Hypothyroidism

HYPOTHYROIDISM Results from ------------1. IDIOPATHIC HYPOTHYROIDISM ----------- Fibrosis and destruction of the thyroid gland. 2. HASHIMOTO’S THYROIDITIS----------------- Marked lymphocytic infiltration of the gland and destruction Clinical features ----------1. Skin -----

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MYXEDEMA -------------- Doughy generalized non pitting edema. This presents as a PUFFY FACE with thickening of lips, broadening of nose and macroglossia.

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Coldness of the skin ----------------- due to low BMR Dryness of skin due to decreased sweat. Paleness of the skin -------------- due to a combination of anemia, decreased blood supply and increased deposition of GAGs in the dermis

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4. 5. Results 1. 2. 3. 4.

Yellowish hue due to hypercarotenemia ----------- in palms, soles and nasolabial folds.  Poor wound healing Hair ----

 Sparce and brittle most noticeable in the lateral eyebrows, beard, axilla and pubes. Nail  Grow slowly and brittle Sweating ----------- Decreased. Acanthosis nigricans. HYPERCORTISOLISM from: Adrenocortical hyperplasia Adenoma or carcinoma of the adrenal cortex Iatrogenic (glucocorticoid therapy) pituitary ACTH secreting adenoma.

Manifestations are ----------------1. FAT REDISTRIBUTION ----------- with increased fat deposition in the supraclavicular area, buffalo hump, moon facies, protuberant abdomen. The face is puffy and telangiectatic. 2. EASY BRUISING.

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DEVELOPMENT OF PETECHIAE AND ECCHYMOSES. IMPAIRED WOUND HEALING. CUTANEOUS STRIAE ---------------- BROAD AND PURPLE. CUTIS MARMORATA. DUE TO EXCESS ANDROGENS---------- Acne vulgaris

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Hirsutism  Male pattern baldness. HYPERPIGMENTATION ------------------ due to excess of ACTH. ADDISON’S DISEASE

Results 1. 2. 3. 4. 5.

from ---------Autoimmune disorders Chronic infections Metastatic tumors Vascular phenomenon Prolonged glucocorticoid therapy

Clinical features ---------1. Hyperpigmentation ---------- it is one of the earliest signs of Addison’s disease. The pigmentation occurs due to compensatory excess production of ACTH by the pituitary. It manifests as ---------- Suntan persisting well into the winter  Marked darkening of folds, frictional areas and palmer creases  Nevi may darken  Lentigo like lesions may develop  Darkening of hair  Longitudinal pigmented bands in the nails. 2. Vitiligo is present in 15%.

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Loss of body hair especially in the axillae in women due to the loss of adrenal androgens.

GRANULOMA Granulomatous inflammation is a distinctive type of chronic inflammatory reaction in which the predominant cell type is an epitheloid cell which is an activated macrophage with a modified epithelial like appearance. A granuloma is a focal area of granulomatous inflammation. This is often surrounded by a collar of mononuclear leucocytes principally lymphocytes and occasionally plasma cells. In H&E, the epitheloid cells have a PALE PINK GRANULAR CYTOPLASM WITH INDISTINCT CELL BOUNDARIES OFTEN APPEARING TO MERGE INTO ONE ANTOTHER. THE NUCLEUS IS LESS DENSE THAN THAT OF A LYMPHOCYTE (VESICULAR), IS OVAL OR ELONGATED AND MAY SHOW FOLDING OF THE NUCLEAR MEMBRANE. Older granulomas have a enclosing rim of fibroblasts and CT. frequently the epitheloid cells fuse to form giant cells in the periphery or sometimes in the centre of the granuloma. The giant cells comprise of large mass of cytoplasm containing 20 or more small nuclei arranged either peripherally (LANGHAN’S GIANT CELL) or haphazardly (FOREIGN BODY GIANT CELL). HISTOLOGICAL CLASSIFICATION: 1. EPITHELOID GRANULOMA WITHOUT NECROSIS          

Sarcoidosis Tuberculoid leprosy Tuberculosis --- LUPUS VULGARIS Lichen scrofulosorum Foreign body granuloma Chronic cutaneous leishmaniasis Granulomatous rosacea Cheilitis granulomatosa (MIESCHER MELKERSSON ROSENTHAL) Allergic granulomatous reaction ---- silica, zirconium, aluminium, beryllium Collagen inplant granuloma

2. EPITHELOID GRANULOMA WITH NECROSIS     

Tuberculosis Non tuberculous mycobacteria Tertiary syphilis Cryptococcosis Histoplasmosis

3. PALISADING GRANULOMA      

Granuloma annulare Rheumatoid nodule NLD Rheumatic nodule Actinic granuloma Occasional examples of deep fungal infection

4.

MIXED CELL GRANULOMA (lymphocytes and plasma cells are present alongwith epitheloid cells which may form loose clusters)

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Keratin granuloma (ruptured cyst, folliculitis) Sporotrichosis Chromomycosis Blastomycosis Phaeohyphomycosis Coccidiodomycosis Candidial granuloma Cryptococcosis Cat scratch disease Non tuberculosis mycobacteria. Persistent arthropod bite

ANOTHER CLASSIFICATION: 1. Tuberculoid granuloma 2. Sarcoidal granuloma 3. Palisading granuloma

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Foreign body granuloma ------------ can induce both allergic and non allergic type of granuloma ALLERGIC ------------------- sea urchin, beryllium, zirconium, silica, tattoo and insect bite. NON ALLERGIC ------------ Paraffin, silica, talc, starch, cacti Suppurative granuloma. LICHENOID DERMATITIS

Lichenoid inflammation is a diffuse band like infiltrate of small lymphocytes clustered about a dermalepidermal junction and obscuring the interface. Apoptotic or necrotic keratinocytes are often present. LICHENOID DERMATITIS, LYMPHOCYTES EXCLUSIVELY /PREDOMINANT (mixed with plasma cells and eosinophils)-----------------1. LP 2. Benign lichenoid keratoses 3. PLC 4. LE----------- lichenoid forms 5. MCTD 6. GVHD, lichenoid stage 7. EM 8. PLEVA, early stages 9. parapsoriasis/mycosis fungoides, patch/plaque stage 10. Sezary syndrome 11. Pigmented purpuric dermatitis, lichenoid type (Gougerot Blum) 12. Lichen striatus 13. Lichenoid tattoo reaction 14. secondary syphilis LICHENOID DERMATITIS, EOSINOPHILS PRESENT ----------------1. Lichenoid drug eruptions 2. Arthropod bite reactons 3. Histiocytosis X 4. Mastocytosis/Telangiectasia macularis eruptive perstans LICHENOID DERMATITIS, PLASMA CELLS PRESENT ----------1. Lichenoid actinic keratoses 2. Bowen’s disease 3. Erythroplasia of Queyret 4. Secondary syphilis 5. zoon’s plasma cell balantitis LICHENOID DERMATITIS WITH MELANOPHAGES 1. Post inflammatory hyperpigmentation 2. regressed melanocytic lesion LICHENOID DERMATITIS, HISTIOCYTES PREDOMINANT 1. Lichen nitidus 2. Actinic reticuloid 3. Chronic actinic dermatitis 4. Histiocytosis X LICHENOID DERMATITIS, MAST CELLS PREDOMINANT 1. Urticaria pigmentosa.