Transcript Subacute Thyroiditis And Related Disorders

Richard M. Jordan, MD, Regional Dean,
School of Medicine
Texas Tech Health Sciences Center at Amarillo
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Subacute Thyroiditis – (DeQuervain’s Thyroiditis,
Granulomatous Thyroiditis, Giant Cell Thyroiditis) A Post Viral
Syndrome with Thyroid Pain.
Painless Thyroiditis – (Subacute Lymphocytic Thyroiditis, Silent
Thyroiditis) Probable Variant of Autoimmune (Hashimoto’s)
Thyroiditis. Excludes Women with Painless Thyroiditis
Occurring within 1 Year of Delivery.
Postpartum Thyroiditis – Probable Variant of Autoimmune
Thyroiditis, Similar to Painless Thyroiditis But Occurring
Postpartum.
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Drug Induced Thyroiditis – Amiodarone, Lithium, Interleukin2, Denileukin Diffitoxin.
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Radiation Induced – Occurs Post Radioactive Iodine Treatment.
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Preceding Viral Infection with Sore Throat, Fever,
Myalgias
May occur in Clusters
Damage to the Thyroid Follicles with Release of Thyroid
Hormone
Goiter with Neck Pain – Can Radiate to Jaw or Ear
Elevated Sedimentation Rate, Elevated Thyroglubulin
Triphasic Course – Hyperthyroidism to Hypothyroidism
to Euthyroidism
Permanent Hypothyroidism may develop in 10-15%
Acute viral infection
Presents with viral prodrome, thyroid tenderness, and hyperthyroid symptoms
Pathology
Disruption and Collapse of the Thyroid Follicles
Infiltration with Inflammatory Cells
Neutrophils
Lymphocytes
Histiocytes
Multinucleated “Giant” Cells
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Suppressed Radioactive Iodine Update in
Hyperthyroid Phase
Sedimentation Rate approximately 50 mm/h
Treatment – NSAIDS or Steroids, Beta Blocker
in Hyperthyroid Phase
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Probable Variant of Autoimmune (Hashimoto’s) Thyroiditis
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Sedimentation Rate is Normal or Slightly Elevated
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May have Elevated Antithyroid Peroxidase (TPO) Levels
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Thyroglobulin Levels Are Elevated
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Pathology-Lymphocytic Infiltration which Persists in Recovery
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Clinical Course-Similar to Subacute Thyroiditis; Hyperthyroidism
(Usually Mild) Followed by Recovery or Hypothyroidism
Permanent Hypothyroidism Develops in 20-50%
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Hyperthyroidism-Mild may require no therapy. If
Symptomatic give beta-bockers
Hypothyroidism-If Symptomatic or TSH>10mU/L
give thyroid hormone replacement
Monitor for the development of hypothyroidism
Painless Thyroiditis vs Factitious Thyrotoxicosis
Painless Thyroiditis
Goiter
Factitious Thyrotoxicosis
Small
Usually Absent
Thyroglobulin
Elevated
Undetectable
Occupation
Not Specific
Access to Thyroid Hormone
Variant of Autoimmune (Hashimoto’s)
Thyroiditis
 Follows Delivery
 Autoimmune Damage to the Follicles with
Release of Thyroid Hormone
 Painless with Small Goiter
 Variable Triphasic Course
 Suppressed Radio Iodine Uptake
 Sedimentation Rate-<30 mm/h
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Prevalence
7 to 10 Percent of All Pregnancies
Most Common Variety of Hyperthyroidism Associated with
Pregnancy
Risk Factors
Elevated TPO Antibodies – 50% Will Develop Postpartum Thyroiditis
Type I Diabetes Mellitus – 25% Will Develop Postpartum Thyroiditis
Postpartum Thyroiditis with Prior Pregnancy
Pathology
Lymphocytic Infiltration, Disruption of Follicles, Germinal Centers
Variant of Hashimoto’s Thyroiditis
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Course
25% - Classic Triphasic Response
35% - Only Hyperthyroidism
40% - Only Hypothyroidism
Persistent Hypothyroidism
After 4 years 25 to 50% have hypothyroidism or
Goiter or Both
56% with a Hypothyroid Phase Develop Permanent
Hypothyroidism
Patients with Postpartum Hypothyroidism
Require Yearly Screening
Postpartum
Goiter
Small, No Bruit
Course
Duration
Mild, Short Duration
Graves’ Disease
Small to Large, Bruit Present
Mild to Severe, Long
Opthalmopathy Absent
May Be Present
Iodine Uptake
Low
Normal to Elevated
TSI
Absent
Present
* TSI-Thyroid Stimulating Immunoglobulin
 Hyperthyroid
 Hypothyroid
Hormone
 Selenium
Phase – Beta Blocker
Phase – Thyroid
During Pregnancy in TPO
Positive Patients
Hypothyroidism-Iodine Induced
Overt Hypothyroidism – 5%
Subclinical Hypothyroidism – 25%
Hyperthyroidism – 3-5%
Type 1- (Jod-Basedow, Iodine-Induced),
Underlying MNG, Graves’ Disease
Type 2 – Chemical Destructive Thyroiditis
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I123 Uptake is Usually Suppressed in Both Types
Of the I123 Detectable Type 1 is Likely
Presence of the Diffuse Goiter, MNG or TSI
suggests Type 1
Color Flow Doppler
◦ Increased Flow (increased vascularity) – Type 1
◦ Decreased Flow (absent vascularity) – Type 2
◦ Interpretation Difficult
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Type 1
Thionamides (Methimazole or PTU)
Radioactive Iodine (If I123 Uptake is Detectable)
Thyroidectomy (Failure of Other Options)
Type 2
Prednisone 40 mg daily for 6 to 12 weeks
Uncertain If Type 1 or Type 2 (Usually the Case)
Start Prednisone 40 mg and Methimazole 40 Mg daily
Measure Thyroid Function in 6 weeks
If Improved Taper Methimazole
If Unimproved Taper Prednisone
Type 1
Thionamides (Methimazole or PTU)
Radioactive Iodine (If I123 Uptake is Detectable)
Thyroidectomy (Failure of other options)
 Type 2
Prednisone 40 mg daily for 6 to 12 weeks
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Uncertain if Type 1 or Type 2 (Usually the Case)
Start Prednisone 40 mg and Methimazole 40 Mg daily
◦ Measure Thyroid Function in 6 weeks
◦ If Improved Taper Methimazole
◦ If Unimproved Taper Prednisone
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Interferon Alfa-10% Hypothyroidism,
Painless Thyroiditis, or Graves Disease
Interleukin 2% Painless Thyroiditis
Lithium-Painless Thyroiditis But
Hypothyroidism more common
Denileukin Difitox