2. Thyroid gland produces two principal
hormones … thyroxine & tri iodo
thyronine which regulate the metabolic rate of
the body.
Iodine is essential for the synthesis of thyroid
hormones
More than half of the body’s total content is
found in the thyroid gland
3.
4.
5.
6.
7.
8.
9.
10. Hypothalamo pituitary axis
The hypothalamo-pituitary
axis is a classical
negative feedback
regulatory mechanism in
which secretion of TSH
is modulated by thyroid
hormones. Release of
TSH from the pituitary
gland is stimulated by
thyrotropin releasing
hormone (TRH) from the
hypothalamus.
11. Hypothalamo pituitary axis
A small increase in T3
and T4 produces a
diminished TSH
response to TRH at the
pituitary level.
T3 and T4 act at the
hypothalamic level by
inhibiting mRNA for TRH
synthesis.
Only unbound fractions
of hormone are
metabolically active and
only this free hormone
has an inhibitory effect
on the secretory activity
of the thyroid.
dopamine
physiologically inhibits
TSH secretion
glucocorticoids have
been shown to dull the
response of the
pituitary to TRH
oestrogens increase
the sensitivity of
thyrotrophs to TRH
18. High T3 or T4 gives
decreased TSH
subunit synthesis
inactive
thyrotrophs may
lose the capacity
to respond to
reduced T3 or T4
levels
19. inhibits TSH release
potentiates the
effect of thyroid
hormones on
thyrotrophs, ie
thyroid hormone has
inhibitory effects on
TSH release
derives from the
median eminence of
the hypothalamus
thyrotropin
releasing
hormone, ie
stimulates TSH
release
somatostatin TRH
21. cretinism
- congential absence of T3 and T4 or
chronic iodine deficiency during childhood
- retarded growth
- sluggish movements
- mental deficiencies
22. myxedema
- low rate of metabolism and lethargy
- decreased body temp
- decreased heart rate
- outer skin becomes scaley
- myxodema – swelling of sub-cu connective
tissues
27. Thyroid function in pregnancy
Four factors alter thyroid function in pregnancy
Transient increase in hcG during first trimester
which stimulates TSH-R
The estrogen induced rise in TBG during the
first trimester which is sustained during
pregnancy
Alterations in the immune system ,leading to
onset, exacerbation ,or amelioration of an
underlying auto immune thyroid disease
Increased urinary iodide excretion ,which can
cause impaired thyroid hormone production
28. Iodine supplementation is considered to be
important in women with precarious iodine
intake
Maternal hypothyroidism occurs in 2 to 3% of
women of child bearing age & is associated
with increased risk of developmental delay in
the offspring
Thyroid hormone requirements are increased
by 25 to 50µg/day during pregnancy
30. Thyroid function tests
Estimation of thyroid
hormones
Total T4
Total T3
Estimation of free
hormone fraction
Free T4 fraction
%FT4
Free T3 fraction
%FT3
THBR
Estimates of free
hormone
concentration
FT4E (T4 X %FT4)
FT3E (T3 X % FT3)
FT4I (T4 X THBR)
FT3I (T3 X THBR)
T4: TBG ratio
31. Thyroid function tests
Serum binding
proteins
Thyroxine binding
globulin
Thyroxine binding
prealbumin
Tests for auto immune
thyroid disease
Anti thyroglobulin
Abs
Anti TPO antibodies
TSH receptor anti
bodies
Other hormones &
thyroid related
proteins
TRH
Thyroglobulin
calcitonin
32. Measurement of T4,T3 &rT3
METHOD
Immunoassay
Chemiluminiscence
The major clinical role for T3 measurements are in
the diagnosis & monitoring of hyperthyroid pts
with suppressed TSH &normal FT4
r T3 test is not always elevated with illness.It is
seldom used in pts with euthyroid sick syndrome
Specifially,renal failure is associated with low r T3
conc.
35. Determination of free thyroid
hormones
Direct assays – currently serve as reference
methods
Indirect assays - more widely available for
general laboratory use
36. Direct methods
Direct measurement of FT4&FT3 is a technical
challenge as free hormone conc. are low in serum
healthy individuals
Assays for free thyroid hormones must be capable of
measuring sub picomole amounts
Only minimal dilution of serum specimens is allowed
as dilution alters the binding of drugs, FFAs and
other substances to serum proteins
37. Methods
Equilibrium dialysis
Ultra filtration techniques
these techniques physically separate free hormone
from protein bound hormone (before direct
measurement of the free fraction with a sensitive T4
or T3 immunoassay)
These methods are unaffected by variations in SBPs
or thyroid hormone auto antibodies
38. Indirect methods
More convenient & less expensive than direct
methods
Automated immuno assay instuments
Two step immunoassay
One step immunoassay
These methods estimate free hormone conc.
by using antibody extraction techniques
39. FT4 is 0.03% of total serum T4
FT3 is 0.3% of total serum T3
Because T3 is less firmly bound by TBG than is
T4 the dialyzable fraction of T3 is appreciably
greater (by almost 10 times) than that of T4
40. Free hormone estimates
FT4E = total T4 X %FT4
The free hormone fraction as measured
dialysis or ultra filtration of diluted serum
containing tracer T4 or t3 is multiplied by the
respective total hormone concentration to
obtain indirect estimates
THBR = %uptake(patient serum)/% uptake
(reference serum)
41. Invitro I –T3resin uptake by Resin
A known amount of I-T3 is added to a standard
volume of serum from a patient
The amount of I-T3 which binds to the serum
proteins varies inversely with the endogenous
thyroid hormones already bound to serum
proteins(TBG)
Residual free I-T3 then adsorbed by resin is
removed from the sample and then adsorbed/bound
I is measured
42. FT4 index
Unlike direct free T4 methods , index methods
measure both the serum total T4 & the free T4
fraction
They have an advtantage that they can define
whether an abnormal FT4 estimate is due to
abnormal hormone production or due to abnormal
protein binding
An FT4 index is sometimes directly calculated
using the percentage T-uptake
FT4I =total T4(µg/dl) x % thyroid uptake/ 100
43.
44. Plasma TSH
Method- Immunoassay
-chemiluminiscence
Secretion of TSH occurs in a circadian fashion
Primary Hypothyroidism-TSH increased
Secondary hypothyroidism-TSH ,T3 ,T4 are low
Primary hyper thyroidism –TSH decreased
Secondary hyperthyroidism-TSH,T3,T4 high
45. TSH stimulation test
Measurement of serum T4 after TSH injection
No response - primary
Increase of T4- secondary
Useful for distinguishing primary from
secondary hypothyroidism
46. TRH response test
TRH administration will stimulate the
production of TSH
Useful for differentiating hypothalamic from a
pituitary hypotyroidism
There is increase of TSH after TRH in
hypothalamic disorder
47. If the hypothalamo pituitary axis is normal .the
T3 and T4 secretions will be increased
An abnormal response is seen in
Hyperthyroidism – T4 elevated
Hypopituitarism- T4 Levels subnormal
Primary hypothyroidism-exaggerated response
48.
49.
50. Determination of thyroid binding
globulin
TBG is the thyroid binding globulin with the
greatest affinity for T4
TBG is very important for regulating the conc. And
availability of the FT4 hormone.
Method - immunoassay
- commercial kit methods available
- chemiluminiscence
Estrogen induced TBG excess and congenital
TBG deficiency are important abnormalities that
affect the test results
51. Calculation of T4:TBG & T3:TBG
ratios
These ratios correlate with FT4 or FT3 conc.
And are particularly useful in sera with altered
TBG conc.
failures:They may fail however to compensate
for TBG variants with reduced T4 affinity & for
abnormal albumin binding
Ref . Interval is 3.8 to 4.5
52. Determination of thyroglobulin
Method –immunometric assay method
These assays are based on the use of two or
more monoclonal antibodies directed to
different portions of the Tg molecule
Difficulty: interference with anti-Tg antibodies
as seen in pts with thyroid cancer
Heterophilic antibody interference(HAMA)
Ref interval is 3 to 42 μg/dl
53. Thyroglobulin is used primarily as tumor marker in
pts carrying a diagnosis of differentiated thyroid
carcinoma
Tg levels are elevated in
Thyroid follicular &papillary carcinoma
Certain non neoplastic conditions like..,
Thyroid adenoma
Subacute thyroiditis
hashimoto’s thyroiditis
Grave’s disease
54. Serum Tg conc. are
not increased in pts
with medullary thyroid
carcinoma
Serial measurements
of Tg is most useful in
detecting recurrence
of diff. thyroid
carcinoma following
surgical resection
Tg determination is
used as an adjunct to
ultrasound and radio
iodine scanning
Assessment of serum
Tg also aids in
management of
infants with congenital
hypo thyroidism
In hyperthyroidism-Tg
Low conc.-
thyrotoxicosis factita
55. Determination of antithyroid
antibodies
Anti thyroid antiodies are found in autoimmune
diseases and certain malignancies
These autoantibodies are directed against
several thyroid and thyroid hormone antigens
Tg (Tg Ab)
Thyroid peroxidase(TPO Ab)
Thyroid receptor(TR Ab)
TSH,T4,T3
56. The presence of TPO antibodies is a risk
factor for autoimmune thyroid dysfunction
However there is a high prevalence of anti-
TPO antibodies in the elderly
With sensitive assays,low conc of TPO
antibodies may be detected in some healthy
individuals—they may have occult or
subclinical thyroid dysfunction
57. Method
RIA
CHEMILUMINISCENCE based immunometry
Radioimmunometric technique
Reference value is ≤2U/ml(with sensitive
chemiluminiscence assay)
Detectable conc. Of TPO Ab are seen in
hashimoto’s thyroiditis,idiopathic myxedema,
grave’s disease, Type 1 IDDM
58. Determination of thyrotropin
receptor antibodies
Thyrotropin receptor antibodies are a group of related
immunoglobulins that bind to TSH receptors
Seen in pts with Graves disease & other auto immune
thyroid disorders
These Ab s demonstrate substantial heterogeneity
Some cause thyroid stimulation , where as others
have no effect or decrease thyroid secretion by
blocking the action of TSH
59. Invitro bioassays assess the capacity of
immunoglobulins to stimulate functional activity of
thyroid gland such as..,
1.adenylatecyclase stimulation
2. c AMP formation
3.colloid mobilization
4.iodothyronine release
TSI s are present in 95% of pts with untreated
Grave’s disease
TSI measurement is also used for following the
course of therapy & predicting relapse & remission
61. calcitonin
Calcitonin is secreted by the para follicular or
C cells ,which arise from the neural crest & are
distributed through out the thyroid gland
A marker for medullary thyroid carcinoma
(tumor of C cells)
Ref range ≤ 25pg/m L in men and ≤20 pg/m L
62. Normal ranges
T3 :120-190 ng/dl
r T3 : 10-25 ng/dl
T4 : 5-12 µg/dl
Thyroglobulin:3-5 µg/dl
TRH :5-60 ng/L
TSH :0.5-5 µU/ L
Thyroxine binding globulin :1-2 mg/dl