Postpartum thyroiditis differential diagnosis: Difference between revisions

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==Differentiating Postpartum Thyroiditis from other Diseases==
==Differentiating Postpartum Thyroiditis from other Diseases==
===Differentiating postpartum thyroiditis from other causes of thyroiditis===
===Differentiating postpartum thyroiditis from other causes of thyroiditis===
*Postpartum thyroiditis must be differentiated from other causes of [[thyroiditis]], such as [[De Quervain's thyroiditis]], [[Hashimoto's thyroiditis]], [[Riedel's thyroiditis]], and suppurative thyroiditis.<ref name="urlThyroiditis — NEJM">{{cite web |url=http://www.nejm.org/doi/full/10.1056/NEJMra021194 |title=Thyroiditis — NEJM |format= |work= |accessdate=}}</ref>
*Postpartum thyroiditis must be differentiated from other causes of [[thyroiditis]], such as [[De Quervain's thyroiditis]], [[Hashimoto's thyroiditis]], [[Riedel's thyroiditis]], and suppurative thyroiditis.<ref name="urlThyroiditis — NEJM">{{cite web |url=http://www.nejm.org/doi/full/10.1056/NEJMra021194 |title=Thyroiditis — NEJM |format= |work= |accessdate=}}</ref><ref name="pmid28781832">{{cite journal| author=Akuzawa N, Yokota T, Suzuki T, Kurabayashi M| title=Acute suppurative thyroiditis caused by Streptococcus agalactiae infection: a case report. | journal=Clin Case Rep | year= 2017 | volume= 5 | issue= 8 | pages= 1238-1242 | pmid=28781832 | doi=10.1002/ccr3.1048 | pmc=5538065 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28781832  }}</ref>
{| align="center"
{| align="center"
|-
|-
Line 453: Line 453:
!
!
! colspan="4" |Symptoms and Signs
! colspan="4" |Symptoms and Signs
! colspan="6" |Labs
! colspan="7" |Labs
!
!Mechanisum
!
|-
|-
!
!
Line 471: Line 470:
!RAI
!RAI


uptake
U
!Thyroid U/S
!Thyroid U/S
!
!Microscopic
!
 
Picture
!aetology
|-
|-
!Persistent
!Persistent
hyperthyroidism
hyperthyroidism
![[Grave's disease]]
![[Grave's disease]]
!Present
!+
!Small painful
!Small
painful
mass
mass
!Present
!Present
Line 488: Line 490:
!High
!High
!Absent
!Absent
!High
!
!High
!
!diffusely enlarged
!diffusely
enlarged
hypervascular
hypervascular


heterogeneous echotexture
heterogeneous
 
echotexture


!
!
hyperplastic
follicles due to
eosinophilic
cytoplasm
scalloping
!
!
|-
|-
Line 501: Line 516:
hyperthyroidism
hyperthyroidism
![[Silent thyroiditis]]
![[Silent thyroiditis]]
!Present
!+
!Small painless
!Small
painless
goiter
goiter
!Present  
!Present  
Line 513: Line 529:
!High
!High
!50%
!50%
!Normal
!NL
!low
!
!markedly decreased vascularity
!markedly
decreased
 
vascularity
 
variable
 
heterogeneous
 
texture
 
!Lymphocytic
 
infiltration
 
Lymphoid


variable heterogeneous texture
follicles


!
!
!
|-
|-
![[Postpartum thyroiditis]]
![[Postpartum thyroiditis]]
!Present
!+
!Small painless  
!Small
painless  
goiter
goiter
!Present
!Present
Line 535: Line 566:
!High
!High
!>80% 
!>80% 
!High
!
!low
!
!hypoechoic diffusely enlarged with normal or decreased vasclarity
!hypoechoic
!
diffusely
 
enlarged
 
with
 
normal
 
or decreased
 
vasclarity
!variable
 
heterogeneous
 
texture
 
hypoechogenic
!
!
|-
|-
![[De Quervain's thyroiditis|Subacute (de Quervain's)]]
![[De Quervain's thyroiditis|Subacute (de Quervain's)]]
[[De Quervain's thyroiditis|granulomatous thyroiditis]]
[[De Quervain's thyroiditis|granulomatous thyroiditis]]
!Present
!+
!Small painful  
!Small
painful  
mass
mass
!Present
!Present
Line 555: Line 604:
!High
!High
!Absent
!Absent
!High
!
!low
!
!diffusely enlarged with normal or decreased vasclarity
!diffusely
!
enlarged &
 
normal or
 
decreased
 
 vasclarity
!Giant cells
 
Granulomas
 
!
!
|-
|-
![[Factitious thyrotoxicosis|Factitious]]
![[Factitious thyrotoxicosis|Factitious]]
[[Factitious thyrotoxicosis|thyrotoxicosis]]
[[Factitious thyrotoxicosis|thyrotoxicosis]]
!Present
!+
!Normal
!Normal
!Absent
!Absent
Line 573: Line 632:
!High
!High
!Absent
!Absent
!NL
!↓
!Normal
!Normal
!low
!Normal
!Normal
 
!
histology
!
!
|-
|-
!acute suppurative  
!acute suppurative  
thyroiditis
thyroiditis
!Present
!+
!Small painful
!Small
painful
mass
mass
!Present
!Present
Line 593: Line 655:
!High
!High
!Absent
!Absent
!High
!
!low
!
!variable heterogeneous texture hypoechogenic
!variable
heterogeneous
 
texture
 
perithyroidal
 
hypoechoic
 
space due to
 
abcess
!
!
!
!
Line 603: Line 676:
![[De Quervain's thyroiditis|Subacute (de Quervain's)]]  
![[De Quervain's thyroiditis|Subacute (de Quervain's)]]  
[[De Quervain's thyroiditis|granulomatous thyroiditis]]
[[De Quervain's thyroiditis|granulomatous thyroiditis]]
!Present
!+
!Small painful  
!Small
painful  
mass
mass
!Present  
!Present  
Line 615: Line 689:
!High
!High
!Absent
!Absent
!High
!
!low
!
!diffusely enlarged with normal or decreased vasclarity
!diffusely
!
enlarged  
 
&normal or
 
decreased
 
 vasclarity
!Giant cells
 
Granulomas
 
!
!
|-
|-
![[Postpartum thyroiditis|Postpartum]]
![[Postpartum thyroiditis|Postpartum]]
[[Postpartum thyroiditis|thyroiditis]]
[[Postpartum thyroiditis|thyroiditis]]
!Present
!+
!Small painless
!Small
painless
goiter
goiter
!Present  
!Present  
Line 635: Line 720:
!High
!High
!>80% 
!>80% 
!High
!
!low
!
!hypoechoic diffusely enlarged with normal or decreased vasclarity
!hypoechoic
!
diffusely
 
enlarged&
 
normal or
 
decreased
 
vasclarity
!variable
 
heterogeneous
 
texture
 
hypoechogenic
!
!
|-
|-
!acute suppurative  
!acute suppurative  
thyroiditis
thyroiditis
!Present
!+
!Small painful  
!Small
painful  
mass
mass
!Present  
!Present  
Line 655: Line 756:
!High
!High
!Absent
!Absent
!High
!
!low
!
!variable heterogeneous texture hypoechogenic
!variable
heterogeneous
 
texture
 
perithyroidal
 
hypoechoic
 
space due to
 
abcess
!
!
!
!
Line 665: Line 777:
|[[Postpartum thyroiditis|Postpartum]]
|[[Postpartum thyroiditis|Postpartum]]
[[Postpartum thyroiditis|thyroiditis]]
[[Postpartum thyroiditis|thyroiditis]]
|Present
| +
|Small painless
|Small
painless
goiter
goiter
|Present
|Present
Line 677: Line 790:
|Low
|Low
|>80% 
|>80% 
|High
|
|low
|
| hypoechoic diffusely enlarged with normal or decreased vasclarity
| hypoechoic
|
diffusely
 
enlarged
 
& normal or
 
decreased
 
vasclarity
|variable
 
heterogeneous
 
texture
 
, hypoechogenic
|
|
|-
|-
|[[Silent thyroiditis|Silent]]
|[[Silent thyroiditis|Silent]]
[[Silent thyroiditis|thyroiditis]]
[[Silent thyroiditis|thyroiditis]]
|Present
| +
|Small painless  
|Small
painless  
goiter
goiter
|Present  
|Present  
Line 697: Line 826:
|Low
|Low
|Present
|Present
|Normal
|NL
|low
|
|markedly decreased vascularity
|markedly
decreased
 
vascularity
 
variable
 
heterogeneous
 
texture
 
|Lymphocytic infiltration


variable heterogeneous texture
Lymphoid follicles


|
|
|
|-
|-
|[[De Quervain's thyroiditis|Subacute (de Quervain's)]]
|[[De Quervain's thyroiditis|Subacute (de Quervain's)]]
[[De Quervain's thyroiditis|granulomatous thyroiditis]]
[[De Quervain's thyroiditis|granulomatous thyroiditis]]
|Present
| +
|Small painful
|Small
painful
mass
mass
|Present  
|Present  
Line 720: Line 860:
|Low
|Low
|Absent
|Absent
|High
|
|low
|
|diffusely enlarged with normal or decreased vasclarity
|diffusely
|
enlarged
 
normal or
 
decreased
 
 vasclarity
|Giant cells
 
Granulomas
 
|
|
|-
|-
|[[Infectious thyroiditis|acute suppurative]]
|[[Infectious thyroiditis|acute suppurative]]
[[Infectious thyroiditis|thyroiditis]]
[[Infectious thyroiditis|thyroiditis]]
|Present
| +
|Small painful  
|Small
painful  
mass
mass
|Present  
|Present  
Line 740: Line 891:
|Low
|Low
|Absent
|Absent
|High
|
|low
|
|variable heterogeneous texture
|variable
heterogeneous
 
texture
 
perithyroidal
 
hypoechoic
 
space due to


hypoechogenic
abcess
|
|
|
|
Line 752: Line 912:
|[[Riedel's thyroiditis|Riedel's]]
|[[Riedel's thyroiditis|Riedel's]]
[[Riedel's thyroiditis|thyroiditis]]
[[Riedel's thyroiditis|thyroiditis]]
|Present
| +
|Small painful  
|Small
painful  
mass
mass
|Present  
|Present  
Line 762: Line 923:
|Low
|Low
|75%
|75%
|High
|
|low
|
|homogeneously hypoechoic
|homogeneously
hypoechoic
 
fibrotic
 
invasion of the


fibrotic invasion of the
adjacent


adjacent structures
structures
|
|
|
|
Line 774: Line 940:
|[[Postpartum thyroiditis|Postpartum]]
|[[Postpartum thyroiditis|Postpartum]]
[[Postpartum thyroiditis|thyroiditis]]
[[Postpartum thyroiditis|thyroiditis]]
|Present
| +
|Small painless  
|Small
painless  
goiter
goiter
|Present
|Present
Line 784: Line 951:
|Low
|Low
|>80% 
|>80% 
|High
|
|low
|
|hypoechoic diffusely enlarged with normal or decreased vasclarity
|hypoechoic
|
diffusely
 
enlarged&
 
normal
 
or decreased
 
vasclarity
|variable
 
heterogeneous
 
texture,
 
hypoechogenic
|
|
|-
|-
|[[Hashimoto's thyroiditis|Hashimoto's]]
|[[Hashimoto's thyroiditis|Hashimoto's]]
[[Hashimoto's thyroiditis|thyroiditis]]
[[Hashimoto's thyroiditis|thyroiditis]]
|Present
| +
|Painful
|Painful
mass
mass
Line 802: Line 984:
|Low
|Low
|95%
|95%
|High
|
|low
|
|heterogeneous echotexture
|heterogeneous
echotexture
 
decreased
 
vasclarity
 
hypoechoic
 
micronodules
|lymphoid
 
follicles


decreased vasclarity
Germinal centers


hypoechoic micronodules
|
|
|
|-
|-
|Acute suppurative
|Acute suppurative
thyroiditis
thyroiditis
|Present
| +
|Small painful
|Small
painful
mass
mass
|Present  
|Present  
Line 824: Line 1,017:
|Low
|Low
|Absent
|Absent
|High
|
|low
|
|variable heterogeneous texture
|variable
heterogeneous
 
texture
 
perithyroidal
 
hypoechoic
 
space due to
 
abcess


hypoechogenic
|
|
|
|

Revision as of 20:53, 20 October 2017

Postpartum thyroiditis Microchapters

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Overview

Historical Perspective

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Pathophysiology

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Differentiating Postpartum Thyroiditis from other Diseases

Epidemiology and Demographics

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Diagnosis

Diagnostic Criteria

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

Overview

Postpartum thyroiditis must be differentiated from other causes of thyroiditis, such as De Quervain's thyroiditis, Hashimoto's thyroiditis, Riedel's thyroiditis, and suppurative thyroiditis. Postpartum thyroiditis must be differentiated from other causes of thyroiditis, such as De Quervain's thyroiditis, Riedel's thyroiditis, and suppurative thyroiditis. Postpartum thyroiditis must also be differentiated from other diseases which cause hypothyroidism. As Postpartum thyroiditis may cause transient thyrotoxic symptoms, the diseases causing thyrotoxicosis must also be considered in the differential diagnosis.

Differentiating Postpartum Thyroiditis from other Diseases

Differentiating postpartum thyroiditis from other causes of thyroiditis

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)
Painful subacute (De Quervain's) thyroiditis
  • Unknown
  • 20-60
  • Giant cells
  • Granulomas
Silent thyroiditis
  • Autoimmune
  • All ages, peak at 30-40
  • Lymphocytic infiltration
  • Lymphoid follicles
Postpartum thyroiditis
  • Autoimmune
  • Childbearing age
  • Lymphocytic infiltration
Riedel's thyroiditis
  • Unknown
  • 30-60
  • Dense fibrosis
Suppurative thyroiditis
  • Infection
  • Children, 20-40
  • Abscess formation

Differentiating postpartum thyroiditis from other causes of hypothyroidism

  • Postpartum thyroiditis must be differentiated from other causes of hypothyroidism on the basis of history and symptoms and laboratory findings:[3][4][1][5][6][7]
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)
Riedel's thyroiditis - - Normal/↑ Normal/↓ Normal/↓ Normal/↓ Normal Normal Usually present
Infectious thyroiditis + + Normal Normal Normal Normal Normal Normal Absent
Transient hypothyroidism Subacute (de Quervain's) thyroiditis +/- +/- ↑/ ↓/ Normal Normal Low/absent
Postpartum thyroiditis +/- +/- ↑/ ↓/ Normal Normal/↑ Present (high titer)
Silent thyroiditis - - ↑/ ↓/ Normal Normal Present (high titer)
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.

Differentiating postpartum thyroiditis from other causes of thyrotoxicosis

  • Postpartum thyroiditis can initially present with thyrotoxicosis which must be differentiated from other causes of thyrotoxicosis.[3][4][1][5][6][7][8][9][10]
Disease History and symptoms Laboratory findings Additional findings
Fever Pain TSH Free T4 T3 T3RU Thyroglobin TRH TSH Receptor Antibody TPOAb^
Thyroiditis Postpartum thyroiditis +/- +/- ↑/ ↓/ Normal Normal/↑ Absent Present (high titer)
Hashimoto's thyroiditis (Hashitoxicosis) - - * Normal/ Normal/↓ Normal/ Normal Absent Present (high titer)
Subacute (de Quervain's) thyroiditis +/- +/- ↑/ ↓/ Normal Normal Absent Low/absent
Silent thyroiditis - - ↑/ ↓/ Normal Normal Absent Present (high titer)
Primary hyperthyroidism Grave's disease - - Normal/ Normal Present Absent
  • Patient may have opthalmopathy and dermopathy
Toxic thyroid nodule - - Normal/↑ ↑(hot nodule) Normal/ Normal Absent Absent

-

Secondary hyperthyroidism Pituitary adenoma - - Normal/↑ Normal/ Normal Absent Absent
  • Inappropriately normal or increased TSH
Tertiary hyperthyroidism Tertiary hyperthyroidism - - Normal/ Absent Absent
  • Inappropriately normal or increased TSH
Drug induced Amiodarone type 1 - - Normal/↑ Normal/ Normal Absent Absent
  • High urinary iodine
Amiodarone type 2 - - Normal/↑ Absent/↓ Normal/ Normal Absent Absent
  • High urinary iodine
Others Factitious thyrotoxicosis - - Normal/↑ Normal Absent Absent
  • Decreased thyroglobulin
Trophoblastic disease - - Normal/↑ - Normal Absent Absent

-

Struma ovarii - - Normal/↑ - Normal Absent Absent

-

(†)T3RU; Triiodothyronine Resin uptake. (^)TPOAb; Thyroid peroxidase antibodies.

Symptoms and Signs Labs Mechanisum
Fatiuge Neck

swelling

Low

mood

Irritability TSH FT4 TPO ab ESR RAI

U

Thyroid U/S Microscopic

Picture

aetology
Persistent

hyperthyroidism

Grave's disease + Small

painful mass

Present Present

early

Low High Absent diffusely

enlarged hypervascular

heterogeneous

echotexture

hyperplastic

follicles due to

eosinophilic

cytoplasm

scalloping

Transient

hyperthyroidism

Silent thyroiditis + Small

painless goiter

Present

late

Present

early

Normal

or Low

High 50% NL markedly

decreased

vascularity

variable

heterogeneous

texture

Lymphocytic

infiltration

Lymphoid

follicles

Postpartum thyroiditis + Small

painless goiter

Present

late

Present

early

Normal

or Low

High >80%  hypoechoic

diffusely

enlarged

with

normal

or decreased

vasclarity

variable

heterogeneous

texture

hypoechogenic

Subacute (de Quervain's)

granulomatous thyroiditis

+ Small

painful mass

Present

late

Present

early

Normal

or Low

High Absent diffusely

enlarged &

normal or

decreased

 vasclarity

Giant cells

Granulomas

Factitious

thyrotoxicosis

+ Normal Absent Present

early

Normal

or Low

High Absent NL Normal Normal

histology

acute suppurative

thyroiditis

+ Small

painful mass

Present

late

Present

early

Normal

or Low

High Absent variable

heterogeneous

texture

perithyroidal

hypoechoic

space due to

abcess

Destructive

hyperthyroidism

Subacute (de Quervain's)

granulomatous thyroiditis

+ Small

painful mass

Present

late

Present

early

Normal

or Low

High Absent diffusely

enlarged

&normal or

decreased

 vasclarity

Giant cells

Granulomas

Postpartum

thyroiditis

+ Small

painless goiter

Present

late

Present

early

Normal

or Low

High >80%  hypoechoic

diffusely

enlarged&

normal or

decreased

vasclarity

variable

heterogeneous

texture

hypoechogenic

acute suppurative

thyroiditis

+ Small

painful mass

Present

late

Present

early

Normal

or Low

High Absent variable

heterogeneous

texture

perithyroidal

hypoechoic

space due to

abcess

Transient

hypothyroidism

Postpartum

thyroiditis

+ Small

painless goiter

Present

late

Present

early

Normal

or High

Low >80%   hypoechoic

diffusely

enlarged

& normal or

decreased

vasclarity

variable

heterogeneous

texture

, hypoechogenic

Silent

thyroiditis

+ Small

painless goiter

Present

late

Present

early

Normal

or High

Low Present NL markedly

decreased

vascularity

variable

heterogeneous

texture

Lymphocytic infiltration

Lymphoid follicles

Subacute (de Quervain's)

granulomatous thyroiditis

+ Small

painful mass

Present

late

Present

early

Normal

or High

Low Absent diffusely

enlarged

normal or

decreased

 vasclarity

Giant cells

Granulomas

acute suppurative

thyroiditis

+ Small

painful mass

Present

late

Present

early

Normal

or High

Low Absent variable

heterogeneous

texture

perithyroidal

hypoechoic

space due to

abcess

Persistent

hypothyroidism

Riedel's

thyroiditis

+ Small

painful mass

Present

late

Present

early

High Low 75% homogeneously

hypoechoic

fibrotic

invasion of the

adjacent

structures

Postpartum

thyroiditis

+ Small

painless goiter

Present

late

Present

early

High Low >80%  hypoechoic

diffusely

enlarged&

normal

or decreased

vasclarity

variable

heterogeneous

texture,

hypoechogenic

Hashimoto's

thyroiditis

+ Painful

mass

Present

late

Present

early

High Low 95% heterogeneous

echotexture

decreased

vasclarity

hypoechoic

micronodules

lymphoid

follicles

Germinal centers

Acute suppurative

thyroiditis

+ Small

painful mass

Present

late

Present

early

High Low Absent variable

heterogeneous

texture

perithyroidal

hypoechoic

space due to

abcess

References

  1. 1.0 1.1 1.2 "Thyroiditis — NEJM".
  2. Akuzawa N, Yokota T, Suzuki T, Kurabayashi M (2017). "Acute suppurative thyroiditis caused by Streptococcus agalactiae infection: a case report". Clin Case Rep. 5 (8): 1238–1242. doi:10.1002/ccr3.1048. PMC 5538065. PMID 28781832.
  3. 3.0 3.1 Bindra A, Braunstein GD (2006). "Thyroiditis". Am Fam Physician. 73 (10): 1769–76. PMID 16734054.
  4. 4.0 4.1 McDermott MT (2009). "In the clinic. Hypothyroidism". Ann. Intern. Med. 151 (11): ITC61. doi:10.7326/0003-4819-151-11-200912010-01006. PMID 19949140.
  5. 5.0 5.1 Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR (2007). "Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999-2002)". Thyroid. 17 (12): 1211–23. doi:10.1089/thy.2006.0235. PMID 18177256.
  6. 6.0 6.1 Lania A, Persani L, Beck-Peccoz P (2008). "Central hypothyroidism". Pituitary. 11 (2): 181–6. doi:10.1007/s11102-008-0122-6. PMID 18415684.
  7. 7.0 7.1 De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Stockigt J. "Clinical Strategies in the Testing of Thyroid Function". PMID 25905413.
  8. "Clinical Finding and Thyroid Function in Women with Struma Ovarii".
  9. Vaidya B, Pearce SH (2014). "Diagnosis and management of thyrotoxicosis". BMJ. 349: g5128. PMID 25146390.
  10. "Think thyrotoxicosis factitia - measure thyroglobulin | The BMJ".

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