Thyroiditis: Difference between revisions

	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

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Latest revision as of 11:43, 25 October 2017

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:

Hashimoto's thyroiditis
De Quervain's Thyroiditis or granulomatous thyroiditis
Silent thyroiditis
Postpartum thyroiditis
Riedel's thyroiditis
Suppurative thyroiditis

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	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 thyroiditis from other causes of hypothyroidism

The diagnosis of thyroiditis is usually made on the physical examination, thyroid function tests and various other diagnostic tests are listed in the table below:^[2]^[3]^[1]^[4]^[5]^[6]

Disease		History and symptoms		Laboratory findings							Additional findings
Disease		Fever	Pain	TSH	Free T4	T3	T3RU†	Thyroglobin	TRH	TPOAb^	Additional findings
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 thyroiditis	-	-	↑/↓	↓/↑	Normal	↓	Normal/↑	Normal	Absent**	History of hyperthyroidism History of trauma History of drug use, surgery, or radiation
	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
Disease		Fever	Pain	TSH	Free T4	T3	T3RU†	Thyroglobin	TRH	TSH Receptor Antibody	TPOAb^	Additional findings
Thyroiditis	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
	Postpartum thyroiditis	+/-	+/-	↑/↓	↓/↑	Normal	↓	↑	Normal/↑	Absent	Present (high titer)	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
Primary hyperthyroidism	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
Drug induced	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

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:

Dietary selenium supplementation is considered to be protective against the autoimmune diseases of the thyroid.

Drug Regimen for Hashimoto's thyroiditis

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

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

The drugs used in the treatment of silent thyroiditis are:^[19]^[20]^[21]^[22]^[23]^[24]^[25]^[26]
Corticosteroids
Tamoxifen
Mycophenolate mofetil(used in combination with corticosteroids)

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

↑ ^1.0 ^1.1 ^1.2 "Thyroiditis — NEJM".
↑ ^2.0 ^2.1 Bindra A, Braunstein GD (2006). "Thyroiditis". Am Fam Physician. 73 (10): 1769–76. PMID 16734054.
↑ ^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.
↑ ^4.0 ^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.
↑ ^5.0 ^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.
↑ ^6.0 ^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.
↑ "Clinical Finding and Thyroid Function in Women with Struma Ovarii".
↑ Vaidya B, Pearce SH (2014). "Diagnosis and management of thyrotoxicosis". BMJ. 349: g5128. PMID 25146390.
↑ "Think thyrotoxicosis factitia - measure thyroglobulin | The BMJ".
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ Volpé R (1993). "The management of subacute (DeQuervain's) thyroiditis". Thyroid. 3 (3): 253–5. PMID 8257868.
↑ Feely J, Peden N (1984). "Use of beta-adrenoceptor blocking drugs in hyperthyroidism". Drugs. 27 (5): 425–46. PMID 6144501.
↑ 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.
↑ Schubert MF, Kountz DS (1995). "Thyroiditis. A disease with many faces". Postgrad Med. 98 (2): 101–3, 107–8, 112. PMID 7630839.
↑ Singer PA (1991). "Thyroiditis. Acute, subacute, and chronic". Med. Clin. North Am. 75 (1): 61–77. PMID 1987447.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.

Template:WikiDoc Sources

[urlThyroiditis_—_NEJM-1] 1.0 ^1.1 ^1.2 "Thyroiditis — NEJM".

[pmid16734054-2] 2.0 ^2.1 Bindra A, Braunstein GD (2006). "Thyroiditis". Am Fam Physician. 73 (10): 1769–76. PMID 16734054.

[pmid19949140-3] 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.

[pmid18177256-4] 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.

[pmid18415684-5] 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.

[pmid25905413-6] 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.

[urlClinical_Finding_and_Thyroid_Function_in_Women_with_Struma_Ovarii-7] "Clinical Finding and Thyroid Function in Women with Struma Ovarii".

[pmid25146390-8] Vaidya B, Pearce SH (2014). "Diagnosis and management of thyrotoxicosis". BMJ. 349: g5128. PMID 25146390.

[urlThink_thyrotoxicosis_factitia_-_measure_thyroglobulin_|_The_BMJ-9] "Think thyrotoxicosis factitia - measure thyroglobulin | The BMJ".

[pmid24434360-10] 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.

[pmid25266247-11] 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.

[pmid20886353-12] 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.

[pmid3427792-13] 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.

[pmid8257868-14] Volpé R (1993). "The management of subacute (DeQuervain's) thyroiditis". Thyroid. 3 (3): 253–5. PMID 8257868.

[pmid6144501-15] Feely J, Peden N (1984). "Use of beta-adrenoceptor blocking drugs in hyperthyroidism". Drugs. 27 (5): 425–46. PMID 6144501.

[pmid22443972-16] 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.

[pmid7630839-17] Schubert MF, Kountz DS (1995). "Thyroiditis. A disease with many faces". Postgrad Med. 98 (2): 101–3, 107–8, 112. PMID 7630839.

[pmid1987447-18] Singer PA (1991). "Thyroiditis. Acute, subacute, and chronic". Med. Clin. North Am. 75 (1): 61–77. PMID 1987447.

[pmid8120524-19] 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.

[pmid9497955-20] 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.

[pmid263470-21] 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.

[pmid7560814-22] 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.

[pmid5694137-23] 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.

[pmid12698518-24] 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.

[pmid20067381-25] 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.

[pmid21568724-26] 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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 == 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|Hashimoto’s thyroiditis]]. However, all the types of thyroiditis may progress to permanent [[hypothyroidism]]. [[Silent thyroiditis|Painless sporadic thyroiditis (silent thyroiditis)]], [[Postpartum thyroiditis|painless postpartum thyroiditis]], and [[De Quervain's thyroiditis|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 [[Euthyroid|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 [[Toxic multinodular goiter|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-123|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.
+Thyroiditis refers to an [[inflammation]] of the [[thyroid gland]]. It is classified into [[Hashimoto's thyroiditis]], [[DeQuervain'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|hashimoto’s thyroiditis]]. However, all the types of thyroiditis may progress to permanent [[hypothyroidism]]. [[Silent thyroiditis|Painless sporadic thyroiditis (silent thyroiditis)]], [[Postpartum thyroiditis|painless postpartum thyroiditis]], and [[De Quervain's thyroiditis|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 hormones|thyroid hormone]] stores are depleted, there is often a progression through a period of [[Euthyroid|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 [[Toxic multinodular goiter|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-123|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.
-==Flowchart==
-{{familytree/start |summary=Sample 1}}
-{{familytree | | | | | | | | | | | | A01 | | |A01=Neck pain}}
-{{familytree | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | }}
-{{familytree | | | | | | B01 | | | | | | | | | | | B02 | | |B01=Yes|B02=No}}
-{{familytree | | | | | | |!| | | | | | | | | | | | |!| }}
-{{familytree | | | | | | C01 | | | | | | | | | | | C02 |C01=RAIU*|C02=Presenting symptoms and TFTs}}
-{{familytree | | | | |,|-|^|-|-|.| | | | | | | |,|-|^|-|-|-|v|-|-|-|.| }}
-{{familytree | | | | D01 | | | D02 | | | | | | D03 | | | | D04 | |D05|D01=Increased|D02=Decreased|D03=Hyperthyroid|D04=Hypothyroid|D05=Euthyroid}}
-{{familytree | | | | |!| | | | |!| | | | | | | |!| | | | | |!| | | |!|}}
-{{familytree | | | | |!| | | | |!| | | | | | | H01 | | | | |!| | | |!|H01=RAIU*}}
-{{familytree | | | | |!| | | | |!| | | | | |,|-|^|-|.| | | |!| | | |!|}}
-{{familytree | | | | E01 | | | E04 | | | | E02 | | E03 | | E04 | | |E06 |E01=Suppurative thyroiditis|E02=Increased|E03=Decreased|E04=Hashimoto's thyroiditis|E06=Riedel's thyroiditis}}
-{{familytree | | | | | | | | | | | | | | | |!| | | |!| }}
-{{familytree | | | | | | | | | | | | | | | F01 | | F02 |F01=Graves disease†|F02=De Quervain's thyroiditis
-Silent thyroiditis
-Postpartum thyroiditis}}
-{{familytree/end}}
-<small>†Grave's disease is not a thyroiditis,*RAIU; Radioiodine uptake. </small>
-<small>Modified from <ref name="urlThyroiditis: Differential Diagnosis and Management - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2000/0215/p1047.html#afp20000215p1047-b7 |title=Thyroiditis: Differential Diagnosis and Management - American Family Physician |format= |work= |accessdate=}}</ref></small>
 ==Classification==
 Thyroiditis is classified into the following types:
-*[[Hashimoto's thyroiditis]].
+*[[Hashimoto's thyroiditis]]
-*[[DeQuervain's Thyroiditis]] or Granulomatous Thyroiditis
+*[[DeQuervain's Thyroiditis|De Quervain's Thyroiditis]] or granulomatous thyroiditis
 *[[Silent thyroiditis]]
 *[[Postpartum thyroiditis]]
 *[[Riedel's thyroiditis]]
-*[[Suppurative thyroiditis]]
+*Suppurative thyroiditis
 <br><br>
 {{Family tree/start}}
@@ Line 45: / Line 23: @@
 ==Differentiating Thyroiditis from Other Diseases==
-Various forms of thyroiditis can be differentiated from each other on the basis of pathological and laboratory findings:<ref name="urlThyroiditis — NEJM">{{cite web |url=http://www.nejm.org/doi/full/10.1056/NEJMra021194 |title=Thyroiditis — NEJM |format= |work= |accessdate=}}</ref>
+Various forms of thyroiditis can be differentiated from each other on the basis of [[pathological]] and laboratory findings:<ref name="urlThyroiditis — NEJM">{{cite web |url=http://www.nejm.org/doi/full/10.1056/NEJMra021194 |title=Thyroiditis — NEJM |format= |work= |accessdate=}}</ref>
 {| align="center"
 |-
@@ Line 59: / Line 37: @@
 | align="center" style="background:#DCDCDC;" |[[Hashimoto's thyroiditis]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*Autoimmune
+*[[Autoimmune]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
 *All ages, peak at 30-50
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*Lymphocytic infiltration
+*[[Lymphocytic]] infiltration
-*Germinal centers
+*[[Germinal centers]]
-*Fibrosis (in some variants)
+*[[Fibrosis]] (in some variants)
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*[[Thyroid function tests|Increased TSH]] (hypothyroidism)
+*[[Thyroid function tests|Increased TSH]] ([[hypothyroidism]])
 *[[Thyroid peroxidase|TPO antibodies]] present in high titer
 *[[I-123 thyroid imaging|I-123]] uptake usually decreased
@@ Line 78: / Line 56: @@
 *20-60
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*Giant cells
+*[[Giant cells]]
-*Granulomas
+*[[Granulomas]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*[[Thyroid function tests|Increased TSH]] (hypothyroidism) and/or
+*[[Thyroid function tests|Increased TSH]] ([[hypothyroidism]]) and/or
-* [[Thyroid function tests|Decreased TSH]] (Thyrotoxicosis)
+* [[Thyroid function tests|Decreased TSH]] ([[thyrotoxicosis]])
 *[[Thyroid peroxidase|TPO antibodies]] absent or very low titer
 *[[I-123 thyroid imaging|I-123]] uptake decreased
@@ Line 92: / Line 70: @@
 *All ages, peak at 30-40
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*Lymphocytic infiltration
+*[[Lymphocytic]] infiltration
-*Lymphoid follicles
+*[[Lymphoid follicles]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*[[Thyroid function tests|Increased TSH]] (hypothyroidism) and/or
+*[[Thyroid function tests|Increased TSH]] ([[hypothyroidism]]) and/or
-* [[Thyroid function tests|Decreased TSH]] (transient hypothyroidism)
+* [[Thyroid function tests|Decreased TSH]] (transient [[hypothyroidism]])
 *[[Thyroid peroxidase|TPO antibodies]] present in high titer
 *[[I-123 thyroid imaging|I-123]] uptake usually decreased
@@ Line 108: / Line 86: @@
 *Lymphocytic infiltration
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*[[Thyroid function tests|Increased TSH]] (hypothyroidism) and/or
+*[[Thyroid function tests|Increased TSH]] ([[hypothyroidism]]) and/or
-* [[Thyroid function tests|Decreased TSH]] (transient hypothyroidism)
+* [[Thyroid function tests|Decreased TSH]] (transient [[hypothyroidism]])
 *[[Thyroid peroxidase|TPO antibodies]] present in high titer
 *[[I-123 thyroid imaging|I-123]] uptake usually decreased
@@ Line 119: / Line 97: @@
 *30-60
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*Dense fibrosis
+*Dense [[fibrosis]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
 *[[Thyroid function tests|Normal TSH]] (euthyroidism)
@@ Line 131: / Line 109: @@
 *Children, 20-40
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*Abscess formation
+*[[Abscess]] formation
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
 *[[Thyroid function tests|Normal TSH]] (euthyroidism)
@@ Line 137: / Line 115: @@
 *[[I-123 thyroid imaging|I-123]] uptake normal
 |}
-==Diagnosis==
 ===Differentiating thyroiditis from other causes of hypothyroidism===
-*The diagnosis of thyroiditis is usually made on the physical examination, [[thyroid function tests]] and various other diagnostic tests listed in the table below:<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>
+*The diagnosis of thyroiditis is usually made on the physical examination, [[thyroid function tests]] and various other diagnostic tests are listed in the table below:<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>
 {| class="wikitable" align="center" style="border: 0px; margin: 3px;"
@@ Line 148: / Line 124: @@
 ! rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Additional findings
 |-
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Fever
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Fever </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Pain
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Pain </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Free T4
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Free T4</small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3 </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3RU<small>†
+! 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> Thyroglobin </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TRH
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TRH </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TPOAb^
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TPOAb^ </small>
 |-
 | rowspan="3" style="background:#DCDCDC;" |[[Primary hypothyroidism]]
@@ Line 162: / Line 138: @@
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
-| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''<small>*
+| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''<small>*</small>
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''''↓'''''
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''''↓'''''
@@ Line 185: / Line 161: @@
 *[[Riedel's thyroiditis]] usually presents with hard and fixed thyroid mass.
 |-
-| align="center" style="background:#DCDCDC;" |[[Infectious thyroiditis]]
+| align="center" style="background:#DCDCDC;" |Infectious thyroiditis
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" | +
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" | +
@@ Line 196: / Line 172: @@
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
 | align="left" style="padding: 5px 5px; background: #F5F5F5;" |
-*[[Thyroiditis|Infectious thyroiditis]] associated with [[neck pain]]
+*Infectious thyroiditis associated with [[neck pain]]
 |-
 | rowspan="3" style="background:#DCDCDC;" |[[Hypothyroidism|Transient hypothyroidism]]
@@ Line 239: / Line 215: @@
 |-
 | rowspan="8" style="background:#DCDCDC;" |Others
-| align="center" style="background:#DCDCDC;" |Drug-induced
+| align="center" style="background:#DCDCDC;" |Drug-induced thyroiditis
 | rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
 | rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
@@ Line 251: / Line 227: @@
 | rowspan="5" align="left" style="padding: 5px 5px; background: #F5F5F5;" |
 * History of [[hyperthyroidism]]
-* History of trauma
+* History of [[trauma]]
-*History of drug use, surgery, or radiation
+*History of drug use, surgery, or [[radiation]]
 |-
-| align="center" style="background:#DCDCDC;" |Radiation-induced
+| align="center" style="background:#DCDCDC;" |Radiation-induced thyroiditis
 |-
-| align="center" style="background:#DCDCDC;" |Trauma induced
+| align="center" style="background:#DCDCDC;" |Trauma induced thyroiditis
 |-
-| align="center" style="background:#DCDCDC;" |Radioiodine induced
+| align="center" style="background:#DCDCDC;" |Radioiodine induced thyroiditis
 |-
 | align="center" style="background:#DCDCDC;" |Thyroidectomy
@@ Line 276: / Line 252: @@
 |-
 |}
-<br style="clear:left" />''<small>(†)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]].'' </small>
+<br style="clear:left" />
+<br>
+''<small>'''†''':T3RU; Triiodothyronine Resin Uptake''
+''<small>'''^''': TPOAb; [[Thyroid peroxidase]] antibodies''
+''<small>'''*''': [[TSH]] may be decreased transiently in the [[thyrotoxicosis]]''
+''<small>'''**''': TPOAb may be present in drug-induced [[Hypothyroidism|hypo]]/[[hyperthyroidism]] such as [[Interferon-alpha]], [[Interleukin 2|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.<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>
 {| class="wikitable" align="center" style="border: 0px; margin: 3px;"
 ! colspan="2" rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Disease
@@ Line 286: / Line 271: @@
 ! rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Additional findings
 |-
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Fever
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Fever</small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Pain
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Pain </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Free T4
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Free T4 </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3 </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3RU<small>†
+! 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> Thyroglobin </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TRH
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TRH </small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH Receptor Antibody
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH Receptor Antibody</small>
-! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TPOAb^
+! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TPOAb^</small>
 |-
 | rowspan="4" style="background:#DCDCDC;" |[[Thyroiditis]]
@@ Line 301: / Line 286: @@
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
-| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''<small>*
+| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''<small>*</small>
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''''↓'''''
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''''↓'''''
@@ Line 400: / Line 385: @@
 | rowspan="1" style="background:#DCDCDC;" |[[Tertiary hyperthyroidism]]
 | align="center" style="background:#DCDCDC;" |[[Hyperthyroidism|Tertiary hyperthyroidism]]
-| 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;" |↑
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
@@ Line 464: / Line 449: @@
 | 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;" | -
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
@@ Line 478: / Line 463: @@
 | 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;" | -
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
 | align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
@@ Line 486: / Line 471: @@
 |-
 |}
-<small>''(†)T3RU; Triiodothyronine Resin uptake. (^)TPOAb; [[Thyroid peroxidase]] antibodies.''</small>
+<small>''†''T3RU; Triiodothyronine Resin uptake<br>
+''^''TPOAb; [[Thyroid peroxidase]] antibodies</small>
+==Diagnosis==
+The following flowchart describes the clinical approach to the diagnosis of thyroiditis.
+===Stepwise clinical diagnosis of thyroiditis===
+{{familytree/start |summary=Sample 1}}
+{{familytree | | | | | | | | | | | | A01 | | |A01=Neck pain}}
+{{familytree | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | }}
+{{familytree | | | | | | B01 | | | | | | | | | | | B02 | | |B01=Yes|B02=No}}
+{{familytree | | | | | | |!| | | | | | | | | | | | |!| }}
+{{familytree | | | | | | C01 | | | | | | | | | | | C02 |C01=[[RAIU]]*|C02=Presenting symptoms and [[TFTs]]‡}}
+{{familytree | | | | |,|-|^|-|-|.| | | | | | | |,|-|^|-|-|-|v|-|-|-|.| }}
+{{familytree | | | | D01 | | | D02 | | | | | | D03 | | | | D04 | |D05|D01=Increased|D02=Decreased|D03=[[Hyperthyroid]]|D04=[[Hypothyroid]]|D05=[[Euthyroid]]}}
+{{familytree | | | | |!| | | | |!| | | | | | | |!| | | | | |!| | | |!|}}
+{{familytree | | | | |!| | | | |!| | | | | | | H01 | | | | |!| | | |!|H01=[[RAIU]]*}}
+{{familytree | | | | |!| | | | |!| | | | | |,|-|^|-|.| | | |!| | | |!|}}
+{{familytree | | | | E01 | | | E04 | | | | E02 | | E03 | | E05 | | |E06 |E01=[[Suppurative thyroiditis]]|E02=Increased|E03=Decreased|E04=[[De Quervain's thyroiditis]]|E05=[[Hashimoto's thyroiditis]]|E06=[[Riedel's thyroiditis]]††}}
+{{familytree | | | | | | | | | | | | | | | |!| | | |!| }}
+{{familytree | | | | | | | | | | | | | | | F01 | | F02 |F01=[[Grave's disease]]†|F02=[[Silent thyroiditis]] <br> [[Postpartum thyroiditis]]}}
+{{familytree/end}}
+''‡TFT'': Thyroid function tests (TSH, T4, and T3)<br>
+''†'': [[Grave's disease]] is not a thyroiditis<br>
+''*'': RAIU; Radioiodine uptake<br>
+''††'': One third of [[Riedel's thyroiditis]] presents with [[hypothyroidism]]
+<br>
 ==Treatment==
 ===Treatment of Hashimoto's thyroiditis===
 The drugs used in the treatment of Hashimoto's thyroiditis are:<ref name="pmid24434360">{{cite journal |vauthors=Caturegli P, De Remigis A, Rose NR |title=Hashimoto thyroiditis: clinical and diagnostic criteria |journal=Autoimmun Rev |volume=13 |issue=4-5 |pages=391–7 |year=2014 |pmid=24434360 |doi=10.1016/j.autrev.2014.01.007 |url=}}</ref><ref name="pmid25266247">{{cite journal |vauthors=Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM |title=Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement |journal=Thyroid |volume=24 |issue=12 |pages=1670–751 |year=2014 |pmid=25266247 |pmc=4267409 |doi=10.1089/thy.2014.0028 |url=}}</ref>
-#[[Levothyroxine]]:
+[[Levothyroxine]]:
-#*lifelong synthetic [[levothyroxine]] (L-[[T4]]) is used to treat the hypothyroidism in Hashimoto's disease.
+*lifelong synthetic [[levothyroxine]] (L-[[T4]]) is used to treat the hypothyroidism in Hashimoto's disease.
-#*Main goals of levothyroxine replacement therapy are:
+*Main goals of levothyroxine replacement therapy are:
-#**Resolution of the [[hypothyroid]] symptoms and signs including biological and physiologic markers of [[hypothyroidism]]
+**Resolution of the [[hypothyroid]] symptoms and signs including biological and physiologic markers of [[hypothyroidism]]
-#**Normalization of serum [[thyrotropin]] with improvement in thyroid hormone concentrations
+**Normalization of serum [[thyrotropin]] with improvement in thyroid hormone concentrations
-#**To avoid overtreatment (iatrogenic thyrotoxicosis)
+**To avoid overtreatment (iatrogenic thyrotoxicosis)
-#*Side effects include [[atrial fibrillation]] and [[osteoporosis]]
+*Side effects include [[atrial fibrillation]] and [[osteoporosis]]
-#[[Corticosteroid|Corticosteroids]]:
+[[Corticosteroid|Corticosteroids]]:
-#*A short course of [[glucocorticoids]] can be used in the treatment of IgG4-related variant of Hashimoto's thyroiditis.
+*A short course of [[glucocorticoids]] can be used in the treatment of IgG4-related variant of Hashimoto's thyroiditis.
-#[[Selenium]]:
+[[Selenium]]:
-#*Dietary [[selenium]] supplementation is considered to be protective against the [[autoimmune diseases]] of the [[thyroid]].
+*Dietary [[selenium]] supplementation is considered to be protective against the [[autoimmune diseases]] of the [[thyroid]].
 ====Drug Regimen for Hashimoto's thyroiditis====
@@ Line 508: / Line 520: @@
 ===Treatment of de Quervain's thyroiditis thyroiditis===
 The drugs used in the treatment of [[de Quervain's thyroiditis]] are:<ref name="pmid20886353">{{cite journal |vauthors=Engkakul P, Mahachoklertwattana P, Poomthavorn P |title=Eponym : de Quervain thyroiditis |journal=Eur. J. Pediatr. |volume=170 |issue=4 |pages=427–31 |year=2011 |pmid=20886353 |doi=10.1007/s00431-010-1306-4 |url=}}</ref><ref name="pmid3427792">{{cite journal |vauthors=Yamamoto M, Saito S, Sakurada T, Fukazawa H, Yoshida K, Kaise K, Kaise N, Nomura T, Itagaki Y, Yonemitsu K |title=Effect of prednisolone and salicylate on serum thyroglobulin level in patients with subacute thyroiditis |journal=Clin. Endocrinol. (Oxf) |volume=27 |issue=3 |pages=339–44 |year=1987 |pmid=3427792 |doi= |url=}}</ref><ref name="pmid8257868">{{cite journal |vauthors=Volpé R |title=The management of subacute (DeQuervain's) thyroiditis |journal=Thyroid |volume=3 |issue=3 |pages=253–5 |year=1993 |pmid=8257868 |doi= |url=}}</ref><ref name="pmid6144501">{{cite journal |vauthors=Feely J, Peden N |title=Use of beta-adrenoceptor blocking drugs in hyperthyroidism |journal=Drugs |volume=27 |issue=5 |pages=425–46 |year=1984 |pmid=6144501 |doi= |url=}}</ref>
-#[[NSAIDs]]
+*[[NSAIDs]]
-#[[Prednisone]]
+*[[Prednisone]]
-#[[Atenolol]]
+*[[Atenolol]]
-#[[Levothyroxine (oral)|Synthetic levothyroxine]]
+*[[Levothyroxine (oral)|Synthetic levothyroxine]]
 ====Drug Regimens for de Quervain's thyroiditis====
 * '''For pain'''
@@ Line 526: / Line 538: @@
 ===Treatment of silent thyroiditis===
 The drugs used in the treatment of silent thyroiditis are:<ref name="pmid22443972">{{cite journal |vauthors=Samuels MH |title=Subacute, silent, and postpartum thyroiditis |journal=Med. Clin. North Am. |volume=96 |issue=2 |pages=223–33 |year=2012 |pmid=22443972 |doi=10.1016/j.mcna.2012.01.003 |url=}}</ref><ref name="pmid7630839">{{cite journal |vauthors=Schubert MF, Kountz DS |title=Thyroiditis. A disease with many faces |journal=Postgrad Med |volume=98 |issue=2 |pages=101–3, 107–8, 112 |year=1995 |pmid=7630839 |doi= |url=}}</ref><ref name="pmid1987447">{{cite journal |vauthors=Singer PA |title=Thyroiditis. Acute, subacute, and chronic |journal=Med. Clin. North Am. |volume=75 |issue=1 |pages=61–77 |year=1991 |pmid=1987447 |doi= |url=}}</ref>
-#[[Atenolol]]
+*[[Atenolol]]
-#[[Metoprolol]]
+*[[Metoprolol]]
-#[[Levothyroxine (oral)|Synthetic levothyroxine]]
+*[[Levothyroxine (oral)|Synthetic levothyroxine]]
 ====Drug Regimen for silent thyroidits====
 * '''For thyrotoxic symptoms'''
@@ Line 538: / Line 550: @@
 ===Treatment of Riedel's thyroidtis===
 *The drugs used in the treatment of silent thyroiditis are:<ref name="pmid8120524">{{cite journal |vauthors=Zimmermann-Belsing T, Feldt-Rasmussen U |title=Riedel's thyroiditis: an autoimmune or primary fibrotic disease? |journal=J. Intern. Med. |volume=235 |issue=3 |pages=271–4 |year=1994 |pmid=8120524 |doi= |url=}}</ref><ref name="pmid9497955">{{cite journal |vauthors=Vaidya B, Harris PE, Barrett P, Kendall-Taylor P |title=Corticosteroid therapy in Riedel's thyroiditis |journal=Postgrad Med J |volume=73 |issue=866 |pages=817–9 |year=1997 |pmid=9497955 |pmc=2431527 |doi= |url=}}</ref><ref name="pmid263470">{{cite journal |vauthors=Chopra D, Wool MS, Crosson A, Sawin CT |title=Riedel's struma associated with subacute thyroiditis, hypothyroidism, and hypoparathyroidism |journal=J. Clin. Endocrinol. Metab. |volume=46 |issue=6 |pages=869–71 |year=1978 |pmid=263470 |doi=10.1210/jcem-46-6-869 |url=}}</ref><ref name="pmid7560814">{{cite journal |vauthors=Bagnasco M, Passalacqua G, Pronzato C, Albano M, Torre G, Scordamaglia A |title=Fibrous invasive (Riedel's) thyroiditis with critical response to steroid treatment |journal=J. Endocrinol. Invest. |volume=18 |issue=4 |pages=305–7 |year=1995 |pmid=7560814 |doi=10.1007/BF03347818 |url=}}</ref><ref name="pmid5694137">{{cite journal |vauthors=Thomson JA, Jackson IM, Duguid WP |title=The effect of steroid therapy on Riedel's thyroiditis |journal=Scott Med J |volume=13 |issue=1 |pages=13–6 |year=1968 |pmid=5694137 |doi=10.1177/003693306801300103 |url=}}</ref><ref name="pmid12698518">{{cite journal |author=Dabelic N, Jukic T, Labar Z, Novosel SA, Matesa N, Kusic Z |title=Riedel's thyroiditis treated with tamoxifen |journal=Croat. Med. J. |volume=44 |issue=2 |pages=239–41 |year=2003|pmid=12698518 |doi= |url=http://www.cmj.hr/2003/44/2/12698518.pdf|format=PDF}}</ref><ref name="pmid20067381">{{cite journal |vauthors=Levy JM, Hasney CP, Friedlander PL, Kandil E, Occhipinti EA, Kahn MJ |title=Combined mycophenolate mofetil and prednisone therapy in tamoxifen- and prednisone-resistant Reidel's thyroiditis |journal=Thyroid |volume=20 |issue=1 |pages=105–7 |year=2010 |pmid=20067381 |doi=10.1089/thy.2009.0324 |url=}}</ref><ref name="pmid21568724">{{cite journal |vauthors=Fatourechi MM, Hay ID, McIver B, Sebo TJ, Fatourechi V |title=Invasive fibrous thyroiditis (Riedel thyroiditis): the Mayo Clinic experience, 1976-2008 |journal=Thyroid |volume=21 |issue=7 |pages=765–72 |year=2011 |pmid=21568724 |doi=10.1089/thy.2010.0453 |url=}}</ref>
-#[[Corticosteroids]]
+*[[Corticosteroids]]
-#[[Tamoxifen]]
+*[[Tamoxifen]]
-#[[Mycophenolate sodium|Mycophenolate mofetil]](used in combination with [[corticosteroids]])
+*[[Mycophenolate sodium|Mycophenolate mofetil]](used in combination with [[corticosteroids]])
 ====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.