Hypothyroidism Homeopathic Cure

Thyroid Diet by Tim Garrett

The thyroid diet program can help improve your thyroid function through food. The diet also aims to eliminate foods that can negatively affect your thyroid gland, cause inflammation or interfere with your body's natural hormonal balance. The thyroid diet does not replace the medications, so be sure not to stop taking thyroid medications even if you are on the thyroid diet. You should always consult your doctor before following the thyroid regimen. To follow this diet, including foods containing iodine and selenium, eat plenty of fruits and vegetables and limit sugar and gluten. Thyroid diet program has been designed and tested in clinical practice and based on advanced nutritional science and help many people who struggle with thyroid-related health problems. The reason the program is gaining so much popularity among individuals is that it offers a stress-free method to lose weight. The thyroid diet program is a truly innovative program and blends well with other wellness programs that naturally support healthy metabolism and Vitamin Multivitamin to daily energy. Consume less meat and milk for most of the chemicals you should not eat and that are found in the fat of meat and dairy products. The less meat and milk you consume, the less your body will expose these toxic substances that destroy the thyroid hormone. When eating meat, take half of your portion and consume less meat with each meal. As charcoal can trigger cancer, prefer to cook your meat on a grill. Temperance can solve thyroid problems as it does in many things. Cow's milk is usually delicious, but it can disturb those who have lactose intolerance. If you suffer from wind, stomach cramps, constipation or other disruptive symptoms, adjust your diet. Continue reading...

Thyroid Truth Diet Summary


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Thyroid Disease during Pregnancy

The prevalence of hyperthyroidism is around 5 per 1,000 and hypothyroidism about 3 per 1,000 in women. As the conditions are generally much more common in the female it is to be expected that they will appear during pregnancy. Developments in our understanding of thyroid physiology 1 and immunology 2 in pregnancy as well as improvements in thyroid function testing 3 have highlighted the importance of recognising and providing appropriate therapy to women with gestational thyroid disorders.

Screening For Thyroid Disease

People with type 1 diabetes are at higher risk for autoimmune thyroid disease most frequently the thyroid is underactive (Hashimoto's thyroiditis), but it can also sometimes be overactive (Graves' disease). Your doctor will check you for thyroid disease when you are first diagnosed with type 1 diabetes and then every one to two years. Thyroid abnormalities also increase with age, and your doctor therefore may do thyroid tests periodically even if you have type 2 diabetes.

Epidemiology of Congenital Hypothyroidism

The incidence of congenital hypothyroidism (CH) as detected by common neonatal screening programs, is approximately 1 3,000-1 4,000 in live births 1 . Very recently, in the Netherlands a higher incidence of 1 1,800 was observed using a screening based on thyroxine (T4), thyrotropin (TSH) and thyroxine-binding globulin (TBG) measurement 2 . With this strategy, the incidence of various types of CH was estimated 1 2,200 for permanent CH with 1 2,500 of thyroidal origin, 1 21,000 of central origin, and 1 12,000 for transient hypothyroidism. For unknown reasons, the female male ratio in CH is consistently 2 1. Newborn infants with Down syndrome have an increased risk for CH of approximately 1 140.

Genetic and Other Causes of Congenital Hypothyroidism

Severe central hypothyroidism due to isolated TSH deficiency frequently results from TSH-P subunit (TSHB) mutations 4, 5 . Similarly, TSH deficiency may be found as a component of combined pituitary hormone deficiencies Fig. 1. Anatomic and functional levels at which CH may occur, including exogenous and maternal causes of transient CH. *Antithyroid medication, iodine deficiency blocking TSHR antibodies. Fig. 1. Anatomic and functional levels at which CH may occur, including exogenous and maternal causes of transient CH. *Antithyroid medication, iodine deficiency blocking TSHR antibodies. Table 1. Genetic causes of congenital hypothyroidism Central (pituitary) hypothyroidism

Hypothyroidism Introduction

Hypothyroidism is the result of inadequate thyroid hormone production to maintain body processes. It may be the result of congenital thyroid abnormality and therefore present in infancy or it may become notable during the first two years of life. It appears later when production is inadequate to maintain body processes as rapid growth increases the need for hormones. Acquired causes of the condition may be thyrotoxicosis, thyroidectomy, irradiation, infections, and dietary deficiency of iodine. Secretions of the thyroid gland include thyroid hormone (thyroxine, T4 and triiodothyronine, T3) which are bound to proteins in the blood (thyroxine-binding globulin, TBG) and thyrocalcitonin (maintains calcium levels in blood). The hormones are controlled by the thyroid-stimulating hormone (TSH) that is secreted by the anterior pituitary gland. Treatment of hypothyroidism is by thyroid hormone replacement, which involves prompt intervention in the infant and gradually increasing amounts of...

Thyroid Disease in Turner Syndrome

An association between Turner syndrome (TS) and thyroid disease was first suggested by Atria et al. 1 in 1948 when they reported post mortem findings of a small thyroid gland with lymphocytic infiltration in a young woman with Turner syndrome. Many authors reported on a higher prevalence of hypothyroidism and an association with positive thyroid antibodies in TS patients (table 2) 2, 6, 7, 24, 29, 32, 37 . Hypothyroidism is found in up to 35 of TS patients. Thyroid autoimmunity seems to be even more common in females with Turner syndrome with a prevalence of up to 52 15 . A positive family history was reported by Wilson et al. 37 . This group found an increased incidence of thyroid antibodies in patients with TS and their first degree relatives. The incidence of thyroid antibodies was 30 in patients compared to 1.7 in an age matched control group and 22 in the mothers of the TS patients (vs. 6.6 in the controls). Larissa et al. 21 found a preferential parental segregation of...

Antithyroid Drug Therapy

In contrast to oral iodine therapy (see below), thiouracil drugs do not prevent thyroid gland hyperplasia. Thus, thyroid enlargement may occur during therapy. The thyroid gland may become softer and the outlines of the gland more difficult to distinguish 99 . Because radioactive iodine is less effective in large than in small glands 59, 99, 107 , thyroid size should be continuously monitored for progressive thyroid enlargement that may make the patient an unsuitable candidate for radioactive iodine treatment. If the gland enlarges, this may also be due to hypothyroidism. Thus, patients should be monitored for TSH elevations. After initiation of treatment with PTU or MMI, maximal clinical responses are seen after 4-6 weeks, at which time biochemical hypothyroidism develops. The thionamide dose can then be reduced 30-50 . To achieve a euthyroid state, the dose of MMI or PTU can either be reduced further, or supplementation with L-thyroxine started. An apparent difference between the...

Clinical Outcomes of Congenital Hypothyroidism

In contrast to physical signs, the neurodevelopmental outcome of patients with CH largely depends on the early initiation and maintenance of adequate postnatal L-T4 therapy, especially in cases of severe hypothyroidism (T4 < 5 xg dl). Despite neonatal screening, 10 of early treated infants with severe hypothyroidism are likely to require special education 17 . Subtle differences in intelligence, school performance and neuropsychological tests in comparison to control individuals, classmates and siblings have been detected in adults with CH despite early L-T4 treatment 18, 19 . While in some studies the severity of CH was correlated with poor developmental outcome, recent observations indicate that delayed and inadequate hormone substitution is a main predictor of clinical outcome 18, 20 . Children with CH may have selective deficits on visual, language, motor, attention and memory abilities 21 . Auditory brainstem evoked potentials were abnormal in 25 of early-treated patients with...

Thyroid Disease in Diabetes Mellitus

Autoimmunthyroiditis describes a group of thyroid diseases with destruction of thyroid tissue due to an autoimmune reaction. Classification of these diseases is not consistent in the literature. Most frequently, Hashimoto thyroidi-tis with antibodies against thyroid antigens is found. These antibodies are directed towards thyroid peroxidase (TPO-Ab), thyreoglobulin (TG-Ab) and or TSH-receptor antigen (TRAK). The majority of patients with positive thyroid antibodies have normal thyroid function. Elevated TSH levels as a marker for subclinical hypothyroidism are found in about 15 in the antibody positive patient group. Overt primary hypothyroidism due to autoimmune thyroiditis is seen in 3-5 of patients 3, 8, 19 . Clinical findings of hypothyroidism like goiter, weight gain, fatigue, cold intolerance and bradycardia are rare because of screening for TSH and autoantibodies in patients with type 1 diabetes (table 1). In the study of Kaspers et al. 16 , evidence for thyroid disease was...

Diagnostic WorkUp of Congenital Hypothyroidism

Confirmatory serum measurements of TSH and T4 are required, along with thyroid hormone binding proteins and serum free T4. In cases of maternal autoimmune thyroid disorder, assessment of TSHR blocking antibodies may indicate a transient form of CH. Thyroglobulin levels tend to be high in dyshormonogenesis and low in thyroid agenesis. Thyroid ultrasono-graphy and or thyroid scan are considered optional for management of CH 1 but are necessary to clarify the underlying source of CH, to distinguish between thyroid aplasia, ectopy or inborn errors of T4 synthesis. Testing thyroid function in first degree relatives may be informative because of the variable penetrance of inherited CH. Measurement of iodine or iodotyrosines in urine are helpful if iodine exposure, iodine deficiency or recycling defects are considered. It is clinically important to distinguish permanent or transient forms of CH. If imaging studies reveal ectopic or absent thyroid tissue, hypothyroidism is probably permanent....

Hypothyroidism in Infancy Childhood and Adolescence

Hypothyroidism during childhood and adolescence can result from a variety of congenital or acquired defects (table 2). Table 3. Symptoms of childhood hypothyroidism Some children present with an asymptomatic goiter, whereas others may present with mild tenderness or a sensation of fullness in the anterior neck 41 . The course of hypothyroidism is often so insidious that neither the child nor the parents are aware of the physical changes that have occurred. These children often have marked growth retardation before the disease is recognized, and the expected effect on linear growth emphasizes the importance of serial growth measurements in all children. Children who develop hypothyroidism before age 2 years may suffer some irreversible central nervous system damage and developmental delay, the onset of hypothyroidism developed after infancy does not cause mental retardation 42 (table 3). Deceleration of linear growth is an important sign that is helpful in the early recognition of this...

Primary prevention of hypothyroidism

Primary prevention of disease focuses on risk factor identification and modification. Risk factors may stem from genetic predispositions and environmental exposures. There is a genetic predisposition to the most common cause of hypothyroidism, autoimmune thyroiditis, which occurs approximately tenfold more frequently in women than men and affects approximately one in seven female children of affected women. However, autoimmune thyroiditis appears to be a polygenic disorder (8) for which there can currently be only general predictions of disease risk. A number of other rare monogenic disorders causing hypothyroidism have been described. Familial combined pituitary hormone deficiencies (9) and isolated thyrotropin (TSH) deficiency (10) cause central hypothyroidism. The thyroid gland may be congenitally resistant to TSH action as the result of a mutation in the TSH receptor (11), its related Gsa subunit (12), or the TSH p-subunit (13). Inherited defects in thyroid hormone biosynthesis...

Tertiary prevention of hypothyroidism Avoiding Complications

Potential complications of recognized hypothyroidism and its treatment are preventable with sustained thyroxine therapy and appropriate clinical and laboratory monitoring. Myxedema coma is a life-threatening syndrome of multisystem organ failure resulting from prolonged profound thyroid hormone deficiency, usually with superimposed sepsis, drug intoxication, or an ischemic vascular event (52). Anecdotally, the hypothyroid patient who is elderly or has a history of previous noncompliance, other systemic illness, alcohol abuse, social isolation, and economic deprivation is at greatest risk. A second potential complication in hypothyroid patients who are suboptimally treated is persistence of risk factors for atherosclerosis. In this setting, the serum low-density lipoprotien cholesterol (53) concentration may remain elevated. In one small trial of patients with treated hypothyroidism and ischemic heart disease undergoing follow-up coronary catheterization after angioplasty, the patients...

Secondary prevention of hypothyroidism Early Diagnosis And Treatment

Hypothyroid Follow

Hypothyroidism fulfills the criteria for early detection, either through testing prompted by clinical suspicion (case finding) or by routine testing of all individuals in a defined group (screening). First, hypothyroidism is highly prevalent, particularly in clinically identifiable subsets of the population, such as older women. Second, its consequences can be clinically significant whether one considers the morbidity of subsequent myxedema or the long-term vascular effects of associated hyperlipidemia and these consequences can be avoided by early diagnosis and therapy. Third, clinical diagnosis alone can be inaccurate. Fourth, the diagnostic test, serum TSH measurement, can successfully identify individuals with early disease, so interventions are possible before development of adverse consequences of untreated disease. Importantly, the screening test is accurate, safe, and inexpensive. Furthermore, once hypothyroidism is diagnosed, treatment is also effective, safe, and...

Iodine Deficiency and Supplementation

Iodine deficiency produces a spectrum of disorders - endemic goiter, hypothyroidism, cretinism, and congenital anomalies - that are termed the iodine deficiency disorders. Despite substantial global progress against iodine deficiency, it is estimated that 750 million people worldwide, or approximately 15 of the population, remain iodine deficient and goitrous. In iodine-deficient areas, multiple nutritional and environmental influences contribute to the prevalence and severity of iodine deficiency disorders. Even nowadays, iodine nutrition in children and iodine supplementation of pregnant women remains a medical challenge and ought to be optimized. In Europe, nearly two-thirds of the populations live in countries that are iodine deficient. Damage to reproductive function and to the development of the fetus and newborn is the most important consequence of iodine deficiency. The fetal brain is particularly vulnerable to maternal hypothyroidism in iodine deficiency, and iodine...

Iodine Deficiency

Iodine is essential for thyroid hormone synthesis and is present in soil, water and air. Iodine deficiency disorders (IDD), which was referred to as endemic goiter up to thirty years ago refers to iodine deficiency that can be prevented by ensuring an adequate intake of iodine in population 64 . Goiter is the most frequent and visible manifestation of IDD and is an important health problem. It effects intellectual growth in neonates and children and almost 20 million people living in developing countries have some degree of brain damage due to the effects of iodine deficiency (ID). ID in the mother results in deficiency of the neonate. The most striking feature of ID is endemic cretinism. In severe iodine deficiency, endemic goiter and cretinism increased perinatal death, decreased fertility rate and increased infant mortality occur. Combined iodine and selenium deficiency causes a severe form of cretinism in some areas. Two types of endemic cretinism have been defined 65-67 . In...


In patients with hypothyroidism, the lipoprotein abnormality most commonly seen is an elevated LDL level, although elevated levels of triglycerides and Lp(a) have also been reported (10). The mechanism of the lipid derangement is attributed to the decrease in the excretion of cholesterol through the biliary tree and the inhibition in the activity of hepatic lipase. With thyroid replacement therapy, the elevation in various lipids usually resolves unless other contributing factors such as diabetes or primary lipid disorders coexist (2).

The Hypothalamic PituitaryThyroid Axis

It appears that most of the critical events in thyroid morphogenesis take place in the first 60 days of gestation in humans. For this reason, morphogenic errors during this period result in developmental thyroid abnormalities. These may cause displacement of cells derived from the thyroid anlagen leading to abnormal thyroid migration and ectopic thyroid tissue. Mutations in thyroid transcription factors may also lead to abnormalities in thyroid development resulting in congenital hypothyroidism 16, 19, 36 . Also, the thryroglossal duct may not degenerate but persist as a fistulous tract containing some thyroid follicular cells from which thyroglossal cysts or rarely thyroid carcinoma may arise.

Fetal Thyroid Development and Function

Fertility is impaired in hypothyroid women with autoimmune thyroid disease and if such patients do achieve pregnancy the hypothyroid state is associated with a higher incidence of miscarriage early in pregnancy reviewed in 14 . Thyroid autoimmunity, as evidenced by the presence of anti-thyroid antibodies, present during early pregnancy even in the euthyroid situation, is associated with an increased risk of subsequent miscarriage 25 . Thyroid autoantibody positive women miscarry at a rate of between 13 and 22 compared to 3.3-8.4 in control euthyroid antibody negative women 14 . While the association between thyroid antibodies and miscarriage is strong that between these antibodies and recurrent abortion is less so. In the euthyroid woman with thyroid antibodies no specific treatment can be offered to reduce the antibody titres one uncontrolled study in euthyroid thyroid antibody positive women with recurrent abortion reported a significant success rate with thyroxine administration 26...

Hyperthyroidism and Pregnancy

Subacute thyroiditis causes such as hyperemesis gravidarum, toxic multinodular goitre, toxic adenoma and subacute thyroiditis may occur. It should be noted that most women with nausea and vomiting in pregnancy do not have hyperthyroidism. Rarer causes include struma ovarii, hydatidiform mole and one reported case of a TSH receptor mutation activated only during pregnancy 27 (table 3).

Effects of Hyperthyroidism on Mother and Child

Congestive heart failure and thyroid storm may also occur and the risk of pre-eclampsia is significantly higher in women with poorly controlled hyperthyroidism and low birth weight may be up to nine times as common. Neonatal hyperthyroidism, prematurity and intra-uterine growth retardation may be observed. A retrospective review documented a 5.6 incidence of fetal death or stillbirth in 249 pregnancies from hyperthyroid mothers and a further 5 fetal and neonatal abnormalities. Women with thyroid hormone resistance who, despite being euthyroid, had high levels of circulating T4 had a significantly increased miscarriage rate compared to euthyroid unaffected couples 30 . However, a recent study of women with subclinical hyperthyroidism, comprising 1.7 of women, showed no significant adverse pregnancy outcomes suggesting that treatment of this condition in pregnancy is not warranted 31 . Nevertheless, there is no doubt that overt clinical and biochemical hyperthy-roidism should...

Mortality and Recurrence Rates

One large study (130) found that favorable prognostic factors were longer duration (> 6 mo) of goiter, age less than 60 yr and goiter smaller than 10 cm. In another series (124), the important prognostic factors were tumor size and fixation, extracapsular extension, and retrosternal involvement. In a third study (131), unfavorable prognostic factors were large cell lymphoma, tumor resectability, and possibly male sex, whereas preexisting Hashimoto's thyroiditis was a favorable prognostic factor, which has also been reported by others (132). Others (128,132) find that advanced age (> 65 yr), hoarseness, stridor, hepatosplenom-egaly, axillary lymph nodes, vocal cord paralysis, and chest x-ray showing a superior mediastinal mass are all poor prognostic indicators.

Fetal Thyroid Function and Maternal Thyroid Hormones

Consequently, if the mother has T4 deficiency then the fetus will be T3-deficient even if maternal T3 is normal. This is because during early development serum-derived T3 essentially does not contribute to cerebral T3. Studies have shown that normal concentrations of T3 alone in the maternal or fetal circulation without normal T4 concentrations have no protective effect on the fetal brain because during fetal and postnatal development cerebral structures depend entirely on the local generation of T3 from T4 by type II 5'-iodothyronine deiodinase (D2), the activity of which is inversely related to the availability of T4 17 . This might explain why in most cases of congenital hypothyroidism in a newborn with a mother who has normal thyroid function there is no permanent severe central nervous system damage when T4 is administered in the first 3 months of neonatal life. In this case, the fetal brain has not been severely damaged before birth and normal...

Maternal Fetal Unit and the Function of the Fetal Thyroid Gland

(FT4) is much higher than in adult sera and the concentrations of T4 that are available to developing tissues reach values that are comparable to those know to be biologically active in their mothers 28, 29 (fig. 2). The T4-binding proteins and the concentrations of maternal T4 or FT4 that are allowed to pass the placental barrier determine the concentrations of FT4 in the fetal fluids and this is determined ontogenically. Therefore, it has become clear why an efficient barrier to complete maternal thyroid hormone transfer is necessary as the same concentrations that are available in the maternal sera might possibly be toxic to the developing fetal tissues 22, 30 . However, if the fetus is hypothyroid the placenta allows T4 from the mother to pass to the fetus in larger quantities 31 .

Sensorimotor Examination

Parkinson's disease, and normal pressure hydrocephalus. Dysarthria would alert the clinician to possible extrapyramidal disorders, bilateral strokes, de-myelinating disease, and motor neuron disease. Sensory abnormalities (e.g., peripheral neuropathy) may be associated with B12, other vitamin deficiency states, thyroid disease, or a paraneoplastic syndrome. Cerebellar signs might raise concerns about cerebrovascular disease, spinocerebellar degeneration, a paraneoplastic syndrome, and Creutzfeldt-Jakob disease. In Alzheimer's disease, especially early in its course, the sensorimotor examination tends to be relatively benign. Some researches have pointed out that the presence of extrapyramidal signs in patients with a profile otherwise consistent with Alzheimer's disease suggests a worse prognosis (33). Extrapyramidal signs may indicate the presence of Lewy body variant of AD (34). In general, if a patient with dementia presents with focal or multifocal neurological signs, the...

Interindividual Variability and Polymorphism

Allelic variants, which arise by point mutations in the wild-type gene, are the source of interindividual variation in the CYP activity. Amino acid substitutions can result in an increase or more commonly a decrease in CYP activity. Environmental factors known to affect CYP levels include medications (e.g., barbiturates, anticonvulsants, rifampin, tro-glitazone, isoniazide), foods (e.g., cruciferous vegetables, charcoal broiled beef), social habits (e.g., alcohol consumption, cigarette smoking), and disease status (diabetes, inflammation, viral and bacterial infection, hyperthyroidism, and hypothyroidism.5 Due to recessive inheritance of gene mutation, some CYP enzymes can be absent or poorly expressed in a certain percentage of the population leading to increased pharmacological response or toxic effects of drugs.26-28 The two major polymorphically expressed enzymes are CYP2C19 and CYP2D6. The poor metabolizer phenotype of CYP2C19 is found in 2-3 of Caucasians and African-Americans...

Function of the Thyroid Gland in the Neonate and Infant

The weight of the neonatal thyroid gland is a good indicator of maternal iodine intake during pregnancy. On an adequate maternal iodine intake, the weight of the neonatal thyroid is less than 1.5 g 48 . Due to the increased turnover of iodine and consequently of thyroglobulin in the early neonatal period, decreased iodine intake will bring about an increased consumption of reserve colloid, as a result of the increased activity of the follicular cells which would at the beginning cause a decrease in thyroid weight. Then due to the iodine deficiency, after prolonged TSH stimulation there might be hypertrophy of the follicular epithelium and hyperplasia may occur leading to an increase in thyroid weight. In areas of severe iodine deficiency, average thyroid weights in term newborn infants are approximately 3 g 49 . Recent studies have shown that neonates with pathological levels of TSH in the first days of life which have physiological levels of TSH at follow-up within the first or...

Differential diagnosis

A Low Thyroid RAIU Silent lymphocytic thyroiditis Subacute painful thyroiditis Drug-induced (amiodarone, lithium, Silent lymphocytic thyroiditis Subacute painful thyroiditis Drug-induced (amiodarone, lithium, uninodular toxic goiter is another major cause of hyperthyroidism, especially in areas of marginal iodine intake. The natural history of multinodular goiter (Plummer's disease) appears to be the gradual development of autonomy, leading first to subclinical and then to overt hyperthyroidism (19). The prevalence of thyroid nodularity generally increases with age, especially in women in one English postmortem study, 23 of women over age 60 had nodular glands (20). A German postmortem study (in an area of moderate iodine deficiency) found nodules in 88 of elderly women (21). Thyrotoxicosis is frequently iatrogenic, the result of overzealous thyroid hormone replacement therapy for hypothyroidism or of TSH-suppressive therapy for thyroid cancer. In older patients with autonomous...

Treatment of subclinical thyrotoxicosis

Be treated with estrogen replacement and bisphosphonates and tachycardia with P-blockers. However, once a persistently suppressed TSH level has been documented, the goal of specific therapy is to normalize the serum TSH using small doses of MMI or PTU. Definitive therapy with 131I may be carried out, especially in patients with goiter, although large doses may be required in the setting of a normal 24-h RAIU. The thyroid 131I uptake may be enhanced by the prior administration of recombinant human TSH (78,79). Early therapy may be especially beneficial for patients with multinodular goiter, given an expected progression to overt hyperthyroidism (80). Treatment with antithyroid drugs has been shown to have a beneficial effect on osteoporosis in two small studies (81,82). Additionally, treatment of subclinical hyperthyroidism does seem to decrease the risk for atrial fibrillation (77). Some authors (16,35) advocate aggressive treatment for subclinical hyperthyroidism, whereas others...

Hypothesis on the Cause and Mechanism of Autoimmune Disease

Tis, adrenalitis, insulitis T1D, and others 15 . In IPEX, a high incidence of T1D and its early onset (within 1 year in the majority of cases 21 , see above) could be attributed to so severe a deficiency or dysfunction of natural Treg. Notably, thorough depletion of natural Treg from the normal immune system can induce novel autoimmune diseases that have been postulated to be of autoimmune etiology in humans, but with little evidence. For example, autoimmune neuritis or autoimmune myocarditis, resembling human CIDP (chronic inflammatory demyelinating polyneuropathy) or giant cell myocarditis, respectively, can be induced in NOD and BALB c mice, respectively ( 25 , Ono et al., unpublished data). Third, this possible mechanism of autoimmune disease implies that a single causative agent or a single genetic abnormality affecting the Treg-mediated control, or the balance between Treg and self-reactive effector T cells, may lead to the occurrence of different autoimmune diseases, frequently...

More Than Adequate Iodine Intake

Although not excessive, studies in more than adequate iodine intake (see table 4) following iodine prophylaxis, also pointed out the possible development of thyroid autoantibodies. Zois et al. 85 investigated the iodine status and the impact of iodine prophylaxis on the prevalence of autoimmune thyroiditis among schoolchildren in a formerly iodine-deficient community in northwestern Greece. The findings were compared to those obtained from a similar survey carried out 7 years previously in the same area. A total of 302 schoolchildren (12-18 years of age) from a mountainous area of northwestern Greece were examined for the presence of goiter, and blood and urine samples were collected for assessment of thyroid function, antithyroid antibodies and urinary iodine excretion. Median urinary iodine concentration in the children was 200 xg l. Thyroid function was normal in all but 7 children, who had subclinical hypothyroidism (2.5 ). Antithyroid antibodies (antithyroid peroxidase and or...

Duties And Obligations

What should the states' obligations be, particularly in light of competing needs for limited resources Mandatory screening adopted with public health rationale does not necessarily mean that everyone benefits from testing. Health care consumers, particularly those in areas using multiplayer systems of care, have widely differing levels of access to tests and interventions. Changes to one's health insurance can create substantial potential for harm if insurers refuse to pay for expenditures associated with a ''preexisting'' (genetic) condition, or impose premium increases that make treatments (even co-pays) unafford-able. Furthermore, the type of genetic test reporting can have devastating consequences. For example, California's newborn screening reporting requirements does not require reporting actual values, but rather only abnormal results. A recent case resulted in permanent injury because the actual values, which showed consistency for congenital hypothyroidism, were not reported....

Receptor Specific Nuclear Actions Genomic Actions

Response elements the transcriptional activity is altered by an interaction directly or indirectly with a complex array of transcriptional cofactors including corepressors, coactivators, integrators. Even unliganded TRs interact with core-pressors and repress expression rather than being an inactive passive receptor. This also explains that TR knockout mice are not suffering from as pronounced a hypothyroidism as might be expected 97 .

Summary and Conclusions

Several transporters that mediate the cellular entry of TH have been identified, but most of them are not specific for thyroid hormones. Up to now only two truly TH-specific transporters have been found OATP1C1 with high preference for T4 and MCT8 with preference for T3 as the ligand 21 . Since delivery of TH to the cells is a crucial mechanism for subsequent TH action, abnormalities in these transporters probably result in disease, e.g. a described mutation in the MCT8 caused tissue-specific hypothyroidism in the brain with milder affection of other organs 39 . In both qualitative and quantitative terms, deiodination is by far the most important pathway of thyroid hormone metabolism. Deiodination by the deiodinases D1-D3 are extremely important for TH delivery to its intracellular action mechanisms. The deiodinase activities are actively regulated in a variety of fashions, and active differentially in various tissues. Clinically, the importance of the deiodinases in the regulation of...

The Thyroid and Autoimmunity in Children and Adolescents

Thyroid autoimmunity is the commonest disease process to affect thyroid function. The prevalence of thyroid autoimmunity increases throughout life, with a possible decline in frequency in the very old as a 'healthy survivor' effect. The mere presence of thyroid autoimmunity, as demonstrated by the presence of thyroid autoantibodies or focal thyroiditis, for example, does not equal thyroid disease, since the majority of people with focal thyroiditis do not become hypothyroid 1 . On the other hand, as far as we know the formation of thyroid-stimulating antibodies (TSAb) leads to Graves' disease in the great majority of subjects, even if in rare cases their levels may oscillate and be associated with a fluctuating clinical course. After a brief review of the basic immunological mechanisms which underlie autoimmune thyroid diseases, this chapter will focus on the comparatively few studies which have looked specifically at the pathogenic mechanisms in these disorders in children and...

Mechanisms of Thyroid Autoimmunity

It is well established that a complex interplay of diverse environmental and genetic susceptibility factors interact in predisposing an individual to autoimmune thyroid disease (fig. 1). Moreover, the contribution that each factor makes varies from patient to patient, and as yet there are no clear genotype-phenotype correlations. We have shown that polymorphisms in the thyroid stimulating hormone receptor (TSH-R) are associated with Graves' disease but not autoimmune Clinical autoimmune thyroid disease Clinical autoimmune thyroid disease Fig. 1. Interaction of factors predisposing to autoimmune thyroid disease. hypothyroidism 2 . The other known genetic loci associated with thyroid autoimmunity, namely HLA, CTLA-4 and PTPN22, are shared between these 2 thyroid conditions, as well as many other autoimmune diseases reviewed in 3 . Several environmental factors have been delineated but some of these remain controversial and of unknown action, such as smoking and stress 4, 5 . Evidence...

Discharge And Home Healthcare Guidelines

GGoiter is the enlargement of the thyroid gland. It is usually a response to a thyroid hormone deficiency (primary hypothyroidism) that results in the hypersecretion of thyroid-stimulating hormone (TSH) from the anterior pituitary gland. Oversecretion leads to subsequent thyroid hypertrophy and hypervascularity. The body's response may compensate for thyroid hormone deficiency, leaving the patient asymptomatic. Goiter may also occur in conjunction with hyperthyroidism, known as Graves' disease. Finally, goiter may occur with the growth of thyroid tumors. Secondary hypothy-roidism occurs with TSH deficiency in the pituitary gland and is not associated with goiter. Most goiters are classified as simple (or nontoxic). They result from any enlargement of the thyroid gland that is not caused by an inflammation or a neoplasm. Simple goiters can be classified as sporadic or endemic and are not associated initially with either hyperthyroidism or hypothyroidism. Sporadic goiters occur after a...

Debate on Newborn Screening Programs

To detect CH, primary TSH screening is used in most European countries, Japan and Australia. However, using this approach, some forms of CH including delayed TSH elevation in infants with TBG deficiency or low birth weight, central hypothyroidism and hypothyroxinemia are missed. In North America, a T4-based program with additional measurement of TSH in samples with lowest T4 concentration is commonly used 1 . Primary T4 screening with backup TSH measurements has the potential to detect primary hypothyroidism, TBG deficiency and central hypothyroidism. The recall rate for primary hypothyroidism in both approaches is 0.05 , and the rate of false positive results is higher using the primary T4 strategy.

Treatment Recommendations

Because poor compliance has major consequences, initial and ongoing counseling of parents is of utmost importance. Education of parents by trained professionals should address the etiology of hypothyroidism, the benefit of early diagnosis in preventing mental retardation, the appropriate L-T4 application, and the importance to follow treatment regimens and regular visits. Thus, the pediatrician plays a central role to provide a medical home for every child with CH to coordinate care and lifelong disease management. 1 American Academy of Pediatrics Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics 2006 117 2290-2303. 2 Kempers MJE, Lanting CI, van Heijst AFJ, et al Neonatal screening for congenital hypothyroidism based on thyroxine, thyrotropin, and thyroxine-binding globulin measurement potentials and pitfalls. J Clin Endocrinol Metab 2006 91 3370-3376. 3 Olivieri A, Stazi MA, Mastroiacovo P, et al A population-based study on the frequency of additional...

Gender Ethnicracial And Life Span Considerations

Hyperthyroidism is most frequently found in women as compared with men, and some experts suggest that the hormone cycles of women may in some way affect the incidence of thyroid disease. Although it can affect all ages, it is most typically diagnosed in 20- to 40-year-olds and is unusual in children, teenagers, and people over 65 years of age. When hyperthyroidism occurs in the elderly, their symptoms may be more subtle than those of younger persons, and the classic signs may even be absent. Occasionally, an elderly person with hyperthyroidism has apathy or withdrawal instead of the more typical hypermetabolic state. No specific gender and ethnic racial considerations exist in hyperthyroidism.

Primary Nursing Diagnosis

Most patients are diagnosed and treated on an outpatient basis. The goal of treatment is to return the patient to the euthyroid (normal) state and to prevent complications. Graves' disease is treated pharmacologically (see below). Radioactive iodine (131I) is given for two purposes for diagnosing imaging in low doses and for therapeutic destruction of the thyroid gland in larger doses. Radioactive iodine is considered the definitive and most common treatment, but it is not without risks. The principal disadvantage is hypothyroidism because 40 to 70 of patients treated with 131I develop hypothyroidism within 10 years after treatment. Other complications include parathyroid damage and exacerbation of hyperthyroidism. Surgical treatment with thy-roidectomy is no longer the preferred choice of therapy for Graves' disease but is an alternative therapeutic approach in some situations. In particular, it is used for patients who cannot tolerate antithyroid drugs, have significant...

Resistance to Thyroid Hormone in Childhood

Occasionally, a patient is seen in the clinic with apparent hypo- and or hyperthyroid symptoms but with conflicting results of thyroid function tests they have a nonsuppressed or even slightly increased TSH inappropriate for the invariably increased free T4 in serum. This combination of hormone levels can have several causes but there are two major ones namely a TSH-producing pituitary adenoma and resistance to thyroid hormone (RTH). The latter will be the subject of this chapter. The basic problem in RTH is a decreased sensitivity of tissues to thyroid hormone. The decreased sensitivity is also present in the pituitary, where it leads to a blunting of the feedback of thyroid hormone on the pituitary. This in turn results in the above mentioned increased secretion of TSH and thereby of T4. As will be explained below, the insensitivity is caused by mutations in the thyroid hormone receptor beta isoform that reduce thyroid hormone binding affinity. This does not just lead to a...

Viruses Affecting the Thyroid

The effect of viruses on the thyroid is an area that has been underresearched there are few reports of specific viruses being associated with thyroid disease. Both acute and subacute thyroiditis have long been thought to have a viral etiology, but no specific association has been found despite numerous studies measuring broad spectra of viral antibodies in paired serum samples. However, an association between antibodies reactive with microsomal and or thyro-globulin fractions of thyroid tissue has been found in 20-40 of congenital rubella sera. Thyroid function was found to be abnormal (showing both hypo- and hyperthyroidism) in 5 of all congenitally infected children being restricted to those with thyroid autoantibodies. The finding of rubella virus antigen in a biopsy of thyroid tissue from a 5-year-old boy with congenital rubella and Hashimoto's thyroiditis suggests that virus may persist in the tissue even though no virus is isolated. It is interesting to note that there is a...

Directions for the Future

The discovery of the genetic cause of Pendred syndrome opened up new opportunities in the study of thyroid, ear and kidney physiology. The next challenge is to translate these findings into clinically relevant interventions. Genetic testing can identify carriers in high-risk populations, and this information can then be used for genetic counseling and family planning. The thyroid disease per se does not cause overwhelming disability however, early, complete thyroid

Regulation Of Thyroid Function

Thyroid-stimulating hormone binds to a single class of heptihelical G protein-coupled receptors (see Chapter 2) in the basolateral surface membranes of thyroid follicular cells. The TSH receptor is the product of a single gene, but it is comprised of two subunits held together by a disulfide bond. It appears that after the molecule has been properly folded and its disulfide bonds formed, a loop of about 50 amino acids is excised proteolytically from the extracellular portion of the receptor. The a-subunit includes about 300 residues at the amino terminus and contains most of the TSH binding surfaces. The -subunit contains the seven-membrane-spanning a-helices and the short carboxyl-terminal tail in the cytoplasm. Reduction of the disulfide bond may lead to release of the a-subunit into the extracellular fluid, and may have important implications for the development of antibodies to the TSH receptor and thyroid disease (see below). Binding of TSH to the receptor results in activation...

Use of Diuretics in the Treatment of Hypertension in Renal Impairment

Hypertension is a consequence of renal impairment and if untreated accelerates the decline in renal function to end-stage renal failure. Moreover, hyperlipidemia and glucose intolerance are more common in chronic renal failure, and cardiovascular morbidity and mortality are significantly increased, particularly in patients on dialysis in whom BP control is often difficult. The major cause of hypertension in renal failure is sodium retention and ECV expansion, so-called volume-dependent hypertension. Additional factors may include increased sympathetic nerve acuity, hyperparathyroidism, hypothyroidism, increased and decreased production and or action of endogenous vasoconstrictors (e.g., angiotensin II, endothelin, nitric oxide inhibitors), and vasodilators (e.g., prosta-

Regulation Of Thyroid Hormone Secretion

Thyroid function with bodily needs (Chapter 38). In the absence of TSH, thyroid cells are quiescent and atrophy, and, as we have seen, administration of TSH increases both synthesis and secretion of T4 and T3. Secretion of TSH by the pituitary gland is governed by positive input from the hypothalamic hormone thyrotropin-releasing hormone (TRH) and negative input from thyroid hormones. Little TSH is produced by the pituitary gland when it is removed from contact with the hypothalamus and transplanted to some extrahypotha-lamic site, and disruption of the TRH gene reduces the TSH content of mouse pituitaries to less than half that of wild-type litter mate controls. Positive input for thyroid hormone secretion thus originates in the central nervous system by way of TRH and the anterior pituitary gland. TRH increases the expression of the genes for both the a-and -subunits of TSH and increases the post-transla-tional incorporation of carbohydrate that is required for normal potency of...

Childhood Hyperthyroidism

Hyperthyroidism occurs much less commonly in children than hypothyroidism, yet is a far more virulent condition 7, 8 . In children the most common cause of childhood thyrotoxicosis is Graves' disease, which is characterized by diffuse goiter, hyperthyroidism and occasionally ophthalmopathy 6, 9-11 . Other causes of childhood hyperthyroidism include toxic nodules, toxic multinodular goiters, acute and subacute thyroiditis, and the ingestion of thyroid hormone 6, 9-11 . Central to considering the use of radioactive iodine and other treatment options in Graves disease in the pediatric population, is recognition of the natural history of the autoimmune disorder. One must also consider how long antithyroid drug therapy should be continued before moving on to definitive therapy. When spontaneous remission of Graves' disease does not occur, prolonged drug therapy will control the hyperthyroid state and is used by some clinicians however, years of treatment with antithyroid drugs do not...

Post 131I Cancer Risks

It is important to note that iodine deficiency and exposure to nuclides other than 131I may have contributed to the increased risk of thyroid cancer in the young following the Chernobyl reactor explosion 70-72 . In comparison, rates of thyroid cancer were not increased in the more than 3,000 children exposed to 131I from the Hanford reactor site in an iodine replete region 75 . An increase in thyroid cancer has not been observed in about 6,000 children who received 131I for diagnostic procedures 72, 76 .

Treatment Approaches for Children

Because young children are less likely to have remission than older children on drug treatment 15, 16 , prolonged drug therapy may be needed. If there are no toxic effects, continuing antithyroid drugs is reasonable until the child is considered old enough for radioactive iodine therapy. Alternatively, thyroidec-tomy or ablative radioactive iodine therapy can be considered if reactions to medications develop or there is the desire to avoid prolonged drug use. Children 10 years of age and older account for 80 of the pediatric cases of Graves' disease. For this age group, radioactive iodine or antithyroid drugs can be considered as first-line treatment options. In determining if drug therapy is likely to be successful, TRAb levels and thyroid size may be predictive of remission rates. The presence of low TRAb levels and a small thyroid suggests the possibility of remission on medical therapy. Yet, if TRAb levels are high and the thyroid is large, the odds of spontaneous remission are...

Juvenile Graves Ophthalmopathy Incidence and Symptomatology

The incidence rates start to increase as of the age of 20 years. Below the age of 20 years the occurrence of GO is a rare event. Incidence rates (cases per 100,000 population per year) are in the age groups 5-9, 10-14, and 15-19 years for females 3.5, 1.8 and 3.3, respectively, and for males 0, 1.7 and 0, respectively. Only 6 of the 120 incident cases of GO observed in this cohort study were below the age of 20 years. A more detailed study published recently from the same department found that of 1,662 cases ages < 18 years, with thyroid-related abnormalities, evaluated at the Mayo Clinic in Rochester, Minn., USA, during the 15-year interval (1985 to 1999), 35 children with GO were identified. Of these, 6 had received radioactive iodine (RAI), 1 patient had RAI plus antithyroid drugs, 9 had partial or total thyroidectomy, and the rest antithyroid medications for their thyroid problem. Four patients did not require treatment. Of the 35 children with GO, 31...

Clinical manifestation

Skin manifestations diffuse hyperpigmen-tation lower extremity edema hypertrichosis, usually most pronounced over the face, limbs, and chest sclerodermoid changes angiomas whitening of the proximal nails hepatomegaly splenomegaly lymphaden-opathy abnormal estrogen levels with gynecomastia hypothyroidism hyperprol-actinemia hypoparathyroidism Neurologic manifestations progressive bilateral symmetric disturbances involving both motor and sensory nerves begins distally and has progressive proximal spread osteosclerotic myeloma or monoclonal gammopathy

Imaging of the Normal and Affected Thyroid in Childhood

Imaging has undergone major advances over the past three decades and has revolutionized the evaluation of patients with thyroid disease. However, the use of thyroid imaging is in general not evidence-based, and there have been few cost-benefit evaluations of medical imaging 1 .

Molecular Analyses Of Peripheral Blood And Postoperative Surveillance Of Thyroid Carcinomas

The application of RT-PCR to detect circulating thyroid-specific mRNA in recurrent thyroid cancer was first reported in a study in which all patients with thyroid carcinoma and metastases were tested positive for circulating thyroglobulin (TG) mRNA, whereas patients without metastases were tested negative. 9 In a subsequent study, 10 circulating mRNA transcripts of TG, thyroid peroxidase (TPO), and RET PTC1 were used as tumor markers in patients with thyroid disease. Although there was a correlation between existence of these transcripts in peripheral blood and diagnosis of thyroid carcinoma, TG and TPO mRNA transcripts could be detected in the peripheral blood of all control subjects as well as in several human cell lines when PCR assay sensitivity was increased. Finally, an optimistic study was published, 11 which reported an RT-PCR assay to detect blood-borne TG mRNA that was more sensitive than the conventional TG serum assay. However, in the study of the authors, 12 only a weak...

Selenium Deficiency and Supplementation

The essential trace element selenium is involved in thyroid hormone synthesis, metabolism and action. In several regions of the world people are exposed to inadequate selenium supply because selenium contents of surface soils have been depleted by erosion and glacial washout similar to iodine. Therefore, plant and animal food chains contain inadequate amounts of both of these elements. Deficiencies of selenium and iron can act in concert with iodine deficiency to impair thyroid metabolism and modify the response to prophylactic iodine. The effects of selenium and iron status on iodine and thyroid metabolism share certain parallels. Selenium deficiency reduces the activity of the selenium-dependent deiodinase and peroxidase enzymes and thereby impairs thyroid metabolism in iodine-deficient populations 21-24 . Similarly, iron deficiency reduces heme-dependent thyroperoxidase activity, impairs thyroid metabolism, and influences the response to iodine in iodine deficiency disorders....

Vitamin A Supply and Zinc Status

In a double-blind, randomized clinical trial, children with vitamin deficiency were given iodized salt and either vitamin A or placebo at 0 and 5 months. At baseline, increasing severity of vitamin A deficiency was a predictor of greater thyroid volume and higher concentrations of TSH and thyroglobulin. In children with vitamin A deficiency, the odds ratio for goiter was 6.51 (95 CI 2.94-14.41). Severity of vitamin A deficiency was also a strong predictor of higher concentrations of total T4 the odds ratio for hypothyroidism in vitamin A deficiency was 0.06 (95 CI 0.03-0.14). During the intervention, mean thyroglobulin, median TSH, and the goiter rate significantly decreased in the vitamin A-treated group compared with those in the placebo group. The findings indicate that vitamin A deficiency in severely iodine deficient children increases TSH stimulation and thyroid size and reduces the risk for hypothy-roidism. This effect could be due to decreased vitamin A-mediated suppression of...

Papers Mri Of Normal Thyroid Gland

Lingual Thyroid Vallecula Mri

Acute suppurative thyroiditis and thyroid abscess are rare disorders and congenital pyriform fistula should be suspected, especially in case of recurrent infections on the left side. MRI or CT is valuable in addition to barium esopha-gography in the workup of such patients 153 . Diffuse Thyroid Disease In Graves' disease both T1- and T2-weighted images show a diffusely increased but slightly heterogeneous signal 156 . Dilated vessels within the thyroid can often be identified 157 . In autoimmune thyroiditis the thyroid appears heterogeneous on T1-weighted images and often with diffusely increased signal on T2-weighted images 157 . A morphological overlap on T1- and T2-weighted images is seen between patients with Graves' disease, subacute thyroiditis and Hashimoto's thyroiditis, but additional calculation of the diffusion coefficient can distinguish Graves' (highest values) from the other two 158 . In subacute thyroiditis T1-weighted images demonstrate regions of abnormality with...

Pituitary causes of secondary amenorrhoea

During Months Pregnancy

Hyperprolactinaemia is the commonest pituitary cause of amenorrhoea. There are many causes of a mildly elevated serum prolactin concentration, including stress, and a recent physical or breast examination. If the prolactin concentration is greater than 1000 m l then the test should be repeated and if still elevated it is necessary to image the pituitary fossa (CT or MRI scan). Hyperpro-lactinaemia may result from a prolactin-secreting pituitary adenoma, or from a non-functioning 'disconnection' tumour in the region of the hypothalamus or pituitary, which disrupts the inhibitory influence of dopamine on prolactin secretion. Large non-functioning tumours are usually associated with serum prolactin concentrations of less than 3000 m l, while prolactin-secreting macroade-nomas usually result in concentrations of 8000 m l or more. Other causes include hypothyroidism, poly-cystic ovary syndrome (up to 2500 mU l) and several drugs (e.g. the dopaminergic antagonist phenothiazines, domperidone...

Further investigations of female infertility

Male Groin Hernia Examination

Miscarriage, termination of pregnancy, ectopic pregnancy Chronic illnesses (diabetes, hypertension, renal disease) Known endocrine disorders, e.g. hypothyroidism, PCOS Previous STD's, e.g. Chlamydia Known endometriosis Galactorrhoea Cervical smear history Current medication including folate

Iron Deficiency and Supplementation

Clinical trials were done in primary schools in an area of endemic goiter in the mountains of Cote d'Ivoire. At that time, the median urinary iodine concentration and the goiter rate by palpation in school-aged children in this region were 28 xg l and 45 , respectively, indicating moderate to severe iodine deficiency. Goitrous, school-aged children were divided into two groups nonan-emic or with iron deficiency anemia. All children received an oral dose of 0.4 ml iodized poppy seed oil (Lipiodol ) containing 200 mg or 0.2 g of iodine. At 15 and 30 weeks, thyroid volume was significantly reduced in the nonan-emic group compared to the group with iron deficiency. A sharp difference in goiter prevalence was apparent at 15 and 30 weeks, when goiter rates were 62 and 64 in the anemic group but only 31 and 12 in the nonanemic children. Median TSH values were lower (p < 0.01), and T4 values were greater (p < 0.01) in the nonanemic children. Thus, in this study, both anatomic (thyroid...

Utimobranchial Complex

Heterozygous Pax-8+ mice show no specific pheno-type. Pax8+' mice have a higher prevalence of elevated plasma TSH than wildtype littermates, but their thyroid gland appears histologically normal. Homozygous Pax8 ' mice present with growth retardation and die within 2-3 weeks. Only the formation of the endoderm-derived follicular cells is affected (31 days) and thyroid glands are hypoplastic with absent median anlagen derivatives (i.e., follicular cells), whereas lateral anlagen derivatives (parafollicular calcitonin-producing C cells) are present 27 . The thyroid is composed completely of calcitonin producing cells. The early neonatal death of Pax-8 mice is due to their severe hypothyroidism (the administration of T4 to Pax-8 ' mice allows the animals to survive), and to the retarded development of other organ systems (such as bone, spleen and intestine). The absence of Pax-8 is still compatible with very early stages of thyroid development (appearance of the thyroid...

Secondary Adrenal Insufficiency

Cranial mass, such as headache or visual field defects, or defects in other pituitary hormones such as gonadotropins, which usually are lost first (female irregular or absent menses male erectile dysfunction), followed by hypothyroid symptoms, followed finally by loss of ACTH.

Rectal Evacuatory Disorder

Faecal impaction is an important risk factor for incontinence and predominantly affects older people, especially those living in institutions 41,95 , but also children 25, 41, 145 . In the elderly, approximately 50 of nursing home residents will suffer from faecal incontinence 41, 233, 234 prolonged retention of stool in the rectum, perhaps secondary to incomplete evacuation during defecation but also as a consequence of other factors, such as physical immobility, inadequate diet and water intake, depression, dementia, associated metabolic disorders (e.g. hypothyroidism) and use of constipating drugs (e.g. narcotics, antipsychotics and antidepres-sants), can lead to faecal impaction 95 . This may result in overflow incontinence, which can be exacerbated by laxative use 235 , which causes liquid stool to seep around the faecal bolus 236 . The presence of an impacted mass will also stimulate the secretion of large volumes of mucus, which will further aggravate

Diagnostic categories in infertility

Increased levels of prolactin interfere with normal pulsatile secretion of GnRH, resulting in anovulation, amen-orrhoea and occasionally galactorrhoea associated with low FSH and oestradiol levels. Hyperprolactinaemia is a feature of prolactin producing pituitary adenomas or tumours blocking inhibitory control of the hypothalamus. Other causes include primary hypothyroidism, chronic renal failure, and drugs such as the combined oral pill, dopamine depleting agents (reserpine, methyldopa) and dopamine receptor inhibiting agents (metoclopramide and phenothiazines).

Endocrine investigations Table 391

A more permanent, but still moderate elevation (greater than 700 mIU 1) is associated with hypothyroidism and is also a common finding in women with PCOS, where prolactin levels up to 2500 mlU l have been reported 1 . PCOS may also result in amenorrhoea, which can therefore create diagnostic difficulties, and hence appropriate management, for those women with hyperprolactinaemia and polycystic ovaries. Amenorrhoea in women with PCOS is secondary to acyclical ovarian activity and continuous oestrogen production. A positive response to a progestogen challenge test (e.g. medroxyprogesterone acetate 10 mg daily for 5 days), which induces a withdrawal bleed will distinguish patients with PCOS related hyperprolactinaemia from those with polycystic ovaries and unrelated hyperprolacti-naemia, because the latter causes oestrogen deficiency and therefore failure to respond to the progestogen challenge.

Oligodendrocytes And Their Ancestry

The ability of certain combinations of growth factors to enhance progenitor cell self-renewal is counterbalanced by the action of other signaling molecules that promote oligodendrocyte generation. The most extensively studied of such signaling molecules is thyroid hormone (TH), which has been of particular interest due to the severe deficiencies in myelination that occur in children or experimental animals that are hypothyroid for genetic, nutritional, or experimental reasons 14-19 . Conditioned medium from cultured oligodendrocytes also inhibits the proliferation of O-2A OPCs and promotes oligodendrocyte generation, and this effect may be mediated in part by transforming growth factor-6 (TGF-6 20,21 ). Still other cytokines, such as leukemia inhibitory effector (LIF) and ciliary neurotrophic factor (CNTF), also have been found to enhance the generation of oligodendrocytes from O-2A OPCs 22-24 . It is important to note that these same factors, when applied to other precursor cells,...

Pendrins Function in the Thyroid

Parts Fly Rod

Iodination of thyroglobulin and formation of thyroid hormone. Thus, patients with severe mutations in either will have severe congenital hypothyroidism. In contrast, in the total absence of pendrin, organification is only partially inhibited and most patients remain clinically euthyroid. Thus, an alternative, as yet unidentified, pathway, or pathways, must exist by which iodide can exit the apical border of the cell. It is possible that mutations in the components of these other pathways may explain the disease in patients with clinical Pendred syndrome, but without PDS mutations.

Thyroid Hormone Transport

More than 99 of the circulating thyroid hormone is bound to plasma proteins but can be liberated with great rapidity for entry into cells. The thyroid hormone-binding proteins are comprised of thyroxine-binding globulin (TBG), transthyretin (TTR or thyroxine-binding prealbumin), human serum albumin (HSA) and lipoproteins. Their functions are most probably to ensure a constant supply of TH to the cells and tissues by preventing urinary loss 3 , protect the organism against abrupt changes in thyroid hormone production and degradation, protect against iodine deficiency 2 and target the amount of TH delivery by ensuring a site-specific, enzymatic alteration of TBG 4 . TBG has by far the highest affinity for T4, the result of which being that TBG binds 75 of serum T4, whereas TTR binds 20 and HSA 5 2 . Some of the properties of the binding proteins are displayed in table 1. Abnormalities of the TH-binding proteins do not cause alterations in the metabolic state of the individual nor do...

Effects of thyrotoxicosis Bone Effects

Multiple studies of the effects of subclinical thyrotoxicosis on bone have provided conflicting results since the first study by Ross et al. (44) demonstrating reduced bone density in patients receiving TSH-suppressive doses of l-T4. Grant et al. (45) found no significant differences in forearm bone mineral density among postmenopausal women on long-term TSH-suppressive doses of l-T4, those on replacement l-T4 doses, and euthyroid controls. However, in a large study of postmenopausal women, Schneider et al. (46) found significantly lower bone density at multiple skeletal sites in women taking more than 200 g of l-T4 daily versus those taking smaller doses of thyroid hormone. Studies by Lehmke et al. (47) and Kung et al. (48) found lower bone densities in postmeno-pausal women with subclinical thyrotoxicosis secondary to TSH-suppressive doses of l-T4. Campbell et al. (49) showed increased markers of bone turnover in hypothyroid postmenopausal women treated with TSH-suppressive versus...

Monitoring of the Fetus in a Mother with Graves Disease

As neonatal thyrotoxicosis is known to be associated with neurological impairment in some cases there is a requirement to monitor the fetus rather than wait till birth to diagnose thyroid dysfunction. The use of serial in utero ultrasonographic measurements has been shown to accurately measure fetal thyroid size 42 . If the fetal thyroid does not reduce in size in response to antithyroid drug administration then transplacental passage of TsAb causing fetal hyper-thyroidism should be suspected. A recent comprehensive study by Luton et al. 43 showed that the sensitivity and specificity of fetal thyroid ultrasound at 32 weeks for the diagnosis of clinically relevant fetal thyroid dysfunction was 92 and 100 , respectively. with suppressed TSH. In those patients who are hyperthyroid antithyroid drugs may be given. The diagnosis of gestational thyrotoxicosis will be confirmed by noting the absence of TSH receptor stimulating antibodies. (b) Toxic multinodular goitre and toxic adenoma...

Endocrine Complications

Because most patients harbor macroadenomas, hypopituitarism develops from compression of normal surrounding pituitary tissue by the expanding tumor mass causing amenorrhea and impotence in half of acromegalic patients (15,37), with secondary hypothyroidism and hypoadrenalism in approximately 20 .

Testing For Autoimmune Diseases

I mentioned in Chapter 3 that people with type 1 diabetes are at risk for other autoimmune diseases, especially thyroid disease and celiac disease. When your child is diagnosed with type 1 diabetes, he should also be screened for autoimmune thyroid disease. His doctor will do these thyroid tests at intervals or if there is a problem with your child's growth, because low thyroid hormone levels can slow down growth.

Examination of the newborn infant

The examiner should be prepared to answer maternal questions and discuss the merits of BCG and hepatitis B vaccination, and routine screening tests if appropriate. Universal newborn hearing screening has recently been introduced in the United Kingdom. Universal biochemical screening for phenylketonuria and hypothyroidism during the newborn period is well established. In addition, galactosaemia, cystic fibrosis, haemoglobinopathies and various aminoacidopathies are screened for in some parts of the United Kingdom.

Primary Adrenal Insufficiency Addisons Disease

Suncongentcral Hemorrhage

Autoimmune adrenocorticol insufficiency has a genetic predisposition and is associated with a high incidence of other endocrine gland failure. Although initially named after those who described the syndrome Schmidt's syndrome (adrenal insufficiency and thyroiditis) or Carpenter's syndrome (hypoadrenal-ism, hypothyroidism, and type 1 diabetes mellitus) , these disorders are now grouped into polyglandular failure syndrome types I and II (8). Type I is inherited in an autosomal recessive pattern, with hypoparathyroidism, mucocutaneous candidiasis, and adrenal insufficiency being the most infamous triad of endocrine gland failures. Type II is familial half the time and is linked to HLA antigens B8 (DW3), DR3, and DR4. In type II patients, adrenal insufficiency is present in 100 of patients, with autoimmune thyroid disease, 70 , or insulin-dependent type 1 diabetes mellitus, 50 , in decreasing order of occurrence. Although these syndromes are uncommon, it is important to be aware that one...

Physiologic Effects Of Thyroid Hormones

The importance of the thyroid hormones for normal development of the nervous system is well established. Thyroid hormones and their receptors are present early in the development of the fetal brain, well before the fetal thyroid gland becomes functional. T4 and T3 present in the fetal brain at this time probably arise in the mother and readily cross the placenta to the fetus. Some evidence suggests that maternal hypothyroidism may lead to deficiencies in postnatal neural development, but direct effects of thyroid deficiency on the fetal brain have not been established. However, failure of thyroid gland development in babies born to mothers with normal thyroid function have normal brain development if properly treated with thyroid hormones after birth. Maturation of the nervous system during the perinatal period has an absolute dependence on thyroid hormone. During this critical period thyroid hormone must be present for normal development of the brain. In rats made hypothyroid at...

Treatment of overt hyperthyroidism

Pretreatment with antithyroid medications may help protect older patients or others at risk for cardiac complications by decreasing thyroid hormone stores (71), although this concept has recently been challenged (72,73). Most patients will become euthyroid within weeks after receiving a single large dose of radioiodine the remaining 10-20 of patients require retreatment 6 mo to a year later. Within a year of treatment, up to 90 of patients will become hypothyroid the other 10 become hypothyroid at a rate of 2-3 per year (70). Surgery is another option for treatment of younger patients with hyperthyroidism. It is especially useful for patients with very large goiters and or compressive symptoms who often require multiple doses of 131I. Subtotal or near-total thyroidectomy is the procedure of choice. The most common adverse effects of thyroidectomy are injury to the parathyroids, resulting in hypocalcemia, and injury to the recurrent laryngeal nerve. Patients should be treated...

Optimal Iodine Intake

These recommendations derive from consensus statements by several groups, including the International Council for Control of Iodine Deficiency Disorders, the World Health Organization, UNICEF, and the Food and Nutrition Board of the US National Academy of Sciences. The amounts are based on the following the calculated daily thyroid hormone turnover in euthyroidism, the iodine intake producing the lowest values for serum thyrotropin (TSH) and for serum thyroglobulin (TG), the amount of thyroid hormone replacement necessary to restore euthyroidism to athyreotic subjects, the iodine intake associated with the smallest thyroid volumes in populations, and the lowest incidence of transient hypothyroidism in neonatal screening with blood spot TSH. About 90 of iodine is eventually excreted in the urine. The median urinary iodine concentration in casual ('spot') samples, expressed as micrograms per liter ( g l), is currently the most practical biochemical laboratory marker of community iodine...

Fetal Maternal Relationships

Pregnancy affects thyroid homeostasis. An increased excretion of iodine in the urine accounts for the increase in thyroid volume even in areas of moderate dietary iodine intake 4 . Some studies, however, do not show an increase in urinary iodine during pregnancy. In either case the increase in thyroid volume is the result of imbalance between the intake and increased requirements of iodine during pregnancy 5 . Iodine deficiency during pregnancy is associated with maternal goitre and reduced maternal thyroxine (T4) level. While thyroid size increases in areas of iodine deficiency it does not do so in those regions that are iodine sufficient even in moderate iodine-deficient regions urinary iodine excretion is higher in all trimesters than in non-pregnant women and may be causative in maternal goitre formation as assessed by ultrasound. The increase in thyroid volume already referred to is substantially greater in iodine-deficient areas. This gestational goitrogenesis is preventable by...

The Future Is Here Functional Foods

If your breakfast this morning included calcium-fortified orange juice and toast made with folate-enriched flour, you are a consumer of functional foods. Just what is a functional food As the fastest growing category of new food products, these are foods or food components to which manufacturers have added ingredients that are known or believed to promote health and prevent disease (see Chapter 4, What Do the Terms Fortified and Enriched Mean page 92). Although the name functional foods is new, the concept is not when it was discovered in the early part of the 20th century that some thyroid disease was caused by a deficiency of the mineral iodine, manufacturers began enriching table salt with iodine. Since that time, we have also seen vitamin D-for-tified milk, breakfast cereals fortified with a variety of vitamins and minerals, and the addition of preservatives that are themselves antioxidants to almost all processed foods (see Chapter 3, Cholesterol-Lowering Margarine, page 66). The...

Deiodination of Iodothyronines

D1 has both outer and inner ring deiodination activities, but appears particularly important for the generation of plasma T3 and clearance of reverse T3 by outer ring deiodination. D1 is positively regulated at the pretranscriptional level by T3, and is very potently inhibited by the antithyroid drug propylth-iouracil. In humans, therefore, it might be expected that hyperthyroidism would induce D1 with subsequent relative increase in T3 production. Hyperthyroidism is indeed commonly associated with a higher increase in plasma T3 compared to T4, and D1 activity has also been demonstrated to be approximately 3-fold elevated in thyroid glands from Graves' disease compared to euthyroid control glands 51 . D2, on the other hand, has only outer ring deiodination activity, preferring T4 over reverse T3 as substrate, and it is increased in hypo- and decreased in hyperthyroidism. This regulation by the thyroid state can occur both by pre- and posttranslational mechanisms. D2 is particularly...

The Role of Thyroid Radiation in Causing Thyroid Cancer External Irradiation

A large U.S. study, for example, reported a slight elevation of thyroid cancer mortality following treatment of hyperthyroidism with 131I, but the absolute risk was small and the underlying thyroid disease appeared to play a role Above-ground nuclear weapons testing in Nevada between 1951 and 1963 released radioactive particles into the atmosphere that exposed thousands of individuals across the continental United States to radioiodine fallout. Exposure was highest for children who drank milk from a backyard cow or goat that had ingested grass contaminated with radioiodine. A study from the National Cancer Institute (34) concluded that nuclear weapons fallout had resulted in an average cumulative thyroid dose of 0.02 Gy (2 rad) in Americans, but for those under age 20 it was 0.1 Gy (10 rad), within the range known to cause thyroid cancer in children (30). The National Academy of Sciences (35) reported that about 50,000 excess cases of thyroid cancer would result from these...

Pharmacologic Highlights

Treatment consists of replacing the deficient hormone with synthetic thyroid hormone low doses are initially used, and the dose is increased every 1 to 2 months based on the clinical response and serial laboratory measurements that show normalization of thyroid-stimulating hormone (TSH) levels in primary hypothyroidism. The patient begins to experience clinical benefits in 3 to 5 days, which level off after approximately 4 to 6 weeks. After the dose is stabilized, patients can be monitored with laboratory measurement of TSH annually. The patient with myxedema is generally weak and therefore progressively immobile. Hypothyroidism exposes the patient to the risk of skin breakdown. One goal is to increase the patient's mobility while accommodating her or his extreme weakness with frequent rest periods. Provide meticulous skin care.

Fsh and lhomas Pituitary Tumors Secreting Fsh Or Lh

FSH- and LH-secreting tumors are usually clinically silent. Rare cases of tumors presenting with clinical features have been reported. A 28-yr-old Finnish woman presented with oligoamenorrhea and pelvic pain. A detailed assessment revealed elevated FSH and estradiol with an appropriately suppressed LH enlarged ovaries with multiple cysts were seen on pelvic ultrasound examination. Both gonadotropins and the a-subunit exhibited a paradoxic response to TRH, and MRI revealed a pituitary macroadenoma. After removal of the pituitary tumor, all hormone values normalized, and the patient resumed normal menstrual cycles. In another report, transsphenoidal tumor resection was found in a girl who presented with precocious puberty. LH hypersecretion from a pituitary adenoma was also documented in two cases. Thus, varying degrees of hypopituitarism may occur in these patients, with decreased libido and erectile dysfunction in men and oligo- or amenorrhea in women. Alternatively, central...

The Role of Host Genes in Determining the Phenotype of Autoimmune Disease

Determine which organs or tissues are targeted by the responses 52, 53 . The genetic class="intexttaglink" data-tid="15506" href="/makeup.html">makeup of the host mainly determines the phenotype of the autoimmunity triggered by altered T cell regulation. For example, NTx predominantly produces autoimmune oophoritis in the A strain, autoimmune gastritis in the BALB c but not DBA 2 strain (which shares the H-2d MHC haplotype), and no apparent organ-specific autoimmunity in the C57BL 6 strain 53 . Administration of neutralizing anti-IL-2 mAb produced gastritis in BALB c mice, exacerbated T1D in NOD mice 25 , and produced de novo autoimmune peripheral neuritis in NOD mice 25 . ATx and subsequent fractionated X irradiations predominantly induces thyroiditis in PVG c rats with the RT1c MHC haplotype, and T1D in MHC congenic PVG-RT1u rats 54 . Thus, MHC and non-MHC genes contribute to determining the phenotype of autoimmune disease triggered upon reduction or dysfunction of natural Treg. Polymorphisms of these genes may affect the formation of a...

Chronic Inflammation And Ilhealth - References

Penhale WJ, Farmer A, McKenna RP, Irvine WJ (1973) Spontaneous thyroiditis in thymectomized and irradiated Wistar rats. Clin Exp Immunol 15 225-236 11. Sugihara S, Izumi Y, Yoshioka T, Yagi H, Tsujimura T, Tarutani O, Kohno Y, Murakami S, Hamaoka T, Fujiwara H (1988) Autoimmune thyroiditis induced in mice depleted of particular T cell subsets. I. Requirement of Lyt-1 dull L3T4 bright normal T cells for the induction of thyroiditis. J Immunol 141 105-113 14. McKeever U, Mordes JP, Greiner DL, Appel MC, Rozing J, Handler ES, Rossini AA (1990) Adoptive transfer of autoimmune diabetes and thyroiditis to athymic rats. Proc Natl Acad Sci U S A 87 7618-7622

Impact of Therapy

Because most surgeons find it nearly impossible to remove all thyroid tissue routinely at surgery, uptake of 131I is almost always seen in the thyroid bed postoperatively, which must be ablated before 131I will optimally concentrate in metastatic deposits (69,70). Although there continues to be debate concerning the use of 131I to ablate uptake in the thyroid bed after near-total thyroidectomy (71,72), there are several compelling reasons to do it. First, a thyroid remnant can obscure 131I uptake in cervical or lung metastases (69,70). Second, high serum levels of TSH, which are necessary to enhance tumor 131I uptake, cannot be achieved with a large thyroid remnant (73). Third, serum Tg is most sensitive in detecting cancer when measured during hypothyroidism or with rhTSH stimulation after thyroid bed uptake has been ablated (74). Fourth, there is evidence that recurrence and cancer mortality rates are lower after total thyroid ablation.

Child Development

Thyroid hormones are major factors for the normal development of the brain. The mechanisms of actions of thyroid hormones in the developing brain are mainly mediated through two ligand-activated thyroid hormone receptor isoforms 50 . It is known that thyroid hormone deficiency may cause severe neurological disorders resulting from the deficit of neuronal cell differentiation and migration, axonal and dendritic outgrowth, myelin formation and synapto-genesis 23 . This is the situation well documented in iodine-deficient areas where the maternal circulating thyroxine concentrations are too low to provide adequate fetal levels particularly in the first trimester. Recent work has raised concern that in an iodine-sufficient area maternal thyroid dysfunction (hypothyroidism, subclinical hypothyroidism or hypothyroxinaemia) during pregnancy results in neuro-intellectual impairment of the child. Two studies, have shown that a low thyroid hormone concentration in early gestation can be...

Thyroid lymphoma

Primary thyroid lymphoma is an uncommon but life-threatening disorder that often poses a major diagnostic dilemma because it is encountered so infrequently. Typically it arises in the setting of Hashimoto's thyroiditis, sometimes in patients with long-standing hypothyroidism. The neoplasm may go unrecognized for several months until the patient develops airway obstruction symptoms, and when it does become apparent that it is a malignancy, an erroneous diagnosis of ATC is sometimes made. It is important to identify the tumor as a thyroid lymphoma since its prognosis is much better than that of ATC. Nevertheless, many patients continue to die from this tumor because the diagnosis is often delayed, which is challenging because when it is diagnosed at an early stage it has an excellent prognosis.

Cryptic PHTS

Because the spectrum of PHTS may be broader than was previously believed, it would be important to recognize cryptic cases. Since CS, in and of itself, is difficult to diagnose clinically, PTEN mutation frequencies in series of 'CS' individuals ranged from a low of 10 (Tsou et al., 1997) to a high of 81 (Marsh et al., 1998b). The highest mutation frequencies are obtained when CS is strictly defined by the operational diagnostic criteria of the International Cowden syndrome Consortium (Table 3.2) (Liaw et al., 1997 Marsh et al., 1998b). A study was performed that ascertained CS-like probands in which the subjects were not required to meet the Consortium criteria but were required to have a minimum of breast cancer and thyroid disease in a single individual or in two first-degree relatives (Marsh et al., 1998a). Sixty-four unrelated probands were enrolled, and one germline mutation was found, in a family with follicular thyroid cancer, bilateral breast cancer and endometrial cancer....


Contrary to systemic lymphomas, female preponderance is the rule for thyroid lymphoma (29) because it originates from active lymphoid cells in chronic lymphocytic thyroiditis, which occurs more often in women. Among 812 patients with thyroid lymphoma reported in 16 large series (29), females outnumbered males by almost 3 1, and the mean age was 62.7 yr however, the female-to-male ratio under age 60 was 1.5 1 compared with 5 1 over age 60 (29). Although this is a disease of older women, about one-third of 568 patients in one review (29) were under age 60 yr. History. A close association exists between thyroid lymphoma and Hashimoto's thyroiditis. The relative risk of thyroid lymphoma among people with Hashimoto's thyroiditis living in Sweden was 67-fold greater than expected, after an average follow-up of 8.5 yr (121). Another study (122) found that the frequency of thyroid lymphoma among 5592 women aged 25 yr or older with chronic thyroiditis living in Japan was increased 80-fold. The...

Screening methods

The serum TSH should be the first thyroid function test obtained in patients suspected of thyroid dysfunction or in the screening of older patients or those at risk for thyroid disease. A serum TSH level below the lower limits of detectabil-ity in any given assay raises the suspicion of thyrotoxicosis. A patient with a TSH value below the normal range but still detectable is probably not thyrotoxic, and the test should be repeated in a few months. Further studies are warranted in patients whose serum TSH is undetectable and who are not receiving thyroid hormone therapy (Fig. 1). A careful physical exam, especially of the thyroid, should be carried out in all patients, since the presence of a goiter would make the diagnosis of thyroid dysfunction more likely. We usually obtain thyroperoxidase (TPO) and thyroglobulin (Tg) antibodies and some measure of thyroid hormone levels, primarily a serum T4, free T4 (or index), and total T3 (or free T3). If either or both of the thyroid antibodies...

Iodine Excess

Severe iodine deficiency moderate iodine deficiency mild iodine deficiency None clinical increasing risks for autoimmune thyroiditis and hyperthyroidism (mostly in the elderly) Excessive dietary iodine may increase the risk of thyroiditis, hyperthy-roidism, hypothyroidism, and goiter 73 . In healthy adults, short-term iodine intakes of 500-1,500 xg day have mild inhibitory effects on thyroid function. The consequences of prolonged exposure to high intakes of iodine, particularly in children, are less clear. Endemic goiter in children has been described in coastal Japan, where iodine intake from seaweed was > 10,000 xg day. Lower intakes, in the range of 400-1,300 xg day, from iodine-rich drinking water, were associated with increased serum thyrotropin and thyroid volume in a small sample of Chinese children. In children, excess dietary iodine has been associated with goiter and thyroid dysfunction. In a report of what the authors called 'endemic coastal goiter' in Hokkaido, Japan 74...


Because D1 is a selenoprotein, one might expect to find decreased D1 enzyme activity in selenium deficiency, and in rats this was indeed demonstrated for hepatic and renal D1 70, 71 . There are, however, differences in the organ sensitivity to selenium deficiency, so studies may show difference in results depending on the organs studied. Furthermore, it is difficult to study in humans, because it is difficult to find pure, isolated selenium deficiency. Yet, mildly elevated serum T4 levels have been described in selenium-deficient humans 70-73 . Selenium supplementation in an area with both iodine and selenium deficiency has resulted in an unexpected reduction of serum T4, and in some an increase of serum TSH as indication of worsening of hypothy-roidism 74, 75 . This reaction might be explained by selenium deficiency causing reduced Dl-catalyzed inner ring deiodination of iodothyronines, thereby protecting against hypothyroidism. These results are in contrast to a study by Roti et al....


Screening for extracolonic malignancy has proven less fruitful. Unlike colorectal cancer screening, there has been no reported evidence that early screening or therapy has improved the prognosis of duodenal and periampullary adenomatous disease. 23 Nevertheless, screening for am-pullary tumors is also recommended with upper endos-copy every 1-3 years, beginning at age 20-25 years. Screening should be performed with both forward and side viewing scopes with random biopsies taken. In regard to other common extracolonic tumors, annual physical exam is recommended for thyroid disease. 21 Hepatoblastoma screening includes annual liver ultrasound with alpha-fetoprotein level until the age of 6 in patients diagnosed with FAP in infancy. 1

Newborn Screening

Newborn screening (NS) for congenital hypothyroidism (CH) is one of the major achievements of preventive medicine 1, 2 . Although since 1972 the problem of CH has been resolved in developed countries by the implementation of NS for CH, the problem exists for developing countries that still have no NS programs for CH 2, 3 . Since diagnosis based on clinical findings is delayed in most instances because of few symptoms and signs, hypothyroidism in the newborn period is almost always overlooked and delayed diagnosis leads to the most severe outcome of CH, mental retardation. In a study from Denmark, it was emphasized that only 10 of the affected infants were diagnosed within the first month of life, 35 within 3 months. 70 were diagnosed within the first year, while in the remainder the diagnosis was delayed to the 3rd and 4th years of life 4 . In a retrospective analysis of 1,000 cases of CH from Turkey, the mean age at diagnosis was 49 months and only 3.1 of cases were diagnosed within...


Human goiter, related to iodine deficiency, is an important health problem in certain parts of the world. In some areas, consumption of cruciferous plants can be a contributing factor to human endemic goiter. A goiter is produced when the seeds of various Brassica species are fed as part of the diet to animals. It is likely that

Clinical Syndrome

In contrast, the thyroid disease associated with Pendred syndrome rarely presents in infancy, usually appearing in late childhood or early adolescence as diffuse or multinodular goiter. Typically, the patients are clinically euthyroid, although mild, compensated hypothyroidism, characterized by elevated TSH with normal thyroxin and tri-iodothyronine levels, is often present. However, clinical presentation is variable and Massa et al. recently described a case of documented Pendred syndrome in whom the presenting thyroid pathology was a painless, benign solitary thyroid nodule that resolved after hormone replacement 8 . The size of the goiter is also variable, and may be small, detectable only on close physical examination, or may reach massive proportions, causing significant cosmetic problems or even tracheal compression (fig. 1) 9 . Although the goiter tends to recur after surgery, partial thyroidectomy may be required. The histological appearance of the thyroid tissue is...

History And Exam

This 26-yr-old man had 1 year of unusual persistent headaches and 3 months of blurry peripheral vision in both eyes that had gradually encroached on central vision. He then found that letters disappeared or doubled vertically or horizontally when he tried to read. His doctor discovered hypothyroidism with a low TSH and obtained brain imaging. He


Total thyroidectomy is the procedure of choice for Graves' disease 68, 91, 92 . New surgical techniques, such as minimally invasive thyroidectomy and minimally invasive video-assisted thyroidectomy have recently been described 93 . Whereas it can take several months for the hyperthyroid state to remit after 131I treatment, the hypothyroid state occurs much sooner after surgery, being dependent on the clearance of circulating thyroid hormone. Following subtotal thyroidectomy, relief of hyperthyroidism is achieved in about 80 of children and adults, and hypothyroidism develops in about 60 of individuals 94, 95 . Hyperthyroidism recurs in about 10-15 of patients after subtotal thyroidectomy 68, 94, 95 . In comparison, hyperthyroidism recurs in less than 3 of children and adults who undergo total thyroidectomy, and hypothyroidism is nearly universal 68, 94-96 .

Thyroid Hormones

As already mentioned in Chapter 39, growth is stunted in children suffering from unremediated deficiency of thyroid hormones. Treatment of hypothyroid children with thyroid hormone results in rapid catch-up growth rates, which are accompanied by accelerated maturation of bone. Conversely, hyperthyroidism in childhood increases the rate of growth, but, because of early closure of the epiphyses, the maximum height attained is not increased. Thyroidectomy of juvenile experimental animals produces nearly as drastic an The effects of thyroid hormones on growth are intimately entwined with GH. T3 and T4 have little if any growth-promoting effect in the absence of GH. Plasma concentrations of both GH and IGF-I are reduced in hypothyroid children and adults and restored by treatment with thyroid hormone (Fig. 13).

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