Thyroiditis

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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. It is classified into Hashimoto's thyroiditis, de Quervain's Thyroiditis, silent thyroiditis, postpartum thyroiditis, Riedel's thyroiditis, and suppurative thyroiditis. These forms of thyroiditis can be differentiated from each other on the basis of pathological and laboratory findings. Thyroiditis can lead to hypothyroidism or transient hyperthyroidism. The hypothyroid phase of thyroiditis results from the gradual depletion of stored thyroid hormones. Chronic hypothyroidism is predominantly associated with hashimoto’s thyroiditis. However, all the types of thyroiditis may progress to permanent hypothyroidism. Painless sporadic thyroiditis (silent thyroiditis), painless postpartum thyroiditis, and painful subacute thyroiditis (de Quervain's thyroiditis) usually lead to transient hyperthyroidism (thyrotoxicosis) when the preformed thyroid hormones are released from the damaged gland. As thyroid hormone stores are depleted, there is often a progression through a period of euthyroidism to hypothyroidism. Suppurative thyroiditis is the result of an infection usually in the patients with preexisting thyroid disease (Hashimoto's thyroiditis, thyroid cancer, or multinodular goiter), immunosuppression, and congenital anomalies (pyriform sinus fistula). The diagnosis of thyroiditis is usually made on the physical examination, thyroid function tests, thyroid ultrasound, iodine uptake, thyroglobulin, and thyroid peroxidase antibodies. Histopathological analysis is also helpful to differentiate thyroiditis from other thyroid diseases. The treatment of thyroiditis is usually symptomatic. Beta blockers are used for the symptoms of thyrotoxicosis and levothyroxine is helpful to improve the symptoms of hypothyroidism. NSAIDs are helpful in alleviating the pain in de Quervain's thyroiditis and corticosteroids are specifically used in Riedel's thyroiditis. Antibiotics are usually reserved for the suppurative thyroiditis.

Classification

Thyroiditis is classified into the following types:



 
 
 
 
 
 
 
 
 
 
 
 
Thyroiditis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hashimoto's thyroiditis
 
 
DeQuervain's Thyroiditis
 
Silent thyroiditis
 
 
 
Postpartum thyroiditis
 
 
Riedel's thyroiditis
 
 
Suppurative thyroiditis
 
 
 




Differentiating Thyroiditis from Other Diseases

Various forms of thyroiditis can be differentiated from each other on the basis of pathological and laboratory findings:[1]

Conditions Causes Age at onset Pathological findings Diagnostic approach
Hashimoto's thyroiditis
  • All ages, peak at 30-50
Painful subacute (De Quervain's) thyroiditis
  • Unknown
  • 20-60
Silent thyroiditis
  • Autoimmune
  • All ages, peak at 30-40
Postpartum thyroiditis
  • Autoimmune
  • Childbearing age
  • Lymphocytic infiltration
Riedel's thyroiditis
  • Unknown
  • 30-60
Suppurative thyroiditis
  • Infection
  • Children, 20-40

Differentiating thyroiditis from other causes of hypothyroidism

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
  • Infectious thyroiditis associated with neck pain
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 thyroiditis - - ↑/↓ ↓/↑ Normal ↓ Normal/↑ Normal Absent**
Radiation-induced thyroiditis
Trauma induced thyroiditis
Radioiodine induced thyroiditis
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 thyroiditis causing thyrotoxicosis from other causes of hyperthyroidism

  • Hashimoto's thyroiditis can initially present with thyrotoxicosis (hashitoxicosis) which must be differentiated from other causes of thyrotoxicosis.[2][3][1][4][5][6][7][8][9]
Disease History and symptoms Laboratory findings Additional findings
Fever Pain TSH Free T4 T3 T3RU† Thyroglobin TRH TSH Receptor Antibody TPOAb^
Thyroiditis Hashimoto's thyroiditis (Hashitoxicosis) - - ↑* ↓ Normal/↓ Normal/↓ Normal/↑ Normal Absent Present (high titer)
Subacute (de Quervain's) thyroiditis +/- +/- ↑/↓ ↓/↑ Normal ↓ ↑ Normal Absent Low/absent
Postpartum thyroiditis +/- +/- ↑/↓ ↓/↑ Normal ↓ ↑ Normal/↑ Absent Present (high titer)
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

Diagnosis

The following flowchart describes the clinical approach to the diagnosis of thyroiditis.

Stepwise clinical diagnosis of thyroiditis

 
 
 
 
 
 
 
 
 
 
 
Neck pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
RAIU*
 
 
 
 
 
 
 
 
 
 
Presenting symptoms and TFTs‡
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increased
 
 
Decreased
 
 
 
 
 
Hyperthyroid
 
 
 
Hypothyroid
 
Euthyroid
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
RAIU*
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suppurative thyroiditis
 
 
De Quervain's thyroiditis
 
 
 
Increased
 
Decreased
 
Hashimoto's thyroiditis
 
 
Riedel's thyroiditis††
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Grave's disease†
 
Silent thyroiditis
Postpartum thyroiditis

‡TFT: Thyroid function tests (TSH, T4, and T3)
†: Grave's disease is not a thyroiditis
*: RAIU; Radioiodine uptake
††: One third of Riedel's thyroiditis presents with hypothyroidism

Treatment

Treatment of Hashimoto's thyroiditis

The drugs used in the treatment of Hashimoto's thyroiditis are:[10][11] 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

Corticosteroids:

  • A short course of glucocorticoids can be used in the treatment of IgG4-related variant of Hashimoto's thyroiditis.

Selenium:

Drug Regimen for Hashimoto's thyroiditis

Treatment of de Quervain's thyroiditis thyroiditis

The drugs used in the treatment of de Quervain's thyroiditis are:[12][13][14][15]

Drug Regimens for de Quervain's thyroiditis

  • 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

Treatment of silent thyroiditis

The drugs used in the treatment of silent thyroiditis are:[16][17][18]

Drug Regimen for silent thyroidits

  • 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

Treatment of Riedel's thyroidtis

Drug Regimens for Riedel's thyroidtis

The effectiveness of therapy and dosages for Riedel's thyroiditis have not yet been assessed completely. As a result, the exact dosage regimens and duration of therapy cannot be defined. The current recommendations are based on the clinical manifestations, associated conditions, and the response to treatment.

  • Preferred regimen (1): Prednisone 15-60mg PO q24h for 6 months to 2 years
  • Preferred regimen (2): Prednisone 500 mg PO q24h for 6 months to 2 years
  • Alternative regimen (1): Tamoxifen 10-20 mg PO q24h for 6 months to 2 years
  • Alternative regimen (1): Mycophenolate mofetil 1 g PO q12h for 6 months to 2 years

Related Chapters

References

  1. ↑ 1.0 1.1 1.2 "Thyroiditis — NEJM".
  2. ↑ 2.0 2.1 Bindra A, Braunstein GD (2006). "Thyroiditis". Am Fam Physician. 73 (10): 1769–76. PMID 16734054.
  3. ↑ 3.0 3.1 McDermott MT (2009). "In the clinic. Hypothyroidism". Ann. Intern. Med. 151 (11): ITC61. doi:10.7326/0003-4819-151-11-200912010-01006. PMID 19949140.
  4. ↑ 4.0 4.1 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.
  5. ↑ 5.0 5.1 Lania A, Persani L, Beck-Peccoz P (2008). "Central hypothyroidism". Pituitary. 11 (2): 181–6. doi:10.1007/s11102-008-0122-6. PMID 18415684.
  6. ↑ 6.0 6.1 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.
  7. ↑ "Clinical Finding and Thyroid Function in Women with Struma Ovarii".
  8. ↑ Vaidya B, Pearce SH (2014). "Diagnosis and management of thyrotoxicosis". BMJ. 349: g5128. PMID 25146390.
  9. ↑ "Think thyrotoxicosis factitia - measure thyroglobulin | The BMJ".
  10. ↑ Caturegli P, De Remigis A, Rose NR (2014). "Hashimoto thyroiditis: clinical and diagnostic criteria". Autoimmun Rev. 13 (4–5): 391–7. doi:10.1016/j.autrev.2014.01.007. PMID 24434360.
  11. ↑ Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM (2014). "Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement". Thyroid. 24 (12): 1670–751. doi:10.1089/thy.2014.0028. PMC 4267409. PMID 25266247.
  12. ↑ Engkakul P, Mahachoklertwattana P, Poomthavorn P (2011). "Eponym : de Quervain thyroiditis". Eur. J. Pediatr. 170 (4): 427–31. doi:10.1007/s00431-010-1306-4. PMID 20886353.
  13. ↑ Yamamoto M, Saito S, Sakurada T, Fukazawa H, Yoshida K, Kaise K, Kaise N, Nomura T, Itagaki Y, Yonemitsu K (1987). "Effect of prednisolone and salicylate on serum thyroglobulin level in patients with subacute thyroiditis". Clin. Endocrinol. (Oxf). 27 (3): 339–44. PMID 3427792.
  14. ↑ Volpé R (1993). "The management of subacute (DeQuervain's) thyroiditis". Thyroid. 3 (3): 253–5. PMID 8257868.
  15. ↑ Feely J, Peden N (1984). "Use of beta-adrenoceptor blocking drugs in hyperthyroidism". Drugs. 27 (5): 425–46. PMID 6144501.
  16. ↑ Samuels MH (2012). "Subacute, silent, and postpartum thyroiditis". Med. Clin. North Am. 96 (2): 223–33. doi:10.1016/j.mcna.2012.01.003. PMID 22443972.
  17. ↑ Schubert MF, Kountz DS (1995). "Thyroiditis. A disease with many faces". Postgrad Med. 98 (2): 101–3, 107–8, 112. PMID 7630839.
  18. ↑ Singer PA (1991). "Thyroiditis. Acute, subacute, and chronic". Med. Clin. North Am. 75 (1): 61–77. PMID 1987447.
  19. ↑ Zimmermann-Belsing T, Feldt-Rasmussen U (1994). "Riedel's thyroiditis: an autoimmune or primary fibrotic disease?". J. Intern. Med. 235 (3): 271–4. PMID 8120524.
  20. ↑ Vaidya B, Harris PE, Barrett P, Kendall-Taylor P (1997). "Corticosteroid therapy in Riedel's thyroiditis". Postgrad Med J. 73 (866): 817–9. PMC 2431527. PMID 9497955.
  21. ↑ Chopra D, Wool MS, Crosson A, Sawin CT (1978). "Riedel's struma associated with subacute thyroiditis, hypothyroidism, and hypoparathyroidism". J. Clin. Endocrinol. Metab. 46 (6): 869–71. doi:10.1210/jcem-46-6-869. PMID 263470.
  22. ↑ Bagnasco M, Passalacqua G, Pronzato C, Albano M, Torre G, Scordamaglia A (1995). "Fibrous invasive (Riedel's) thyroiditis with critical response to steroid treatment". J. Endocrinol. Invest. 18 (4): 305–7. doi:10.1007/BF03347818. PMID 7560814.
  23. ↑ Thomson JA, Jackson IM, Duguid WP (1968). "The effect of steroid therapy on Riedel's thyroiditis". Scott Med J. 13 (1): 13–6. doi:10.1177/003693306801300103. PMID 5694137.
  24. ↑ Dabelic N, Jukic T, Labar Z, Novosel SA, Matesa N, Kusic Z (2003). "Riedel's thyroiditis treated with tamoxifen" (PDF). Croat. Med. J. 44 (2): 239–41. PMID 12698518.
  25. ↑ Levy JM, Hasney CP, Friedlander PL, Kandil E, Occhipinti EA, Kahn MJ (2010). "Combined mycophenolate mofetil and prednisone therapy in tamoxifen- and prednisone-resistant Reidel's thyroiditis". Thyroid. 20 (1): 105–7. doi:10.1089/thy.2009.0324. PMID 20067381.
  26. ↑ Fatourechi MM, Hay ID, McIver B, Sebo TJ, Fatourechi V (2011). "Invasive fibrous thyroiditis (Riedel thyroiditis): the Mayo Clinic experience, 1976-2008". Thyroid. 21 (7): 765–72. doi:10.1089/thy.2010.0453. PMID 21568724.



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