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  • 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  
    • pathogenesis
      • association, to various degrees, with chronic autoimmune thyroiditis (Hashimoto disease)
    • clinical syndromes
      • silent thyroiditis
      • postpartum thyroiditis
      • Riedel thyroiditis
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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