Thyroid Disease in Adults

292 Pages·2011·21.23 MB·English

by  Ernst Nyström

Ernst Nyström · Gertrud E. B. Berg · Svante K.G. Jansson
Ove Tørring · Stig V. Valdemarsson
Thyroid Disease in Adults

Ernst Nyström · Gertrud E. B. Berg
Svante K.G. Jansson · Ove Tørring
Stig V. Valdemarsson
Thyroid Disease
in Adults
Prof. Ernst Nyström Ove Tørring
Sahlgrenska Academy, Institution for Clinical Science
University of Gothenburg, and Education
Institute of Endocrinology Karolinska Institutet
41345 Göteborg Södersjukhuset
Sweden Sjukhusbacken 11
[email protected] 11883 Stockholm
Sweden
Gertrud E. B. Berg Email: [email protected]
Sahlgrenska University Hospital
Department of Oncology Stig V. Valdemarsson
41345 Göteborg Skanes Universitets
Sweden Sjukhus/Lund
[email protected] Dept. of Oncology
22185 Lund
Svante K.G. Jansson Sweden
Sahlgrenska University Hospital [email protected]
Department of Surgery
41345 Göteborg
Sweden
[email protected]
ISBN: 978-3-642-13261-2 e-ISBN: 978-3-642-13262-9
DOI: 10.1007/978-3-642-13262-9
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Foreword
Th is book is a compilation of updated and expanded editions of two Swedish books
previously published by Nycomed AB, Th yroxine Treatment of Adults and Th yrotoxi-
cosis in Adults.
Th e aim was to produce a clinical handbook for thyroid disease to be used by general
practitioners and internal medicine specialists, but also to be of value for specialists
more directly devoted to thyroid disease. To facilitate reading and use in everyday
work, we have included numerous illustrations as well as concise summary boxes.
We have invested much time in harmonizing the diff erences that exist in the practical
management of patients with thyroid disease between clinicians and clinics in Sweden.
We thereby hope to have reached some form of consensus, which we believe will not
only be applicable to Sweden, but also have a more general acceptance.
Bo Ch. Warin at Nycomed AB has provided tremendous support and has been
an enthusiastic, patient and faithful motivator. Media Center TVB AB in Linköping,
Sweden, has been invaluable in coordinating the work on the book and contributing to
text processing, illustrations, diagrams, photos and layout.
We have also received help from our many colleagues who have contributed towards
the illustrations and off ered good advice and valuable points of view. But most of all, we
wish to thank Associate Professor Leif Tallstedt of St. Erik’s Eye Hospital, Stockholm,
Sweden and Dr. Kerstin Norrsell, Ophthalmology Clinic, Sahlgrenska University
Hospital, Mölndal, Sweden, for help with matters relating to ophthalmology, Dr. Johan
Mölne, Department of Pathology, Sahlgrenska University Hospital, for contributing
to the section on cytological diagnostics, as well as for cytology/PAD images. We
thank Dr. Anders Höög, Department of Endocrine Pathology, Karolinska University
Hospital, Solna, for cytological images.
In addition, we would like to thank Agneta Lundström, at Medical Physics and
Technology, Sahlgrenska University Hospital, for help with photos. Many thanks to
Consultant Barbara Bergman, Clinical Radiology, Sahlgrenska University Hospital,
for help with ultrasound images, and Consultant Madis Suurküla for pictures from
nuclear medical investigations on patients with thyroid cancer. We have also gratefully
received photographs from Rolf Hägglund in Mölndal.
Finally we would like to thank Associate Professor Ola Winqvist, Clinical
Allergologic Research Unit, Karolinska University Hospital, Solna, for invaluable
comments on the section relating to immunology and the thyroid, Professor Robert
Eggertsen, Mölnlycke Vårdcentral (primary care), and Regional Medical Offi cer
Anders Ehnberg, Strömsunds Hälsocentral, for the large amount of work they have
invested in reviewing and commenting on the book from the perspective of a primary
care provider.
Sweden, November 2010 Prof. Ernst Nyström
V

Contents
Chapter 1
Historical Background
1.1 Goitre and iodine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.3 Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Chapter 2
Anatomy and Physiology
2.1 The Embryologic Development
and Anatomy of the Thyroid Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.2 Iodine and the Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.3 TSH and TSH Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.4 Synthesis and Secretion of Thyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.5 Hypothalamus–Pituitary–Thyroid Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.6 Deiodinases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.7 Mechanisms of Action of Thyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.8 Biochemical Indicators of the Peripheral
Eff ects of Thyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.9 Factors Aff ecting Thyroid Hormone Homeostasis . . . . . . . . . . . . . . . . . . . . . . 24
2.10 Eff ects of General Illness and Pharmaceuticals (NTI) . . . . . . . . . . . . . . . . . . . . . . 25
Chapter 3
Biochemical Investigations
3.1 TSH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.2 TRH-Stimulated TSH Secretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.3 Thyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.4 Free Thyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5 Analytical Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.6 Reference Ranges (Normal Values) for
Thyroid-Associated Hormone Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.7 Antibodies Against Thyroperoxidase (TPOAb) . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.8 Antibodies Against the TSH Receptor (TRAb) . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.9 Thyroglobulin (Tg) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.10 Antibodies Against Thyroglobulin (TgAb) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
VII
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3.11 Thyroxine-Binding Globulin (TBG)
and Transthyretin (Prealbumin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.12 Calcitonin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.13 Iodine in Urine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.14 Genetic Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.15 Analytical Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Chapter 4
Other Investigations
4.1 Investigations Using Radionuclides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.2 Positron Emission Tomography (PET) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.3 X-ray, CT, and MR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.4 Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
4.5 Fine-Needle Biopsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Chapter 5
Clinical Investigation of the Thyroid
5.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.2 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Chapter 6
Iodine and the Thyroid Gland in Health and Sickness
6.1 Global Aspects of Iodine Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
6.2 Thyroid Dysfunction Caused by Excessive Iodine Intake . . . . . . . . . . . . . . . 73
6.3 Iodine in Foodstuff s and Medical Preparations . . . . . . . . . . . . . . . . . . . . . . . . . 74
6.4 Iodine Blocking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Chapter 7
Autoimmunity and the Thyroid Gland
7.1 Immunological Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
7.2 Autoimmunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
7.3 Predisposing Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
7.4 Exogenous Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
7.5 Autoimmune Polyglandular Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
7.6 Immunological Markers in Clinical Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
7.7 Treatment Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
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Chapter 8
Growth Regulation of the Thyroid Gland
8.1 TSH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
8.2 Hyperplasia and Goitre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
8.3 Neoplasms and Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Chapter 9
Thyroiditis and Pathogenesis
9.1 Thyroiditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
9.2 Autoimmune Thyroiditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
9.3 Other Triggering Factors for Thyroiditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Chapter 10
Causes of Hypothyroidism
10.1 Primary Hypothyroidism and Chronic Autoimmune Thyroiditis . . . . . . . . 107
10.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
10.3 Hypothyroidism After Treatment for Hyperthyroidism . . . . . . . . . . . . . . . . . . 108
10.4 Hypothyroidism After Surgery for Nontoxic Multinodular Goitre . . . . . . . 108
10.5 Hypothyroidism After Surgery for Thyroid Cancer . . . . . . . . . . . . . . . . . . . . 109
10.6 Central Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
10.7 Iodine-Induced Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
10.8 Iatrogenic (Medicine-Induced) Hypothyroidism. . . . . . . . . . . . . . . . . . . . . . . 109
10.9 Hypothyroidism After External Radiation
of the Head and Neck Regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
10.10 Other Causes of Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Chapter 11
Symptoms of Hypothyroidism
11.1 Autoimmune Thyroiditis – Natural Progression . . . . . . . . . . . . . . . . . . . . . . . 111
11.2 Organ-Related Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
11.3 Symptoms and Findings in Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . 114
11.4 Central Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
IX