week 9- thyroid and hepatis Flashcards

1
Q

• What is rT3 (reverse T3)?

A

o Usu ↑ in hypothyroidism
o help dx “sick thyroid” pts (who are euthyroid) from true hypothyroid cases
o in a body under stress (illness, fasting, high cortisol) T4 is deiodinized to rT3 instead of T3
o (“step down”, instead of “step up”)= (-) charge in diff spot
o Metabolic enzyme function ↓ → Stresses inhibit 5’-deiodinase → ↓ T4 to T3, ↑ rT3
o Sxs of Wilson’s (temp) syndrome: hypothyroid, ↑rT3, corrected by giving T3 (Not accepted by mainstream)

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2
Q

• What is significance of BBT?

A

o reflects metabolic rate controlled by thyroid hormones
o N = 97.6-98.2 F
o Menstruating females take BBT on d2-4 of menses
o ↓ quite common, may = hypothyroidism
o ↑ BBT less common, may = hyperthyroidism
o Look for other sxs thyroid dz

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3
Q

• What are thyroid antibodies? Risk factors?

A

o =auto-Abs
o Stimulating: a-Thyroid receptor =Thyroid stimulating Igs (TSI)
o Blocking: a-thyroperoxidase (a-TPO); Thyroglobulin (a-TGLB)

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4
Q

• What is Graves dz?

A

o MC cause hyperthyroid (80-85%)
o dt stimulation of TSHRs by TSI, over stimulate thyroid activity
o Abs arise 2nd to defect in T-suppressor cells → clone of T-helper to interact with thyroid Ags → stimulate B cells to make TSI
o a-TPO and a-TGLB often seen

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5
Q

• what are ssx of graves?

A
o	→ sympatho-adrenergic activity and metabolism
o	↓ TSH, ↑ T3/T4
o	Exophthalmos
o	Warm pulsating goiter
o	Tachycardia
o	Fine tremor (hand)
o	Pretibial myxedema
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6
Q

• how is Graves diagnosed?

A

o ↑T3, T4; ↓TSH

o gland non-palpable or smooth symmetric goiter

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7
Q

• Describe fetal thyroid development, and how it’s affected by Graves?

A

o fetus dependent on mom’s T4 until 10-12 wks
o 20 wks, responsive to its own TSH, low thyroid function
o IgG Abs in Graves cross placenta → fetal hyperthyroid after 20 wks gestation
o Antithyroid drugs (methimazole, propylthiouracil) also cross placenta → tx both maternal and fetal hyperthyroid

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8
Q

• What is RAIU (radioactive iodine uptake)?

A

o Scintillation counter measures radioactivity 6 & 24 hrs after I(123) given
o Uptake varies greatly by iodine status: Indigenous diet (normal uptake 10% vs 90%); Amiodarone, Contrast study, Topical betadine

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9
Q

• What causes abnormal RAIU results?

A

o Sx ↑: Graves, Toxic goiter
o Sx ↓: Thyroiditis (Subacute, Active Hashimoto’s), Hormone ingestion (Thyrotoxicosis factitia, Hamburger Thyrotoxicosis); Excess I- intake in Graves’ (Jod-Basedow effect); Ectopic thyroid carcinoma (Struma ovarii)

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10
Q

• What is hashimoto’s thyroiditis?

A
o	MC cause acquired primary hypo
o	mb caused by any environmental trigger
o	F>M,  8:1; Onset usu 30-50 
o	FHx common
o	Early stages may present as hyper
o	Early labs may show normal T4 and TSH, ↑ a-TPO, and less commonly a-Tg
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11
Q

• How is hashimoto’s diagnosed?

A

o RAIU mb ↑ or ↓
o Later: hypo, ↓T4, T3RU, ↑TSH, ↓ RAIU dt gland destruction
o Ab titers much higher in thyroiditis than Grave’s
o Gland mb TTP dt inflammation

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12
Q

• What is Euthyroid sick syndrome?

A

o T4/T3 ↓ in acute & chronic illness (any severe), fasting, starvation, sepsis, surgery, MI, BM transplant
o Abn tests w acute or chronic non-thyroidal systemic illness
o Secondary to:
o ↓ peripheral conversion T4 T3
o ↓ clearance rT3
o ↓ binding T3/T4 to TBG

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13
Q

• What are common causes of ESS w fidnings?

A

o NTI (MC): ↓T3; N TSH, T4; mb dt ↓ T3 →4
o 20% ICU pts: ↓T3/T4; N TSH; mb dt ↓ TBG, albumin
o severe illness: ↓TSH, T3/T4; HTH and Pit involved
o cirrhosis, hepatitis, acute psych: ↑ T4; TSH & T3 N or ↑

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14
Q

• what are screening recommendations for thyroid dz in adults?

A

o USPSTF: say insufficient evidence for or against routine screening
o AAFP: high-risk populations: F w FHx thyroid dz, F >35, prego, abd PE, DM, AI Hx
o ATA: start at a 35 (+ q5 yrs)

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15
Q

• What are some good and not-so-good indications to screen for hypothyroid?

A

o High suspicion: goiter, delayed reflexes
o Intermediate: Fatigue, wt gain/difficulty losing wt, Cold intolerance, Dry, rough, pale skin, Constipation, FHx, Hoarseness
o Low, non-specific sxs: Coarse, dry hair, Hair loss, Muscle cramps/aches, Depression, Irritability, Memory loss, Abn menstrual cycles, ↓ libido

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16
Q

• What are some good and not-so-good indications to screen for hyperthyroid?

A

o High: goiter, thyroid bruit, lid lag, proptosis
o Med: Fatigue, Wt loss despite ↑appetite, Heat intolerance/sweating, Fine tremor, FHx, ↑BMs, ↑HR/palpitations, Staring gaze
o Low: Nervousness, Insomnia, Breathlessness, Light or absent menstrual periods, Wt loss, Muscle weakness, Warm moist skin, Hair loss

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17
Q

• What is recommended prenatal thyroid screening?

A

o Universal screening before preg not recommended
o Prenatal serum TSH testing is recommended if high risk or known thyroid dysfunction
o Non-Consensus on TSH screening for all prego vs high-risk at time of first visit or by 9th wk

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18
Q

• What is neonatal thyroid screening for congenital hypothyroid?

A

o All infants screened at 2-4 d
o congenital hypo usu unaffected at birth, dt placental transfer of T4; but must get tx by 2-3wks
o otherwise → mental retardation
o if mom is hypo, significant impairment of neurointellectual development despite early tx
o 3 screening strategies: (1) primary TSH, backup T4 in infants w ↑ TSH, (2) primary T4, backup TSH w ↓T4, (3) both T4 and TSH (IDEAL)

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19
Q
  • Total T4: ↑
  • T3RU: ↑
  • FTI: ↑
  • TSH: ↓
  • FT4: ↑
  • Total T3: ↑
A

o Primary hyper

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20
Q
  • Total T4: ↓
  • T3RU: ↓
  • FTI: ↓
  • TSH: ↑
  • FT4: ↓
  • Total T3: ↓/N
A

o Primary hypo

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21
Q
  • Total T4: ↑
  • T3RU: ↓
  • FTI: N
  • TSH: N
  • FT4: N
  • Total T3: N
A

pregnancy

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22
Q

• What is viral hepatitis?

A

o 5 viruses, A-E
o affinity for hepatocyte, induce liver injury, usu immune-mediated mechanism
o Diff physical,chemical composition, mechanisms to replicate within infected cells

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23
Q

• Hx of viral hepatitis?

A

o Contagious jaundice, 8th century, Pope Zacharias ordered isolation of affected
o Virchow, 1865, epidemic jaundice dt mucous plug in the papilla of Vater
o early 20th century linking vaccination, blood drawing, blood transfusion and parenteral tx of syphilitic pts w contaminated needles, development of “serum hepatitis”
o WW II, >200,000 cases of jaundice in american, >5 million cases in germans
o MacCallum 1940’s, suggested both enteric (“infectious hepatitis”, “hepatitis A”) and parenteral/sexual (“serum hepatitis”, “hepatitis B”) transmission could occur
o mid-20th century, “A & B” had diff clinical courses, suggesting different etiologies

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24
Q

• What was the Willowbrook state school’s role in elucidating hepatitis viruses?

A

o 1950s and 60s: 1000s of intellectually disabled children, mostly w trisomy 21 →jaundice freq, ↑ LFTs; Newly admitted children exposed to infectious material, w parental consent → criticism
o found diff filterable infx agents caused 2 clinical patterns of hepatitis
o One inoculum of serum (MS1, initials of infected child) → illness, short inc, like epidemic hepatitis (A)
o Another, MS2 (same child who later developed the 2nd form of jaundice) →illness, longer inc, like B
o Boggs used MS1 in Marmoset monkeys (1967), Humans incarcerated at Joliet State Penitentiary (US Army 1970)

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25
• How was hepatitis B discovered?
o 1963, Dr. Baruch Blumberg (nobel prize 1976), identified a protein (“Australia Ag” reacted to Abs from pts w hemophilia and leukemia o Assoc w infx hepatitis 1966 o virus specifically seen by electron microscopy in 1970
26
• how was hepatitis A discovered?
o 1973, NIH, in fecal samples from ppl inoculated w MS1 serum from Willowbrook o Electron microscopy: 27 nm spherical viral particles, aggregates after incubation of fecal samples w convalescent serum o successfully adapted to grow in culture by end of 1970’s
27
• how was hepatitis D discovered?
o 1977, Rizetto in Turin, identitied new Ag in both liver and serum in carriers of HBsAg o HDV= defective virus, genome is negative circular ssRNA, encodes single nucleocapsid protein (delta Ag) o To replicate, Requires envelope of HBV w HBsAg
28
• How was hepatitis C discovered?
o End of 1970’s, found most cases of post-transfusion hepatitis were not dt A, B, D (20% dt cardiac surgery w blood transfusion) o known as non-A, non-B hepatitis (NANBH) o identified by Houghton, 1989, Chiron Corporation o Retrospective testing showed 90% of non-A, non-B hepatitis was HVC
29
• What is hepatitis E?
o epidemic waterborne, similar to A o first recognized in India in 1980 o Causative agent identified in Uzbekistan in 1983 o Genome cloned in 1990 and fully sequenced shortly after
30
• What are “infectious” and “serum” viral hepatitis? NANB?
o Infectious: became known as HAV o Serum: B, D o NANB: E (enterically transmitted), C (parenterally transmitted), F, G?
31
• What are sources of virus for the 5 hep viruses? Route of transmission?
o A, E: feces o B, C, D: blood/blood-derived body fluids o A, E: fecal, oral o B, C, D: percutaneous, permucosal
32
• Which of the 5 hep viruses can be chronic infx? How are they prevented?
o Chronic: B, C, D o A, B: pre/post-exposure immunization o C: blood donor-screening; risk behavior modification o D: pre/post-exposure immunization; risk behavior modification o E: ensure safe drinking water
33
• What is the hepatitis A virus?
o Naked RNA virus o Related to enteroviruses, formerly known as enterovirus 72, now put in its own family: heptovirus o One stable serotype only o Difficult to culture: primary marmoset cell culture, also in vivo in chimpanzees and marmosets o 4 genotypes exist, but in practice most of them are group 1
34
• How is hepatitis A spread?
o Close personal contact household, sexual, day care) o Contaminated food, water (infx food handlers, raw shellfish) o Blood exposure (rare) ( IV drugs, transfusion)
35
• What is the geographic distribution of HABV infx?
o High: S and Central America, Africa, Greenland, Middle East, South Asia o Med: S and E Europe, North Eurasia o Low: N America, Australia o Very low: N Europe
36
• What are clinical features of hepatitis A?
o Inc: avg 30 d (r 15-50) o Jaundice: 10% < 6, 40-50% 6-14, 70-80% > 14 o Comp: fulminant, cholestatic, relapsing hepatitis o Chronic sequelae: none
37
• How is HAV diagnosed?
o Acute: serum HAV-IgM by EIA o Immunity: HAV-IgG by EIA. o Cell culture: difficult, up to 4 wks, not routine o Direct Detection: EM, RT-PCR of feces. detect earlier than serology but rarely done
38
• What is the typical serological course of hepatitis A?
o Fecal HAV peaks @ 1-3 mos (correlated w sxs) o ↑ ALT 1-3 mos? o IgM a-HAV present 1-5 mos o Total a-HAV plateaus after 1 ye (IgG)
39
• What does CDC say about HAV prevention?
``` o Vaccine is primary o 2006: Universal infant vaccination o 1996, Adults w ↑ risk infx or its adverse consequences: o Traveler to HAV endemic country o MSM o Illegal drugs o chronic liver dz o clotting factor dos ```
40
• what is the hepatitis B virus?
o dsDNA virus (+ strand not complete) o Replication involves a reverse transcriptase o Complete Dane particle 42 nm, 28 nm electron dense core, w HBcAg and HBeAg. coat and 22 nm free particles contain HBsAg o At least 4 phenotypes of HBsAg: adw, adr, ayw and ayr. o HBcAg is single serotype o HBV has 8 genotypes (A-H): A and C predominate in US, B and D also present. Genotype F in S America and Alaska. A, D, E in Africa. D in Russia (USSR), B and C in Asia o Can’t culture
41
• What are the relative concentrations of HBV in diff body fluids?
o High: blood, serum, wound exudates o Mod: semen, vaginal fluid, saliva o Low/not detectable: urine, feces, sweat, tears, breast milk
42
• What is the geographic distribution of chronic HBV infection?
o High: Alaska, N Canada, S Greenland, N Brazil, Africa, Asia o Med: Brazil, N Africa, E Europe, Middle East o Low: N America, Argentina, N Greenland, N Europe, Australia
43
• Describe the structure of the hepatitis viruses:
o A: ssRNA → capsid o B: (elongated or spherical) dsDNA (partial ss) →HBeAg →HBcAg →nucleocapsid →envelope (lipid from host cell) → HBsAg o C: ssRNA →nucleocapsid →envelope → glycoproteins o D: tiny ssRNA → small and large delta Ag → HBsAg o E: ssRNA → unenveloped, 32-34nM
44
• What are clinical features of hepatitis B?
``` o Inc: avg 60-90 d (r 45-180) o Jaundice: 10% < 5, 30-50% > 5 o Acute fatalitiy: 0.5-1% o Chronic: 30-90% < 5, 2-10% > 5 o mortality dt chronic liver dz: 15-25% ```
45
• what is typical serologic course of acute HBV w/o chronic progression?
``` o HBsAG 4-24 wks (correlated w sxs) o IgM a-HBc 6-32 wks o a-HBs after 32 wks o HbeAg: 4-12 wks o a-HBe: after 12 wks o total a-HBc plateaus at 16 wks ```
46
• what is typical serologic course of chronic HBV?
``` o HBsAg plateaus at 12 wks o Total a-HBc plateaus at 16 wks o IgM a-HBc 6-36 wks o HBeAg: 6wks – yrs o a-HBe mb seen yrs later ```
47
• how is hepatitis B diagnosed?
o HBsAg: general marker of infx o HBsAb: document recovery/immunity o a-HBc IgM: marker of acute o a-HBc IgG: past or chronic o HBeAg: indicates active replication = infectiveness o a-Hbe: virus no longer replicating. Mb (+) for HBsAg, made by integrated HBV o HBV-DNA: indicates active replication, more accurate than HBeAg esp in cases of escape mutants. monitoring response to tx
48
* HBsAG: (-) * Total a-HBc: (-) * IgM a-HBc: (-) * a-HBs: (-)
o never infected
49
* HBsAG: (+) * Total a-HBc: (-) * IgM a-HBc: (-) * a-HBs: (-)
o early acute, or transient after vaccine
50
* HBsAG: (+) * Total a-HBc: (+) * IgM a-HBc: (+) * a-HBs: (-)
o acute
51
* HBsAG: (-) * Total a-HBc: (+) * IgM a-HBc: (+) * a-HBs: (-)
o acute resolving
52
* HBsAG: (-) * Total a-HBc: (+) * IgM a-HBc: (-) * a-HBs: (+)
o recovered from past infx and immune
53
* HBsAG: (+) * Total a-HBc: (+) * IgM a-HBc: (-) * a-HBs: (-)
o chronic infx
54
* HBsAG: (-) * Total a-HBc: (-) * IgM a-HBc: (-) * a-HBs: (+)
o vaccine immunity
55
• what are possible outcomes HBV infx?
o Acute o → chronic: 3-5% of adult-acquired, 95% infant-acquired o → chronic hepatitis: 12-25% in 5 yrs o HCC 6-15% in 5 yrs → death or transplant o Liver failure, 20-23% in 5 yrs → death or transplant
56
• What is HBV infx?
o >200 million carriers worldwide o Established cause of chronic hepatitis and cirrhosis o Human carcinogen: cause up to 80% HCC
57
• Who gets chronic HBV dz?
o Rule of thumb, the younger the age, the more likely to become chronic o Neonates: 95% chronic, most asx o Infant-6 yrs: 30% chronic o >6: 3-5% chronic
58
• What is HBV perinatal transmission?
o *in the absence of postexposure prophylaxis o If mother (+) HBsAg and HBeAg: 70%-90% of infants infx → 90% become chronic o If (+) HBsAg only: 20% of infants infected → 90% become chronic
59
• What is the strategy to eliminate HBV transmission?
o (Advisory Committee on Immunization Practices CDC) o Prevent perinatal HBV transmission o Universal infant vaccination o Catch-up vaccination of all children and adolescents <19 years o Vaccination of adults in high risk groups
60
• What is the HDV?
o delta agent = defective virus, like viroids in plants o 35 nm particle w delta antigen surrounded by outer coat of HBsAg o tiny ssRNA genome
61
• what are clinical features of HDV infx (w HBV)? How is it spread?
o Co-infection: severe acute dz, low risk chronic o Super-infection: usu chronic, high risk severe chronic liver dz, may present as acute o Spread: percutaneous exposure (IV drugs), per-mucosal (sex)
62
• What is the typical serologic course of HBV-HDV co-infx?
o Weeks after exposure: HBsAg, HDV RNA, IgM-HDV (+total) peak then drop (assoc w sxs, ↑ ALT) o anti-HBs then rises and plateaus
63
• what is typical serologic course of HBV-HDV superinfx?
``` o Similar to co-infx o Esp jaundice as sx o HDV RNA and HBsAg persist o total a-HDV persists (IgM never disappears, IgG rises and plateaus) o ALT oscillates ```
64
• What are sequelae of HBV-HDV infxs?
``` o Co (in healthy ppl): 3-4% fulminant, death; 90% recovery w immunity; rare chronic HBV/HDV hepatitis, cirrhosis o Super (HBV carrier): 7-10% fulminant, death; 10-15% acute, severe, recovery; 80% chronic HBV/HDV, cirrhosis ```
65
• What is geographic distribution of HDV infx?
o High: brazil, some Africa, some Europe o Med: some Africa, middle east o Low: N America, argentina, some Africa, Europe, india, Australia o Very low: Alaska, brazil, South Africa, china o Lots of “no data”
66
• What are recommendations for HDV prevention?
o Co: Pre or post-exposure prophylaxis to prevent HBV | o Super: Education to reduce risk behaviors in chronic HBV pts
67
• What is the HCV?
o Genome like a flavivirus, (+) ssRNA, 10,000 bases, enveloped, 30-60nm o 1 single reading frame, structural genes at 5' end, non-structural genes at 3' end o morphological structure remains unknown o 6 genotypes (1-6) on basis of phylogenetic analysis o 1 and 4 have poorer px and response to interferon tx o In Hong Kong, 1 is 67%, 6 is 25%
68
• How does HCV infect a cell?
o Binds receptor (also for LDL and VLDL) o Enters in endosome → uncoated → genome replicated in cytoplasm o → translated and produced in ER → golgi → combo w genome o → exocytosis
69
• What is geographic prevalence of HCV in blood donors?
o High (>5%): N African country o Med: N Asia, brazil o Low: N America, argentina, china, australia, S Africa, W Europe o Very low: N Europe
70
• What are risk factors assoc w HCV transmission?
o Transfusion or transplant from infx donor o IV drugs o Hemodialysis (yrs of tx) o needles/sharps accidents o Sex/household exposure to anti-HCV-positive contact o Multiple sex partners o Birth of HCV-infx mother
71
• What are clinical features of HCV?
``` o spectrum similar to chronic HBV, but w lower freq o Inc: avg 6-7 wks (r 2-26 wks) o Jaundice: r 20-40% o Chronic hepatitis: 70-85% o Persistent infx: 85-100% o Cirrhosis: 17% o HCC: 2% o Immunity: no known protective Ab response ```
72
• what is typical serologic course of chronic HCV?
o ↑ALT (correlate w sxs) 1-5 mos, then oscillates for years | o a-HCV rises and plateaus at 1 yr
73
• how is HCV infx diagnosed?
o 1) a-HCV: Not useful in acute phase, appears after 4 wks o 2) HCV-RNA (qual or quant): via PCR and branched DNA. Mb dx in acute phase. Mainly to monitor response to antiviral tx o HCV-Ag: EIA. Easiest for monitoring
74
• What are prognostic tests for HCV infx?
o Genotyping: 1 & 4 have worse px, respond poorly to interferon tx (DNA sequencing, PCR-hybridization e.g. INNO-LIPA.) o Serotyping: useful when no detectable RNA o Viral Load: ↑ → poorer px; also monitor IFN tx
75
• What is prevalence of a-HCV in US? Screening?
o Overall: 1.6% o M>>F, esp born 1945-65 o 76% of infected ppl are baby boomers → birth cohort screening by CDC o Also higher in blacks
76
• What is CDCs Hep C prevention strategy?
o Prevent new infxs: Risk-reduction education and awareness; Review and update infx control practices; Screen and test donors; Virus inactivation of plasma-derived products o Reduce risk of liver dz w chronic: Identify and test persons at risk for HCV infx, Counseling, medical evaluation, management of infected ppl
77
• What is HEV?
o Calicivirus-like viruses o Unenveloped RNA virus, 32-34nm in diameter o Single stranded RNA genome, 7.6 kb in size. o Very labile and sensitive o Can only be cultured recently
78
• What are clinical features of HepE infx?
o Inc: avg 40 d (r 15-60) o Fatality: 1-3% (if prego: 15-25%) o Illness severity: ↑ w age o Chronic sequelae: none
79
• What is typical serologic course f HEV infx?
o Feval HEV, ALT, IgM-HEV 3-10 wks (correlate w sxs) | o IgG-HEV rises at 3 wks, plateaus at 10 wks
80
• What are epidemiologic features of HEV?
o outbreaks usu assoc w fecal in water o Several large epidemics in India, USSR, China, Africa, Mexico o US and other nonendemic areas, no documented outbreaks, low prevalence of a-HEV (<2%) → unknown source of infx o Minimal person-to-person transmission
81
• What are prevention and control measures for travelers to HEV-endemic regions?
o Avoid drinking water (and beverages w ice) of unknown purity, uncooked shellfish, uncooked fruit/vegetables not peeled or prepared by self o Igs prepared from donors in Western countries does not prevent infx o Unknown efficacy of Ig prepared from donors in endemic areas