1

( Thyrotoxicosis )
.

(Triiodothyroxine , T3 )
( Thyroxine , T4 )

2
1.

2.
( diffuse goiter ) ,
( single solitary
nodule ) ,
( multinodular goiter )

Graves disease

( Thyrotoxicosis )

( Hyperthyroidism )

2

(Hyperthyroidism)

( Thyrotoxicosis )


( Struma ovarii ) ,

( Thyroiditis )

10

5 1

Graves disease
60-90, Toxic multinodular goiter Toxic
adenoma 10-20 5-10

( Pituitary gland )
(Hypothalamus)
Thyroid Stimulating Hormone (TSH
Thyrotropin)
, Thyroid Stimulsting
Hormone ( TSH )

(Hypothalamus)

Thyroid Releasing Hormone (TRH)

TSH
TSH
Negative feedback

TSH
TSH

TSH

Negative feedback TRH

1

Hypothalamus
TRH

(+)

Pituitary gland
Peripheral tissue
(-)
TSH
(+)

(- )

Thyroid gland

T3, T4 TBG

1.

2.

:

, , (

), , ,
, , ,

,
,

(Vitiligo) ,

(onycholysis) Plummers nails
, ,

: ,
, ,
(resting tachycardia) , ,

(sinus tachycardia) ,
atrial fibrillation
atrial flutter 9-20
(Heart
block) , (systolic)
(diastolic)
Pulse pressure ,

(systolic murmur) (Atortic
valvr) ,
(Mitral valve) ,
(Mitral valve prolapse)

papillary
( rub )
( Pulmonic valve) Means- Lerman
systolic scratch sounds

, high output

: ,
( shortness of breath )

,
,
( stridor ) ( wheeze )

jugular
( plethora )

( Pemberton s Maneuver )

,


(
lid retraction )
( limbus )
( staring eyes )

( lid lag )
( Mullers muscle )
,
( Exophthalmos ) 2

Glycosaminoglycan
( GAG )

, , ,
( chemosis ) ,
,

( lagophthalmos ) , ,

(proximal muscle weakness)

( Thyrotoxicosis hypokalemic periodic paralysis )

Myasthenia gravis
, ,
chorea
delerium , agitation ,

( Thyroid crisis storm )

:

,

(pharyngeal muscle) ,

Graves disease

Toxic multinodula goiter

Toxic adenoma
4

:

,

( Renin ) II
( Angiotensin II )
(Glomerular Filtration Rate : GFR)
GFR

(serum
creatinine)


20

,
,

:
total cholesterol , low
density lipoprotein cholesterol ( LDL ) , high density
lipoprotein cholesterol ( HDL ) , apoprotein B
apoprotein A apoprotein A-I

,
(glucose tolerance)
,

:
cathecholamine
T3
(cortisol),
(Renin),
9Aldosterone),
(angiotensin Converting Enzyme: ACE)
:

luteinizing hormone (LH),
follicular-stimulating hormone (FSH) estrogen
LH


testosterone LH
androgen estrogen
(gynecomastia)
:
(Bone
Formation) (Bone
Resorption)


(Bone tumover)

10

(Bone Mineral Density, BMD)

(Atypical Presentation of Thyrotoxicosis)

1.




, ,

, ,

2. Apathetic Thyrotoxicosis :

(classic or hyperkinetic
thyrotoxicosis)

,

11

Apathetic Thyrotoxicosis
(Thyroid crisis)

2
1.

2.

1.
Serum sensitive TSH (sTSH)

Thyroid
stimulating hormone (TSH)
TSH

TSH (TSH producing tumor)

12

TSH
TSH
TSH
(low normal)
TSH
4 (generation)
TSH (first
generation) Radioimmunoassay (RIA)
TSH
TSH

2 TSH
0.1 /. RIA
TSH
1 /.

TSH (sensitive TSH,

supersensitive TSH) second, third
forth generation)
TSH 0.1, 0.01 0.001 / .

immunoradiometic assay (IRMA), immunofluorometric
assay (IFMA), immunoenzymetric (IEMA)
immunochemilu minometric (ICMA) 3

TSH stimulation test, T3 suppression test
radioactive iodine uptake (RAIU)
sensitive TSH
(Screening test)

0.1 /.

13

free T4 T3
subclinical
hyperthyroidism
TSH
TSH

(chronic TSH
suppression)
Serum T3, T4
T3 T4
T3 T4 (total T3, total T4)
(Bound
form) (free form)
bound form
free from
0.3 T3 0.03 T4 (FT3,
FT4)

(iodothyronine binding proteins (IBPs)

thyroxine binding globulin (TBG),
thyroxine
binding
prealbumin
(TBPA)
Transthyretin albumin TBG
(binging affinity) T3 T4
75-80

IBPs Total T3,
Free T3 total T4, free T4

IBPs
TBG
IBPs
(total T3, total T4)

14

free T3, Free T4

IBPs total T3 total T4
free T3, T4 Euthyroid
hyperthyroxinemia
IBPs total T3, total T4
free T3, T4) Euthyroid
hypothyroxinemia
TBG
total T3, total T4, free T3
free T4 TBG
free T3, free T4 total T3
total T4

IBPs TBG
TBG 2
2 : Thyroid
binding globulin (TBG)
TBG
-
- : ,
tamoxifen, heroine,
perphenazine
-

- Chronic active hepatitis

- Acute intermittent porphyria
- Biliary cirrhosis
- HIV
- oat cell
-
TBG
- (Systemic
illness)

15

- ,

-
(androgen)
- Active acromegaly
-
-
glucocorticoid,
Lasparaginase
- ,

-
Serum free thyroid hormone

IBPs Free
T3, Free T4

1.Equilibium dialysis:


2.Radioimmuno assay (RIA):
2
one-step assay
,

labeled thyroid
hormone analog

IBPs
labeled thyroid hormone
analog IBPs

16

two-step assay:

one-step Equilibrium
dialysis 2

labeled thyroid
hormone analog

labeled thyroid
hormone analog

labeled thyroid hormone
analog IBPs
3.Free thyroxine Index (FT4 I FT3I):

Equilibrium dialysis two step assay

FTI
(total T3, total T4) resin T3 uptake
(RT3U) FT3I total T3
RT3U FT4I total T4
RT3U

FTI fluorescent polarization

immunoassay (FPIA)

90 (T4)
(T3) ,
T3 T4 (T3
toxicosis) 5-30

17

T4 T3 (T4 toxicosis)

T3 toxicosis
Graves disease
(Relapse),
Toxic multinodular goiter, Toxic adenoma

T4 toxicosis
(iodine
induce thyroxicosis)

-blocker, Amiodarone

1.

Total T3 Total T4
sTSH Total T3

Graves diseae

2. TBG
FT4 FT4I total form
sTSH
- FT4
sTSH

- FT4
sTSH
subclinical T3
toxicosis total T3 FT3

18

T4

FT4 T3

hyperthyroidism

or

FT3 TSH Diagnosis

Thyrotoxicosis
T4 toxicosis
T3 toxicosis
Subclinical

TSH producing tumor

inappropriate

TSH

secretion
2. (Radionuclide)
2.1 Radioactive iodidine uptake (RAIU)

RAIU

RAIU
3
- Radioactive
iodine ( 5-20 uCi)
Radioactivity
Radioactive iodine

19

Radioactivity
Radioactive iodine
131- (I 131) 8
123-
I 123 13
, I 123
Radioactivity
10 I 131

I 131 RAIU 24
10-30

RAIU
RAIU
, ,
, , cholestyramine

RAIU
, ,

RAIU
,

RAIU
, ,

RAIU

20

3
Radioactive iodine uptake
(RAIU)
RAIU
Graves disease
Toxic multinodular goiter
Toxic adenoma
Hydratidiform mole
TSH producing tumor
Pituitary resistance to thyroid hormone
RAIU
Transient painless thyroiditis
Subacute painful thyroiditis
Struma ovarii
Thyrotoxic factitia
Lodine induce thyrotoxicosis
Functioning
metastatic
follicular
carcinoma
2.2 Thyroid Scintigraphy (Thyroid Scan)
Technetium-99
99m
(
Tc) 123 (I 123)
Graves disease

, Toxic mitinodular goiter
(hot
nodule)
(cold nodule), Toxic adenoma

(hot nodule)

3.

21

3.1 Thyrotropin Receptor Antibodies ( TSH

receptor Antibodies:TSHRAb) Thyroid stimulating
Antibodies ( TSAb ) Thyroid Stimulating
Immunoglobulin ( TSI )

TSH
adenyl cyclase ATP cyclic AMP

2
1. cyclic
AMP
TSH cyclic
AMP cyclic AMP

2.
TSH Receptor (TSH-binding
inhibition: TBI)
IgG Graves' disease
TSH
TSH TSH receptor Ig G
TSH
receptor
2
TSAb
90 Graves disease TBI
50-90
TSAb TBI
Graves disease
Graves disease

22

TSAb
( relapse )
Graves' disease

TSAb
complete remission
radioactive iodine
, Graves' disease
TSAb

3.2 Serum Thyroglobulin ( Tg )

Tg

Tg RIA IMA
Tg
Graves' disease , Multinodular
goiter, Thyroiditis, Thyroid carcinoma

Tg

Tg

, ( Radioactive iodine )
(T4 )

RAIU Tg

23

Tg

3.3 Anti Thyroid Peroxidase Antibodies ( AntiTPO Antibodies )

Anti-TPO
Graves
disease

( Hypothyroidism ) Graves' disease
subtotal thyroidectomy

4
4

Graves' disease
Toxic multinodular goiter
Toxic adenoma
Hashimotos thyroiditis ( Hashitoxicosis )
Jod-Basedow ( Iodine induced )
TSH- producing pituitary tumor
Hydratidiform mole

24

Subacute thyroiditis
Transient painless thyroiditis ( Postpartum
thyroiditis )
Lymphocyte ( silent ) thyroiditis
Thyrotoxic factitia
Ectopic thyroid: Struma ovarii Metastatic
follicular carcinoma
Drug associated thyroiditis ( amiodarone,
lithium )
Cytokine associated thyroiditis ( Interferon,
Interleukin-2 )
Graves disease
Graves disease

2050 5-10
Graves' disease

,
( diffuse goiter ) ,
( ophthalmopathy )
( dermopathy ) localized myxedema

Graves' disease

Graves' disease

,
, ,

25

Graves' disease
Graves' disease

Human Leucocyte
Antigen ( HlA ) HLA DR3 , HLA-DR4
HLA-DR5 and Gm allotypes
HLA
Graves' disease
cytotoxic lymphocyte antigen 4 ( CTLA-4 )

Hypothalamicpituitary- adrenal axis

Suppressoe T cell

5-10


( B- cell
lymphocyte )

Yersenia enterocolitica

extracellular domain TSH Receptor

Yersenia
enterocolitica
,

26

Heat Shock Protein ( HSP )

Graves' disease

TSH receptor ( TSHR ) , thyroid

peroxidase ( TPO ) , thyroglobulin (TG) thyroidal
iodide transporter
TSHR

Graves' disease 80-100
Graves' disease Ig G TSHR
( TSHRAb )
TSHRAb

Thyroid Stimulating Immunoglobulin ( TSI )
Thyroid Stimualting Antibody ( TSAb )

TSHR
Gprotien , adenylate cyclase
cyclic AMP

TSHR TSH ,
TSHRAb TSH binding inhibitory
immuloglobulin ( TBII )
TSH
TSHR TBII
Graves' disease

Thyroid Peroxidase Antibodies ( TPOAb ),
Thyrogloblin Antibodies ( TgAb )

27

( Hashimotos
thyroiditis ) Graves'
disease

Graves
ophthalmopathy ( Thyroid associated orbitopathy )
Graves' dermopathy
localized myxedema

( Hyperthyroidism ) ,
( diffuse goiter ) ,
( ophthalmopathy )
( dermopathy : localized myxedema)
Graves' disease

Hyperthyroidism diffuse goiter

Graves'
disease
Hyperthyroidism
( ophthalmopathy ) diffuse goiter

( diffuse goiter )

20

28

2-3

2
2
( exopgthalmos ) /
dermopathy Graves' disease
lid lag lid retraction

TSHRAb

Graves' disease

Autoimmune polyglandular syndrome ( Type

1 diabetes, Addisons disease, Hashimotos disease,
premature ovarian failure ) , Rheumatoid arthritis,
Sjogren s syndrome,
vitiligo,
idiopathic
thrombocytopenic
purpura,
pernicious
anemia,
myasthenia gravis, systemic lupus erythrematosus ,
chronic active hepatitis

Graves' disease 3

29
1. ( Medical treatment )
2. ( Subtotal

thyroidectomy )
3. ( Radioactive iodine: I
131
)

Graves' disease
,
69%
, 22%
radioactive iodine ( I 131 )


,
,, ,
,
,,

30

bruit

40

,
, (
6 1 )

( Medical treatment )
1.
( Anti-thyroid drugs )

31

thionamide 3

Propylthiouracil ( 6-propyl-2-thiouracil : PTU )

Methimazole ( 1-methyl-2-mercaptoimidazole
: MMI )
Carbimazole ( 1-methyl-2-thio-3-carbethoxy
imidazole : CMI ) MMI

5
5

PTU
MMI
Serum protein binding
75%
nil
Serum half- life
1.5

4-6
Volume of distribution
20
40
Metabolism of drug during illness
Severe liver disease

Severe kidney disease

Transplacental passage

Levels in breast milk

Potency
1
10
Inhibition of peripheral conversion

32

of T4 to T3
All adverse reactions
3.3%
Major adverse reactions
Agranulocytosis
0.1%(dose related)
Hepatotoxicity
damage cholestasis
Vasculitis

7.1%
0.4%(idiosyncrasy)
hepatocellular

substrate iodination
intermediate TPO
iodination Tg iodinate Tg
iodinated Tg organification

iodothyronine T3 T4
MMI PTU
10-50 , PTU ( 600 . )
5 monodeiodinase
T4 T3
( MMI )
T3
MMI 2

MMI
24 PTU

33

,
cytokine prostacyclin
,
( T cell, B cell, antigenpresenting cell )

Graves' disease PTU 100-300 ./
3 MMI 1030 ./ 2



PTU 300 ./ MMI 30 ./
3-4

PTU 150 ./ 3
MMI 15 .
euthyroidism

Graves' disease
2

euthyroidism

34

PTU 150-300 ./ MMI 10-30 ./

euthyroidism
euthyroidism

-
MMI
PTU

-
PTU
MMI
MMI aplasia cutis

-

PTU
T4 T3

T3
T3 T4 MMI
PTU
- MMI PTU
10
- MMI
( agranulocytosis ) PTU
PTU
( idiosyncrasy )
MMI ( dose
dependent )
MMI 25 .

35

- MMI
( cholestasis )
PTU

PTU

polyarthritis, vasculitis , glomulonephritis lupus- like
syndrome

-

-

PTU MMI
-
euthyroidism
I 131

I131
- thyroid crisis
-

I131

36

2
1. 1-15
, , , , ,
, , ,

2-3

2. 0.2-0.5
agranulocytosis ( granulocyte
250 / . . ) , (PTU) ,
cholestatic jaundice ( MMI ) , aplastic
anemia ,
thrombocytopenia , vasculitis , hypothrobinemia
( PTU ) , hypoglycemia
( MMI ) , myosistis ( MMI )

2.
2.1 ( Beta
adrenergic antagonist )

cathecolamine Beta receptor

Beta receptor

37

peripheral conversion T4 T3
peripheral
tissue


PTU
MMI

PTU MMI

propranolol 20-60 .
2-3
atenolol ,metoprolol

1-2

propranolol

thyroid crisis

asthma, chronic obstructive pulmonary

disease,
heart block, congestive heart failure,
pregnancy ( 2nd, 3rd trimester )
diltiazem, reserpine

38

2.2 Lugols solution SSKI ( Saturated

Solution of Potassium Iodine )

2-4

escaped phenomenon 5- 10
8
:

( thyroid storm )

, ,
, ,
, ,
,
leukemoid eosinophillic granulocytosis
2.3 Dexamethasone
,
preipheral conversion T4 T3

( immunosuppression ) peripheral
conversion T4 T3
PTU
PTU SSKI T3
24-48 2 . 6

( thyroid storm)

2.4 Lithium carbonate

39

thionamide iodide
300-450 . 8

radioactive iodine
( diabetic
insipidus )

1-2
euthyroidism 6-8

4-8

2-4

euthyroidism ( 4-8 )

euthyroidism
4-12 PTU 50 .
MMI . 5 .
euthyroidism
PTU 50 .
MMI 2.5-5 .
6

40

Hashimotos
thyroiditis, Subacute thyroiditis

-
-

-
-
- ,
bruit
2

-
-
-

41

1 . ( Thyroid
function test )

2-3
euthyroidism

euthyroidism
-
11/2 2

T3
T4 T3
T4
sTSH

T3 T4
T3 toxicosis
T3

T4 s TSH T4
sTSH

42

2.
complete blood count ( CBC )

, CBC
agranulocytosis

TSI , HLA DR3, TRH test

T3 suppression test

Graves'
disease
( subtotal thyroidectomy )

I 131

1.
2. ,

3.

( cosmetic effect )

43

4.
I 131
5.

6. ( Relapse )

I131
7.

8. ( poor
compliance )
I 131
9. Graves' disease

-
0- 3.1

( asphyxia )

- ( vocal cord
paralysis ) 0-4.4
Recurrrent laryngral nerve

0-3.6

44

1-7

-
( permanent hypothyroidism )
4.0-29.7

-
( relapse hyperthyroidism )

0.6-17.9
-
,
( keloid )
,

1.

45

recurrent
laryngeal nerve ,

2.

euthyroidism

Lugols solution SSKI

follicular ,
colloid




7-10
bruits thrills

3.

( Radioactive Iodine : I 131 )
I 131

46

I131
-

I131

20-40

I 131

47

- subclinical
hyperthyroidism I 131
( Atrial
fibrillation )
I 131
1.
congenital malformation

( congenital hypothyroidism )


pregnancy test
I 131 10

I 131
6
2.
3.

17 25

2.
Radioiodine uptake
3.

4.
Graves' ophthalmopathy

5.

6.

7.
poor compliance

48

I 131
1.
I131
euthyroidism

I 131

2
I 131 I 131

euthyroidism

131
I 3 7
propranolol

thyroxine
thyroxine I 131 4
2. Graves
ophthalmopathy I 131

ophthalmopathy
prednisolone
0.4-0.5 . . 1
I131

49

2-3
ophthalmopathy
I 131
I 131
I131
I 131
1. Repeated small dose regimen I
131
2 millicurie ( mCi )
3-6
Euthyroidism
2. Fixed dose regimen
( 5-10 mCi )
3. Sliding scale regimen I 131

4. Standard formular regimen

RAIU
( 50-75 uCi
), ( 100 uCi
) , ( 150-200 uCi
)
hypothyroidism

( )
% uptake

= 100 uCi x

50

I 131

I
131

7 I 131

I 131

I131 2

( Radiation
thyroiditis )

I131

51

8
4
propanolol
I131

ohthalmopathy
T3, T4 TSH
12
euthyroidism 8-12
euthyroidism
6 1 3-6

I131

Lugol s
solution 3 SSKI 1 1
6-12
euthyroidism

euthyroidism

I 131

52

I131 6

( Pregnancy
induced hypertension ) , , ,
, , ,


, ,
,
,

1.

Hyperdynamic

53

, , , ,
, , ,
,

2.

TBG ( Thyroid Binding Globulin )

( total T4 total T3 )

, ( lid lag
, exophthalmos ) , onycholysis ,
, 100
Valsava Maneuver ,
bruits

total T4 total T3
TBG

total T4 22 ug% total T3
350 ng% total T4
total T3
total T4
total T3

54

FT4 /
FT3I FT4I / FT3I
sTSH FT4 single
step 2 3
FT4I FT3
FT4I
TSH
1 2
physiologic transient hyperthyroxinemia
hCG ( human Chorionic Gonadotropin )
RAIU

FT4
TSH


Graves disease

( transient hyperthyroidism of hyperemesis

gravidarum ) Graves disease
T3

ophthalmopathy , dermopathy / TSHR Ab

3070
hCG ,
hCG ( TSHR
TSH

55

TSH )
desialylated hCG TSHR

hCG T3
w non-thyroidal illness

,

16-20
TSH

Graves disease

1. Graves disease

2.
Graves disease

56

32-36

TSH

3.

PTU
MMI aplasia cutis

MMI
MMI
PTU

1.

Graves disease

FT4 ( High normal )

57

150
PTU 3
euthyroidism
3-6 50-100
MMI
PTU
aplasia cutis

FT4 2-4

Intrauterine growth
retardation ,postnatal bradycardia syndrome,
, ,

6-12

2
( Lugols solution SSKI )

( Neonatal goiter )

58

2.

premature labor
2

PTU
agranulocytosis

3. ( I 131 )
Graves
disease

( congenital malformation )
2

PTU 100
MMI
PTU
PTU

2
Graves disease
RAIU

( postpartum thyroiditis ) RAIU

59

bruit 2
RAIU

Graves disease

Toxic adenoma ( Goetsch s disease )

Toxic adenoma Autonomously Functioning
Thyroid Nodules ( AFTN ) 5

( solitary thyroid nodule )

( benign tumor )
follicular
adenoma ( hot
nodule )

toxic adenoma

( autonomous function )
somatic point
mutation TSHR intracellular
loop 3 transmembrane segment 6

( Gs protein ) TSHR

60

TSH

mutation
TSHR

Toxic adenoma 40

5-10

( autonomous )

ophthalmopathy
dermopathy

T3 T4

TSH TSH

Toxic adenoma

61

Graves disease
( cold nodule )
thyroid scan
hot
functioning nodule

thyroid scan Graves disease
cold nodule
( Fine
Needle Aspiration and Biopsy : FNAB )

follicular neoplasm

euthyroidism
Toxic adenoma
I
131

Toxic adenoma
( remission )

I131
Graves disease
10-15 mci.
( uptake )
Percutaneous
Ethanol Injection ( PEI ) 95% ethanol 2-4

62

xylocaine 1-2
3-8 ethanol
protein denature cellular dehydration
necrosis fibrosis
ethanol

20


10

Toxic multinodular
disease )

goiter (

Plummers

( multinodular goiter )

( benign tumor )

toxic multinodular goiter

63

TPOAb TSHRAb

somatic mutation TSHR

TSHR
TSH
multinodular goiter
translocation
chromosome 5 12

( Jod-Basedow
phenomenon )

Toxic multinodular goiter

multinodular goiter

toxic multinodular
goiter Graves disease
toxic multinodular goiter
atrial fibrillation
ophthalmopathy
dermopathy

toxic multinodular goiter Graves disease

ophthalmopathy dermopathy

64

toxic
multinodular goiter
thyroid scan

TSH T3 T4

T3
T4 TSH
T3 toxicosis

multinodular goiter

thyroid scan

hot
functional nodules

toxic
adenoma
euthyroidism

65

euthyroidism
toxic
multinodular goiter
I131

Graves disease

ethanol
( Percutaneous Ethanol Injection : PEI )

Subacute thyroiditis
Subacute thyroiditis ( De Quervain , subacute
granulomatous thyroiditis )

HLABw 35

haplotype
cytotoxic T-cell
( diffuse )

66

2-3
50

( creeping
thyroiditis )

colloid

50

T3 , T4 TSH
4-10
24

radioactive iodine uptake
5%
erythrocyte sedimentation rate ( ESR )

multinucleated gigant cell

67

2 3
1-2

15

( nonsteroid anti-inflammaltory drug : NSAIDs )

corticosteroid
prednisolone 20-40

24-48 5-10

2-3 10

propranolol

Transient painless thyroiditis

68

subacute
lymphocytic thyroiditis, silent thyroiditis )

Hashimotos thyroiditis


Hashimoto s thyroiditis subacute
thyroiditis
30-50
variant form
Hashimoto s thyroiditis Antithyroid
antibody
Autoimmune
thyroiditis


HLA haplotype HLA-DR3

cytokine
subacute thyroiditis

1-2
2-8

50-60

subacute thyroiditis

ophthalmopathy dermopathy

2-4 40

69

autoimmune thyroiditis
50

T4 ,T3
TSH T3 T4
20 radioactive iodine uptake
1
ESR
50
T4

TSH antiTG antibodies anti-TPO antibodies 25

50

:
propranolol 40-120 atenolol
25-50 2-3
prednisolone

50100 8-12

70

4-6

Postpartum thyroiditis

36
variant form chronic autoimmune
thyroiditis 1
25 HLA- B ,
DR3 haplotype
anti-TPO titer

1-4
1
2-8


2-8

ophthalmopathy dermopathy

25-50

transient painless thyroiditis

T3 T4
TSH radioactive iodine uptake

71

T4 TSH
T4
anti- TPO antibodies
65-85

propranolol

Hashimoto s thyroiditis
chronic lymphocytic
thyroiditis , chronic autoimmune thyroiditis

SLE, rheumatoid
arthritis, Type 1 DM, adrenal insufficiency, vitiligo

Hashimotos thyroiditis

HLA Graves disease

( diffuse euthyroid goiter )

72

Hashitoxicosis
Graves disease

ophthalmopathy
dermopathy
Graves disease

consistency
( rubbery ) (scallop)

60
consistency
firm

euthyroidism ..

microsomal
antibody, Tg antibody anti- TPO
titer radioactive iodine uptake

( fine needle aspiration and biopsy )


lymphoid germinal center follicular cell
fibrosis

73

( suppressive
dose ) L-thyroxine 150200

( replacement dose )
50-150
TSH

Iodine- Induced
thyrotoxicosis
Basedow disease )

( Jod-

10

( 1 )

multinodular goiter
autonomous function

automonous
nodule


autonomous nodule

74

setpoint
( iodostat )

ophthaompathy dermopathy

( contrast media )

T3 T4 TSH
radioactive iodine uptake

75

Inappropriate
secretion
stimulating hormone

of

thyroid-

2 1) TSH
producing pituitary tumor 2 ) pituitary resistance to
thyroid hormone
TSH producing tumor

( pituitary adenoma )
TSH

TSH
25 TRH

radioactive iodine

T3, T4, FT4 TSH

(
TSH )
TSH alpha subunit
alpha
subunit intact TSH 1
CT scan
MRI

76

octreotide

Pituitary resistance to thyroid hormone

5 deiodinase

mutation c- erbA gene resistance

T3, T4, FT4 TSH

alpha subunit
intact TSH 1
TSH producing pituitary tumor

TSH producing pituitary tumor

TSH
Thyrotoxicosis due to Trophoblastic Neoplasm

trophoblast
( hydratidiform moles )
human
chorionic gonadotropin ( hCG )
TSH subunit
hCG

ophthalmopathy dermopathy

77

T3 T4 FT4 TSH
hCG
hCG
TSH RIA
TSH
raioactive iodine uptake


( ultrasonography )

choriocarcinoma

hCG

hyperemesis gravidarum
70
hyperemesis gravidarum

hyperemesis
gravidarum
1-10

78

Gravesdisease
Thyrotoxicosis factitia

T4 FT4
T3
T4 FT4 T3
TSH

radioactive iodine update

Thyroglobulin


radioactive iodine
Thyroglobulin

79

plasmapheresis
Ectpic thyroid

strama ovarii

(metastatic thyroid carcinoma)

Struma ovarii

(ovarian teratoma)

radioactive iodine uptake
thyroglobulin

whole body scan I131

Functioning Metastatic Thyroid Carcinoma

80

T thyroglobulin
whole body scan I131

I131

Amiodarone Induced Thyrotoxicosis

Amiodarone

37.2
Total T4
FT4 T3
TSH

81

2-12
Amiodarone
2 Type I
Type II

radioactive
iodine uptake Type I

Interlenkin 6

Amiodarone

Ophthalmopathy dermopathy

( prednisolone )

perchlorate

82

1 2 : Graves disease
ophthalmopathy

3 : ophthalmopathy

4 : ophthalmopathy
Graves disease
chemosis, venous
obstruction

5 : pretibial myxedema
6 :
localized myxedema

83

8 : localized
7 : distal onycholysis
myxedema, typically the
( Plummers nail )
skin is thickened, nonGraves disease
tenderred and violaceous
in color, with coarse hairs
and little pitting edema

9 : thyroid acropatchy
vitiligo autoimmune thyroid
disorder

11 :
palmar erythema

Graves disease

10 :

12 : toxic
multinodular goiter

84

13: Toxic adenoma

14 : Scintigraphy
appearance
of thyroid in Graves
15 : Scintigraphic appearance

16 : Scintigraphic appearance
of solitary toxic adenoma
of toxic
multinodular goiter

85

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