Hypothyroidism case presentation

A case presentation on two different cases of hypothyroidism

1. Dr Prasenjit Mitra Senior Resident AIIMS Jodhpur

2. Case 1 History: A 50 year old housewife complains of progressive weight gain of 20 pounds in 1 year, fatigue, slight memory loss, slow speech, dry skin, constipation, and cold intolerance. Physical examination: Vital signs include a temperature 96.8 o F, pulse 58/minute and regular, BP 140/100. She is moderately obese and speaks slowly and has a puffy face, with pale, cool, dry, and thick skin. The thyroid gland is slightly enlarged, firm, not nodular, mobile, and not tender. The deep tendon reflex time is delayed. Laboratory studies: CBC and differential WBC are normal. The serum T4 concentration is 3.8 ug/dl (N=4.5-12.5), the serum TSH is 23.0 miU /ml (N=0.2-3.5), and the serum cholesterol is 255 mg/dl.

3. Case 2 History: A 50 year old housewife complains of progressive weight gain of 20 pounds in 1 year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin, constipation, and cold intolerance. Physical examination: Vital signs include a temperature 96.8 o F, pulse 58/minute and regular, BP 110/60. She is moderately obese and speaks slowly and has a puffy face, with pale, cool, dry, and thick skin. The thyroid gland is not palpable. The deep tendon reflex time is delayed. Laboratory studies: CBC and differential WBC are normal. The serum T4 concentration is 3.8 ug/dl (N=4.5-12.5), the serum TSH is 1 miU /ml (N=0.2-3.5), and the serum cholesterol is 255 mg/dl (N<200).

4. Hypothyroidism

5. Hypothyroidism

6. Classification

7. Primary Hypothyroidism

8. Primary Hypothyroidism

9. Central hypothyroidism

10. Central Hypothyroidism

11. Central Hypothyroidism

12. Signs and Symptoms

13. Signs and Symptoms

14. Laboratory Evaluation Reference – Harrison’s Endocrinology, 4 th ed.

15. Laboratory Evaluation Reference – Williams Endocrinology, 13 th ed.

16. Laboratory Evaluation Reference – Williams Endocrinology, 13 th ed.

17. Pre-analytical Variables Age Both TSH and FT4 concentrations are higher in children, especially in the 1st week of life and throughout the 1st year. TSH increases with age Increased Mean variability Pregnancy ↑ Estrogen levels  ↑ 2-3x mean TBG concentration than pre-pregnancy level by 20 weeks of gestation  shift in the TT4 and TT3 reference range to approximately 1.5 times the nonpregnant level by 16 weeks of gestation ↑ HCG levels cross-react partly with TSH receptor  mildly suppressed levels. The peak rise in HCG and nadir in serum TSH level occurs together at about 10-12 weeks of gestation.

18. Analytical methods

19. Analytical methods

20. Analytical methods

21. Analytical methods

22. Analytical methods

23. Measurement of TSH

24. Measurement of TSH

25. Measurement of T3 and T4 Assay Hierarchy Direct Equilibrium dialysis Ultrafiltration Indirect Immunoassay One step Immunoassay Two step Immunoassay Free Hormone hypothesis

26. Measurement of T3 and T4 fT 4 pbT 4 Dialysis/ Ultrafiltration Competitive immunoassay Mass Spectrometry

27. Measurement of T3 and T4

28. Measurement of T3 and T4

29. Reference ranges

30. Further investigations

31. Inference

32. Recent advances

33. Recent advances Reference – Harrison’s Endocrinology, 4 th ed.

34. Case 1 History: A 50 year old housewife complains of progressive weight gain of 20 pounds in 1 year, fatigue, slight memory loss, slow speech, dry skin, constipation, and cold intolerance. Physical examination: Vital signs include a temperature 96.8 o F, pulse 58/minute and regular, BP 140/100. She is moderately obese and speaks slowly and has a puffy face, with pale, cool, dry, and thick skin. The thyroid gland is slightly enlarged, firm, not nodular, mobile, and not tender. The deep tendon reflex time is delayed. Laboratory studies: CBC and differential WBC are normal. The serum T4 concentration is 3.8 ug/dl (N=4.5-12.5), the serum TSH is 23.0 miU /ml (N=0.2-3.5), and the serum cholesterol is 255 mg/dl.

35. Case 2 History: A 50 year old housewife complains of progressive weight gain of 20 pounds in 1 year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin, constipation, and cold intolerance. Physical examination: Vital signs include a temperature 96.8 o F, pulse 58/minute and regular, BP 110/60. She is moderately obese and speaks slowly and has a puffy face, with pale, cool, dry, and thick skin. The thyroid gland is not palpable. The deep tendon reflex time is delayed. Laboratory studies: CBC and differential WBC are normal. The serum T4 concentration is 3.8 ug/dl (N=4.5-12.5), the serum TSH is 1 miU /ml (N=0.2-3.5), and the serum cholesterol is 255 mg/dl (N<200).

36. Thank you …