Hypothyroidism: Difference between revisions

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#redirect:[[Hypothyroidism]]
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'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
{{WikiDoc CMG}}; {{AE}}  
{{Hypothyroidism}}
{{CMG}}; {{AE}} {{MIR}}
 
{{SK}}Primary hypothyroidism; Secondary hypothyroidism; Tertiary hypothyroidism; Decrease thyroid hormone; Hypo-functioning thyroid
 
==Overview==
==Overview==
[[Thyroxine]] (T4) and [[triiodothyronine]] (T3) are produced from the [[thyroid gland]]. [[Thyroid hormones]] are important in regulating various body functions and their deficiencies are associated with different symptoms including decrease in energy metabolism, decreased [[appetite]], cold intolerance, and lower basal body temperature (due to low basal metabolic rate).<ref name="pmid19949140">{{cite journal |vauthors=McDermott MT |title=In the clinic. Hypothyroidism |journal=Ann. Intern. Med. |volume=151 |issue=11 |pages=ITC61 |year=2009 |pmid=19949140 |doi=10.7326/0003-4819-151-11-200912010-01006 |url=}}</ref> [[Iodine deficiency]] is recognized as the most common cause of hypothyroidism world-wide. In developed countries and areas with sufficient iodine, the most common cause of hypothyroidism is [[chronic autoimmune thyroiditis]] [[Hashimoto's thyroiditis|(Hashimoto’s thyroiditis)]]. [[Hashimoto's thyroiditis|Hashimoto’s thyroiditis]] has a higher prevalence in women than in men.<ref name="pmid11836274">{{cite journal |vauthors=Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, Braverman LE |title=Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III) |journal=J. Clin. Endocrinol. Metab. |volume=87 |issue=2 |pages=489–99 |year=2002 |pmid=11836274 |doi=10.1210/jcem.87.2.8182 |url=}}</ref><ref name="pmid18177256">{{cite journal |vauthors=Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR |title=Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999-2002) |journal=Thyroid |volume=17 |issue=12 |pages=1211–23 |year=2007 |pmid=18177256 |doi=10.1089/thy.2006.0235 |url=}}</ref> Signs and symptoms of hypothyroidism are mostly related to the magnitude of the thyroid hormone deficiency and the acuteness of the development of hormone deficiency.<ref name="pmid3753833">{{cite journal |vauthors=Zimmerman RS, Brennan MD, McConahey WM, Goellner JR, Gharib H |title=Hashimoto's thyroiditis. An uncommon cause of painful thyroid unresponsive to corticosteroid therapy |journal=Ann. Intern. Med. |volume=104 |issue=3 |pages=355–7 |year=1986 |pmid=3753833 |doi= |url=}}</ref> However, the typical clinical manifestations of hypothyroidism may vary depending on the cause of hypothyroidism. Clinical scenario, if associated with secondary and tertiary hypothyroidism, may present other coexisting endocrine deficiencies such as [[hypogonadism]] and [[adrenal insufficiency]] that may mask the manifestations of hypothyroidism. Although the diagnosis of hypothyroidism is mainly a laboratory diagnosis, the coexisting conditions and wide variation in clinical presentation may make the diagnosis difficult.<ref name="pmid18415684">{{cite journal |vauthors=Lania A, Persani L, Beck-Peccoz P |title=Central hypothyroidism |journal=Pituitary |volume=11 |issue=2 |pages=181–6 |year=2008 |pmid=18415684 |doi=10.1007/s11102-008-0122-6 |url=}}</ref> On the other hand, subclinical hypothyroidism is mostly asymptomatic, but may transform to clinical hypothyroidism. Recent evidence has shown that subclinical hypothyroidism may lead to various complications, such as [[hyperlipidemia]], increased risk of [[cardiovascular disease]] (even [[heart failure|heart failure)]], [[somatic]] and [[neuromuscular]] symptoms, and [[infertility]].<ref name="pmid8371604">{{cite journal |vauthors=O'Brien T, Dinneen SF, O'Brien PC, Palumbo PJ |title=Hyperlipidemia in patients with primary and secondary hypothyroidism |journal=Mayo Clin. Proc. |volume=68 |issue=9 |pages=860–6 |year=1993 |pmid=8371604 |doi= |url=}}</ref><ref name="pmid7605150">{{cite journal |vauthors=Diekman T, Lansberg PJ, Kastelein JJ, Wiersinga WM |title=Prevalence and correction of hypothyroidism in a large cohort of patients referred for dyslipidemia |journal=Arch. Intern. Med. |volume=155 |issue=14 |pages=1490–5 |year=1995 |pmid=7605150 |doi= |url=}}</ref>
This section provides a short and straight to the point overview of the disease or symptom.  The first sentence of the overview must contain the name of the disease.


==Classification==
==Causes==
The table below presents a classification of isolated thyroid disorders and its causes based on the classification:<ref name="pmid1578958">{{cite journal |vauthors=Colon-Otero G, Menke D, Hook CC |title=A practical approach to the differential diagnosis and evaluation of the adult patient with macrocytic anemia |journal=Med. Clin. North Am. |volume=76 |issue=3 |pages=581–97 |year=1992 |pmid=1578958 |doi= |url=}}</ref> <ref name="pmid15643019">{{cite journal |vauthors=Gharib H, Tuttle RM, Baskin HJ, Fish LH, Singer PA, McDermott MT |title=Subclinical thyroid dysfunction: a joint statement on management from the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Endocrine Society |journal=J. Clin. Endocrinol. Metab. |volume=90 |issue=1 |pages=581–5; discussion 586–7 |year=2005 |pmid=15643019 |doi=10.1210/jc.2004-1231 |url=}}</ref><ref name="pmid25347444">{{cite journal |vauthors=Rugge JB, Bougatsos C, Chou R |title=Screening and treatment of thyroid dysfunction: an evidence review for the U.S. Preventive Services Task Force |journal=Ann. Intern. Med. |volume=162 |issue=1 |pages=35–45 |year=2015 |pmid=25347444 |doi=10.7326/M14-1456 |url=}}</ref><ref name="pmid22954017">{{cite journal |vauthors=Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, Pessah-Pollack R, Singer PA, Woeber KA |title=Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association |journal=Thyroid |volume=22 |issue=12 |pages=1200–35 |year=2012 |pmid=22954017 |doi=10.1089/thy.2012.0205 |url=}}</ref>
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
* [[Life threatening cause 1]]
* [[Life threatening cause 2]]
* [[Life threatening cause 3]]


{| class="wikitable" align="center" style="border: 0px; font-size: 90%; margin: 3px;"
===Common Causes===
! colspan="2" rowspan="3" align="center" style="background: #4479BA; color: #FFFFFF; " |Classification
* [[Common cause 1]]
! colspan="3" rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Origin of the defect
* [[Common cause 2]]
! colspan="3" style="background: #4479BA; color: #FFFFFF; " |Causes
* [[Common cause 3]]
|-
* [[Common cause 4]]
! rowspan="2" style="background: #4479BA; color: #FFFFFF; " |Endogenous causes
* [[Common cause 5]]
! colspan="2" style="background: #4479BA; color: #FFFFFF; " |Exogenous causes
|-
! style="background: #4479BA; color: #FFFFFF; " |<small>Thyroid</small>
! style="background: #4479BA; color: #FFFFFF; " |<small>Pituitary</small>
! style="background: #4479BA; color: #FFFFFF; " |<small>Hypothalamus</small>
! style="background: #4479BA; color: #FFFFFF; " |Surgery or radiation
! style="background: #4479BA; color: #FFFFFF; " |Other causes
|-
! colspan="2" align="center" style="background: #DCDCDC; " |Primary hypothyroidism
| align="center" | <nowiki>+</nowiki>
| align="center" | <nowiki>-</nowiki>
| align="center" |  -
|
* [[Congenital hypothyroidism]]
* [[Hashimoto's thyroiditis|Autoimmune (Hashimoto's) thyroiditis]]
* Resistance to [[TSH]]
|
* After [[hyperthyroidism]] or [[thyroid cancer]] treatment:
** [[Thyroidectomy]]
** [[Radioiodine|Radioiodine therapy]]
* [[Radiation therapy|Radiation]] for non-thyroid-related [[Head and neck cancer|head and neck malignancies]] including [[lymphoma]]
|
* [[Iodine-deficiency|Iodine deficeincy]]
* Drug induced thyroiditis
** [[Amiodarone]]
** [[Lithium]]
** Thionamide
** [[Interferon]]
** [[Sunitinib]]
** [[Rifampicin]]
** [[Thalidomide]]
* [[Thyroiditis|Acute infectious thyroiditis]]
* Trauma-induced
|-
! colspan="2" style="background: #DCDCDC; " |Transient hypothyroidism
| align="center" |<nowiki>+</nowiki>
| align="center" |<nowiki>+</nowiki>
| align="center" | -
|
* [[De Quervain's thyroiditis|Subacute (de Quervain’s) thyroiditis]]
* [[Postpartum thyroiditis]]
|
* Major surgeries
|
|-
! rowspan="2" style="background: #DCDCDC; " |Central Hypothyroidism
! style="background: #DCDCDC; " |Secondary
OR


Pituitary originated
==Diagnosis==
| align="center" |<nowiki>-</nowiki>
Shown below is an algorithm summarizing the diagnosis of <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
| align="center" |<nowiki>+</nowiki>
{{familytree/start |summary=PE diagnosis Algorithm.}}
| align="center" | -
{{familytree | | | | A01 | | | A01= }}
|
{{familytree | | | | |!| | | | }}
* [[Pituitary]] mass lesions, especially [[pituitary adenomas]]
{{familytree | | | | B01 | | | B01= }}
* [[Brain cyst|Brain cysts]] and [[Brain abscess|abscesses]]
{{familytree | | |,|-|^|-|.| | }}
* [[Meningiomas]]
{{familytree | | C01 | | C02 | C01= | C02= }}
* [[Dysgerminomas of pineal gland|Dysgerminomas]]
* [[Metastatic tumor|Metastatic tumors]]
* [[Craniopharyngioma|Craniopharyngiomas]]
* [[Pituitary apoplexy]]
* [[Sheehan's syndrome|Sheehan syndrome (postpartum pituitary necrosis)]]
* Idiopathic isolated TSH deficiency
* [[Lymphocytic hypophysitis|Lymphocytic or granulomatous hypophysitis]]
|
* Surgery of [[Pituitary adenoma|pituitary adenomas]]
* [[Radiation therapy]] to:
** [[Pituitary adenoma|Pituitary adenomas]]
** Other mass lesions near pituitary gland
|
* [[Head trauma]] with injury to the stalk
|-
! style="background: #DCDCDC; " |Tertiary
OR


Hypothalamus originated
{{familytree/end}}
| align="center" |<nowiki>-</nowiki>
| align="center" |<nowiki>-</nowiki>
| align="center" | +
|
* [[Hemochromatosis]]
* [[Histiocytosis]]
* Developmental abnormalities
* [[Aneurysm|Internal carotid aneurysms]]
* Other [[central nervous system]] ([[CNS]]) tumors
* Idiopathic isolated [[TRH]] deficiency
|
* [[Radiation]] in high doses to:
** Brain
** [[Infratemporal]]
** [[Nasopharyngeal Cancer|Nasopharyngeal]]
** [[Oropharyngeal]]
|
* [[Infections]]
** [[Tuberculosis]]
** [[Syphilis]]
** [[Toxoplasmosis]]
* [[Sarcoidosis]]
|}
 
== Differentiating different causes of hypothyroidism ==
Various kinds of hypothyroidism can be differentiated from each other on the basis of history and symptoms and laboratory findings:<ref name="pmid19949140" /><ref name="pmid18177256" /><ref name="pmid18415684" />
 
{| class="wikitable" align="center" style="border: 0px; margin: 3px;"
! colspan="2" rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Disease
! colspan="3" align="center" style="background: #4479BA; color: #FFFFFF; " |History and symptoms
! colspan="7" align="center" style="background: #4479BA; color: #FFFFFF; " |Laboratory findings
! rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Additional findings
|-
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Fever
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Goiter
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Pain
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Free T4
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3RU
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Thyroglobin
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TRH
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TPOAb
|-
| rowspan="3" style="background:#DCDCDC;" |Primary hypothyroidism
| align="center" style="background:#DCDCDC;" |[[Hashimoto's thyroiditis|Autoimmune]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
Diffuse
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |N/'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |N/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* May be accompanied by other [[autoimmune diseases]]
|-
| align="center" style="background:#DCDCDC;" |[[Thyroiditis]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |N/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*[[Thyroiditis|Infectious thyroiditis]] associated with [[neck pain]]
|-
| align="center" style="background:#DCDCDC;" |Others
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |N/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* History of [[hyperthyroidism]]
* Drug history
|-
| colspan="2" style="background:#DCDCDC;" |Transient hypothyroidism
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* May present primarily with [[hyperthyroidism]]
|-
| colspan="2" style="background:#DCDCDC;" |Subclinical hypothyroidism
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |N/'''↑'''
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* Asymptomatic
|-
| rowspan="2" align="center" style="background:#DCDCDC;" |Central Hypothyroidism
| align="center" style="padding: 5px 5px; background: #DCDCDC;" |Pituitary
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| rowspan="2" align="center" style="padding: 5px 5px; background: #F5F5F5;" |N/'''''↓'''''
| rowspan="2" align="center" style="padding: 5px 5px; background: #F5F5F5;" |N/'''''↓'''''
| rowspan="2" align="center" style="padding: 5px 5px; background: #F5F5F5;" |N/'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↓'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* Other [[Pituitary hormone|pituitary hormone deficiencies]] signs
|-
| align="center" style="padding: 5px 5px; background: #DCDCDC;" |Hypothalamus
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* Other [[Pituitary hormone|pituitary hormone deficiencies]] signs
|-
| colspan="2" style="background:#DCDCDC;" |Resistance to TSH/TRH
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |N/'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |N/'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''/'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* Rare
|}
 
==Screening==
*According to the Endocrine Society and the European Society for Pediatric Endocrinology, screening for [[Cretinism|congenital hypothyroidism]] ([[cretinism]]) is recommended in all [[neonates]]. Screening is recommended because early detection of [[cretinism]] and early treatment will prevent the consequences of the disease which may be [[mental retardation]].<ref name="pmid24446653">{{cite journal| author=Léger J, Olivieri A, Donaldson M, Torresani T, Krude H, van Vliet G et al.| title=European Society for Paediatric Endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism. | journal=J Clin Endocrinol Metab | year= 2014 | volume= 99 | issue= 2 | pages= 363-84 | pmid=24446653 | doi=10.1210/jc.2013-1891 | pmc=4207909 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24446653  }}</ref>
*In a worldwide view of strategies, screening of [[cretinism]] is been held in many countries including the United States. The screening helped in detecting the newborn with hypothyroidism. These cases are around 2000 annually in the United States and 12,000 worldwide.<ref name="pmid24629860">{{cite journal| author=Ford G, LaFranchi SH| title=Screening for congenital hypothyroidism: a worldwide view of strategies. | journal=Best Pract Res Clin Endocrinol Metab | year= 2014 | volume= 28 | issue= 2 | pages= 175-87 | pmid=24629860 | doi=10.1016/j.beem.2013.05.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24629860  }}</ref>
*The screening of [[cretinism]] can be performed through the following laboratory tests:<ref name="pmid8533594">{{cite journal| author=Asami T, Otabe N, Wakabayashi M, Kikuchi T, Uchiyama M| title=Congenital hypothyroidism with delayed rise in serum TSH missed on newborn screening. | journal=Acta Paediatr Jpn | year= 1995 | volume= 37 | issue= 5 | pages= 634-7 | pmid=8533594 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8533594  }}</ref><ref name="pmid23154158">{{cite journal| author=Büyükgebiz A| title=Newborn screening for congenital hypothyroidism. | journal=J Clin Res Pediatr Endocrinol | year= 2013 | volume= 5 Suppl 1 | issue=  | pages= 8-12 | pmid=23154158 | doi=10.4274/jcrpe.845 | pmc=3608007 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23154158  }}</ref>
**Measuring the level of [[Thyroxine|thyroxine hormone]] (T4)
**[[Blood]] [[TSH]] assay
**Both [[thyroxine]] and [[TSH]] levels


== Diagnosis ==
==Treatment==
Hypothyroidism diagnosis can be made based on the laboratory findings<ref name="pmid1578958">{{cite journal |vauthors=Colon-Otero G, Menke D, Hook CC |title=A practical approach to the differential diagnosis and evaluation of the adult patient with macrocytic anemia |journal=Med. Clin. North Am. |volume=76 |issue=3 |pages=581–97 |year=1992 |pmid=1578958 |doi= |url=}}</ref><ref name="pmid15643019">{{cite journal |vauthors=Gharib H, Tuttle RM, Baskin HJ, Fish LH, Singer PA, McDermott MT |title=Subclinical thyroid dysfunction: a joint statement on management from the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Endocrine Society |journal=J. Clin. Endocrinol. Metab. |volume=90 |issue=1 |pages=581–5; discussion 586–7 |year=2005 |pmid=15643019 |doi=10.1210/jc.2004-1231 |url=}}</ref><ref name="pmid25347444">{{cite journal |vauthors=Rugge JB, Bougatsos C, Chou R |title=Screening and treatment of thyroid dysfunction: an evidence review for the U.S. Preventive Services Task Force |journal=Ann. Intern. Med. |volume=162 |issue=1 |pages=35–45 |year=2015 |pmid=25347444 |doi=10.7326/M14-1456 |url=}}</ref><ref name="pmid22954017">{{cite journal |vauthors=Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, Pessah-Pollack R, Singer PA, Woeber KA |title=Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association |journal=Thyroid |volume=22 |issue=12 |pages=1200–35 |year=2012 |pmid=22954017 |doi=10.1089/thy.2012.0205 |url=}}</ref> although choice of best lab test uncertain<ref name="pmid32349628">{{cite journal| author=Fitzgerald SP, Bean NG, Falhammar H, Tuke J| title=CLINICAL PARAMETERS ARE MORE LIKELY TO BE ASSOCIATED WITH THYROID HORMONE LEVELS THAN WITH TSH LEVELS: A SYSTEMATIC REVIEW AND META-ANALYSIS. | journal=Thyroid | year= 2020 | volume=  | issue=  | pages=  | pmid=32349628 | doi=10.1089/thy.2019.0535 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32349628  }} </ref>.
Shown below is an algorithm summarizing the treatment of <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
 
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start}}
{{familytree | | | | | | | | A01 |A01= }}  
{{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= History, signs, and symptoms suggestive of [[hypothyroidism]]}}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= |B02= }}
{{familytree | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | |B01= Measure '''[[FT4]]''' and '''[[TSH]]'''}}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{familytree | | | C01 | | | | | | | | |!| |C01= }}
{{familytree | | | | | B01 | | | | | | | | | | | | | | | | | | B02 | | |B01= Normal '''[[FT4]]''', Elevated '''[[TSH]]'''>5.5| B02 = Decresased level of '''[[FT4]]'''}}
{{familytree | |,|-|^|.| | | | | | | | |!| }}
{{familytree | | | | | |!| | | | | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | }}
{{familytree | D01 | | D02 | | | | | | D03 |D01= |D02= |D03= }}
{{familytree | | | | | C01 | | | | | | | | | | | C02 | | | | | | | | | | | | C03 | | | | | | | | | | | | | | C01 = [[Subclinical hypothyroidism]] | C02 = Elevated '''[[TSH]]''' > 5.5 | C03 = Normal '''[[TSH]]''' level OR
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
Decreased '''[[TSH]]''' level < 0.2}}
{{familytree | E01 | | | | | | | E02 | | | E03 |E01= |E02= |E03= }}
{{familytree | | | | | |!| | | | | | | | | | | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | | | | | | | | | |!| | | | |!| }}
{{familytree | | | | | |`|-|-|-|-| T01 |-|-|-|-|-|'| | | | | | | | | | | | | T02 | T01 = Check '''anti-thyroid autoantibodies''' and
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }}
'''[[TPOAb]]''' | T02 = Check '''[[TRH]]'''}}
{{familytree | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |!| }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | | | |,|-|-|-|-|^|-|-|-|-|.|}}
{{familytree | | | | | | D01 | | | | | | | | D02 | | | | | | | | | D03 | | | | | | | | D04 | D01 = Increased | D02 = Normal | D03 = Normal or increased | D04 = Decreased }}
{{familytree | | | | | | |!| | | | | | | | | |!| | | | | | | | | | |!| | | | | | | | | |!| }}
{{familytree |boxstyle=text-align: left; | | | | | | D01 | | | | | | | | D02 | | | | | | | | | D03 | | | | | | | | D04 | D01 = •[[Autoimmune thyroiditis]] <br> • Resistance to TSH | D02 = •[[Iodine deficeincy]] <br> •[[Thyroiditis]] | D03 = •Pituitary related hypothyroidism | D04 = •Hypothalamus related hypothyroidism}}
{{familytree/end}}
{{familytree/end}}


==History and symptom ==
==Do's==
The common symptoms and signs of clinical hypothyroidism are listed in the table below. The appearance of symptoms depends on the degree of hypothyroidism severity: <ref name="pmid25305308">{{cite journal |vauthors=Carlé A, Pedersen IB, Knudsen N, Perrild H, Ovesen L, Laurberg P |title=Hypothyroid symptoms and the likelihood of overt thyroid failure: a population-based case-control study |journal=Eur. J. Endocrinol. |volume=171 |issue=5 |pages=593–602 |year=2014 |pmid=25305308 |doi=10.1530/EJE-14-0481 |url=}}</ref><ref name="pmid25086165">{{cite journal |vauthors=Diaz A, Lipman Diaz EG |title=Hypothyroidism |journal=Pediatr Rev |volume=35 |issue=8 |pages=336–47; quiz 348–9 |year=2014 |pmid=25086165 |doi=10.1542/pir.35-8-336 |url=}}</ref><ref name="pmid25122491">{{cite journal |vauthors=Samuels MH |title=Psychiatric and cognitive manifestations of hypothyroidism |journal=Curr Opin Endocrinol Diabetes Obes |volume=21 |issue=5 |pages=377–83 |year=2014 |pmid=25122491 |pmc=4264616 |doi=10.1097/MED.0000000000000089 |url=}}</ref>
* The content in this section is in bullet points.


{| class="wikitable"
==Don'ts==
! align="center" style="background: #4479BA; color: #FFFFFF; " |Symptoms
* The content in this section is in bullet points.
! align="center" style="background: #4479BA; color: #FFFFFF; " |Constituitional
! align="center" style="background: #4479BA; color: #FFFFFF; " | HEENT
! align="center" style="background: #4479BA; color: #FFFFFF; " |Neuromuscular
! align="center" style="background: #4479BA; color: #FFFFFF; " |Other findings
|-
| align="center" style="background: #DCDCDC; " |More common
|
* [[Fatigue]]
* Cold intolerance
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
|
* [[Hoarseness]]
* [[Goiter]]
* Fullness in the throat and neck
|
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
|
* [[Macroglossia]]
* [[Obstructive sleep apnea]]
* [[Paresthesia]]
* Nerve entrapment syndromes ([[carpal tunnel syndrome]])
* [[Blurred vision]] (central hypothyroidism)
|-
| align="center" style="background: #DCDCDC; " |Less common
|
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* [[Fever]]
** If accompanied by [[thyroiditis]]
|
* [[Sore throat]]
* [[Periorbital edema]]
|
* Slowed speech and movements
|
* Pituitary hyperplasia followed by [[hyperprolactinemia]]
* [[Ataxia]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
* [[Cardiomegaly]]
* [[Pericardial effusion]]
* [[Ascites]]
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Infertility]]
|}


== Differentiating hypothyroidism from other diseases: ==
==References==
[[Hypothyroidism (patient information)|Hypothyroidism]] should be differentiated from other diseases causing [[hypopituitarism]].<ref name="pmid9541295">{{cite journal |vauthors=Sato N, Sze G, Endo K |title=Hypophysitis: endocrinologic and dynamic MR findings |journal=AJNR Am J Neuroradiol |volume=19 |issue=3 |pages=439–44 |year=1998 |pmid=9541295 |doi= |url=}}</ref><ref name="pmid7758238">{{cite journal |vauthors=Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH |title=Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature |journal=Clin. Endocrinol. (Oxf) |volume=42 |issue=3 |pages=315–22 |year=1995 |pmid=7758238 |doi= |url=}}</ref><ref name="pmid26262437">{{cite journal |vauthors=Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S |title=Diagnosis of Primary Hypophysitis in Germany |journal=J. Clin. Endocrinol. Metab. |volume=100 |issue=10 |pages=3841–9 |year=2015 |pmid=26262437 |doi=10.1210/jc.2015-2152 |url=}}</ref><ref name="pmid7629223">{{cite journal |vauthors=Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S |title=Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings |journal=J. Clin. Endocrinol. Metab. |volume=80 |issue=8 |pages=2302–11 |year=1995 |pmid=7629223 |doi=10.1210/jcem.80.8.7629223 |url=}}</ref><ref name="pmid8345854">{{cite journal |vauthors=Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H |title=Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus |journal=N. Engl. J. Med. |volume=329 |issue=10 |pages=683–9 |year=1993 |pmid=8345854 |doi=10.1056/NEJM199309023291002 |url=}}</ref><ref name="pmid21668725">{{cite journal |vauthors=Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS |title=Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman |journal=Emerg Med Australas |volume=23 |issue=3 |pages=372–5 |year=2011 |pmid=21668725 |doi=10.1111/j.1742-6723.2011.01425.x |url=}}</ref><ref name="pmid9747750">{{cite journal |vauthors=Dejager S, Gerber S, Foubert L, Turpin G |title=Sheehan's syndrome: differential diagnosis in the acute phase |journal=J. Intern. Med. |volume=244 |issue=3 |pages=261–6 |year=1998 |pmid=9747750 |doi= |url=}}</ref>
{{Reflist|2}}
<small>
{| class="wikitable"
! rowspan="3" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Diseases}}
! rowspan="3" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Onset}}
! colspan="5" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Manifestations}}
! colspan="4" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Diagnosis}}
|-
! colspan="4" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|History and Symptoms}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Physical examination}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Laboratory findings}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Gold standard}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Imaging}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Other investigation findings}}
|-
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Trumatic delivery}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Lactation failure}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Menstrual irregularities}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Other features}}
|-
![[Sheehan's syndrome]]
|Acute
|<nowiki>++</nowiki>
| ++
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|Symptoms of:
* [[Adrenal insufficiency]]
 
* [[Hypothyroidism]]
|
* [[Breast tissue]] [[atrophy]]
 
* Decreased [[axillary]] and [[pubic]] hair growth
|
* [[Pancytopenia]]
 
* [[Eosinophilia]]
 
* [[Hyponatremia]]
 
* Low [[fasting plasma glucose]]
 
* Decreased levels of [[anterior pituitary]] [[hormones]] in blood
 
|
* Clinical diagnosis 
 
* Most senitive test: Low baseline [[prolactin]] levels w/o response to [[Thyrotropin-releasing hormone|TRH]]
|CT/MRI:
* Sequential changes of pituitary enlargement followed by:
* Shrinkage and [[necrosis]] leading to decreased sellar volume or [[empty sella]]
|
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
![[Lymphocytic hypophysitis]]
|Acute
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* Associated with [[autoimmune]] conditions
 
* Generalized [[headache]]
 
* Retro-orbital or Bitemporal [[pain]]
 
* Mass lesion effect such as [[Visual field defect|visual field defects]]
|
* [[Diabetes insipidus|DI]]
 
* [[Autoimmune]] [[thyroiditis]]
|
* Decreased pituitary hormones([[Gonadotropins]] most common)
 
* [[Hyperprolactinemia]](40%)
 
* [[Growth hormone|GH]] excess
|
* [[Pituitary gland|Pituitary]] [[biopsy]]: [[lymphocytic]] [[Infiltration (medical)|infiltration]]
|
* [[CT]] & [[MRI]]: Features of a [[Pituitary gland|pituitary]] [[mass]]
 
* Diffuse and homogeneous contrast enhancement
|[[Assay|Assays]] for:
* Anti-TPO 
* Anti-Tg Ab
|-
![[Pituitary apoplexy]]
|Acute
|<nowiki>+/-</nowiki>
|<nowiki>++</nowiki>
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|Severe [[headache]]
* [[Nausea and vomiting]]
* Paralysis of eye muscles ([[diplopia]])
* Changes in vision
|
* [[Visual acuity]] defects
 
* [[Cranial nerve palsies|CN palsies]] (nerves III, IV, V , and VI)
 
|
* Decreased levels of [[anterior]] pituitary hormones in blood.
|
* [[Magnetic resonance imaging|MRI]]
|
* [[CT]] scan without [[Contrast medium|contrast]]: Hemorrhag<nowiki/>e on [[CT]] presents as a hyperdense lesion


* [[MRI]]: If inconclusive [[CT]]  
[[Category:Help]]
|
[[Category:Projects]]
[[Blood tests]] may be done to check:
[[Category:Resident survival guide]]
* [[PT]]/[[INR]] and [[aPTT]]
[[Category:Templates]]


* [[Pituitary gland|Pituitary]] [[hormonal]] assay
{{WikiDoc Help Menu}}
|-
{{WikiDoc Sources}}
![[Empty sella syndrome]]
|Chronic
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* [[Erectile dysfunction]]
 
* [[Headache]]
 
* Low [[libido]]
 
|
* Signs of raised [[intracranial pressure]] may be present
 
* [[Nipple discharge|Nipple]] discharge
|
* Decreased levels of  pituitary hormones in blood.
|
* [[MRI]]
|
* [[Empty sella]] containing [[Cerebrospinal fluid|CSF]]
|
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
![[Simmond's Disease|Simmonds' disease]]/[[Pituitary]] [[cachexia]]
|Chronic
|<nowiki>+/-</nowiki>
| +
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* [[Cachexia]]
* [[Premature aging|Premature]] aging
|
* Progressive [[emaciation]]
 
* Loss of body hair
|
* Decreased levels of anterior pituitary hormones in blood.
|
* [[Magnetic resonance imaging|MRI]]
|
* Done to rule out any pituitary cause
|
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
! [[Primary hypothyroidism|Hypothyroidism]]
|Chronic
|<nowiki>+/-</nowiki>
|<nowiki>-</nowiki>
|[[Oligomenorrhea]]/[[menorrhagia]]
|
* Cold intolerance
* [[Constipation]]
|
* Dry skin
 
* [[Bradycardia]]
 
* Hair loss
 
* [[Myxedema]]
 
* Delayed relaxation phase of deep [[Tendon reflex|tendon reflexes]]
|
* Low [[T3]],[[T4]]
 
* Normal/ low [[Thyroid-stimulating hormone|TSH]]
 
* Rest of pituitary hormone levels WNL
|
* [[TSH]] levels
|
* Done to rule out any pituitary cause
|
*Assays for anti-TPO and anti-Tg Ab
*FNA biopsy
|-
![[Hypogonadotropic hypogonadism]]
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* [[Hot flushes]]
 
* Energy and mood changes
 
* Decreased [[libido]]
|
* [[Breast tissue]] [[atrophy]]
* Decreased [[maturation]] of [[vaginal]] [[mucosa]]
|
* Low [[estrogen]], [[testosterone]]
 
* High [[FSH]]/[[Luteinizing hormone|LH]]
|
* [[FSH]]
* [[Luteinizing hormone|LH]]
|
* Done to rule out any pituitary cause
|
* Genetic tests  ([[karyotype]])
* Measurement of total and free [[testosterone]] and [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] concentrations
|-
!Hypoprolactinemia
|Chronic
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|
* [[Infertility]]
* Subfertiliy
|
* Puerperal agalactogenesis
|
* No workup is necessary
|
* Decreased prolactin levels
|
* Done to rule out any pituitary cause
|
* [[Prolactin]] assay in [[3rd trimester]]
 
* [[Luteinizing hormone|LH]], [[Follicle-stimulating hormone|FSH]]
 
* [[Thyrotropin]] and free [[thyroxine]]
|-
![[Panhypopituitarism]]
|Chronic
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* [[Polyuria]]
 
* [[Polydipsia]]
* Features of [[hypothyroidism]] and [[hypoadrenalism]]
|
* [[Growth failure]]
 
* B/L [[hemianopsia]]
 
* [[Papilledema]]
|
* All pituitary hormones decreased
|
* [[Magnetic resonance imaging|MRI]]
|
* Done to rule out any pituitary cause
|
* Left hand and wrist [[radiograph]] for [[bone age]]
|-
![[Primary adrenal insufficiency]]/[[Addison's disease]]
|Chronic
|<nowiki>-</nowiki>
| -
|<nowiki>-</nowiki>
|
* [[Hypoglycemia]]
 
* [[Hypotension]]
|
* [[Dehydration]]
 
* [[Hyperpigmentation]]
 
* loss of [[pubic]] and [[axillary]] hair
 
|
* [[Hyponatremia]] with/without [[hyperkalemia]]
 
* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
|
* Abdominal [[Computed tomography|CT]]
|
* Abdominal [[Computed tomography|CT]]
|
* Serum [[cortisol]] testing
 
* Serum [[ACTH]] testing
 
* Anti-adrenal [[Antibody|Ab]] testing
|-
![[Menopause]]
|Chronic
|<nowiki>-</nowiki>
|<nowiki>+/-</nowiki>
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
* [[Hot flashes]]
* [[Insomnia]]
* [[Weight gain]] and [[bloating]]
* Mood changes
|
* [[Vaginal atrophy]]
* Loss of pelvic [[muscle tone]]
|
* ↑ [[FSH]]
* ↓ [[Estradiol]] and [[inhibin]]
|
* [[FSH]] > [[LH]]
|Normal
|
* [[Endometrial biopsy]]
|}
<small>
 
Hypothyroidism must be differentiated from other causes of headache,polyuria and polydypsia.
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Disease
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Causes
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Symptoms
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Diagnosis and treatment
|- Diagnostic criteria of SIADH include:
 
|[[SIADH]]
|[[SIADH]] is a syndrome characterized by excessive release of [[Vasopressin|antidiuretic hormone]] (ADH or vasopressin) from the [[posterior pituitary]] gland or another source. The result is [[hyponatremia]], and sometimes [[fluid]] overload
|
*[[Nausea]] / [[vomiting]]
*[[Cramps]]
*[[Depressed mood]]
*[[Irritability]]
*[[Confusion]]
*[[ Hallucinations]]
*[[Seizures]], [[stupor]] or [[coma ]]
|
*[[Hyponatremia ]] <135 mmol/l
 
*Effective serum [[osmolality]]<275mosm
 
*Urine [[sodium]] concentration>40mmol/litre
 
*Plasma [[uric acid]] <200;FeUrate>12%
 
*Absence of [[Edematous malnutrition|edematous]] disease like[[ cardiac failure]], [[liver cirrhosis]],[[ nephrotic syndrome]].
 
*Normal [[adrenal]] and [[thyroid]] function
 
|-
|[[Cerebral salt wasting syndrome]]
 
|[[ Cerebral salt wasting syndrome]] is defined as the[[ renal]] loss of [[sodium]] during [[Intracranial Bleeding|intracranial]] [[disease]] leading to [[hyponatremia]] and a decrease in extracellular [[fluid]] volume
 
*[[Trauma]]
*[[Tumor]]
*[[Hematoma]]
 
|The patient is
*[[Hypovolemic]]
*[[Hyponatremia|Hyponatremic]]
 
|Treatment is
*[[Hydration]] and
*[[Sodium]] replacement
|-
|[[Adrenal insufficiency]]
 
|[[Adrenal insufficiency]]
* [[ Mineralocorticoid deficiency]] is present. [[Secondary]] or [[tertiary adrenal insufficiency]] will  have preserved[[ mineralocorticoid]] function owing to  separate feedback mechanisms
Adrenal insufficiency can be
*[[Primary]]
*[[Secondary]]
*[[Tertiary]]
 
Common causes of primary [[adrenal]] insufficiency:
*[[Autoimmune]]
*[[Iatrogenic]]
*[[Drugs]]
* [[Adrenal hemorrhage]]
*[[Cancer]]
*[[Infection]]
*[[Congenital]]
*Secondary [[Adrenal gland|adrenal]] insufficiency: ( [[Aldosterone]]) levels normal
*Most common causes are:
*[[Traumatic brain injury (TBI) ]]
*[[Panhypopituitarism]] 
*Tertiary [[Adrenal gland|adrenal]] insufficiency
*Exogenous[[ steroid]] administration is the most common cause of tertiary [[adrenal]] insufficiency
|
* [[Fatigue]]
*[[ Muscle weakness]]
* [[Loss of appetite]]
*[[ Weight loss]]
* [[Abdominal pain]]
*[[Diarrhea]]
*[[Vomiting]]
 
Chronic disease is characterized by
*[[Weight loss]]
*Sparse [[axillary]] hair
*[[Hyperpigmentation]]
*[[Orthostatic hypotension]].
 
Acute [[addisonian]] crisis is characterized by:
*[[Fever]]
*[[ Hypotension]]
|The diagnosis of [[Addisons]] disease is made through rapid [[ACTH]] administration and measurement of [[cortisol]].
*Lab findings include:
*[[White blood cell]] count with moderate [[neutropenia]]
*[[Lymphocytosis]]
*[[ Eosinophilia]]
*[[Hyperkalemia]]
* [[Hypoglycemia]]
*[[Hyponatremia]]
* Morning low plasma [[cortisol]].
The definitive diagnosis is the [[cosyntropin]] or [[ACTH]] stimulation test. A[[ cortisol]] level is obtained before and after administering [[ACTH]]. A normal person should show a brisk rise in [[cortisol]] level after [[ACTH]] administration.
 
 
Management: The management of [[Addison]] [[disease]] involves:
*[[Gluocorticoid]]
*[[Mineralocorticoid]]
*[[Sodium chloride]] replacement.
[[Adrenal gland|Adrenal]] crisis:
*In adrenal crisis,measure [[cortisol]] level,then rapidly administer
*[[ Fluids]]
*[[ Hydrocortisone]] 
|-
|[[Hypopituitarism]]
| Abnormality in [[anterior pituitary]] function
Etiology is as follows:
*[[Pituitary]] [[tumors]]
*[[Sellar tumors]]
*[[Head trauma]]
*[[Infection]]
*[[Empty sella]]
*[[Infiltration]]
*Idiopathic
*[[Congenital]]
|
[[Signs]] and [[symptoms]] of[[ hypopituitarism]] vary, depending on the deficient
 
[[hormone ]] and severity of the disorder,some of the [[symptoms]] may be as follows:
* [[Fatigue]]
* [[Weight loss]]
* Decreased [[libido]]
* Decreased [[appetite]]
* Facial [[puffiness]]
* [[Anemia]]
* [[Infertility]]
*[[ Cold insensitivity]].
* [[Amenorrha]]
*[[Inability to lactate]] in [[breast feeding]] women
* Decreased [[facial]] or[[ body hair]] in men
* [[Short stature]] in children
|
* [[History]] and[[ physical examination]], including [[visual field]] testing, are important.
 
The [[Treatment-resistant depression|treatment]] of permanent [[hypopituitarism]] consists of replacement of the peripheral [[hormones]]
*[[Hydrocortisone]]
*[[DHEA]]
*[[Thyroxine]]
*[[Testosterone]] or [[oestradiol]]
*[[ Growth hormone]]
*[[Surgery]] and/or
*[[ Radiotherapy]] to restore normal [[endocrine]] function and quality of life
*Life long [[Monitoring competence|monitoring]] of serum [[hormone]] levels and [[symptoms]] of hormone deficiency or excess is needed in these [[patients]]
|-
|[[Hypothyroidism]]
|Hypofunctioning of the thyroid gland due to multifactorial etiology ranging from congenital to [[autoimmune]] causes described below:
*[[Congenital]]
*[[Autoimmune]]
*[[Drugs]]
*Post [[surgery]]
*Post [[radiation]]
*Infiltrative e.g., [[amyloid]]
|
*[[ Fatigue]]
* [[Constipation]]
*[[ Dry skin]]
*[[ Weight gain]]
* [[Cold intolerance]]
*[[ Puffy face]]
*[[ Hoarseness]]
*[[ Muscle weakness]]
* Elevated blood [[cholesterol]] level
* [[Bradycardia]]
*[[ Myopathy]]
*[[ Depression]]
* Impaired [[memory]]
| Diagnosis of [[hypothyroidism]] is based on [[blood]] tests:
*T3([[triiodothyronine]])
*T4([[Thyroxine]]) and
*TSH ([[thyroid]] stimulating hormone).
*Signs and [[symptoms]] are neither [[sensitive]] nor [[specific]] for the [[diagnosis]].
*[[TSH]] is the most [[Sensitive Skin|sensitive]] tool for [[Screening (medicine)|screening]],diagnosis and [[Treatment-resistant depression|treatment]] follow up, when[[ pituitary]] is normal.
*The [[drug]] of choice for treatment is [[Levothyroxine]]
|-
|[[Psychogenic polydipsia]]
| Also called as primary [[polydipsia]] is characterized by[[ polyuria]] and [[polydipsia]]. Causes are:
 
*Adverse effect of a [[medication]]
*Traumatic[[ brain]] injury
*[[Psychiatric]] disorders such as [[schizophrenia]]
* Defect in the [[hypothalamus]]
|
*[[Polyuria]]
*[[Polydipsia]]
*[[Confusion]]
*[[Lethargy]]
*[[Psychosis]]
*[[Seizures]] and
*Sometimes, even death
|Evaluation of[[ psychiatric]] patients with [[polydipsia]] requires an evaluation for other medical causes of polydipsia, [[polyuria]],[[ hyponatremia]], and the syndrome of inappropriate secretion of [[antidiuretic]] hormone.
*The management strategy in[[ psychiatric]] patients should include:
 
*[[Fluid]] restriction and[[ behavioral]] and [[pharmacologic]] modalities.
*The water deprivation test is the [[gold standard]] test
|}
 
==References==
{{reflist|2}}

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