Hipertiroidisme

Hipertiroidisme Kepaniteraan ilmu penyakit dalamRSUD CILEGON UNIVERSITAS YARSIDEFINISI (Sudoyo,W Aru,dkk.2006)

TirotoksikosisvshipertiroidismeApapun sebabnya, manifestasi klinisnya samaEfek ini disebabkan ikatan T3 dengan T3-inti makin penuh

(Sudoyo,W Aru,dkk.2006)

THE THYROID GLANDwww.univ-st-etienne.fr/lbti/Mednucl/AtlasEnd/thyroide/OOHIIIIOHONH2Thyroxine (T4)OOHIIIOHONH23,5,3-Triiodothyronine (T3)THYROID HORMONESFEEDBACK REGULATIONTHE HYPOTHALAMIC-PITUITARY-THYROID AXISHormones derived from the pituitary that regulate the synthesis and/or secretion of other hormones are known as trophic hormones.Key players for the thyroid include:TRH - Thyrophin Releasing HormoneTSH - Thyroid Stimulating HormoneT4/T3 - Thyroid hormonesPITUITARY-THYROID AXIS

HM Goodman, BASIC MEDICAL ENDOCRINOLOGY 3rd Ed.+

Negative Feedback Loop8

Thyroid Disease Can Have Widespread EffectsThyroid

Increased LDL CholesterolElevatedTriglyceridesLiver

ConstipationDecreased GI Activity Intestines

Decreased FertilityMenstrual AbnormalitiesMay Harm Development of InfantReproductiveSystem

DepressionDecreased ConcentrationGeneral Lack of InterestBrain

Decreased Heart RateIncreased/DecreasedBlood PressureDecreased CardiacOutputHeart

Decreased FunctionFluid Retention and EdemaKidneysThyroid Disease AffectsMany Body Systems and Overall Health9

Hormon tiroid berfungsi untuk mengendalikan kecepatan metabolisme tubuh. Hormon tiroid mempengaruhi kecepatan metabolisme tubuh melalui dua cara :1. Merangsang hampir setiap jaringan tubuh untuk menghasilkan protein.2. Meningkatkan jumlah oksigen yang digunakan oleh sel. (fitriani,2010)http://yosefw.wordpress.com/2008/06/10/penggunaan-obat-antitiroid-pada-pasien-hipertiroidisme/

etiologi

Etiologi

Hipertiroidisme primer : penyakit Graves, struma multinodosa toksik, adenoma toksik, metastasis karsinoma tiroid fungsional, struma ovarii, mutasi reseptor TSH, obat kelebihan yodium (fenomena Jod Basedow).2

Tiroiditis silent, destruksi tiroid (tanpa amiodarone, radiasi, infark adenoma), asupan hormon tiroid yang berlebihan (tirotoksikosis factitia)2

Hipertiroidisme sekunder: adenoma hipofisis yang mensekresi TSH, sindrom resistensi hormon tiroid, tumor yang mensekresi HCG, tirotoksikosis gestasional2

Lebih dari 90 % hipertiroidisme adalah akibat penyakit graves dan nodul tiroid toksik.Signs and Symptoms Of HyperthyroidismBulging Eyes/Unblinking StareMenstrual Irregularities orLight PeriodExcessive Vomiting in PregnancyFirst-Trimester MiscarriageFamily History ofThyroid Diseaseor Diabetes

NervousnessIrritabilityDifficulty SleepingSwelling (Goiter)Frequent Bowel MovementsWarm, Moist Palms

Hoarseness orDeepening of VoiceDifficulty SwallowingRapid or Irregular Heartbeat

InfertilityWeight LossHeat IntoleranceIncreased SweatingPersistentSore or Dry Throat14Common Signs and Symptomsof HyperthyroidismNervousnessIrritabilityDifficulty SleepingBulging EyesUnblinking StareGoiterRapid HeartbeatIncreased SweatingHeat IntoleranceUnexplained Weight LossScant Menstrual PeriodsFrequent Bowel MovementsWarm, Moist PalmsFine Tremor of Fingers

May Include:15

TABLE1.MAJOR SYMPTOMS AND SIGNS OF HYPERTHYROIDISM AND OF GRAVES DISEASE AND CONDITIONS ASSOCIATED WITH GRAVES DISEASE 5Manifestations of hyperthyroidismSymptomsHyperactivity, irritability, altered mood, insomniaHeat intolerance, increased sweatingPalpitationsFatigue, weaknessDyspneaWeight loss with increased appetite (weight gainin 10 percent of patients)PruritusIncreased stool frequencyThirst and polyuriaOligomenorrhea or amenorrhea, loss of libidoSignsSinus tachycardia, atrial fibrillationFine tremor, hyperkinesis, hyperreflexiaWarm, moist skinPalmar erythema, onycholysisHair lossMuscle weakness and wastingCongestive (high-output) heart failure, chorea, periodicParalysis (primarily in Asian men), psychosis*

Manifestations of Graves diseaseDiffuse goiterOphthalmopathyA feeling of grittiness and discomfort in the eyeRetrobulbar pressure or painEyelid lag or retractionPeriorbital edema, chemosis, scleral injectionExophthalmos (proptosis)Extraocular-muscle dysfunctionExposure keratitisOptic neuropathyLocalized dermopathyLymphoid hyperplasiaThyroid acropachy

Conditions associated with Graves diseaseType 1 diabetes mellitusAddisons diseaseVitiligoPernicious anemiaAlopecia areataMyasthenia gravisCeliac diseaseOther autoimmune disorders associated with the HLA-DR3Haplotype

DiagnosisDiawali oleh kecurigaan klinis. Berdasarkan indeks klinis Wayne and Newcastle yang didasarkan anamnesis dan pemeriksaan klinis yang teliti.Dilanjutkan dengan pemeriksaan penunjang untuk konfirmasi diagnosis anatomis, status tiroid dan etiologi

diagnosisUntuk fungsi tiroid diperiksa kadar hormon beredar TT4, TT3, dalam keadaan tertentu sebaiknya fT4 dan fT3, dan TSHUntuk fase awal penentuan diagnosis, perlu T4, T3, dan TSHNamun pada pemantauan hanya T4 saja.InvestigationsThyroid function test:TSH- UndetectableT4 - RaisedT3 - RaisedRAIU- RaisedTSH-receptor antibodies(TRAb)-elevated in Gravess diseaseIsotope scanning- Increased uptakeTreatment of Hyperthyroidism

Anti thyroid drugsChemically block hormone synthesisEnhance evolution to remissionBest indicated for children,adolescents,young adults and pregnant women.Propylthiouracil-100-150mg every 6or 8 hrsCarbimazole- 40-60mg daily initially for 3 weeks,then reduce to 20-40mg for another 8 weeks and maintain at 5-20mg daily for 18-24 months.Methimazole-active metabolite of CarbimazoleDuration of treatment18-24 monthsSide effects- Rash Leukopenia AgranulocytosisControl of adrenergic symptomsAdrenergic antagonists:Propranolol-40-120mg/dayAblative therapy(Surgery & Iodine)Indications:Relapse or recurrance following drug therapyA large goiterFailure to follow medical regimen.Radioactive iodine is simple,effective and economicalComplications of ablative therapyImmediate complications of surgery:Bleeding,injury to recurrant laryngeal nerve and thyroid crises.Other complicationsHypothyroidismRadiation thyroiditis

Complications of thyrotoxicosis1)Cardiac- Heart failure Atrial fibrillation

2)Thyrotoxic crises: or storm:Fulminating increase in signs and symptoms of thyrotoxicosis.Occurs in medically untreated or inadequately treated patients.May be precipitated by surgery or sepsisThe syndrome is characterized by extreme irritability,delirium or coma,fever 41C or more,tachycardia,restlessness,hypotension,vomiting and diarrhea.Treatment of thyroid crisisProvide supportive care;Treat dehydrationAdminister glucose and salineVitamin B complex and glucocorticoidsDigitalization is required in those with atrial fibrillationImmediate and large doses of anti thyroid agents(Eg-propylthiouracil 100mg every 2h)Iodine intravenously or by mouthPropranolol 40-80mg every 6hDexamethasone(2mg every 6h) and to be tapered later.Treatment of ophthalmopathy and DermopathyMethylcellulose eye dropsTinted glassesPersistant diplopia can be corrected by surgeryPapilloedema,loss of visual field or acuity requires urgent treatment with prednisolone 60 mg daily.Majority of patients require no treatment other than reassurance.Dermopathy of Graves rarely requires treatment