Silent thyroiditis differential diagnosis: Difference between revisions

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[[Silent thyroiditis]] must be differentiated from other causes of [[thyroiditis]], such as [[De Quervain's thyroiditis]], [[Hashimoto's thyroiditis]], [[Riedel's thyroiditis]], and suppurative thyroiditis.
[[Silent thyroiditis]] must be differentiated from other causes of [[thyroiditis]], such as [[De Quervain's thyroiditis]], [[Hashimoto's thyroiditis]], [[Riedel's thyroiditis]], and suppurative thyroiditis.
==Differentiating Silent Thyroiditis from other Diseases==
==Differentiating Silent Thyroiditis from other Diseases==
===Differentiating silent thyroiditis from other causes of thyroiditis===
*Silent 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>
*Silent 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>
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*[[I-123 thyroid imaging|I-123]] uptake normal
*[[I-123 thyroid imaging|I-123]] uptake normal
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===Differentiating silent thyroiditis from other causes of hypothyroidism===
*Silent thyroiditis must be differentiated from other causes of [[hypothyroidism]] on the basis of history and symptoms and laboratory findings:<ref name="pmid16734054">{{cite journal |vauthors=Bindra A, Braunstein GD |title=Thyroiditis |journal=Am Fam Physician |volume=73 |issue=10 |pages=1769–76 |year=2006 |pmid=16734054 |doi= |url=}}</ref><ref name="pmid19949140">{{cite journal |vauthors=McDermott MT |title=In the clinic. Hypothyroidism |journal=Ann. Intern. Med. |volume=151 |issue=11 |pages=ITC61 |year=2009 |pmid=19949140 |doi=10.7326/0003-4819-151-11-200912010-01006 |url=}}</ref><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="pmid18177256">{{cite journal |vauthors=Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR |title=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) |journal=Thyroid |volume=17 |issue=12 |pages=1211–23 |year=2007 |pmid=18177256 |doi=10.1089/thy.2006.0235 |url=}}</ref><ref name="pmid18415684">{{cite journal |vauthors=Lania A, Persani L, Beck-Peccoz P |title=Central hypothyroidism |journal=Pituitary |volume=11 |issue=2 |pages=181–6 |year=2008 |pmid=18415684 |doi=10.1007/s11102-008-0122-6 |url=}}</ref><ref name="pmid25905413">{{cite journal |vauthors=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 |title=Clinical Strategies in the Testing of Thyroid Function |journal= |volume= |issue= |pages= |year= |pmid=25905413 |doi= |url=}}</ref>
*Silent thyroiditis must be differentiated from other causes of [[hypothyroidism]] on the basis of history and symptoms and laboratory findings:<ref name="pmid16734054">{{cite journal |vauthors=Bindra A, Braunstein GD |title=Thyroiditis |journal=Am Fam Physician |volume=73 |issue=10 |pages=1769–76 |year=2006 |pmid=16734054 |doi= |url=}}</ref><ref name="pmid19949140">{{cite journal |vauthors=McDermott MT |title=In the clinic. Hypothyroidism |journal=Ann. Intern. Med. |volume=151 |issue=11 |pages=ITC61 |year=2009 |pmid=19949140 |doi=10.7326/0003-4819-151-11-200912010-01006 |url=}}</ref><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="pmid18177256">{{cite journal |vauthors=Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR |title=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) |journal=Thyroid |volume=17 |issue=12 |pages=1211–23 |year=2007 |pmid=18177256 |doi=10.1089/thy.2006.0235 |url=}}</ref><ref name="pmid18415684">{{cite journal |vauthors=Lania A, Persani L, Beck-Peccoz P |title=Central hypothyroidism |journal=Pituitary |volume=11 |issue=2 |pages=181–6 |year=2008 |pmid=18415684 |doi=10.1007/s11102-008-0122-6 |url=}}</ref><ref name="pmid25905413">{{cite journal |vauthors=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 |title=Clinical Strategies in the Testing of Thyroid Function |journal= |volume= |issue= |pages= |year= |pmid=25905413 |doi= |url=}}</ref>


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<br style="clear:left" />''(†)T3RU; Triiodothyronine Resin uptake. (^)TPOAb; [[Thyroid peroxidase]] antibodies. (*)[[TSH]] may be decreased transiently in the [[thyrotoxicosis]]. (**)TPOAb may be present in drug-induced [[Hypothyroidism|hypo]]/[[hyperthyroidism]] such as [[Interferon-alpha]], [[Interleukin 2|interleukin-2]], and [[lithium]].''


Painless thyroiditis must be differentiated from other causes of hyperthyroidism such as Grave's disease and toxic nodular goiter.
===Differentiating silent thyroiditis from other causes of thyrotoxicosis===
 
*Silent thyroiditis can initially present with thyrotoxicosis which must be differentiated from other causes of thyrotoxicosis.<ref name="pmid16734054">{{cite journal |vauthors=Bindra A, Braunstein GD |title=Thyroiditis |journal=Am Fam Physician |volume=73 |issue=10 |pages=1769–76 |year=2006 |pmid=16734054 |doi= |url=}}</ref><ref name="pmid19949140">{{cite journal |vauthors=McDermott MT |title=In the clinic. Hypothyroidism |journal=Ann. Intern. Med. |volume=151 |issue=11 |pages=ITC61 |year=2009 |pmid=19949140 |doi=10.7326/0003-4819-151-11-200912010-01006 |url=}}</ref><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="pmid18177256">{{cite journal |vauthors=Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR |title=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) |journal=Thyroid |volume=17 |issue=12 |pages=1211–23 |year=2007 |pmid=18177256 |doi=10.1089/thy.2006.0235 |url=}}</ref><ref name="pmid18415684">{{cite journal |vauthors=Lania A, Persani L, Beck-Peccoz P |title=Central hypothyroidism |journal=Pituitary |volume=11 |issue=2 |pages=181–6 |year=2008 |pmid=18415684 |doi=10.1007/s11102-008-0122-6 |url=}}</ref><ref name="pmid25905413">{{cite journal |vauthors=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 |title=Clinical Strategies in the Testing of Thyroid Function |journal= |volume= |issue= |pages= |year= |pmid=25905413 |doi= |url=}}</ref><ref name="urlClinical Finding and Thyroid Function in Women with Struma Ovarii">{{cite web |url=https://www.hindawi.com/archive/2013/717584/ |title=Clinical Finding and Thyroid Function in Women with Struma Ovarii |format= |work= |accessdate=}}</ref><ref name="pmid25146390">{{cite journal |vauthors=Vaidya B, Pearce SH |title=Diagnosis and management of thyrotoxicosis |journal=BMJ |volume=349 |issue= |pages=g5128 |year=2014 |pmid=25146390 |doi= |url=}}</ref><ref name="urlThink thyrotoxicosis factitia - measure thyroglobulin | The BMJ">{{cite web |url=http://www.bmj.com/content/349/bmj.g5128/rr/763450 |title=Think thyrotoxicosis factitia - measure thyroglobulin &#124; The BMJ |format= |work= |accessdate=}}</ref>
{| align="center" style="border: 0px; font-size: 90%; margin: 3px;"
{| class="wikitable" align="center" style="border: 0px; margin: 3px;"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Cause of thyrotoxicosis}}
! colspan="2" rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Disease
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |History and symptoms
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="8" align="center" style="background: #4479BA; color: #FFFFFF; " |Laboratory findings
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Additional findings
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Fever 
| style="padding: 5px 5px; background: #F5F5F5;" | +
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Pain
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH
| style="padding: 5px 5px; background: #F5F5F5;" | ?
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Free T4
| style="padding: 5px 5px; background: #F5F5F5;" | ?
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3RU<small>†
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Thyroglobin
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TRH
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH Receptor Antibody
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TPOAb^
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| rowspan="4" style="background:#DCDCDC;" |[[Thyroiditis]]
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="background:#DCDCDC;" |[[Silent thyroiditis]]
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑/'''↓
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present (high titer)
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*May present with [[hypothyroidism]]
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| align="center" style="background:#DCDCDC;" |[[Hashimoto's thyroiditis]] (Hashitoxicosis)
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''<small>*
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''''↓'''''
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present (high titer)
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* May be accompanied by other [[autoimmune diseases]]
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| align="center" style="background:#DCDCDC;" |[[De Quervain's thyroiditis|Subacute (de Quervain's) thyroiditis]]
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑/'''↓
| style="padding: 5px 5px; background: #F5F5F5;" | ?
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓/'''↑'''
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and<br> elevated inflammatory index
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Low/absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*May present with [[hypothyroidism]]
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| align="center" style="background:#DCDCDC;" |[[Postpartum thyroiditis]]
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑/'''↓
| style="padding: 5px 5px; background: #F5F5F5;" | ?
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓/'''↑'''
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present (high titer)
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*May present with [[hypothyroidism]]
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Amiodarone induced thyroiditis-Type 1}}
| rowspan="2" style="background:#DCDCDC;" |[[hyperthyroidism|Primary hyperthyroidism]]
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="background:#DCDCDC;" |[[Grave's disease]]
| style="padding: 5px 5px; background: #F5F5F5;" | Diffuse or nodular goiter
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | ?/Normal/?
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | ? but higher than in Type 2
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | High urinary iodine
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''''↑'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* Patient may have opthalmopathy and dermopathy
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Amiodarone induced thyroiditis-Type 2}}
| align="center" style="background:#DCDCDC;" |[[Toxic thyroid nodule]]
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Normal  
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| style="padding: 5px 5px; background: #F5F5F5;" | ?/absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| style="padding: 5px 5px; background: #F5F5F5;" | High urinary iodine
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑(hot nodule)
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
-
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Central hyperthyroidism}}
| rowspan="1" style="background:#DCDCDC;" |[[Hyperthyroidism|Secondary hyperthyroidism]]
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="background:#DCDCDC;" |[[Pituitary adenoma]]
| style="padding: 5px 5px; background: #F5F5F5;" | Diffuse or nodular goiter
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Normal/?
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | ?
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | Inappropriately normal or high TSH
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*Inappropriately normal or increased TSH
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Trophoblastic disease}}
| rowspan="1" style="background:#DCDCDC;" |[[Tertiary hyperthyroidism]]
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="background:#DCDCDC;" |[[Hyperthyroidism|Tertiary hyperthyroidism]]
| style="padding: 5px 5px; background: #F5F5F5;" | Diffuse or nodular goiter
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |-
| style="padding: 5px 5px; background: #F5F5F5;" | Normal/?
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |-
| style="padding: 5px 5px; background: #F5F5F5;" | ?
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*Inappropriately normal or increased TSH
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Factitious thyrotoxicosis}}
| rowspan="2" style="background:#DCDCDC;" |Drug induced
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="background:#DCDCDC;" |[[Amiodarone| Amiodarone type 1]]
| style="padding: 5px 5px; background: #F5F5F5;" | Variable
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | ?
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | ? Serum thyroglobulin
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*High urinary iodine
|-
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Struma ovarii}}
| align="center" style="background:#DCDCDC;" |[[Amiodarone|Amiodarone type 2]]
| style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Variable
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | ?
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | Abdominal RAIU
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
|}
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent/↓
 
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
{| align="center" style="border: 0px; font-size: 90%; margin: 3px;"
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
! colspan="2" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Disease}}
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Findings}}
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*High urinary iodine
|-
|-
| colspan="1" rowspan="5" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Thyroiditis}}
| rowspan="3" style="background:#DCDCDC;" |Others
| style="padding: 5px 5px; background: #4479BA;" | {{fontcolor|#FFFFFF|Direct chemical toxicity with inflammation}}
| align="center" style="background:#DCDCDC;" |[[Factitious thyrotoxicosis]]
| style="padding: 5px 5px; background: #F5F5F5;" | [[Amiodarone]], [[sunitinib]], [[pazopanib]], [[axitinib]], and other [[tyrosine kinase inhibitors]] may also be associated with a destructive [[thyroiditis]].<ref name="pmid2258582">{{cite journal |vauthors=Lambert M, Unger J, De Nayer P, Brohet C, Gangji D |title=Amiodarone-induced thyrotoxicosis suggestive of thyroid damage |journal=J. Endocrinol. Invest. |volume=13 |issue=6 |pages=527–30 |year=1990 |pmid=2258582 |doi= |url=}}</ref><ref name="pmid24282820">{{cite journal |vauthors=Ahmadieh H, Salti I |title=Tyrosine kinase inhibitors induced thyroid dysfunction: a review of its incidence, pathophysiology, clinical relevance, and treatment |journal=Biomed Res Int |volume=2013 |issue= |pages=725410 |year=2013 |pmid=24282820 |pmc=3824811 |doi=10.1155/2013/725410 |url=}}</ref>
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*Decreased thyroglobulin
|-
|-
| style="padding: 5px 5px; background: #4479BA;" | {{fontcolor|#FFFFFF|Radiation thyroiditis}}
| align="center" style="background:#DCDCDC;" |[[Trophoblastic disease]]
| style="padding: 5px 5px; background: #F5F5F5;" | Patients treated with [[radioiodine]] may develop thyroid pain and tenderness 5 to 10 days later, due to radiation-induced injury and necrosis of thyroid follicular cells and associated [[inflammation]].
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
-
|-
|-
| style="padding: 5px 5px; background: #4479BA;" | {{fontcolor|#FFFFFF|Drugs that interfere with the immune system}}
| align="center" style="background:#DCDCDC;" |[[Struma ovarii]]
| style="padding: 5px 5px; background: #F5F5F5;" | [[Interferon alfa-2a clinical pharmacology|Interferon-alfa]] is a well-known cause of [[thyroid]] abnormality. It mostly leads to the development of de novo [[antithyroid]] [[antibodies]].<ref name="pmid8351956">{{cite journal |vauthors=Vialettes B, Guillerand MA, Viens P, Stoppa AM, Baume D, Sauvan R, Pasquier J, San Marco M, Olive D, Maraninchi D |title=Incidence rate and risk factors for thyroid dysfunction during recombinant interleukin-2 therapy in advanced malignancies |journal=Acta Endocrinol. |volume=129 |issue=1 |pages=31–8 |year=1993 |pmid=8351956 |doi= |url=}}</ref>
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #4479BA;" | {{fontcolor|#FFFFFF|Lithium}}
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | Patients treated with [[lithium]] are at a high risk of developing [[Thyroiditis|painless thyroiditis]] and [[Graves' disease]].
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
|-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/
| style="padding: 5px 5px; background: #4479BA;" | {{fontcolor|#FFFFFF|Palpation thyroiditis}}
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | Manipulation of the [[thyroid gland]] during [[thyroid]] [[biopsy]] or neck [[surgery]] and vigorous palpation during the physical examination may cause transient hyperthyroidism.
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |-
|-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| colspan="1" rowspan="4" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Exogenous and ectopic hyperthyroidism }}
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| style="padding: 5px 5px; background: #4479BA;" | {{fontcolor|#FFFFFF|Factitious ingestion of thyroid hormone}}
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| style="padding: 5px 5px; background: #F5F5F5;" |The diagnosis is based on the clinical features, laboratory findings, and 24-hour [[radioiodine]] uptake.<ref name="pmid2666114">{{cite journal |vauthors=Cohen JH, Ingbar SH, Braverman LE |title=Thyrotoxicosis due to ingestion of excess thyroid hormone |journal=Endocr. Rev. |volume=10 |issue=2 |pages=113–24 |year=1989 |pmid=2666114 |doi=10.1210/edrv-10-2-113 |url=}}</ref>
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
|-
-
| style="padding: 5px 5px; background: #4479BA;" | {{fontcolor|#FFFFFF|Acute hyperthyroidism from a levothyroxine overdose}}
| style="padding: 5px 5px; background: #F5F5F5;" |The diagnosis is based on the clinical features, laboratory findings, and 24-hour [[radioiodine]] uptake.<ref name="pmid23067331">{{cite journal |vauthors=Jha S, Waghdhare S, Reddi R, Bhattacharya P |title=Thyroid storm due to inappropriate administration of a compounded thyroid hormone preparation successfully treated with plasmapheresis |journal=Thyroid |volume=22 |issue=12 |pages=1283–6 |year=2012 |pmid=23067331 |doi=10.1089/thy.2011.0353 |url=}}</ref>
|-
| style="padding: 5px 5px; background: #4479BA;" | {{fontcolor|#FFFFFF|Struma ovarii}}
| style="padding: 5px 5px; background: #F5F5F5;" |Functioning [[thyroid]] tissue is present in an [[ovarian neoplasm]].
|-
| style="padding: 5px 5px; background: #4479BA;" | {{fontcolor|#FFFFFF|Functional thyroid cancer metastases}}
| style="padding: 5px 5px; background: #F5F5F5;" |Large bony [[metastases]] from widely metastatic [[follicular thyroid cancer]] cause symptomatic hyperthyroidism.
|-
| colspan="2" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashitoxicosis }}
| style="padding: 5px 5px; background: #F5F5F5;" |It is an autoimmune thyroid disease that initially presents with hyperthyroidism and a high [[radioiodine]] uptake caused by [[TSH receptor|TSH-receptor]] antibodies similar to [[Graves' disease]]. It is then followed by the development of [[hypothyroidism]] due to the infiltration of the [[thyroid gland]] with [[Lymphocyte|lymphocytes]] and the resultant autoimmune-mediated destruction of [[thyroid]] tissue, similar to chronic [[lymphocytic thyroiditis]].<ref name="pmid5171000">{{cite journal |vauthors=Fatourechi V, McConahey WM, Woolner LB |title=Hyperthyroidism associated with histologic Hashimoto's thyroiditis |journal=Mayo Clin. Proc. |volume=46 |issue=10 |pages=682–9 |year=1971 |pmid=5171000 |doi= |url=}}</ref>
|-
| colspan="2" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma and toxic multinodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" |Toxic adenoma and [[toxic multinodular goiter]] are results of focal/diffuse [[hyperplasia]] of [[thyroid]] follicular cells independent of [[TSH]] regulation. Findings of single or multiple [[nodules]] are seen on physical examination or [[thyroid]] scan.<ref name="pmid2040867">{{cite journal |vauthors=Laurberg P, Pedersen KM, Vestergaard H, Sigurdsson G |title=High incidence of multinodular toxic goitre in the elderly population in a low iodine intake area vs. high incidence of Graves' disease in the young in a high iodine intake area: comparative surveys of thyrotoxicosis epidemiology in East-Jutland Denmark and Iceland |journal=J. Intern. Med. |volume=229 |issue=5 |pages=415–20 |year=1991 |pmid=2040867 |doi= |url=}}</ref>
|-
| colspan="2" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Iodine-induced hyperthyroidism  }}
| style="padding: 5px 5px; background: #F5F5F5;" |It is uncommon but can develop after an [[iodine]] load, such as administration of contrast agents used for [[angiography]] or [[Computed tomography|computed tomography (CT)]], or [[iodine]]-rich drugs such as [[amiodarone]].
|-
|-
| colspan="2" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Trophoblastic disease and germ cell tumors }}
| style="padding: 5px 5px; background: #F5F5F5;" |[[Thyroid-stimulating hormone]] and [[HCG]] have a common alpha-subunit and a beta-subunit with considerable homology. As a result, [[HCG]] has weak thyroid-stimulating activity and high [[titer]] [[HCG]] may mimic hyperthyroidism.<ref name="pmid19605510">{{cite journal |vauthors=Oosting SF, de Haas EC, Links TP, de Bruin D, Sluiter WJ, de Jong IJ, Hoekstra HJ, Sleijfer DT, Gietema JA |title=Prevalence of paraneoplastic hyperthyroidism in patients with metastatic non-seminomatous germ-cell tumors |journal=Ann. Oncol. |volume=21 |issue=1 |pages=104–8 |year=2010 |pmid=19605510 |doi=10.1093/annonc/mdp265 |url=}}</ref>
|}
|}
<small>''(†)T3RU; Triiodothyronine Resin uptake. (^)TPOAb; [[Thyroid peroxidase]] antibodies.''</small>


==References==
==References==

Revision as of 17:17, 5 October 2017

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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

Silent thyroiditis must be differentiated from other causes of thyroiditis, such as De Quervain's thyroiditis, Hashimoto's thyroiditis, Riedel's thyroiditis, and suppurative thyroiditis.

Differentiating Silent Thyroiditis from other Diseases

Differentiating silent thyroiditis from other causes of thyroiditis

Conditions Causes Age at onset Pathological findings Diagnostic approach
Silent thyroiditis
  • Autoimmune
  • All ages, peak at 30-40
  • Lymphocytic infiltration
  • Lymphoid follicles
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
Postpartum thyroiditis
  • Autoimmune
  • Childbearing age
  • Lymphocytic infiltration
Riedel's thyroiditis
  • Unknown
  • 30-60
  • Dense fibrosis
Suppurative thyroiditis
  • Infection
  • Children, 20-40
  • Abscess formation

Differentiating silent thyroiditis from other causes of hypothyroidism

Disease History and symptoms Laboratory findings Additional findings
Fever Pain TSH Free T4 T3 T3RU Thyroglobin TRH TPOAb^
Transient hypothyroidism Silent thyroiditis - - ↑/ ↓/ Normal Normal Present (high titer)
Postpartum thyroiditis +/- +/- ↑/ ↓/ Normal Normal/↑ Present (high titer)
Subacute (de Quervain's) thyroiditis +/- +/- ↑/ ↓/ Normal Normal Low/absent
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
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

Differentiating silent thyroiditis from other causes of thyrotoxicosis

  • Silent thyroiditis can initially present with thyrotoxicosis 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 Silent 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
Postpartum 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.

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".


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