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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Revision as of 17:27, 3 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.

Classification

The most common form of thyroiditis is Hashimoto's thyroiditis.
Resolving thyroiditis
- DeQuervain's Thyroiditis or Granulomatous Thyroiditis
- Postpartum thyroiditis
- Silent thyroiditis
Rare forms of thyroiditis
- Riedel's thyroiditis

Differentiating Thyroiditis from Other Diseases

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

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

Diagnosis

The diagnosis of thyroiditis is usually made on the physical examination, thyroid function tests and various other diagnostic tests listed in the table below:^[1]^[2]^[3]^[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	-	-	↑/↓	↓/↑	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.

Treatment

The drugs used in the treatment of Hashimoto's thyroiditis are:^[7]^[8]

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:

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

The drugs used in the treatment of de Quervain's thyroiditis are:^[9]^[10]^[11]^[12]

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

Related Chapters

References

↑ Bindra A, Braunstein GD (2006). "Thyroiditis". Am Fam Physician. 73 (10): 1769–76. PMID 16734054.
↑ McDermott MT (2009). "In the clinic. Hypothyroidism". Ann. Intern. Med. 151 (11): ITC61. doi:10.7326/0003-4819-151-11-200912010-01006. PMID 19949140.
↑ "Thyroiditis — NEJM".
↑ 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.
↑ Lania A, Persani L, Beck-Peccoz P (2008). "Central hypothyroidism". Pituitary. 11 (2): 181–6. doi:10.1007/s11102-008-0122-6. PMID 18415684.
↑ 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.
↑ 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.

Template:WikiDoc Sources

[pmid16734054-1] Bindra A, Braunstein GD (2006). "Thyroiditis". Am Fam Physician. 73 (10): 1769–76. PMID 16734054.

[pmid19949140-2] McDermott MT (2009). "In the clinic. Hypothyroidism". Ann. Intern. Med. 151 (11): ITC61. doi:10.7326/0003-4819-151-11-200912010-01006. PMID 19949140.

[urlThyroiditis_—_NEJM-3] "Thyroiditis — NEJM".

[pmid18177256-4] 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] 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] 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.

[pmid24434360-7] 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.

[pmid25266247-8] 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.

[pmid20886353-9] 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.

[pmid3427792-10] 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.

[pmid8257868-11] Volpé R (1993). "The management of subacute (DeQuervain's) thyroiditis". Thyroid. 3 (3): 253–5. PMID 8257868.

[pmid6144501-12] Feely J, Peden N (1984). "Use of beta-adrenoceptor blocking drugs in hyperthyroidism". Drugs. 27 (5): 425–46. PMID 6144501.

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@@ Line 265: / Line 265: @@
 Drug Regimen:
 *[[Levothyroxine (oral)|Synthetic levothyroxine]] (L-[[T4]]) 1.6–1.8 μg/kg of body weight per day orally.
+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>
+* '''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): [[Levothyroxine (oral)|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
 ==Related Chapters==