Postpartum thyroiditis differential diagnosis

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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

• 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.

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

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:

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.

Differentiating postpartum thyroiditis from other causes of thyrotoxicosis

• Postpartum thyroiditis can initially present with thyrotoxicosis which must be differentiated from other causes of thyrotoxicosis.

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)	May present with hypothyroidism
	Hashimoto's thyroiditis (Hashitoxicosis)	-	-	↑*	↓	Normal/↓	Normal/↓	Normal/↑	Normal	Absent	Present (high titer)	May be accompanied by other autoimmune diseases
	Subacute (de Quervain's) thyroiditis	+/-	+/-	↑/↓	↓/↑	Normal	↓	↑	Normal	Absent	Low/absent	May present with hypothyroidism
	Silent thyroiditis	-	-	↑/↓	↓/↑	Normal	↓	↑	Normal	Absent	Present (high titer)	May present with hypothyroidism
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
		Fatiuge	Neck swelling	Low mood	Irritability	TSH	FT4	TPO ab	ESR	RAI uptake	Thyroid U/S
Persistent hyperthyroidism	Grave's disease	Present	Small painful mass	Present	Present early	Low	High	Absent	High	High	diffusely enlarged hypervascular heterogeneous echotexture
Transient hyperthyroidism	Silent thyroiditis	Present	Small painless goiter	Present late	Present early	Normal or Low	High	50%	Normal	low	markedly decreased vascularity variable heterogeneous texture
	Postpartum thyroiditis	Present	Small painless goiter	Present late	Present early	Normal or Low	High	>80%	High	low	hypoechoic diffusely enlarged with normal or decreased vasclarity
	Subacute (de Quervain's) granulomatous thyroiditis	Present	Small painful mass	Present late	Present early	Normal or Low	High	Absent	High	low	diffusely enlarged with normal or decreased vasclarity
	Factitious thyrotoxicosis	Present	Normal	Absent	Present early	Normal or Low	High	Absent	Normal	low	Normal
	acute suppurative thyroiditis	Present	Small painful mass	Present late	Present early	Normal or Low	High	Absent	High	low	variable heterogeneous texture hypoechogenic
Destructive hyperthyroidism	Subacute (de Quervain's) granulomatous thyroiditis	Present	Small painful mass	Present late	Present early	Normal or Low	High	Absent	High	low	diffusely enlarged with normal or decreased vasclarity
	Postpartum thyroiditis	Present	Small painless goiter	Present late	Present early	Normal or Low	High	>80%	High	low	hypoechoic diffusely enlarged with normal or decreased vasclarity
	acute suppurative thyroiditis	Present	Small painful mass	Present late	Present early	Normal or Low	High	Absent	High	low	variable heterogeneous texture hypoechogenic
Transient hypothyroidism	Postpartum thyroiditis	Present	Small painless goiter	Present late	Present early	Normal or High	Low	>80%	High	low	hypoechoic diffusely enlarged with normal or decreased vasclarity
	Silent thyroiditis	Present	Small painless goiter	Present late	Present early	Normal or High	Low	Present	Normal	low	markedly decreased vascularity variable heterogeneous texture
	Subacute (de Quervain's) granulomatous thyroiditis	Present	Small painful mass	Present late	Present early	Normal or High	Low	Absent	High	low	diffusely enlarged with normal or decreased vasclarity
	acute suppurative thyroiditis	Present	Small painful mass	Present late	Present early	Normal or High	Low	Absent	High	low	variable heterogeneous texture hypoechogenic
Persistent hypothyroidism	Riedel's thyroiditis	Present	Small painful mass	Present late	Present early	High	Low	75%	High	low	homogeneously hypoechoic fibrotic invasion of the adjacent structures
	Postpartum thyroiditis	Present	Small painless goiter	Present late	Present early	High	Low	>80%	High	low	hypoechoic diffusely enlarged with normal or decreased vasclarity
	Hashimoto's thyroiditis	Present	Painful mass	Present late	Present early	High	Low	95%	High	low	heterogeneous echotexture decreased vasclarity hypoechoic micronodules
	Acute suppurative thyroiditis	Present	Small painful mass	Present late	Present early	High	Low	Absent	High	low	variable heterogeneous texture hypoechogenic