Thyroiditis

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Basics

Description

Inflammation of the thyroid gland that may be painful or painless and is characterized by dysfunction

  • Painful thyroiditis
    • Subacute granulomatous thyroiditis (nonsuppurative thyroiditis, de Quervain thyroiditis, giant cell thyroiditis): self-limited; viral URI prodrome, symptoms and signs of thyroid dysfunction (variable)
    • Infectious/suppurative thyroiditis
      • Can be due to bacterial, fungal, mycobacterial, or parasitic infection of the thyroid
      • Most commonly associated with Streptococcus pyogenes, Staphylococcus aureus, and Streptococcus pneumoniae
    • Radiation-induced thyroiditis: from radioactive iodine therapy (1%) or external irradiation for lymphoma and head/neck cancers
  • Painless thyroiditis
    • Hashimoto (autoimmune) thyroiditis (chronic lymphocytic thyroiditis): most common etiology of chronic hypothyroidism; autoimmune disease; 90% of patients with high-serum antithyroid peroxidase (TPO) antibodies
    • Postpartum thyroiditis (PPT): episode of thyrotoxicosis, hypothyroidism, or thyrotoxicosis followed by hypothyroidism in the 1st year postpartum or after spontaneous/induced abortion in women who were without clinically evident thyroid disease before pregnancy
    • Painless (silent) thyroiditis (subacute lymphocytic thyroiditis): mild hyperthyroidism, small painless goiter, and no Graves ophthalmopathy/pretibial myxedema
    • Riedel (fibrous) thyroiditis: rare inflammatory process involving the thyroid and surrounding cervical tissues; associated with various forms of systemic fibrosis; presents as a firm mass in the thyroid commonly associated with compressive symptoms (dyspnea, dysphagia, hoarseness, and aphonia) caused by local infiltration of the advancing fibrotic process with hypocalcemia and hypothyroidism
    • Drug-induced thyroiditis: interferon-α, interleukin-2, amiodarone, kinase inhibitors, or lithium
    • Palpation thyroiditis: due to palpation of the thyroid gland intra-operatively or during a physical exam or biopsy

Epidemiology

  • Subacute granulomatous thyroiditis: most common cause of thyroid pain; peaks during summer; incidence: 3/100,000/year; female > male (4:1); peak age: 40 to 50 years
  • Suppurative thyroiditis: commonly seen with preexisting thyroid disease/immunocompromise
  • Hashimoto thyroiditis (HT): peak age of onset, 30 to 50 years; can occur in children; primarily a disease of women; female > male (7:1)
  • PPT: occurs within 12 months of pregnancy in 8–11% of pregnancies; occurs in 25% with type 1 diabetes mellitus; incidence is affected by genetic influences and iodine intake.
  • Painless (silent) thyroiditis: accounts for 1–5% of cases; female > male (4:1) with peak age 30 to 40 years; common in areas of iodine sufficiency
  • Reidel thyroiditis: female > male (4:1); highest prevalence age 30 to 60 years

Etiology and Pathophysiology

  • Subacute granulomatous thyroiditis: probably viral
  • Hashimoto disease: Antithyroid antibodies may be produced in response to an environmental antigen and cross-react with thyroid proteins (molecular mimicry). Precipitating factors include infection, stress, sex steroids, pregnancy, iodine intake, and radiation exposure.
  • PPT: autoimmunity-induced discharge of preformed hormone from the thyroid
  • Painless (silent) thyroiditis: autoimmune

Genetics
Autoimmune thyroiditis is associated with the CT60 polymorphism of cytotoxic T-cell lymphocyte–associated antigen 4; also associated with HLA-DR4, HLA-DR5, and HLA-DR6 in whites

Risk Factors

  • Subacute granulomatous thyroiditis: recent viral respiratory infection or HLA-B35
  • Suppurative thyroiditis: congenital abnormalities (persistent thyroglossal duct/pyriform sinus fistula), greater age, immunosuppression
  • Radiation-induced thyroiditis: high-dose irradiation, younger age, female sex, preexisting hypothyroidism
  • Hashimoto disease: family history of thyroid/autoimmune disease, personal history of autoimmune disease (type 1 diabetes, celiac disease), high iodine intake, cigarette smoking, selenium deficiency
  • PPT: smoking, history of spontaneous/induced abortion
  • Painless (silent) thyroiditis: iodine-deficient areas

General Prevention

In patients with autoimmune thyroiditis, selenium and vitamin D supplementation may decrease antibody titers (1),(2).

Commonly Associated Conditions

PPT: family history of autoimmune thyroid disease; HLA-DRB, HLA-DR4, and HLA-DR5

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Basics

Description

Inflammation of the thyroid gland that may be painful or painless and is characterized by dysfunction

  • Painful thyroiditis
    • Subacute granulomatous thyroiditis (nonsuppurative thyroiditis, de Quervain thyroiditis, giant cell thyroiditis): self-limited; viral URI prodrome, symptoms and signs of thyroid dysfunction (variable)
    • Infectious/suppurative thyroiditis
      • Can be due to bacterial, fungal, mycobacterial, or parasitic infection of the thyroid
      • Most commonly associated with Streptococcus pyogenes, Staphylococcus aureus, and Streptococcus pneumoniae
    • Radiation-induced thyroiditis: from radioactive iodine therapy (1%) or external irradiation for lymphoma and head/neck cancers
  • Painless thyroiditis
    • Hashimoto (autoimmune) thyroiditis (chronic lymphocytic thyroiditis): most common etiology of chronic hypothyroidism; autoimmune disease; 90% of patients with high-serum antithyroid peroxidase (TPO) antibodies
    • Postpartum thyroiditis (PPT): episode of thyrotoxicosis, hypothyroidism, or thyrotoxicosis followed by hypothyroidism in the 1st year postpartum or after spontaneous/induced abortion in women who were without clinically evident thyroid disease before pregnancy
    • Painless (silent) thyroiditis (subacute lymphocytic thyroiditis): mild hyperthyroidism, small painless goiter, and no Graves ophthalmopathy/pretibial myxedema
    • Riedel (fibrous) thyroiditis: rare inflammatory process involving the thyroid and surrounding cervical tissues; associated with various forms of systemic fibrosis; presents as a firm mass in the thyroid commonly associated with compressive symptoms (dyspnea, dysphagia, hoarseness, and aphonia) caused by local infiltration of the advancing fibrotic process with hypocalcemia and hypothyroidism
    • Drug-induced thyroiditis: interferon-α, interleukin-2, amiodarone, kinase inhibitors, or lithium
    • Palpation thyroiditis: due to palpation of the thyroid gland intra-operatively or during a physical exam or biopsy

Epidemiology

  • Subacute granulomatous thyroiditis: most common cause of thyroid pain; peaks during summer; incidence: 3/100,000/year; female > male (4:1); peak age: 40 to 50 years
  • Suppurative thyroiditis: commonly seen with preexisting thyroid disease/immunocompromise
  • Hashimoto thyroiditis (HT): peak age of onset, 30 to 50 years; can occur in children; primarily a disease of women; female > male (7:1)
  • PPT: occurs within 12 months of pregnancy in 8–11% of pregnancies; occurs in 25% with type 1 diabetes mellitus; incidence is affected by genetic influences and iodine intake.
  • Painless (silent) thyroiditis: accounts for 1–5% of cases; female > male (4:1) with peak age 30 to 40 years; common in areas of iodine sufficiency
  • Reidel thyroiditis: female > male (4:1); highest prevalence age 30 to 60 years

Etiology and Pathophysiology

  • Subacute granulomatous thyroiditis: probably viral
  • Hashimoto disease: Antithyroid antibodies may be produced in response to an environmental antigen and cross-react with thyroid proteins (molecular mimicry). Precipitating factors include infection, stress, sex steroids, pregnancy, iodine intake, and radiation exposure.
  • PPT: autoimmunity-induced discharge of preformed hormone from the thyroid
  • Painless (silent) thyroiditis: autoimmune

Genetics
Autoimmune thyroiditis is associated with the CT60 polymorphism of cytotoxic T-cell lymphocyte–associated antigen 4; also associated with HLA-DR4, HLA-DR5, and HLA-DR6 in whites

Risk Factors

  • Subacute granulomatous thyroiditis: recent viral respiratory infection or HLA-B35
  • Suppurative thyroiditis: congenital abnormalities (persistent thyroglossal duct/pyriform sinus fistula), greater age, immunosuppression
  • Radiation-induced thyroiditis: high-dose irradiation, younger age, female sex, preexisting hypothyroidism
  • Hashimoto disease: family history of thyroid/autoimmune disease, personal history of autoimmune disease (type 1 diabetes, celiac disease), high iodine intake, cigarette smoking, selenium deficiency
  • PPT: smoking, history of spontaneous/induced abortion
  • Painless (silent) thyroiditis: iodine-deficient areas

General Prevention

In patients with autoimmune thyroiditis, selenium and vitamin D supplementation may decrease antibody titers (1),(2).

Commonly Associated Conditions

PPT: family history of autoimmune thyroid disease; HLA-DRB, HLA-DR4, and HLA-DR5

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