Thyroiditis

Thyroiditis Microchapters
Patient Information
Overview
Classification Hashimoto's thyroiditis Riedel's thyroiditis De quervain thyroiditis Suppurative thyroiditis Postpartum thyroiditis
Differentiating Thyroiditis from Other Diseases
Diagnosis
Treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Furqan M M. M.B.B.S[2], Usama Talib, BSc, MD [3]

Overview

Thyroiditis refers to an inflammation of the thyroid gland.

Classification

• The most common form of thyroiditis is Hashimoto's thyroiditis.
• Resolving thyroiditis
  • DeQuervain's Thyroiditis or Granulomatous Thyroiditis
  • Postpartum thyroiditis
  • Silent thyroiditis
• Rare forms of thyroiditis
  • Riedel's thyroiditis

Differentiating Thyroiditis from Other Diseases

Various forms of thyroiditis can be differentiated from each other on the basis of pathological and laboratory findings:

Conditions	Causes	Age at onset	Pathological findings	Diagnostic approach
Hashimoto's thyroiditis	Autoimmune	All ages, peak at 30-50	Lymphocytic infiltration Germinal centers Fibrosis (in some variants)	Increased TSH (hypothyroidism) TPO antibodies present in high titer I-123 uptake usually decreased
Painful subacute (De Quervain's) thyroiditis	Unknown	20-60	Giant cells Granulomas	Increased TSH (hypothyroidism) and/or Decreased TSH (Thyrotoxicosis) TPO antibodies absent or very low titer I-123 uptake decreased
Silent thyroiditis	Autoimmune	All ages, peak at 30-40	Lymphocytic infiltration Lymphoid follicles	Increased TSH (hypothyroidism) and/or Decreased TSH (transient hypothyroidism) TPO antibodies present in high titer I-123 uptake usually decreased
Postpartum thyroiditis	Autoimmune	Childbearing age	Lymphocytic infiltration	Increased TSH (hypothyroidism) and/or Decreased TSH (transient hypothyroidism) TPO antibodies present in high titer I-123 uptake usually decreased
Riedel's thyroiditis	Unknown	30-60	Dense fibrosis	Normal TSH (euthyroidism) TPO antibodies usually present I-123 uptake decreased or normal
Suppurative thyroiditis	Infection	Children, 20-40	Abscess formation	Normal TSH (euthyroidism) TPO antibodies absent I-123 uptake normal

Diagnosis

• The diagnosis of thyroiditis is usually made on the physical examination, thyroid function tests and various other diagnostic tests listed in the table below:

Disease		History and symptoms		Laboratory findings							Additional findings
		Fever	Pain	TSH	Free T4	T3	T3RU†	Thyroglobin	TRH	TPOAb^
Primary hypothyroidism	Autoimmune (Hashimoto's thyroiditis)	-	-	↑*	↓	Normal/↓	Normal/↓	Normal/↑	Normal	Present (high titer)	May be accompanied by other autoimmune diseases
	Riedel's thyroiditis	-	-	Normal/↑	Normal/↓	Normal/↓	Normal/↓	Normal	Normal	Usually present	Riedel's thyroiditis usually presents with hard and fixed thyroid mass.
	Infectious thyroiditis	+	+	Normal	Normal	Normal	Normal	Normal	Normal	Absent	Infectious thyroiditis associated with neck pain
Transient hypothyroidism	Subacute (de Quervain's) thyroiditis	+/-	+/-	↑/↓	↓/↑	Normal	↓	↑	Normal	Low/absent	May present primarily with hyperthyroidism
	Postpartum thyroiditis	+/-	+/-	↑/↓	↓/↑	Normal	↓	↑	Normal/↑	Present (high titer)	May present primarily with hyperthyroidism
	Silent thyroiditis	-	-	↑/↓	↓/↑	Normal	↓	↑	Normal	Present (high titer)	May present primarily with hyperthyroidism
Others	Drug-induced	-	-	↑/↓	↓/↑	Normal	↓	Normal/↑	Normal	Absent**	History of hyperthyroidism History of trauma History of drug use, surgery, or radiation
	Radiation-induced
	Trauma induced
	Radioiodine induced
	Thyroidectomy
	Subclinical hypothyroidism	-	-	↑	Normal	Normal	Normal	Normal	Normal	Normal/↑	Asymptomatic

(†)T3RU; Triiodothyronine Resin uptake. (^)TPOAb; Thyroid peroxidase antibodies. (*)TSH may be decreased transiently in the thyrotoxicosis. (**)TPOAb may be present in drug-induced hypo/hyperthyroidism such as Interferon-alpha, interleukin-2, and lithium.

Treatment

The drugs used in the treatment of Hashimoto's thyroiditis are:

1. Levothyroxine:
   • lifelong synthetic levothyroxine (L-T4) is used to treat the hypothyroidism in Hashimoto's disease.
   • Main goals of levothyroxine replacement therapy are:
     • Resolution of the hypothyroid symptoms and signs including biological and physiologic markers of hypothyroidism
     • Normalization of serum thyrotropin with improvement in thyroid hormone concentrations
     • To avoid overtreatment (iatrogenic thyrotoxicosis)
   • Side effects include atrial fibrillation and osteoporosis
2. Corticosteroids:
   • A short course of glucocorticoids can be used in the treatment of IgG4-related variant of Hashimoto's thyroiditis.
3. Selenium:
   • Dietary selenium supplementation is considered to be protective against the autoimmune diseases of the thyroid.

Drug Regimen:

• Synthetic levothyroxine (L-T4) 1.6–1.8 μg/kg of body weight per day orally.

The drugs used in the treatment of de Quervain's thyroiditis are:

• For pain
  • Preferred regimen (1): Naproxen: 500 to 1000 mg per day in two divided doses
  • Preferred regimen (2): Ibuprofen: 1200 to 3200 mg per day in three or four divided doses
• For severe condition
  • Preferred regimen (1): Prednisone: 40 mg per day orally
• For hypothyroidism
• Preferred regimen (1): Synthetic levothyroxine (L-T4): 1.6–1.8 μg/kg per day orally
• For thyrotoxic symptoms
  • Preferred regimen (1): atenolol: 25-200mg per day orally
  • Preferred regimen (2): metoprolol: 25-200mg per day orally

The drugs used in the treatment of silent thyroiditis are:

• For thyrotoxic symptoms
  • Preferred regimen (1): atenolol: 25-200mg per day orally
  • Preferred regimen (2): metoprolol: 25-200mg per day orally
• For hypothyroidism
• Preferred regimen (1): Synthetic levothyroxine (L-T4): 1.6–1.8 μg/kg per day orally

Related Chapters

• Hypothyroidism
• Hyperthyroidism
• Graves-Basedow disease

References

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