Clinical featues, diagnosis and treatment

Hypothyroidism is an endocrine disorder caused by deficiency of Thyroid hormone which results in systemic manifestation of a spectrum of symptoms.

Prevalence : Primary hypothyroidism is 1:100 but increases upto  1:20 if patients with subclinical hypothyroidism are included. But  in Mountainous region of Nepal, Iodine deficiency is common.

Female:male= 6:1

Etiology or Causes of Hypothyroidism:

Autoimmune or Hashimoto’s Disease and Iatrogenic causes account for maore than 90% of cases.

Mnemonic- “AITI CIS” ( 80 Kiss)

• Autoimmune- Hashimoto’s thyroiditis, Spontaneous Atrophic hypothyroidism,Grave’s Disease with TSH receptor blocking Ab.
• Iatrogenic – Radioactive Iodine Ablation, Thyroidectomy, Drug- Carbimazole, Methimazole, Lithium, Amiodarone
• Transient Thyroiditis- Subacute or de Quervian’s thyroiditis, Post-partum thyroiditis
• Iodine deficiency- common in mountainous region.
• Congenital- Dyshormonogenesis, Thyroid aplasia
• Infiltrative- Amyloidosis, Reidel’s thyroiditis, sarcoidosis.
• Secondary Hypothyroidism- TSH deficiency

Clinical Features :

Symptoms:

1. Weight gain
2. Cold intoerence
3. Yellowish tinge of skin ( Carotenemia )
4. Fatigue, somnolence
5. hoarseness of voice
6. constipation
7. Aches and pains
8. deafness
9. depression or physosis ( Myxedema madness)
10. Dry skin , hair, alopecia
11. Menorrhagia, Infertility, Galactorrhea, Impotence

The body tissues are infiltrated by the mucopolysaccharides, hyaluronic acid and chondroitin sulphate resulting in low pitched voice, deafness, large tonge and Carpal tunnel syndromes.

Signs:

Weight gain
Hoarse Voice
Goitre
Ascites, Ileus
Bradycardia, Hypertension and Pericardial or pleural effusion.
Macrocytosis, Anemia
Delayed tendon reflexes
Cerebellar ataxia
Myotonia
Myxedema, purplish lips, malar flush, Vitiligo, Erythema ab igne
Periorbital edema, loss of eye brows

Investigations-

Non-specific Lab abnormalities seen:

• Serum Enzymes-  Raised CK, AST, LDH.
• Hypercholesterolemia
• Anaemis- Normochromic normocytis or macrocytic
• Hyponatremia

Thyroid Function Test-

• Serum free T3, T4 and TSH can determine the type of Hypothyroidism. ( Clinical , Subclinical)

Measurement of Thyroid Peroxidase antibodies is helpful

Management-

• Unless its transient Hypothyroidism, patient will require life-long replacement.
• Thyroxine Start and maintainance dose
• TFT can be repeateda after 6 weeks. Adjustment dose .
• Patient feels better in 2-3 weeks.
• Repeat TFT every 1-2 year.

In special conditions :

Ischemic heart disease:  low dose usually started

Pregnancy:- additional dose as needed

Reference : Davidson’s Principle and Practice of Medicine.