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include:
a) lethargy, increased weight, cold intolerance, slow cerebration, constipation;
b) puffy face, dry skin, hoarse voice, slow ankle reflexes;
c) macrocytic anaemia, hypercholesterolaemia;
d) complications (relatively rare) include pericardial effusion, hypertension, psychosis, and
e) coma.
There may be other associated autoimmune disease, e.g. coeliac disease and pernicious anaemia. The aim
is to diagnose the condition early, before frank myxoedema with complications develop.
TSH is raised and free T4 is low. Serum T3 can remain normal for a considerable period of time. If the
cause has been Hashimoto’s thyroiditis3, one may demonstrate TSH receptor antibodies and antibodies to
thyroid components. The ECG may show non-specific ST and T changes and low voltage complexes in
extreme cases.
Management
Before treatment is commenced, it is important to ensure that the patient is not hypopituitary or
hypoadrenal. This can be done by checking ACTH levels.
3 Hashimoto’s thyroiditis: autoimmune, chronic lymphocytic thyroiditis - diffuse infiltration of the thyroid gland
with lymphocytes, leading to diffuse goiter with progressive destruction of the parenchyme and hypothyroidism.
After Hashimoto, Japanese surgeon (1881-1934).
ICAO Preliminary Unedited Version — March 2010 III-4-4
Once the diagnosis has been established, treatment is with thyroxine. It is normal practice to start slowly
in doses of 50 μg per day (or 25 μg/day in the elderly or those with cardiac involvement) and increase
every 2-3 weeks until the correct maintenance dose, as indicated by a normal TSH, is reached. A normal
maintenance dose lies between 100 and 150 μg per day.
Thyroxine should be taken as a single daily dose as its plasma half-life is approximately seven days.
Patients again should be followed for life to ensure compliance.
Operational implications
Florid hypothyroidism is clearly incompatible with aviation duties and the denial of the medical
assessment will probably be between 3-4 months.
Aeromedical considerations
Applicants may be considered for medical assessment in any class provided they remain euthyroid. It
should be a condition that there is a regular supervision by an endocrinologist.
Many endocrinologists use computer recall to ensure follow-up and compliance with medication. The
duration of compliance is a significant problem and many patients when euthyroid cease medication
because they feel so well. Insidious development of hypothyroidism may not be obvious to the patient or
his/her associates; any decrement in performance has obvious implications in the aviation situation.
DISEASES OF THE PITUITARY
A wide variety of diseases can affect the pituitary gland and, in common with other endocrine organs,
result in over or under activity.
DISEASES OF THE ANTERIOR PITUITARY
Anterior pituitary hypofunction
Hypopituitarism may be partial or complete and may be caused by either pituitary or hypothalamic
disease, resulting in hormonal deficiency. Clinical manifestations may vary depending on the extent and
severity of the pituitary hormone deficiency. Thus an individual may present in extremis with acute
adrenal insufficiency or profound hypothyroidism or with rather non-specific symptoms of fatigue or
malaise which could be erroneously labelled as jet lag or crew fatigue.
The commonest cause of hypopituitarism is a pituitary tumour, but there are other infiltrative and vascular
causes.
Clinical features
The emerging tumour may produce local pressure effects, the principal symptoms being headache and
visual field disturbances. The classic visual field defect is an upper quadrantic bitemporal hemianopia if
the tumour is below the optic chiasm. Rarely, pressure on the third ventricle may produce a Korsakofflike
syndrome and the aircrew member may be thought to have an alcohol abuse problem. Funduscopy
may reveal early optic atrophy.
ICAO Preliminary Unedited Version — March 2010 III-4-5
Other clinical features depend on the age of onset, but only disease in adulthood is relevant to aviation
medicine practice. Patients will have rather non-specific symptoms, they may appear pale, but are not
anaemic; the skin has a waxen doll appearance. They have cold intolerance but do not have the classic
myxoedematous appearance. Supine blood pressure may be normal, but orthostatic hypotension may be
present. Women have ammenorrhoea and men may lose their sex drive. Acute hypopituitary crisis may
mimic an acute abdomen or an atypical presentation of decompression sickness. Patients may become
hypoglycaemic but, because of the lack of a sympathetic response, without the classical symptoms;
consequently they may proceed to coma. They develop hyponatraemia, which can also cause coma and,
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Manual of Civil Aviation Medicine 1(123)
