-SP — 001 SD9900033 to ei Mansour El Tahir Farah Supervisor: Prof. El Daw Mukhtar Co-supervisor: Assoc, Prof. El Tom Sirag El Bin Khartoum -1997 r 30-36 ,• v -\ :.-- DISCLAIMER Portions of this document may be illegible in electronic image products, Images are produced from the best available original document. Contents Declaration I Acknowledgement , II Abstract English Ill Abstract Arabic V List of Abbreviations VII List of Tables VIII List of Figures X Chapter I Introduction and Literature Review 1 Objectives of the Study 40 Chapter II Patients and Methods 41 Chapter III Results 45 Chapter IV Discussion ; 75 Conclusion 82 Recommendations 84 References 85 Appendices The Questionnaire 101 I would like to declare that all the research work was done by myself. I consulted all the literature included in this study . This work has not been submitted to any other university . The information in this thesis has not been published elsewhere. ifp I would like to express my deep gratitude to my supervisor Professor El Daw Mukhtar whose continued enthusiasm and support had guided and encouraged me throughout the study period . This work would not been possible without the benefit of his generous help and leading advices . I am greatly indebted to Dr. El Tom Sirag El Din for his valuable comments and leading advices , helping me alot during preparation of this thesis . My great thanks to the staff in the diagnostic and research laboratory centre , who gave every possible help during my work . I am greatly appreciating the help that had been provided by all doctors technicians and patients . Finally , I am grateful to Aiman A. Al-Hamid for typing the manuscript. II Thyroid diseases comprise a major health problem in Sudan . Although clinical diagnosis of thyroid diseases often easy , there are many diagnostic difficulties . So , laboratory investigations are essential in certain conditions . 97 Sudanese subjects were included in this study . According to the clinical features , patients were divided into three groups , either hyper or hypothyroid , and the control group . Laboratory diagnosis of these individuals was established in the Diagnostic and Research Laboratory Centre in Khartoum Teaching Hospital. The thyroid hormones studied are T3 , T4 , FT4 (by enzyme immunoassay) and TSH (be the ultrasensitive enzyme immunoassay).. Serum T3 concentration was found to be high in 66% of the hyperthyroid patients , and low in 75% of the hypothyroid patients , and normal in 66.7% of the control group . Serum T4 concentration was normal in one-third of the hyperthyroid patients , and one-fourth of the Iiypothyroid patients , and 90.9% of the control eroup . Ill FT4 was normal in the control group , low in 95% of the hypothyroid patients , and high in 66% of the hyperthyroid patients . Signs of hyperthyroidism were associated with high honnonal levels more than symptoms do . Hyperkinesis and eye signs had a significant correlation with the hormonal levels . No significant correlation was found between symptoms and signs of hypothyroidism and hormonal levels . So , clinical evaluation of the patients is very important before assessing the laboratory values , and the free T4 is more specific in the diagnosis of thyroid diseases . IV PAGES ARE MISSING IN THE ORIGINAL DOCUMENT TRH : Thyrotrophin-Releasing Hormone TSH : Thyroid-Stimulating Hormone. T4 : Thyroxine. T3 : Triiodothyronine. FT4 : Free Thyroxine. FT3 : Free Triiodothyronine. VII List of Tables Tab. (I): Age and sex distribution of hyper and hypothyroidism in 64 Sudanese patients . 51 Tab. (2) : Geographical distribution of 64 Sudanese patients with hyper and hypothyroidism . 51 Tab. (3) : Occupations of 64 Sudanese patients with hyper and hypothyroidism. 52 Tab. (4) : Symptoms of hyperthyroidism in 44 Sudanese patients. 52 Tab. (5) : Signs of hyperthyroidism in 44 Sudanese patients . 53 Tab. (6) : Mean values (± SD) of T3 , T4 , FT4 , and TSH in 97 hyper , hypothyroid and normal individuals . 54 Tab. (7) : T3 level in 97 hyper, hypothyroidism and normal Sudanese individuals . 54 Tab. (8) : FT4 level in 97 hyper, hypothyroidism and normal Sudanese individuals . 55 Tab. (9) : T4 level in 97 hyper , hypothyroidism and normal Sudanese individuals . 55 Tab. (10) : TSH level in hyper , hypothyroidism and normal 97 Sudanese patients . 56 Tab. (11) : Mean biochemical values (± SD) in hyper, and hypothyroid 64 Sudanese patients . 56 Tab. (12) : Symptoms of hyperthyroidism and mean values of T3 , T4 , FT4 and TSH in 44 Sudanese patients . 57 VIII Tab. (13) : Signs of hyperthyroidism and mean values of T3 , T4 , FT4 , and TSH in 44 Sudanese patients . 58 Tab. (14) ; Age distribution of 64 Sudanese patients with hyper. and hypothyroidism . 59 Tab. (15) : Symptoms of hypothyroidism in 20 Sudanese patients . 59 Tab. (16) : Signs of hypothyroidism in 20 Sudanese patients . 60 Tab. (17) : Symptoms of hypothyroidism and mean values of T3 , T4 , FT4 , and TSH in 20 Sudanese patients . 60 Tab. (18) : Signs of hypothyroidism and mean values of T3 , T4 , FT4 , and TSH in 20 Sudanese patients . 6.1 Tab. (19) : T3 level in relation to presence or absence of symptoms of hyperthyroidism in 44 Sudanese patients. 62 Tab. (20) : T3 level in relation to presence or absence of hyperkinesis , exophthalmos , lid retraction and lid lag in 44 hyperthyroid Sudanese patients . 63 IX List of Figures Fig. (I) : Sex distribution of hyper, and liypothyroidism in 64 Sudanese patients . 64 Fig. (2) : Age distribution of hyper, and hypothyroidism in 64 Sudanese patients . 65 Fig. (3) : Geographical distribution of 64 Sudanese patients with hyper, and hypothyroidism . 66 Fig. (4) : Symptoms of hyperthyroidism in 44 Sudanese patients. 67 Fig. (5) : Signs of hyperthyroidism in 44 Sudanese patients . 68 Fig. (6) : Symptoms of hypothyroidism in 20 Sudanese patients. 69 Fig. (7) : Signs of hypothyroidism in 20 Sudanese patients . 70 Fig. (8) : T3 level in hyper., hypothyroidism and normal 97 Sudanese individuals. 71 Fig. (9) : PT4 level in hyper. , hypothyroidism and normal 97 Sudanese individuals . 72 Fig. (10) : T4 level in hyper. , hypothyroidism and normal 97 Sudanese individuals . 73 Fig, (II) : TSH level in hyper. , hypothyroidism and normal 97 Sudanese patients . 74 X The thyroid gland was first described by Galen in 150 - 200 (1) . A further description was given by Vesalius in 1543 . In 1656 , the organ was named the thyroid or oblong shield by Wharton (1). The role of the gland in the body was the subject of pleasant, and interesting speculation . Wharton suggested that the gland was there to round out and beautify the neck , particularly , in females to whom for this reason a larger gland has been assigned . Other suggestions were that the gland was lymphatic gland , receptacle for worms , and a lubricant organ for larynx . Until 1884 , the gland was proposed as a vascular shunt cushioning the brain against sudden increases in blood flow (1). The relationship between the thyroid and various body functions was studied by experimental thyroidectomy as early as 1827 , and the concept of an internal secretory function was formulated by King , nine years later .The parathyroids were-first described by Gley in 1891 . The Reverdins and Kocher in 1883 , became aware of the similarity between myxoedema and the clinical picture which developed after successful removal of the thyroid . The injection of glycerin extract of thyroid to relieve myxoedema , and finally the feeding of lightly cooked sheep thyroid , with successful relief of the disease , completed the background for modern knowledge about thyroid function (2) . Ancient Chinese treated cretins with sheep thyroid . The association of iodine With the working of the thyroid was made in 1896 by Baumann . In 1900 , Gley and Bourcet , identified the -1- presence of organic iodine in plasma in combination with serum protem . In 1926 and 1927 , Hamgton and Barger elucidated the chemical structure of thyroxine (T4) (3) . Later Gross and Pitt-Rivers described triiodothyronine (T3) (4) . Goitre was recognized in the earliest history and treated then by eating seaweed or burnt sponge . Hyperthyroidism was recognized first by Parry in 1825 . Graves identified the relation of the ocular complications to the disease in 1835 . De Quervain described the subacute , nonsuppurative , thyroiditis in 1936 , while chronic thyroiditis was described by Riedel in 1866 , and Hashimoto in 1912 . The carcinoma of the thyroid was described by Bums in 1811 (1). -2- The normal adult thyroid gland weighs 15 - 20 gm . It is composed of two encapsulated lobes , one on either side of the trachea , connected by a thin isthmus which crosses the trachea anteriorly just below the cricoid cartilage . Sometimes a pyramidal lobe is found extending superiorly from the isthmus in the midline , indicating the embryological path along which the thyroid developed (5) . The thyroid volume can be measured precisely by ultrasound . It ranged from 10 to 30 ml in one study of normal individuals (6) . In the embryo , the thyroid develops as a pouch in the pharyngeal floor which elongates inferiorly as the thyroglossal duct and becomes bilobar as it descends through the neck . Rarely , one or both thyroid lobes fail to develop (7) . If migration is arrested, the thyroid may remain at the base of the tongue (Imgual thyroid ) or be found at other locations between the base of the tongue and the lower neck . Occasionally , the thyroid follows the developmental path of the thymus into the throat where decades later , it may become manifest as substernal goitre , compressing the trachea or a recurrent laryngeal nerve or even causing superior vena cava obstruction . The arterial supply of the thyroid is drived primarily from paired superior and inferior thyroid arteries . The former arise from the external carotid arteries and ths latter from the thyrocervical trunks . The venous drainage is through the paired superior , middle , and inferior thyroid veins . Normally , two pairs of parathyroid glands lie behind the upper -3- and lower poles of the thyroid . The recurrent laryngeal nerves am along the trachea , medially and behind the lobes of the thyroid (5).