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7/25/2019 Curs Patologia Functionala a Tiroidei 2015
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Corin Badiu, 2015
Patologia functionala a tiroideiHiper- si hipotiroidism
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Hipertiroidismul
Definitie Clasificare Tablou clinic
Explorari paraclinice Etiopatogenie Anatomie patologica Fiiopatologie
E!olutie, complicatii Tratament
"articularitati Boala Basedo# $ra!es $usa %ipertiroidiata
&indromul "lummer Tiroida in sarcina Tiroidite subacute &truma o!arii
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Hipertiroidismul
Definitie'totalitatea manifestarilor clinice si bioc%imicedeterminate de excesul %ormonilor tiroidieni liberi la
ni!elul receptorilor tisulari responsi!i
Clasificare' cu functie tiroidiana crescuta
cu tiroida nefunctionala, (blocata)
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Clasificare (RIC)
Cu productie tiroidianacrescuta
Fara productie de hormoni
- Boala $ra!es
-
$usa multinodulara %ipertiroidiata- *odulul tiroidian toxic +sd "lummer-
- "araneoplaic. coriocarcinom, mola%idatiforma +%C$ T&/.lie-
-
tireotropinomul- sd de reistenta la %% Tir
- Tiroidita subacuta
-
Tiroidita postpartum- atrogen
- Tireotoxicoa factitia sau alimentara(%amburger)
-
Carcinom tiroidian folicular metastaat- &truma o!arii
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Tablou clinic scadere ponderala cu apetit crescut
palpitatii dispnee astenie, fatigabilitate intoleranta la caldura, %ipersudoratie %iperacti!itate, iritabilitate
tulburari de dispoitie, insomnie tranit accelerat
tegumente calde, fine, umede ta%icardie, fibrilatie atriala, C cu debit
crescut
tremor fin, %iperineie, %iperreflexie retractie palpebrala caderea parului, onicolia miopatie, %ipotrofie musculara
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Particularitati
Exoftalmie +in boala Basedo# $ra!es- 3ixedem pretibial
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ParticularitatiExoftalmie +in boala Basedo# $ra!es-
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GO- QOL Chestionar n limba romn+Calitatea !ie4ii n oftalmopatia din boala $ra!es.Basedo#-
$6.768 +$ra!es9 op%t%almopat%:. ;ualit: of life- e!aluea< calitatea !ie4ii pacien4ilor cu oftalmopatiedin boala $ra!es.Basedo# $6.768 aprecia< dou< aspecte' +1- func4ia !iual
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GO- QOL Chestionar n limba romn+Calitatea !ie4ii n oftalmopatia din boala $ra!es.Basedo#-
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Hertel Exophtalmometer
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! "ara simptomatologie oculara
#O
numai simptome$non-infiltrati%&
a&sen'a(ie de corp strin) hiperlacrimare)b&retrac(ie palpebral
*
S
le'iuni de (esuturi moi edem palpebral) chemosis $edem con+uncti%al&
,& absentea& minimeb& moderatec& marcate
.P
proptosis Protru'ia marcat a globilor oculari$/0oftalmie 1 . mm&
,& absentaa& .-2 mm
b& 3-4 mmc& 1 5 mm
2/
afectarea mu6chilore0traoculari
- diplopie) asinergism de con%ergen() oculofrontal 6i oculona'al,& fara modificaria& limitare la pri%irea lateralab& restrictie e%identa a miscariic& glob ocular fi0
3C le'iuni corneene ulcer cornean,& absentaa& ero'iune superficialab& ulcer cornealc& necro'a sau perforatie
7S
afectarea ner%ului optic$scaderea 89&
pn la cecitate,& absentaa& *,:*,-*,:7,
b& *,:4,-*,:*,,c& ; *,:*,,
CLASIFICAREA WERNER (NOSPECS)
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Nodulul autonom tiroidian
(sdr. Plummer)
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Teste diagnostice
"unc(ionale eglaul axei tiroidiene /ormoni +totaliHliberi-
Transport =i efecte periferice 3etabolismul iodului Autoimunitatea $enetica
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=eglarea 80ei >iroidiene T/
T&/
TIH T
Deiodae' D1, D2, D
8eptina
T, T/ , T&/
D2
D2
D1
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>este >SH
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The relationship between serum TSH and free T4 concentration is shown for normal subjects (N) and in thetypical abnormalities of thyroid function: A, primary hypothyroidism !, central or pituitary"dependenthypothyroidism #, thyroto$icosis due to autonomy or abnormal stimulation of the %land &, TSH"dependentthyroto$icosis or thyroid hormone resistance' Note that linear chan%es in the concentration of T4 correspond
to lo%arithmic chan%es in serum TSH'
>SH : >2 : f>2
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T&/
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>h@roid hormones e%aluation
Hormone Metric SI Units Jariations unrelated to t%:roid disease
Total T4 4".. u%/dl 01".41 n2 !indin% protein chan%escompetitors for T4 bindin%
3ree T4 1'15 1'6"'. n%/dl .1"7 p2 2ethodolo%ic factorsAlbumin chan%es&ilution effects
Total T* 67".67 n%/dl .'."'6 n28 !indin% protein chan%escompetitors for T* bindin%
A%e"related chan%esNutrition, illness, dru%s
3ree T*1'*5
1'"1'7 n%/dl *"9 p28 2ethodolo%ic factors as for T4and influences on total T*
e;erse T* .7"47 n%/dl 1'"1'6 n2 Nutrition, illness, sur%ery, dru%s
TSH 1'*"4'1 m-/l .".7 p2< &iurnal ;ariation, pulsatile secretion2edications
TSH "subunit =1' u%/dl =.11 p2 ostmenopausal womenrimary Hypo%onadism
Thyro%lobulin ."1 u%/l .'7"*1 p2> ?ariation in assay standards and antibodies
Values in children may be higher# Assumes biologic potency of -!" Umg$ %ependent on serum &SH and amount of thyroid tissue
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&ubclinical t%:roid diseases
defined as abnormal T&/ despite normal le!elsof free t%:roxinesubclinical TSH fT4
hyperthyroidism N
hypothyroidism N
Bals%em et al, A/7, 2011
Bioc%emical definition of t%:roid d:sfunctionCondition >SH $mAB:l& >h@roid hormones Comments
6!ert %:pert%:roidism K01 Ele!ated TI or T
6!ert %:pot%:rpodism LI5 8o# TI
&ubclinical %:pert%:roidism K 01 *ormal TI and T Clearl: lo# T&/
01 0I *ormal TI and T 8o# but detectable
&ubclinical %:pot%:roidism I5 10 *ormal TI 3ildl: ele!ated T&/
L 10 *ormal TI 3aredl: ele!ated
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T&/ fTI correlation
&erum T&/ . log.linear relations%ip #it% circulating t%:roid%ormone le!els 2 x fTI 100 x T&/
Fatourec%i J,Mayo Clin Proc, 200?M /oerman et al, 2010,EJE
0 I > 12 1@ 20 2I 2> 2
100
10
1
01
001
fTI +pmolHl-
T&/+mNH1-
n O 22: O 00>>@xP112Q5
2 O 02@
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R%at is (normal)S
Diagnosis depends of t%e limits of >SH (normal), (references), (discrimination) !alues too simplistic, impl:ing t%at e!er:t%ing not being normal must be corrected
absolute %ealt% does not exist
discriminationD %alues cut.off !alues important for medical decisions re;uire no#ledge of t%e disease
pre!alence t%e sensiti!it: and specificit: of diagnostic tests clinical conse;uences of a false positi!e H negati!e diagnosis
specifications concerning specimen collection en!ironmental and p%:siological conditions tec%ni;ues and timing preparation and storage anal:tical and t%e statistical met%ods
Brabant et al, EJE, 2006
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T&/ assa:s
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Rang CV, C%ang TC, C%en 3F Associations bet#een subclinical t%:roid disease and metabolic s:ndrome Endocr W 2012
T&/
?,0?5 consecuti!e %ealt%: subects +5,21I 3, ,>>1 R-
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elationship of TSH (after 411 m % TH i';') and thyroid wei%ht (%) in women with clinicallyeuthyroid multinodular %oiter (with permission from Smeulers @, &octer , ?isser T@, Hennemann+: esponse to thyrotrophin"releasin% hormone and triiodothyronine suppressibility in euthyroid
multinodular %oitre' #lin ndocrinolo%y 6:*9,.66)'
T/ si masa tiroidiana
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Gusa endemica
T&/ O ,5 mNH8
fTI O 1,5 pmolH8
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Gusa endemica
T&/ O 0,15 mNH8
fTI O 2,5 pmolH8
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Transport
C i t t A ti il
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Bn this patient with +ra;esC &isease, the mi$ture of antibodies shifted durin% antithyroidtherapy from dominance by TSAb, to a dominant effect by TS!Ab and T!BB, leadin% tospontaneous de;elopment of hypothyroidism' 3rom TaDasu et al, @' ndocrinol' Bn;est'1:47"40., .6'
Coexistenta Anticorpilor
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/COG=8"B8 >B=OBEB8!8
E!identiaa $usa si caracterul difu sau nodular al acesteia *odulul K 1 cm H confirma nodulul L 1 cm C%istii tiroidieni /iper!asculariatie si calcificari
3asoara Dimensiuni tiroida calcul !olum FI$d#Jd*Jd.&K Dimensiuni nodul +in dinamica-
Diferentiaa *odulii tiroidieni de cei extratiroidieni *odulii de c%isti
T t f l i
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Teste morfologice
ECOGRA!A T!RO!"!A#A
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ECOGRA!A T!RO!"!A#A
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adio odo Captarea
Jalori crescute &inte< crescut< de /Tir /ipertiroidism+gusa polinodulara, $ra!es, "lummer-
Deple4ie %ormonalerapia chirurgicala
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Sarcina 6i func(ia tiroidei
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&arcina modifica ec%ilibrul tiroidian' aport de iod crescut +200 ugHi- !olum circulant H de distributie cresterea F$ cu turno!erului iodului imunosupresie interferente %C$ T&/ ni!el crescut de TB$ acti!itatea deiodaei tip pacentara
*ecesar de / tiroidieni pentru de!oltarea fetala Tiroida fetala functioneaa dupa 12 saptamani
fTI si fT in primul trimestru
Sarcina 6i func(ia tiroidei
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Sarcina 6i func(ia tiroidei
Patel et al., Delivery of maternal thyroid hormones to the fetus, TEM 2011, 22,
5, 164-10
Hi i idi l
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Hipertiroidia neonatala
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>iroiditele
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Hipotiroidismul
Definitie Clasificare Tablou clinic
Etiopatogenie E!olutie, complicatii Tratament
"articularitati 3ixedemul congenital
Etiologia hipotiroidismului
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Etiologia hipotiroidismului
"rimar
iatrogen sau autoimun
&ecundar
&dr &%ee%an, tumori%ipofiare, deficitcongenital de T&/
isgene!ii tiroidiene
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isgene!ii tiroidiene
isgene!ii tiroidiene
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isgene!ii tiroidiene&emne de mixedem congenital' la nou n
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/ipotiroidismul neonatal efini"ie
Clasificare'Congenital +1'000.I000-
"ermanent Tranitor
Dobandit
mpact asupra de!oltarii +neuropsi%ice, staturale, pubertare-
Teste' screening pentru %ipotiroidie neonatala
"rofilaxie si Tratament' aportul de iod la mama, %ormoni tiroidieni la copil
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Fatul depinde de T, TI De!oltarea fetusului depinde de / tiroidieni, in special in ceea ce
pri!este &istemul *er!os
Fatul depinde deTI.Tprodusi de mama pana in sapt >.11
Fatul foloseste TI.Tmaterne pentru de!oltarea %ipotalamusului,%ipofiei si glandei tiroide
&istemul *er!os Central depinde de %ormonii tiroidieni. "roliferare neuronala. 3aturare neuronala. 3ieliniare neuronala. Formarea sinapselor
l i l i
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e!#oltarea sistemului ner#os
1 Di!iiune 2 3igrare Agregare siI
Diferentiere
5 &inaptogenea @3oarte cel Q earanare
> 3ieliniare
=e(eaua de cone0iuni neurale
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(este mai pu(in dens
#reierul cu aport suficientde iod
#reierul cu deficit de iod
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!i"otiroidism #on$enital
Clinica deceleaa 1'5000.1'10000+10X 1 luna, 5X primele luni,Q0X primul an, 100X la .I ani-
Bncidenta' 1 la 000
Nna din cele mai obisnuite caue
trata$ilede retard mental
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Cretinism
&tatura scunda,disarmonica,retardare mentala
.4 ani, hipotiroidism
se;er con%enital
luni,hipotiroidism con%enital:fata infiltrata, limba marita
C it ii t it i l d
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Bndicator ScopBodarea srii"ropor4ia de consum casnic a sSH neonatal
propor4ia cu ni!el peste 5 mNH8 KX
Criterii pentru monitori'area programelor decontrol al carentei iodate
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Bndicatori de pre%alenta ai deficitului de iodcriterii pentru o problema importanta de s
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&creening pentru %ipotiroidie neonatala
J l i d f i
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Jalori de referinta
3i d l d lt
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3ixedem la adult
" fil i
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"rofil sanguin
fTI , TI , T T&/ Z . %ipotiroidism primar, * sau . %ipotiroidism central Dislipidemie mixta b +colesterol Z P T$ Z- C[ Z, A8T, A&T Z Anemie macrocitara AT"6 ZZZ . marer etiologic de autoimunitate *a . aparent &AD/, mai ales in %ipotiroidismul central
"8 Z . in %ipotiroidismul primar
T
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Tratament
Administrare orala de %ormoni tiroidieni
Tratament prompt, imediat dupa diagnostic
Doe progresi! crescatoare la I.> sapt
3entinerea terapiei permanente esteCNCA8A
Complianta
T
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Tratament
9arsta Eo'a 'ilnicag
recomandatag:Mgc
,-7 luni *3-3, 5-#,
7-#* luni 3,-43 7-5
#-3 ani 43-#,, 3-7
7-#* ani #,,-#3, 2-3
N#* ani #,,-*,, *-.
Tiro$ina (T4)
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=ecomandarile O
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Jerificarea tratamentului
#onsecinele pe termen lun% ale tratamentul H# sunt strIns le%ate decalitatea urmJririi e;oluiei pacienilor sub tratament'
$aminarea clinicJ include e;aluarea creKterii Ki deG;oltJrii neuro"motoriisi trebuie efectuata la fiecare cIte;a luni Ln timpul primilor * ani de ;iaJ'
CO!CLABB
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CO!CLABB