Updated: 12/9/2021

Other Thyroiditis

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  • Snapshot
    • A 32-year-old G0P1001 woman and her 4-week old newborn come to the clinic for a routine newborn checkup. The mother complains of irritation and palpitations but denies other concerns. A physical examination of the newborn is unremarkable and he is tracking well within his growth curves. A thyroid function test of the mother shows low levels of TSH.
  • Introduction
    • Introduction
      • thyroiditis includes a diverse group of disorders that is characterized by some form of thyroid inflammation
        • all the conditions presented here are not associated with thyroid pain or tenderness
      • clinical syndromes
        • silent thyroiditis
        • postpartum thyroiditis
        • Riedel thyroiditis
  • ETIOLOGY
    • Pathogenesis
      • association, to various degrees, with chronic autoimmune thyroiditis (Hashimoto disease)
  • Silent Thyroiditis
    • Characterized by transient hyperthyroidism (followed sometimes by hypothyroidism) and then recovery; considered a variant form of chronic autoimmune thyroiditis (Hashimoto’s thyroiditis)
      • risk factors
        • positive family history of thyroid autoimmune disease
        • lithium therapy
        • cessation of glucocorticoids
    • Presentation
      • frequently incidentally detected by routine thyroid testing
      • hyperthyroid symptoms developing over 1-2 weeks and lasting 2-8 weeks
        • weakness, fatigue, irritability, palpitations, stare/lid retraction, tachycardia, and tremor
        • the thyroid gland is not painful/tender
      • may be followed by hypothyroidism for 2-8 weeks (usually clinically mild or asymptomatic)
        • cold intolerance, constipation, or fatigue
    • Studies
      • low serum TSH
      • moderately elevated serum free T4
      • normal or slightly elevated T3
    • Treatment
      • no treatment is needed for most patients
      • symptomatic hyperthyroid phase
        • beta-blocker (e.g., propranolol) for prevention of atrial-fibrillation
      • symptomatic hypothyroid phase
        • levothyroxine
  • Postpartum Thyroiditis
    • Autoimmune destructive thyroiditis within one year after delivery characterized by either 1) transient hyperthyroidism 2) transient hypothyroidism or 3) transient hypothyroidism followed by hypothyroidism and then recovery
      • most women recover within one year but about 1 in 5 women will develop permanent hypothyroidism
      • risk factors
        • type 1 diabetes mellitus
        • prior history of postpartum thyroiditis
        • positive antithyroid peroxidase antibodies
    • Presentation
      • presentation can be similar to that in painless thyroiditis, however, many of the symptoms are often attributed to breastfeeding or newborn stress
      • hyperthyroid symptoms developing over 1-2 weeks and lasting 2-8 weeks
        • weakness, fatigue, irritability, palpitations, stare/lid retraction, tachycardia, and tremor
        • the thyroid gland is not painful/tender
      • may be followed by hypothyroidism for 2-8 weeks (usually clinically mild or asymptomatic)
        • cold intolerance, constipation, or fatigue
    • Studies
      • high or high-normal serum free T4 and T3
      • low serum TSH
      • high serum antithyroid peroxidase antibody
    • Treatment
      • asymptomatic patients should be monitored via regular thyroid function tests
      • symptomatic hyperthyroidism phase
        • beta blockers (propranolol is preferred in women who are breastfeeding)
      • symptomatic hypothyroid phase
        • levothyroxine
  • Riedel Thyroiditis
    • An invasive fibrotic process associated with a mononuclear cell inflammation that extends into the perithyroidal soft tissue
      • may occur as part of IgG4-related systemic disease
      • association with chronic autoimmune thyroiditis (Hashimoto thyroiditis)
    • Presentation
      • slowly growing painless goiter that is “stony” hard
      • anterior neck pressure
      • dysphagia
      • hoarseness
      • hypoparathyroidism
      • symptoms of hypothyroidism (e.g., cold intolerance, constipation, or fatigue)
    • Imaging
      • ultrasonography will demonstrate heterogeneous hypoechoic lesions with the absence of vascular flow in the Riedel’s regions
    • Studies
      • laboratory tests
        • normal serum TSH
        • serum calcium and phosphorus for identification of coexist hypoparathyroidism
      • pathology
        • resected thyroid tissue demonstrates hard, white, avascular tissue
        • histology shows intense infiltration of lymphocytes, plasma cells, neutrophils, and eosinophils early in the disease
    • Treatment
      • treat hypothyroidism if present with levothyroxine
      • glucocorticoids and tamoxifen to reduce progression
      • surgical resection if tracheal or esophageal compression is present
    • Complications
      • recurrent pneumonia due to bronchial compression
      • hypoparathyroidism

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