Saturday, March 3, 2012

Hypothyroidism Myxedema

Hypothyroidism is a condition in which the thyroid gland is under-active (it is producing an insufficient amount of thyroid hormones).

Hypothyroidism is the most common thyroid disorder. Severe hypothyroidism can lead to a condition called myxedema, characterized by dry, thickened skin and coarse facial features. So Myxedema is also hypothyroidism but in its extreme form.



Who is at Risk:

As there is very insufficient amounts of circulating thyroid hormones in the body, and since the main purpose of thyroid hormone is to “run the body’s metabolism,” it is understandable that people with this condition will have symptoms associated with a slow metabolism. The estimates vary, but approximately 10 million Americans have this common medical condition. In fact, as many as 10% of women may have some degree of thyroid hormone deficiency. Hypothyroidism is more common than you would believe, and millions of people are currently hypothyroid and don’t know it. It is estimated to affect 3-5% of the adult population. It is more common in women than in men, and the risk of developing hypothyroidism increases with advancing age.

What Causes Hypothyroidism:

Hypothyroidism is most commonly a result of an autoimmune condition known as Hashimoto’s thyroiditis, in which the body’s own immune cells attack and destroy the thyroid gland. Since the activity of the thyroid gland is controlled by other hormones from the pituitary gland and the hypothalamus of the brain, defects in these areas can also cause under-activity of the thyroid gland (such as brain tumors). Previous surgeries on the thyroid or a history of irradiation to the neck are other causes of hypothyroidism. A condition like this can also occur when Hyperthyroidism (Grave’s disease or Toxic goiter) is treated with Radioactive Iodine (I-131) and as a result the thyroid tissue is destroyed resulting in less than normal production of thyroid hormones.

Can Iodine Deficiency lead to Hypothyroididm:

Yes. In areas of the world where there is Iodine deficiency in the diet, severe hypothyroidism can be seen in 5% to 15% of the population. Examples of these areas include Zaire, Ecuador, India, Pakistan, and Chile. Severe iodine deficiency is also seen in remote mountain areas such as the Andes and the Himalayas. Since the addition of iodine to table salt and to bread, iodine deficiency is rarely seen in the United States.

What Are The Symptoms Of Hypothyroidism

An under-active thyroid gland affects all organs and functions within the body, leading to both physical and emotional symptoms. Symptoms of hypothyroidism are usually very subtle and gradual and may be mistaken for symptoms of depression. The following are the most common symptoms of hypothyroidism. However, each individual may experience symptoms differently.
  • dull facial expressions, lack of drive, low mood
  • hoarse voice
  • slow speech
  • droopy eyelids
  • puffy and swollen face
  • weight gain, lethargy, body aches and pains
  • constipation
  • coarse and dry hair
  • coarse, dry, and thickened skin
  • slow pulse or bradycardia.
  • muscle cramps
  • confusion, memory loss, loss of libido (decreased sex drive)
  • increased menstrual flow in women (menorrhagia)
One reason of clinical depression is severe hypothyroidism so if you have depression, it is mandatory to get thyroid hormones evaluated from a good, reliable laboratory. As one of the reasons for hypothyroidism is raised TSH (Thyroid stimulating hormone) due to pituitary disturbances / diseases, it should be kept in mind that there are numerous cases of infertility in women which is due to hypothyroidism.

Diagnosis and Treatment:

Since hypothyroidism is caused by too little thyroid hormone secreted by the thyroid, the diagnosis of hypothyroidism is based almost exclusively upon measuring the amount of thyroid hormone in the blood. There are normal ranges for all thyroid hormones which have been calculated by computers which measure these hormones in tens of thousands of people. If your thyroid hormone levels fall below the normal range, that is consistent with hypothyroidism. These tests are very accurate and reliable and are so routine that they are available to everybody. Diagnosis is made by a doctor working in the field of endocrinology or an endocrinologist. The hormones are evaluated in a laboratory and methods like RIA (radioimmunoassay) give very accurate results of circulating hormones. In most cases the TSH (thyroid stimulating hormone) levels are found very high.

Treatment of Hypothyroidism:

The goal of treatment is to restore the thyroid gland to its normal function, creating normal levels of thyroid hormones in the circulating blood. Specific treatment for hypothyroidism will be determined by your physician based on:
  • Your age, overall health, and medical history
  • Extent of the disease
  • Expectations for the course of the disease
Treatment may include prescription of thyroid hormones (Thyroxine, Levothyroxine, Eltroxin) to replace the deficient hormones. Dosage of thyroid hormone may need to be increased over the years. Yearly or biyearly checkups are usually required to ensure that the proper dosage of thyroid hormones is taken. A patient usually takes thyroid hormones for the rest of his/her life. Remember you should not be shy in discussing with your doctor your blood hormone test results, symptoms, how you feel, and the type of medicine you are taking. The goal is to make you feel better, make your body last longer, slow the risk of heart disease and osteoporosis, in addition to making your blood levels normal. Sometimes that’s easy, when its not, you need a physician who is willing to spend time with you that you deserve while you explore different dosages and other types of medications (or alternative diagnoses).


Monday, February 27, 2012

Causes Of Myxedema

Myxedema (Adult hypothyroidism) is caused by an accumulation of tissue products, such as glycosaminoglycans, in the skin. Myxedema is almost always a result of hypothyroidism. Specific causes of hypothyroidism that can lead to myxedema include Hashimoto’s thyroiditis, thyroidectomy (surgical removal of the thyroid), and Graves’ disease.

The most common cause of hypothyroidism is inflammation of the thyroid gland, which damages the gland's cells. Autoimmune or Hashimoto's thyroiditis, in which the immune system attacks the thyroid gland, is the most common example of this. Some women develop hypothyroidism after pregnancy (often referred to as "postpartum thyroiditis").

Other common causes of hypothyroidism include:
  • Congenital (birth) defects
  • Radiation treatments to the neck to treat different cancers, which may also damage the thyroid gland
  • Radioactive iodine used to treat an overactive thyroid (hyperthyroidism)
  • Surgical removal of part or all of the thyroid gland, done to treat other thyroid problems
  • Viral thyroiditis, which may cause hyperthyroidism and is often followed by temporary or permanent hypothyroidism
Certain drugs can cause hypothyroidism, including:
  • Amiodarone
  • Drugs used for hyperthyroidism (overactive thyroid), such as propylthiouracil (PTU) and methimazole
  • Lithium
  • Radiation to the brain
  • Sheehan syndrome, a condition that may occur in a woman who bleeds severely during pregnancy or childbirth and causes destruction of the pituitary gland.
A number of factors increase the risk of developing myxedema. Not all people with risk factors will get myxedema.

Risk factors for myxedema include:
  • Age over 50 years
  • Autoimmune disorders (diseases in which the immune system attacks the body’s own tissues as foreign substances)
  • Current or previous hypothyroidism
  • Female gender

Sunday, February 26, 2012

Myxedema Pictures Face

Myxedema Pictures Face
Myxedema Pictures Face

Adult woman with the characteristic puffiness that often accompanies hypothyroidism. Her puffiness and hair texture markedly improve after treatment with desiccated thyroid.

Myxedema Pictures Face
Myxedema Pictures Face, Image source: www.type2hypothyroidism.com

This is another example of the resolution of the puffiness (myxedema) following proper treatment of hypothyroidism with desiccated thyroid.

Pretibial Myxedema Picture


Pretibial Myxedema Picture

Swelling of the lower legs brought this 57-year-old woman to a family practice clinic. She had a history of hyperthyroidism with weight loss, tachycardia, and anxiety. This condition was confirmed with blood tests and radioactive iodine(Drug information on iodine) uptake testing. Pretibial myxedema is a classic finding in hyperthyroidism that may appear years before or after development of the endocrine disorder. The distinguishing feature is nonpitting edema of mucinous ground substance on the anterior surface of the lower leg. In the early stages, the overlying skin is erythematous and pruritic. These symptoms usually subside spontaneously over a period of months or years, but topical corticosteroids may be given to relieve the pruritus.

Saturday, February 25, 2012

Myxedema Coma Treatment

Myxedema Coma Treatment

The patient with myxedema coma should be admitted to the intensive care unit, and hypovolemia and electrolyte abnormalities corrected. Mechanical ventilation may be necessary. Cardiovascular status should be monitored carefully, especially after intravenous thyroid hormone replacement. Myocardial infarction must be ruled out and blood pressure stabilized. If possible, pressors and ionotropes should be avoided because of their tendency to provoke arrhythmias in the setting of intravenous thyroid replacement. Patients with hypothermia should be covered with regular blankets; the use of warming blankets should be avoided because the resulting peripheral dilatation may lead to hypotension and cardiovascular collapse.

Thyroid Hormone Replacement
Any patient with suspected myxedema coma should be treated presumptively with thyroid hormone. While there is concern regarding the precipitation of arrhythmias or myocardial infarction by administering large doses of intravenous levothyroxine, this concern must be balanced against T4's potentially life-saving and usually nondetrimental effect.

While the necessity of intravenous thyroid hormone replacement is apparent, some controversy exists regarding the use and dosages of levothyroxine (T4) and liothyronine (T3). Because of the relatively small number of patients with myxedema coma, controlled studies comparing various dosages of T4 and T3 are lacking. Because T3 is more biologically active than T4, and because the conversion of T4 to T3 is suppressed in myxedema coma, some have advocated T3 replacement. However, parental T3 is not only expensive and difficult to obtain, it may also contribute to increased mortality.

Most authorities therefore recommend use of T4 alone. An initial levothyroxine dose of 100 to 500 μg administered intravenously should be followed by 75 to 100 μg administered intravenously daily until the patient is able to take oral replacement. The lower initial dose should be administered to patients who are frail or have other comorbidities, particularly cardiovascular disease. Elderly patients typically require 100 to 170 μg of oral levothyroxine daily.

Antibiotics
Infection is often the cause of the patient's decompensation; therefore, an infectious etiology should be sought with blood and urine cultures as well as a chest radiograph. Some authorities advocate empiric therapy with broad-spectrum intravenous antibiotics.

Steroids
Because of the possibility of secondary hypothyroidism and associated hypopituitarism, hydrocortisone should be administered until adrenal insufficiency has been ruled out. Hydrocortisone should be administered intravenously at a dosage of 100 mg every eight hours. Failure to treat with hydrocortisone in the face of adrenal insufficiency may result in the precipitation of adrenal crisis. A random cortisol level should be drawn prior to therapy, and if not depressed, the hydrocortisone can be discontinued without tapering. An adrenocorticotropic hormone stimulation test can be administered if clinically warranted.

Prognosis
The prognosis for patients with myxedema coma is difficult to define because of the small number of cases reported in the literature. The severity of the condition, however, is clear. One study reported a mortality rate of about 30 percent, while another suggests the mortality rate may be as high as 60 percent. Factors associated with a poor prognosis include advanced age, bradycardia and persistent hypothermia.

Final Comment
Family physicians should be alert for myxedema coma, particularly in elderly women with mental status changes who present during the winter months. An accurate diagnosis generally follows a careful history, physical examination and laboratory evaluation. The most important elements in treatment of myxedema coma are early recognition, presumptive thyroid hormone replacement, hydrocortisone and appropriate supportive care. While myxedema coma carries a significant mortality rate even with appropriate testing and treatment, an early diagnosis of hypothyroidism may well save a patient's life.

References:
www.ncbi.nlm.nih.gov
www.aafp.org

Pretibial Myxedema Photo

Pretibial Myxedema Pictures
Pretibial myxedema photo
Image source: www.signsofunderactivethyroid.com


Pretibial Myxedema images

Pretibial myxedema photo
Image source: http://jcem.endojournals.org

Thyroid dermopathy (localized myxedema) in five patients. A, Nonpitting edema form in pretibial area. B, Plaque form in pretibial area. C, Nodular form in ankle and foot. D, Elephantiasic form. E, Occurrence of thyroid dermopathy in scar tissue.

Friday, February 24, 2012

Treatment For Myxedema

Myxedema Coma Treatment Self-Care at Home

If you have hypothyroidism, be alert to your condition.
  • Call your doctor if you are concerned.
  • Check your blood sugar level if you are diabetic.
  • Warm yourself up with a warm blanket and seek help.
  • Take your prescribed thyroid medication if you missed them earlier.
People with myxedema coma are in a coma or nearly in a coma. They are not able to function normally. Friends or family members should take them to an emergency department immediately. Friends or family members should not give the person in myxedema coma any thyroid medication before taking him or her to the emergency department. If adrenal insufficiency is present, then administration of thyroxin (in the thyroid medication) will provoke an adrenal crisis.

Medical Treatment
  • Intravenous fluids
  • Electrolytes replacement as necessary
  • Thyroid hormones are usually administered through a vein (intravenously or IV) to quickly correct the low thyroid hormone blood level. (Oral thyroid hormone is usually not used for severe myxedema because it may take days or weeks to obtain the proper blood level.)
  • Cortisol or other adrenal cortical hormone intravenously
  • Warming blanket if body temperature is low
  • Glucose supplements if the blood sugar level is low
  • Antibiotics if an infection is present