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Otterbein University Digital Commons @ Otterbein

Nursing Student Class Projects (Formerly MSN) Student Research & Creative Work

Summer 2015

Hashimoto’s Disease: The Underactive Disease

Patty Anderson Otterbein University, [email protected]

Follow this and additional works at: https://digitalcommons.otterbein.edu/stu_msn

Part of the Diseases Commons, Medical Pathology Commons, and the Nursing Commons

Recommended Citation Anderson, Patty, "Hashimoto’s Disease: The Underactive " (2015). Nursing Student Class Projects (Formerly MSN). 121. https://digitalcommons.otterbein.edu/stu_msn/121

This Project is brought to you for free and open access by the Student Research & Creative Work at Digital Commons @ Otterbein. It has been accepted for inclusion in Nursing Student Class Projects (Formerly MSN) by an authorized administrator of Digital Commons @ Otterbein. For more information, please contact [email protected]. Hashimoto’s Disease: The Underactive Thyroid Disease Patty Anderson, RN, BSN Otterbein University, Westerville, Ohio

Introduction Pathophysiological Process and Significance Nursing Implications References Cited The thyroid gland is part of the HT is caused by an overt autoimmune Since HT and hypothyroidism can present itself in a variety of endocrine system and has a response causing thyroid gland Since the thyroid gland regulates the entire metabolism, the Caturegli, P., DeRemigis, A., Chuang, K., Dembele, M., Iwama, ways and level of severity, the most important factor is an widespread function that controls destruction. Loss of immune tolerance thyroid gland indirectly affects every cell, tissue, and organ in A., & Iwama, S. (2013). Hashimoto’s : accurate recognition and diagnosis. Diagnosing should always multiple organ systems and (lack of regulatory T-cells) to normal the body – from muscles, bones, and skin to the digestive Celebrating the centennial through the lens of the Johns begin with a thorough physical exam and obtaining a complete processes. The main function of thyroid cells leads to the production of tract, heart, and brain. Since the thyroid gland is a Hopkins hospital surgical pathology records. American medical history. Taking time to interview the patient and truly the thyroid gland is to produce antibodies directed against thyroid tissue, multisystem functioning gland, there are a wide variety of Thyroid Association, 23(2), 142-150. hear what is being said is crucial. In addition, focusing on one and secrete two different thyroid which causes destruction of the thyroid signs and symptoms that may be present with Hashimoto’s http://dx.doi.org/10.1089/thy.2012.0554 symptom will prevent a healthcare provider from accurately : (T3) gland. This destruction inhibits the release disease and/or any form of hypothyroidism. Regardless of Chiasera, J. M. (2013). Back to the basics: Thyroid gland diagnosing someone with HT. The healthcare provider needs to and thyroxine (T4), both of which of necessary for the which type of hypothyroidism a person may have, the possible structure, function and pathology. Clinical Laboratory be well educated about hypothyroidism and its presenting help to meet the metabolic metabolic processes. signs and symptoms will be the same. Initially, Science, 26(2), 112-117. symptoms. Again, HT and/or hypothyroidism can easily be demands of the entire body. The disease begins with an activated hypothyroidism may present itself in a subclinical manner Davies, T. F. (2015). Pathogenesis of hashimoto’s thyroiditis mistaken for other medical problems due the thyroid gland being When the thyroid gland fails to inflammatory process when an individual (mild and without symptoms), but as the disease progresses (chronic ). Retrieved from a multisystem gland, which is why it is so important for healthcare produce T3/T4 hormones is genetically (familial) and the symptoms become more apparent (NIH, 2013). www.uptodate.com/contents/pathogenesis-of- providers to be well educated about this disease. (primary gland failure) or is not environmentally ( diet, toxins, viral Signs and symptoms that can be seen in someone with a hashimotos-thyroiditis-chronic-autoimmune-thryoiditis When the physical exam and medical history is complete and activated successfully by the infect) predisposed for HT. This hypothyroid disease are: , , dry skin, Gaitonde, D. Y., Rowley, K. D., & Sweeney, L. B. (2012, August hypothyroidism or HT is suspected, diagnostic lab work must be (by the release of inflammatory process initiates the increased sensitivity to cold, muscle weakness, or 1). Hypothyroidism: An update. American Family obtained to confirm the diagnosis. Lab work usually begins with a thyroid stimulating accumulation of the human leukocyte stiffness, coarse brittle thinning hair, brittle nails, hoarse Physician, 86(3), 244-251. Retrieved from TSH level. Normally, a TSH level above normal is indicative of (TSH)), or , this antigen (HLA) Class II antigen-presenting voice, unintentional , , menstrual http://www.aafp.org/afp/2012/0801/p244.html hypothyroidism. In addition, a T4 level should be obtained and results in low levels of circulating cells (APC) into the thyroid gland. HLA irregularities; heavy and excessive bleeding. Physical exam Glick, A. B., Wodzinski, A., Fu, P., Levine, A. D., & Wald, D. N. will be lower than normal with hypothyroidism. Although most thyroid hormone. As low levels of Class II is a set of molecules found on findings that may also be seen are: , goiter, (2013). Impairment of regulatory t-cell function in persons with HT will eventually develop hypothyroidism due to the circulating thyroid hormones antigen-presenting cells such as dendritic diastolic , cognitive impairment, delayed deep autoimmune thyroid disease. American Thyroid the destruction of the thyroid gland, the TSH and T4 may present continue, an overall slowing of the cells and subclasses of macrophages. HLAs tendon reflexes, , altered laboratory results: elevated Association, 23(7), 871-878. normally since hypothyroidism has not occurred at this time. For person’s metabolism occurs. This present antigens from outside of the cell to TSH, decreased Free T4, normal or sometimes decreased Total http://dx.doi.org/10.1089/thy.2012.0514 a definitive diagnosis of HT, a person must test positive for serum underactive thyroid disease is T-lymphocytes. This stimulates the or Free T3, , , and elevated Hampton, J. (2013). Thyroid gland disorder emergencies: antithyroid antibodies. This test confirms the presence of called hypothyroidism (Chiasera, multiplication of T-helper cells. T-helper , Hashimoto’s specific: Elevated serum and coma. AACN Advanced that mistakenly attack the thyroid tissue. A 2013). cells then stimulates B-cells to produce concentrations of TPO autoantibodies (Ross, 2015). Critical Care, 24(3), 325-332. computerized tomography (CT) scan may also be performed to Although there are several antibodies to the specific antigen. When In general, these symptoms are due to the decreased http://dx.doi.org/10.1097/NCI.0b013e31829bb8c3 assess the thyroid gland for size, texture, nodules, and/or causes for hypothyroidism, there is an accumulation of HLA Class II production of thyroid hormone. Most of the symptoms are Mendes, A. (2015). Recognizing hypothyroidism in the inflammation (NIH, 2013). Hashimoto’s Thyroiditis (HT) is molecules in the thyroid gland, this causes not manifested in the early stages of the disease, but as the community: What can nurses and patients do? British Treatment for HT depends upon goiter activity and/or if the most common cause of damage to thyrocytes and causes the disease progresses, the degree of the disease along with Journal Community Nursing, 20(4), 200-202. hypothyroidism is present. If a person with HT does not have hypothyroidism in United States release of thyroid-specific proteins that are clinical manifestations will worsen. When the metabolic rate http://dx.doi.org/10.12968/bjcn.2015.20.4.20 hypothyroidism and/or a goiter, continued monitoring should and is thought to be associated then seen on the cell surface of the encoded drops to a critical level, a life threatening emergency known as NIH (2013). Hashimoto’s disease. Retrieved from take place. If a person with HT has a goiter but is still free of with genetic susceptibility and APC. From here, the APC travels from the “” can occur. This event is characterized by www.niddk.nih.gov/health-information/health- hypothyroidism, healthcare providers may treat the person in an environmental factors. HT is a thyroid gland to the draining lymph nodes , , severe bradycardia and altered topics/endocrine/hashimotos- effort to decrease the size of the goiter. When a person with HT is chronic and of the thyroid. When the encoded APC level of consciousness (Hampton, 2013). Proper diagnoses disease/Documents/hashimoto_508.pdf positive for hypothyroidism, they must be treated with synthetic can present itself in an aggressive interacts with the T-lymphocyte cells and Hashimoto’s thyroiditis is one of the most common and treatment is life or death when dealing with Ross, D. S. (2015). Diagnosis of and for T4 (synthetic T4 stays in the body longer than synthetic T3). The form or a mild form such as silent B-lymphocyte cells in the draining lymph autoimmune diseases in the United States. The name hypothyroidism. hypothyroidism in nonpregnant adults. Retrieved from most common form of synthetic T4 that is currently being used is thyroiditis or postpartum nodes, a production of thyroid of this disease was derived from the 1912 pathology www.uptodate.com/contents/diagnosis-of-and- Synthroid. Once Synthroid is initiated, healthcare providers must thyroiditis leading to an autoantibodies occur against the thyroid report completed by Dr. Hakaru Hashimoto (Caturegli screening-for-hypothyroidism-in-nonpregnant-adults monitor the patient’s lab work closely to prevent the counter undiagnosed hypothyroidism. antigens: (TPO) and et al., 2013). It is estimated that one in 300 persons in effect of . Usually, lab work is rechecked every 3 Regardless of the virulence of the (Tg). Once the production of the United States has been diagnosed with some form months after the initial start of Synthroid and/or if changes are disease, HT can become serious if thyroid autoantibodies (anti-Tg antibodies of hypothyroidism and an estimated 13 million Additional Sources being made to the patient’s Synthroid dosage (NIH, 2013). left untreated (Davies, 2015). and anti-thyroperoxidase antibodies) persons have hypothyroidism, but have not been Fugazzola , L., Cirello, V., & Beck-Peccoz, P. (2012, March 7). Finally, another very important nursing implications is patient occurs, antigen-producing B-lymphocytes, properly diagnosed. Hypothyroidism may not be Microchimerism and endocrine disorders. Journal of Clinical education. It is very important that a patient understands the T helper cells (CD4+), and cytotoxic T cells present until later in life and affects women more than & Metabolism, 97(5). disease, the importance of the treatment, and most importantly, (CD+8), and macrophages infiltrate and men. Often times, hypothyroidism is ignored or http://dx.doi.org/10.1210/jc.2011-3160 compliance with taking medication as prescribed. Noncompliance accumulate in the thyroid gland through misdiagnosed due to the multiple symptoms that Geer, M., Potter, D. M., & Ulrich, H. (2015, March 1). Alternative is not an option with HT. Patient compliance is important in the formation, clonal expansion, and appear similar to other diseases (Gaitonde, Rowley, & schedules of administration. American Journal preventing extreme hypothyroidism such as Myxedema Coma. maturation of self-reactive T lymphocytes Sweeney, 2012). of Health-System Pharmacy, 72, 373-377.

and B-lymphocytes in the lymph tissue of Due to the widespread function of the thyroid gland, http://dx.doi.org/10.2146/ajhp140250

the thyroid gland. This entire process of an untreated hypothyroidism can lead to multisystem Conclusion Nada, A. M., & Hammouda, M. (2014). Immunoregulatory T cells, , cytokine-mediated and complications including; cardiovascular diseases, In conclusion, HT is characterized by the loss of thyroid LFA-3 and HLA-DR in autoimmune thyroid diseases. Indian apoptotic mechanisms of cytotoxicity leads complications, and even life-threatening follicular cells, hypothyroidism, and the presence of Journal of Endocrinology and Metabolism, 18(4), 574-581. to the destruction of the thyroid gland. conditions. An accurate diagnoses and treatment is autoantibodies against tissue-specific antigens such as thyroid Ross, D. S. (2015). Treatment of hypothyroidism. Retrieved from This thyroid gland destruction inhibits the critical. Any form of hypothyroidism such as peroxidase (TPO) and thyroglobulin (Tg). The thyroid tissue is www.uptodate.com/content/treatment-of-hypothyroidism release of the thyroid hormones Hashimoto’s Thyroiditis is a serious disease and identified as having an infiltration of T cells and B cells which are Wang, S., Baidoo, S. E., Liu, Y., Zhu, C., Tian, J., Ma, J., ... Chen, J. Triiodothyronine (T3) and Thyroxine (T4). should be treated as such (Mendes, 2015). reactive against the thyroid antigens. The lymph system of the (2012). -derived leptin contributes to increased This lack of hormone release leads to thyroid gland becomes involved and this leads to the death of the frequency of t-helper type 17 cells in female patients with hypothyroidism and Hashimoto’s thyrocytes with the end result of hypothyroidism and Hashimoto’s hashimoto’s thyroiditis. Clinical and Experimental Thyroiditis (Davies, 2015). Thyroiditis (Glick, Wodzinski, Fu, Levine, & Wald, 2013). Immunology, 171, 63-68. http://dx.doi.org/10.1111/j.1365.2249.2012.04670.x