Medicuss Group

Thyroid consists of follicles (vesicles) made up

of thyroid follicular cells; thyroglobulin
associated with inner surface of follicle

thyroglobuli thyroid
n follicular
(glycoprotei cell
n)
(cuboid
colloid epithelial
cells)

Thyroid follicle
Pituitary-
Hypothalamus
(HPT Axis)

Autoregulation

Abnormal stimulators
 Negative feedback
Hypothalamus

Anterior pituitary

Thyroid Gland

Target Tissue
THYROID HORMONE
1. TRIIODOTHYRONINE :
T3
2. THYROXINE :
TETRAIODOTHYRONINE :
T4
 Growth and Development
Calorigenic Effects
Cardiovascular Effects
Metabolic Effects
PATOPHYSIOLOGY
HYPERTHYROID HYPOTHYROID
- T3, T4 - T3, T4
- BMR - BMR
- SWEAT GLAND - SWEAT GLAND
- HEART BEAT, CO - HEART BEAT, CO
- HYPERTENTION - HYPOTENTION
- BODY TEMPERATURE - BODY TEMPERAT
TEMPERA
- SENSITIVE TO HEAT - SENSITIVE TO COLD
- NERVOUS - LETHARGY
 Hiper Hipo
- BODY WEIGHT - BODY WEIGHT
- MUSCULAR WEAK - COARSE HAIR,
-APETTITE - PUFFY FACE +PALE
THICK SKIN
- MENS : IRREGULAR - MENS : IRREGULER
- EXOPTHALMUS* - CAROTE NEMIA
- GOITRE (PR/SEC) - GOITRE (+/-)
 Hyperthyroidsm

Thyroid swelling

Metabolic rate Protein metabolism mobilization

Of fat from tissue
B-adrenegic receptor

Finetremor
Increased Increased Decreased Decreased Decreased
Heat appetite protein Increased
Lean body mass Fat storage HR rate
production

Weight loss
Weak and dry hair
Adtivation heat
Dissipating tachycardi
mechanism
1. Cutaneus vasa
dilatation
2. Decreased Easy loss of hair
peripheral
GRAVEs (70%)
Gondok multinoduler
toksik/Plummer
Adenoma toksik/Goetsch
 Hipertiroid karena hipersekresi T3
dan T4 dari adenoma yang fungsional
(hot nodule)
Usia > 40 thn
Gejala : BB , lemah, palpitasi,
takikardi, intoleransi panas
Lab : T3 , TSH
1. Kontrol gejala adrenergic: Propanolol
4x 20-40 mg
2. hyperthyroidism turunkan sintesis
hormon tiroid
3. Tatalaksana oftalmopati [pada
Graves]
 Antithyroid drug therapy
Thyroidectomy
131Iodine

Thyroid Storm (thyrotoxic crisis)

life threatening; need
immediate
 Agents that interfere with
production of T3 and T4
Agents that modify tissue
responses to T3 and T4
Destruction of thyroid gland:
surgery; radiation
Propiltiourasil (PTU)
Menghambat sintesa hormon tiroid
menurunkan oksidasi iodine dan iodinasi
tirosin
Mencegah konversi T4 T3 di perifer
Do: 5-7 mg/kg/hr dibagi 3 Do (max 300
mg/hr)

Metimizol (MMI) atau Karbimazol (CBI)

Menghambat sintesis hormon tiroid
Do: 0,50,7 mg/kg/hr dosis tunggal (max
30 mg/hr)
 Kel tdk terlalu besar, gejala ringan
Sampai remisi spontan (6 bln 15 thn)
Relaps 50 60%
Dosis rumatan Dosis terapi bila
kadar T3, T4 dan TSH normal dan
stabil
Th/ dilanjutkan sp 1-2 thn setelah
remisi
Remisi bila
(1) ukuran kel tiroid mengecil
(2) T3, T4 dan TSH normal
Antithyroid drugs

Characteristic Propylthiouracil
Methimazole

Half-life 75 min
About 46 h
Effect on 5-deiodinase Blocks 5-deiodinase
No effect
Effectiveness
(at dose equivalents) ++
+++
Time to achieve euthyroidism Months
Weeks
Dosing schedule Twice daily
Daily

Side effects
Agranulocytosis Idiosyncratic
Dose-dependent
The use of antithyroid
drugs.
Start methimazole,
1020 mg/d*

Measure thyroid indices

(including T3/FT3) monthly

If FT4/FT3 level is normal,

then taper methimazole by 50%

Repeat until TSH level is normal

and methimazole is tapered
to 510 mg/d

Measure thyroid indices every

3 mo; maintain methimazole
for 12 yr
 Sering: rash, urtikaria, demam,
malaise, alergi, eksantem, myalgia
artralgia Ganti obat

Jarang: hepatitis, SLE-like syndrome,

agranulositosis
Sore throat, fever, mouth ulcer
CBC stop treatment OAT
 Usia > 21 tahun (anak dihindarkan)
Do : 80 120 Ci/gr estimasi berat
tiroid
Kel mengecil dan eutiroid dalam 6
12 minggu
Komplikasi : hipotiroidisme
 Indikasi Tiroidektomi
(1) Gagal th/ antitiroid
(2) Toksisitas obat
(3) Tidak patuh
Th/ dg antitiroid sp eutiroid
2 mgg sebelum op KI 5 gtt/hr
Komplikasi : hipoparatiroidisme, jejas
pada N. laryngeus reccurent
Treatment for Graves disease
Therapy Duration Worsens During Advantages Disadvantages
ophthalmopathy pregnancy

ATD 12 yr No Yes Rapid restoration of Side effects

euthyroidism; potential for relapse
immunological remission extremely common

Radioiodine Usually Potentially (in CI Permanent correction of Hypothyroidism

once, 15% of patients) hyperthyroidism; safe ( > 50% in 10
yr);
easily administered environmental
precautions
required pregnancy delay
of 36 mo required

Surgery Day No Yes, during Permanent correction of Hypothyroidism (50% over 25 yr);
surgery second hyperthyroidism usual general anesthesia required; 1%2%
trimester complications: hypoparathyroidism,
recurrent laryngeal nerve paresis
 Reseptor Katekolamin, infeksi, stres
krn operasi katekolamin T3 dan
FT4 >> krisis tiroid
Klinis
Demam
Takikardi, atrial fibrilasi, gagal jantung
Gelisah, delirium, koma
Mual, muntah, diare, ikterik
Laboratorium
T3 , T4 , FT4 , TSH
Terapi
Propanolol 80 mg/m2/hari atau 0,52
mg/kg/hr dalam 3-4 dosis
Digitalis (pada gagal jantung)
 Treatment of thyroid storm
Treatment Dose and route Action

-blockers:
Propranolol 1 mg/min IV (as required) and 6080 mg every Antagonizes effects of
increased adrenergic
4 h po or by NG tubet one, blocks T4-to-T3
conversion
Esmolol 250500 g/kg IV followed by IV infusion
(alternative) 50100 g/kg per min

Thionamides:
Propylthiouracil 8001000 mg po immediately, then 200 mg Blocks new thyroid
hormone synthesis
every 4 h po or by NG tube blocks T4-to-T3
conversion
(propylthiouracil
only)
Methimazole 30 mg po immediately, then 30 mg every 6 h
(alternative) po or by NG tube

Iodine:
Lugols solution 10 drops tid po or by NG tube Blocks thyroid hormone
release
or SSKI 5 drops every 6 h po or by NG tube
or Sodium iodide 0.51.0 g IV every 12 h
Diagnosis: decreased T4 production;
presence of anti-thyroid antibody
(autoimmune)

Treatment:
Replacement therapy with levothyroxine
(T4); 100-150 g
Stable, long half-life (7 d), converted to T 3;
used to treat hypothyroidism, myxedema,
coma, cretinism, simple goiter, nodular goiter
The spesific type of immunologis response :

TSA TSBAG
Thyroid Thyroid Stimulating
stimulating hormone blocking
antibodies antibodies

Graves disease Hashimotos thyroiditis

Primary myxedema
Graves diseases with
goiter,
exophthalmus and
hyperthyroidisme

Hashimotos with
goiter and
Euthyroidism or
hypothyroidism

Primary thyroid failure

 Proses peradangan/inflamasi pada
kelenjar tiroid
Terdiri dari :
(1) Tiroiditis akut
(2) Tiroiditis subakut
(3) Tiroiditis kronis
 Jarang abses
Et : streptococcus, staphylococcus,
pneumococcus
Sumber : infeksi di daerah muka dan
leher yg menyebar scr hematogen ke
klj tiroid sepsis
Th/ : drainage, AB, -bloker, steroid,
propanolol, PTU
 Et/ virus (mumps, coxackie,
adenovirus)
Gejala : hipertiroid ringan, demam,
tiroid eritem, panas, nyeri (+)
Lab : T3 dan T4 , TSH
Sidik tiroid : uptake
Th/
Asetaminofen 0,5 gr 4x/hr
Prednison 20 mg 3x/hr slm 7 10 hr
= Hashimotos thyroiditis,

Merupakan bentuk dari tiroiditis

dengan hipotiroid
Predominasi antitiroglobulin dan
antibodi antitiroid peroksidase
Sembuh sendiri
Th/ antitiroid
 Essentially a biochemical diagnosis in
which free thyroid hormone levels are
normal but TSH is suppressed or
elevated

Subclinical hyperthyroidism: Defined

as a persistently suppressed serum
TSH with normal thyroxine and
triiodothyronine levels.
 Causes of subclinical hyperthyroid
Table 1
Endogenous thyroid conditions

Graves disease
autonomous adenoma
multinodular goiter
thyroiditis (subacute, silent, autoimmune)

Non-thyroidal conditions

euthyroid sick syndrome

acute psychiatric disease
pituitary and hypothalamic disorders
pregnancy
drugs: thyroxine, dopamine, glucocorticoids, aspirin, fenclofenac, furosemide
 Seorang wanita 33 tahun datang dengan
keluhan berdebar-debar yang dirasakan sekitar 1
bulan yang lalu.
Penderita mengeluhkan juga adanya sesak nafas
saat melakukan aktivitas, merasa lekas lelah, lebih
nyaman bila berada di ruangan yang ber-AC. Adanya
peningkatan nafsu makan tetapi berat badan
mengalami penurunan dari 53 kg menjadi 42 kg
yang dirasakan dalam waktu 2 bulan. Keluhan lain
yang dirasakan adalah tangan cepat berkeringat dan
basah dan penderita juga merasa tidak nyaman bila
berada ditengah orang banyak.
 PALPITASI IDIOPATIK (16%)

Jantung (43%)
LIFE THREATENING Lain-lain (10%) Psikiatrik (31%)
ARITMIA!!! VT &VF tirotoksikosis Panic attack
obat Anxiety
Pendukung: aminophylline, atropine,
Dyspnea thyroxine, cocaine,
Somatisasi
Angina pectoris amphetamines
dizzy tobacco, caffeine Khas:
skip a beat, slowing. alkohol Durasi >15 mnt
irregular kontraksi otot dada spontan Gejala akibat
gang. hemodinamik: pheochromocytoma
sinkop, dizziness, mastositosis sistemik penyebab lain (-)
lightheadedness
 Yang diharapkan dari PF?
Pemeriksaan Fisik :
Keadaan Umum :
komposmentis
Vital sign :
Tensi : 140/80 mmHg
hipertensi
Nadi : 124 x/menit
takikardi
Respirasi : 20 x/menit
Suhu : 37,20 C

Kepala : Eksoftalmus +
Leher :
Thyroid membesar
(goiter)
Bruit + hipertiroidisme
Thorax : C/P DBN
Abd : DBN
Ekstremitas : Tremor +,
Lembab +
 Penunjang?
Pemeriksaan Laboratorium
TSH : 0,00001 (0,3 0,4)
T3 : 7,2 (1 2,3 )
FT4 : 8,8 (1,1 3,1)

HIPERTIROID
 Diagnosis?
Th/?