Abstract
Hypothyroidism is a disease in which there is the failure of the pituitary gland in
stimulating thyroid gland which results in disturbance of thyroid hormone
balance. The main hormones related to hypothyroidism include thyroid
stimulating hormone(TSH) and thyroxine(T4). Its symptoms are gradual and they
include tiredness, weight gain, fatigue etc. The symptoms vary a lot depending
on the deficiency of hormones. Hypothyroidism is a graded disease with mild,
subclinical and overt grades depending upon the condition of thyroid and its
functionality. The treatment includes tablet mailny. Serum Ferritin levels can
extremely contribute to the onset of disease. The present study presents a case of
a 52 years old man suffering from hypothyroidism who was referred to an
endocrinologist for checkup. His blood tests were ordered along with the
ultrasound of thyroid tissue. The blood tests and ultrasound indicate the relation
of hypothyroidism with hormonal imbalance and disturbed secretions in the body
along with a strong connection of hypothyroidism to autoimmune disease.
Introduction
Hypothyroidism is defined as the failure of the pituitary gland in stimulating
thyroid gland which in turn results in imbalance of thyroid hormones including
thyroid stimulating hormone and thyroxine mainly. It is also defined as
underactive thyroid. Autoimmune ailment of thyroid is the primary cause of
hypothyroidism. Although it is a curable disease, if left untreated hypothyroidism
can cause hypertension, imbalance lipid profile, loss of fertility, memory less, and
neuromuscular damage. Approximately 5% of people are encountered by it. The
occurrence chances increase with age,with females being more prone than males.
Y Gaitonde
Causes
Major causes of hypothyroidism are listed below
Autoimmune ailment
Autoimmune thyroiditis can appear suddenly or it progresses gradually over the
number of years. The most common autoimmune forms include Hashimoto’s
thyroiditis and atrophic thyroiditis.
Surgery
Surgery of thyroid gland to remove a part or whole gland can make patient prone
to hypothyroidism
Radiation treatment
Taking radiotherapy for any disease result in onset of hypothyroidism.
Congenital
A baby is either born hypothyroid or the thyroid is at wrong [lace or the enzymes
are malfunctioned.
Thyroiditis
The inflammation of thyroid gland causing it to release all TSH in blood and
result in temporary hypothyroidism.
Medicine Reaction
Drugs like amiodarone, lithium, interferon alpha, and interleukin-2 can prevent
normal functioning of thyroid.
Iodine imbalance
Elevated or decreased levels of iodine cause thyroid to not function well because
thyroid hormone production requires balanced iodine.
Pituitary gland damage
Pituitary gland gives thyroid the instructions on how much of hormones it had to
secrete. If it is damaged by radiation or any ailment it can’t instruct thyroid which
in turn can’t produce hormones.
Rare abnormalities
Rare thyroid disorders can impair thyroid ability to secrete hormones properly.
They include amyloidosis in which amyloid a protein deposits on the thyroid
causing it to dysfunction. Similarly in sarcoidosis granulomas deposit on thyroid
thus impairing it and hemochromatosis which is excessive accumulation of iron
on thyroid.
Symptoms
Thyroid symptoms are not specified and are subtle initially especially at older
ages. The symptoms severity vary a lot and mainly depend on deficiency of
hormones. The disease develops gradually over years. Initially barely any
symptoms appear like gradual weight gain or fatigue which is thought to be an
age factor. But then as disease progresses metabolism slows down and obvious
signs appear. They include but are not limited to the following:
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Fatigued body
Cold sensitivity
Constipation
Drier skin
Gaining weight
Puffiness of face.
Weakness of muscles
Mayo Clinic.
Diagnosis
➔ Physical examination
Doctor examines thyroid gland and other physical changes including dryness of
skin, inflammation, slowed down reflex, heart rate slowness.
➔ Blood tests
● The most common and verified method of assessing thyroid functioning is
thyroid stimulating hormone test that gives a detailed analysis of all thyroid
hormones including TSH, thyroxine(T4) and Triiodothyronine(T3)
concentrations.
● The T4 released in the blood becomes adhered to a protein named as
thyroxine-binding globulin. The bounded thyroxine cannot get to the calls
of the body. Only about 1to 2 percent of thyroxine remains free in blood
and reaches to the cells.T4 tests give a measure of how much unattached
T4 is present in blood.
Grades of hypothyroidism
Hypothyroidism is a graded disease. The grades are attributed according to the
TSH secretions, and the level of antibodies.
Overt hypothyroidism
The overt hypothyroidism shows obvious symptoms and thyroid abnormalities
from routine.
Mild hypothyroidism
Patient shows mild, unspecified signs but the concentrations of hormones though
in the normal range are very low. TSH concentrations become high here and
symptoms go away with treatment.
Subclinical hypothyroidism
subclinical hypothyroidism or asymptomatic though have elevated TSH but other
thyroid functionalities are close to normal Evered
Treatment
Most patients are prescribed synthetic levothyroxine to alleviate the symptoms.
It is a drug orally administered and is good for treating hypothyroidism. Y
Gaitonde
Case Description
An elderly man of 52 years suffering from hypothyroidism was referred to an
endocrinologist for a detailed checkup. His blood tests were conducted to analyze
the effects of hypothyroidism on hormones and other related blood components
with special emphasis on serum ferritin, TSH and T4 levels. TSH was found to
be as high as 116uIU/mL while Thyroxine (T4) was low to 4.1ug/dL. Serum
ferritin with 1151ng/mL value was very high indicating a problematic situation.
Thyroid soft tissue ultrasound revealed multiple swollen areas, the hypoechoic
nodules. Among them the largest with 1.4cm size was detected in the mid pole of
the left lobe. Most of the test reports suggested that hypothyroidism may probably
be worsening and affecting body functions, systems and hormones.
Discussion
In clinical terms hypothyroidism is a condition in which thyroid-stimulating
hormone (TSH) secretion is more than the standard range while free
thyroxine(T4) secretion is below the standard range. If it is mild the TSH secreted
above the normal range and thyroxine(T4) is secreted within the normal range.
Chaker
The normal range for TSH is from 0.35mIU/mL to 4.50mIU/mL while a healthy
range should be between 0.5 mIU/mL to 2.50 mIU/mL Sheehan.
In the present case of an elderly man, there is the history of the thyroid function
test of the patient which presents three different concentrations at three different
times so a comparison of them gives a better idea of the condition of the patient
over time. The oldest concentration is in the last month of 2021, where the TSH
of the patient was very high with 115.00ulU/mL. After one month the test was
conducted again and the concentration of 116.00ulU/mL indicates that there is no
improvement in condition but its worsening over time. The reasons could be
carelessness, improper treatment or it might be that the disease is aggravating
with time and implicating the body systems in a negative way The very next
month the patient was again tested for TSH and the results were very encouraging
with a TSH level of 2.9ulU/mL which is within the normal range.
A similar comparison could be made for thyroxine(T4) from the thyroid function
test. The normal range of T4 is from 4.5 to 12ug/dL while the history of the patient
is such that in December 2021, he has a low T4 of 4.0ug/dL. In January 2022,
after one month slightest difference was noticed with 4.1ug/dL T4 which is not
hopeful at all. But the major difference was seen in the most recent result of
February 2022, with a T4 concentration of 10.2ug/dL indicating a proper
treatment of patient and curing of patient.
While in all this TriiodothyronineT3 hormone was stable with 79ng/dL and
89ng/dL for which normal reference range is from 71ng/dL to 180ng/dL.
Now the relation of TSH and T4 is very important to understand the condition of
a hypothyroidism patient. TSH is responsible for required production of T3 and
T4 hormones in the body that in turn are necessary to carry out body functions.
But if TSH is too high like the case presented the T3 and T4 will drop in
concentration which is called hypothyroidism. ref
As thyroid functioning is related to sexual hormones so testodterone serum and
free testosterone were also analyzed. The reports showed normal testosterone
level while free testosterone were low to 5.3pg/mL which may indicate a negative
effect of hypothyroidism on body.
Ferritin serum test reported extremely elevated levels of ferritin that is
1151ng/mL while the normal range for it is 30-400ng/mL. Ferritin is the protein
that supplies iron to the body to be used and stored in its main form. N Adequate
level of Iron is necessary for T3 and T4 production, T4 conversion into active
form of T3 and use of T3 in the cell. Hedberg High serum ferritin levels are linked
with inflammation and stress and damage of cell N According to Takamatsu et
alIncreased ferritin levels in hypothyroid patients are an indication of Hashimoto
disease Takamats. That is understandable because high iron causes thyroid
damage and injury which trigger the production of antithyroid antibodies causing
hashimoto hypothyroidism Edwards which is an autoimmune disorder where the
immune system of the body causes death of thyroid producing cells. This
condition can be verified from the patient's thyroid function test results where
both the antithyroid antibodies Thyroglobulin Antibody and Thyroid Peroxidase
(TPO) Ab are in higher concentration than normal range. With Thyroglobulin
Antibody being 46.7 IU/mL instead of being in range of 0.0-0.9 IU/mL and
Thyroid Peroxidase (TPO) Ab 126IU/mL instead of being in range of 0-34"1U/ml
thus giving a clear indication of hashimoto hypothyroidism. OKeefeOsborn,
The condition is further more clarified by thyroid soft tissue ultrasound which
reported to have multiple bilateral hypoechoic nodules (which is a mass on
thyroid and appear as a dark spot in ultrasound) in both right and left lobes which
are mainly caused by either iodine deficiency or hashimoto disease.
The positive Rh stresses on autoimmune disorder which is. Also researches have
proved that elevated Rh and even Rheumatoid arthritis can be causative agents
for hypothyroidism and Hashimoto’s thyroiditis. Li
Other tests have also been ordered to ensure the actual condition for right
treatment. These include LFT, complete metabolic panel, Urine Culture, Lipid
profile and CBC.
LFT reported echogenic liver which indicates hepatic steatosis, a condition of
fatty liver which is a secondary to different diseases hypothyroidism is main
among them. Kizivat
Triglycerides and cholesterol were high from reference range with values
186mg/L and 389mg/L in lipid profiling. CBC indicated a 12.7g/dL hemoglobin
which is a bit lower than normal range of 13.2g/dL to 16.6g/dL.
Urine culture was normal while the metabolic panel had slight variations in
glucose etc. from normal range.
So the overall medical condition and test reports of the patient makes it evident
that the hypothyroidism of the patient was at a worse stage and was elevating
TSH to the highest levels which lead to dropped levels of T4 and thus thyroid
dysfunction. The elevated ferritin levels plus increased concentration of
antithyroid antibodies indicated the underlying cause to be hashimoto’s disease.
Ultrasound of thyroid soft tissue clarified the damage of thyroid. And that all
refers to proper medical assistance which enabled the patient to attain normal
levels of TSH and T4 as indicated by last reports of his tests
Conclusion
Hypothyroidism is a condition in which the thyroid gland fails to doesn't secrete
required thyroid hormone into the bloodstream of the body causing metabolism
to slow making the sufferer feel tired, put on weight and becomes hypersensitive
to cold. Serum Ferritin levels can extremely contribute to the onset of disease by
increasing antibodies that damage thyroid and cause it to dysfunction. Diagnosis
is done through thyroid function test. Symptoms are nonspecific and onset is
gradual. When diagnosis is completed levothyroxine tablet is suggested to be
taken as a treatment which is capable of balancing hormones in 6 to 8 weeks.
When TSH is back to normal range annual testing is important to have an update
of conditions. Antonelli
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