HIPERTIROID

TIROTOKSIKOSIS & HIPERTIROIDISM

TIROTOKSIKOSIS:keadaanhormontiroidberlebihan yang disebabkanolehoverproduksikelenjartiroid, ataudiluarkelenjartiroid, kebocoarn/hilangnyasimpanankelenjartiroid

HYPERTHYROIDISM:keadaanhormontiroidberlebihan yang disebabkanolehoverproduksikelenjartiroid

Serum TSHs & FT4

TSH ↓, FT4 ↑ → tirotoksikosisTSH ↓, FT4 normal :

T3 tirotoksikosis (FT3 ↑) Tirotoksikosis Subklinik Penyakit Non tiroid

TSH normal, FT4 ↑: TSH-secreting adenoma Pituitary resistance to thyroid hormon Generalized resistance to thyroid hormon

TSH normal, FT4 normal → normal

Klasifikasi Tirotoksikosis

A. Hiperfungsi tiroid (hipertiroid)1. Produksi TSH >>2. Abnormal stimulator tiroid

a. Penyakit Grave (> 90%)b. Tumor trophoblastik

3. Autonomi tiroid intrinsik

a. Adenoma hiperfungsib. Struma multinoduler toksik

…KlasifikasiB. Tidak berhubungan dengan hiperfungsi

tiroid 1.Gangguan simpanan hormon

a. Tiroiditis subakutb. Tiroiditis kronik dengan tirotoksikosis

transien2. Sumber hormon ekstratiroidc. Tirotoksiosis faktitiad. Hamburger Toxicosise. Jaringan tiroid

(1) Struma ovarii(2) Functioning follicular ca.

Manifestation of ThyrotoxicosisSymptoms

- Nervousness- Fatigue- Weakness- Increased

perspiration- Heat intolerance- Hyperactivity- Tremor- Increase apetite- Palpitation- Weight loss- Menstrual

disturbance

Signs-Hyperactivity- Tachycardia/arrythmia- Systolic hypertension- Warm, moist, smooth skin- Stare and eyelid retraction- Tremor- Hyperreflexia- Muscle weakness

PENYAKIT GRAVE

PREVALENSI- Dapat pada semua umur,

umumnya dekade tiga & empat- Rasio wanita : pria = 7 : 1- Faktor genetik : frekuensi ↑

HLA-B8 and DRw3 – kaukasian HLA-Bw36 – Jepang HLA-Bw46 – Cina

PENYAKIT GRAVE(Parry’s disease / Basedow’s disease)

3 Manifestasi mayor :

1. Hipertiroid + struma difus2. Opthalmopati3. Dermopati

Acropachy

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Eksopthalmus

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Tabel Tanda klinis opthalmopati pada penyakit Grave

1. Dalrymple Retraksi kelopak mata bagian atas, memberi kesan mata membelalak

2. Von Graeve Kelopak mata terlambat turun dibandingkan dengan bola mata

3. Joffroy Kulit dahi tidak dapat mengkerut pada waktu kepala sedikit menunduk & mata disuruh melihat obyek yang digerakkan keatas

4. Moebius Kelemahan dalam akomodasi/konvergesi mata

5. Rosenbach Tremor kelopak mata waktu mata menutup

6. Stelwag Mata jarang berkedip

CARDIAC MANIFESTATION- Tachycardia- Atrial fibrillation- LVH and strain on ECG- Premature atrial/ventricular

contractions- Congestive heart failure- Angina with/without coronary artery

disease- Myocardial infarction- Resistance to some drug effects

(digoxin)- Residual cardiomegaly

Systolic BP ↑ Diastolic BP ↓Pulse pressure 50-80 mmHg

GASTROINTESTINAL

- The appetite is usually increased (weight loss).

- Increased frequency of normal bowel movement.

- Occasionally diarrhea occurs.

MUSCLES- Myasthenia

→muscular weakness and atrophy.- Hypokalemic – periodic paralysis

Particularly in young menFrequent in AsiaOccur after a meal/exercise

NEURAL AND MENTAL

- Nervousness, irritability, restless.- Impossible to remain still for an instant.- The tendon reflexes tend to be brisk and

reflex relaxation time is shortened.- Mental: hypomania, euphoria,

hallucination and psychosis.

SKELETON

- Decalcification → osteoporosis.- Ca absorption is reduced.- Fecal & urinary Ca excretion is

augmented.

REPRODUCTIVE SYSTEM

- Menstruation is decreased in volume.- Menstrual cycle may be either

shortened, prolonged or amenorrhea.- Fertility is depressed but pregnancy

nonetheless can develop.

SKIN

- Hot, moist (dripping wet), erythematous.- Plummer’s nails:

the free margin of the nail leaves the nail bed.

- Hair tends to be fine, soft and straight. - Alopecia is rare.- Dermatopathy(thickening of the skin)

CARBOHYDRATE

- Absorption of carbohydrate is accelerated.

- Oral glucose load 30-60 minute blood glucose > 200 mg/dl, 2 h post load is normal.

- Insulin resistance is present.

LIPID

Synthesis and degradation are increased but degradation > synthesis → serum cholesterol level is depressedMalnutrition & weight lossHypermetabolism

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Indeks Wayne

Gejala Nilai Tanda + -S esak nafasPalpitasiMudah lelahSenang hawa panasSenang hawa dinginKeringat berlebihanGugup

Nafsu makan naikNafsu makan turunBerat Badan naikBerat Badan turun

+ 1+ 2+ 2 - 5+ 5+ 3+2

+ 3 - 3 - 3+ 3

Pembesaran tiroidBruit pada tiroidEksopthalmusRetraksi palpebraPalpebra terlambatHiperkinesisTelapak tangan -hangat -lembabNadi < 80x/menit> 90x/menitFibrilasi Atrial

+3+2+2+2+1+4+2+1-3+3+4

-3-2

-2-2-1

>11= Eutiroid 11-18 = tidak jelas tirotoksikosis >19 = Tirotoksikosis

DIAGNOSIS

► Signs and symptoms

► Laboratory :Increased value of

FT3, FT4Decreased value of

TSHIncreased value of

RAIU (hyperfunction)

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D D :Anxiety: ekstremitas dinginOphtalmopathy: - anoreksia - trombosis sinus cavernosus - Tumor RetrobulberHipokalemia periodik paralisis: - pria, usia muda, bangsa Asia - Hipertiroid ringanHipertiroidisme sekunder: - TSH ↑ (tumor hipofise) CT scan & MRI

Pengelolaan•Obat Anti Tiroid•Terapi Bedah•Radiasi

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TerapiA. Mengurangi/menghambat sintesa Hormon 1. PTU (half life=90’) &Metimazol (6 jam) Mengurangi antibodi kel. Tiroid Hambat deiodinasi (T4 T3) Hambat fungsi TPO, mengurangi oksidasi & organifikasi yodium (Tahap Trapping, oksidasi & coupling) Dosis: 3 - 4 X (100 -150mg) sehari (1-2 tahun) hati-hati ibu hamil (goiter fetus) 2. Yodium: - hambat pengeluaran hormon - berefek cepat (pada krisis tiroid) - sebaiknya bersama antitiroid 3. Kortikosteroid Betabloker: propanolol hambat gejala

adrenergik

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TerapiB. Ablasi Kelenjar tiroid: - bila relaps dengan antitiroid - Tak tahan dengan OAT (tiroid) - Struma yang besar 1. Radioaktif: - komplikasi oprasi tak ada - hipotiroid (10 th kemudian) 2. Operasi Tiroidektomi dibuat eutiroid & ditambah Yodium (cegah

krisis tiroid)

Eksophtalmus: - Prednison 120-140mg/hari- Operasi

Keadaan Hipertiroid Lain

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Goiter Multinoduler ToksikBeberapa nodul dari Goiter multinoduler non

toksik 1. umumnya usia agak tua 2. sering disertai aritmia & CHF 3. gejala tiroksikosis tidak berat

Goiter Multinoduler Toksik

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Nodul Toksik-adenoma toksikAdanya nodul tunggal/2-3 yang toksik

(hiperaktif)Nodul sekitarnya tertekanGejala hipertiroid tak menyolok-Adenoma

toksik subklinikPengobatan: Operasi atau Ablasi dengan Iod

radioaktif

SUBACUTE THYROIDITISAn excess of preformed hormone

leaks from the gland owing to the presence of inflammatory disease.

New hormone formation decrease because of TSH increase.

Self-limited – often followed by transient of thyroid hormone insufficiency.

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Tumor yang membuat TSHTumor hipofiseChoriocarcinomaCa testis embrional

Tumor yang buat hormon tiroid

Metastase Ca TiroidTeratoma ovarii