Thyroiditis

Thyroiditis is a catchall term used to describe a variety of conditions that have inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the thyroid gland Thyroid gland The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland in common. It includes pathologies that cause an acute illness with severe thyroid pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain (e.g., subacute thyroiditis and infectious thyroiditis) as well as conditions in which there is no clinically evident inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and the manifestations primarily reflect thyroid dysfunction or a goiter Goiter A goiter is a chronic enlargement of the thyroid gland due to nonneoplastic growth occurring in the setting of hypothyroidism, hyperthyroidism, or euthyroidism. Morphologically, thyroid enlargement can be diffuse (smooth consistency) or nodular (uninodular or multinodular). Goiter (e.g., painless thyroiditis and fibrous Riedel’s thyroiditis). The etiology of thyroiditis is varied and includes autoimmune inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation (most common), bacterial or viral infection, and drug-induced reactions. The inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the thyroid leads to a sequential pathologic process that can result in signs and symptoms of hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism followed by signs and symptoms of hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism. The resulting damage can be temporary or permanent, and the treatment depends on the underlying cause.

Last update:

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Etiology and Pathophysiology

Thyroiditis, or inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the thyroid gland Thyroid gland The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland, has multiple etiologies, including autoimmune conditions, infectious agents, and iatrogenic causes. Each causative condition has a specific pathologic mechanism.

Table: Etiology and pathophysiology of thyroiditis
Category Etiology Pathophysiology
Autoimmune Hashimoto’s thyroiditis
  • Associated with HLA-DR3, DR4, and DR5
  • Thyroid peroxidase (TPO) and thyroglobulin (Tg) antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins destroy the thyroid gland Thyroid gland The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland.
Painless, silent, or lymphocytic thyroiditis
  • Any patient with symptoms of mild hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism for < 2 months with a small diffuse goiter Goiter A goiter is a chronic enlargement of the thyroid gland due to nonneoplastic growth occurring in the setting of hypothyroidism, hyperthyroidism, or euthyroidism. Morphologically, thyroid enlargement can be diffuse (smooth consistency) or nodular (uninodular or multinodular). Goiter or no enlargement
  • Considered a “milder” form of Hashimoto’s thyroiditis
  • Damage to follicular cells with lymphocytic infiltration
Postpartum thyroiditis
  • < 1 year after parturition or abortion
  • No thyroid enlargement or tenderness
  • Lymphocytic infiltration of the thyroid gland Thyroid gland The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland with the formation of germinal centers
  • Resolves spontaneously
Riedel’s thyroiditis
  • Primary fibrosing disorder
  • Dense fibrosis that replaces normal thyroid parenchyma with macrophage and eosinophil infiltration
Infections Subacute granulomatous thyroiditis (De Quervain syndrome)
  • Due to viral infections (usually mumps Mumps Mumps is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. Mumps is typically a disease of childhood, which manifests initially with fever, muscle pain, headache, poor appetite, and a general feeling of malaise, and is classically followed by parotitis. Mumps Virus/Mumps or coxsackievirus Coxsackievirus Coxsackievirus is a member of a family of viruses called Picornaviridae and the genus Enterovirus. Coxsackieviruses are single-stranded, positive-sense RNA viruses, and are divided into coxsackie group A and B viruses. Both groups of viruses cause upper respiratory infections, rashes, aseptic meningitis, or encephalitis. Coxsackievirus); often follows an upper respiratory infection
  • Strong association with HLA-B35
  • Damage to follicular cells
  • Formation of granulomas and fibrosis
Acute suppurative thyroiditis
  • Gram-positive or gram-negative bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview enter via a fistula from the piriform sinus.
  • Bacteria spread hematogenously in immunocompromised patients.
Chronic suppurative thyroiditis Usually caused by Aspergillus or Pneumocystis in immunocompromised patients
Iatrogenic Drug-induced
  • Amiodarone: structurally resembles thyroid hormone and contains iodine
  • Others: α-interferon, lithium, IL-2, and tyrosine
Radiation thyroiditis
  • Presents 5–10 days after radioactive therapy used to treat Graves’ disease, head and neck cancer, or lymphoma.
  • Stored triiodothyronine (T3) and thyroxine (T4) are released as rapid destruction of thyroid tissue occurs.

Clinical Presentation

  • Goiter → mass effect leading to:
    • Discomfort and/or globus sensation
    • Dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming "stuck." Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia
    • Dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea and/or stridor
    • Hoarseness
  • Specific signs and symptoms depend on the underlying cause:
    • Hashimoto’s thyroiditis: 
      • Initially asymptomatic
      • Painless, symmetrical goiter Goiter A goiter is a chronic enlargement of the thyroid gland due to nonneoplastic growth occurring in the setting of hypothyroidism, hyperthyroidism, or euthyroidism. Morphologically, thyroid enlargement can be diffuse (smooth consistency) or nodular (uninodular or multinodular). Goiter develops.
      • Transient hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism followed by permanent hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism
    • Riedel’s thyroiditis: presents along with symptoms of tracheal compression
    • Subacute (De Quervain) thyroiditis: fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever with a painful, enlarged and tender thyroid on palpation ( goiter Goiter A goiter is a chronic enlargement of the thyroid gland due to nonneoplastic growth occurring in the setting of hypothyroidism, hyperthyroidism, or euthyroidism. Morphologically, thyroid enlargement can be diffuse (smooth consistency) or nodular (uninodular or multinodular). Goiter)
    • Suppurative thyroiditis: 
      • Sudden onset of neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain, usually unilateral
      • Fever, dysphagia, and leukocytosis
  • Triphasic clinical course: presents in painless, postpartum, and subacute thyroiditis 
    • Thyrotoxicosis Thyrotoxicosis Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism occurs owing to increased release of preformed/stored thyroid hormones Thyroid hormones The 2 primary thyroid hormones are triiodothyronine (T3) and thyroxine (T4). These hormones are synthesized and secreted by the thyroid, and they are responsible for stimulating metabolism in most cells of the body. Their secretion is regulated primarily by thyroid-stimulating hormone (TSH), which is produced by the pituitary gland. Thyroid Hormones and suppression of TSH and lasts 4–6 weeks.
    • As stores are depleted, and TSH is already suppressed, a hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism phase begins. This phase lasts 4–6 months.
    • TSH will subsequently rise and increase thyroid hormone production, leading to normalization of thyroid function. This phase lasts for several months after onset.
Subacute thyroiditis triphasic clinical course

The triphasic clinical course of subacute thyroiditis:
Subacute thyroiditis usually presents initially with signs of hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism as large amounts of thyroid hormones Thyroid hormones The 2 primary thyroid hormones are triiodothyronine (T3) and thyroxine (T4). These hormones are synthesized and secreted by the thyroid, and they are responsible for stimulating metabolism in most cells of the body. Their secretion is regulated primarily by thyroid-stimulating hormone (TSH), which is produced by the pituitary gland. Thyroid Hormones are released from the destroyed glandular tissue. Then, as storage runs out, thyroid hormone levels begin to drop and thyroid-stimulating hormone (TSH) rises to compensate. Eventually, months after the onset of the disease, hormonal levels stabilize into a euthyroid state.
RAI: radioactive iodine.

Image by Lecturio.
Table: Manifestations of hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism and hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism
Manifestations Hypothyroidism Hyperthyroidism
Metabolic
  • Cold intolerance
  • Decreased sweating
  • Weight gain (lowered basal metabolic rate)
  • Hyponatremia Hyponatremia Hyponatremia is defined as a decreased serum sodium (sNa+) concentration less than 135 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled via antidiuretic hormone (ADH) release from the hypothalamus and by the thirst mechanism. Hyponatremia due to lower free water clearance
  • Heat intolerance
  • Increased sweating
  • Weight loss (increased basal metabolic rate)
Dermatologic
  • Dry, cool skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin due to low blood flow
  • Coarse, brittle hair and nails and diffuse alopecia Alopecia Alopecia is the loss of hair in areas anywhere on the body where hair normally grows. Alopecia may be defined as scarring or non-scarring, localized or diffuse, congenital or acquired, reversible or permanent, or confined to the scalp or universal; however, alopecia is usually classified using the 1st 3 factors. Alopecia
  • Puffy facies
  • Generalized nonpitting edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema (myoedema) due to increased osmotic pressure/water retention
  • Warm, moist skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin (due to vasodilation)
  • Fine hair and onycholysis
  • Pretibial myxedema in Graves’ disease
Ocular Periorbital edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • Ophthalmopathy in Graves’ disease
  • Lid lag/retraction (sympathetic stimulation of levator palpebrae superioris)
Musculoskeletal
  • Hypothyroid myopathy
  • Carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome (CTS) is a complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation is with pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of the nerve's myotomal targets. Carpal Tunnel Syndrome
  • Myxedema (small lump on the surface of muscle when hit with a hammer)
  • Thyrotoxic myopathy
  • Osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis
  • Higher fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures rate
Reproductive
  • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding
  • Reduced libido
  • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility
  • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding
  • Gynecomastia Gynecomastia Gynecomastia is a benign proliferation of male breast glandular ductal tissue, usually bilateral, caused by increased estrogen activity, decreased testosterone activity, or medications. The condition is common and physiological in neonates, adolescent boys, and elderly men. Gynecomastia
  • Reduced libido
  • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility
Neuropsychiatric
  • Hypoactivity
  • Lethargy
  • Fatigue and weakness
  • Depressed mood
  • Delayed or slow reflexes
  • Hyperactivity
  • Restlessness
  • Anxiety
  • Insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia
  • Fine tremors
  • Overactive reflexes
GI
  • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation due to decreased motility
  • Decreased appetite
  • Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea due to increased motility
  • Increased appetite
Cardiovascular
  • Bradycardia
  • Dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea on exertion
  • Decreased cardiac output
  • Tachycardia, palpitations, and tachyarrhythmias
  • Dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
  • Chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain and systolic hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension due to higher sensitivity of beta-adrenergic receptors

Diagnosis

  • The signs and symptoms of thyroiditis will be characteristic of their respective thyroid hormone levels ( hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism versus hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism).
  • Goiter characteristics should be examined via palpation.
  • Thyroid function test results will depend on the clinical phase:
    • Thyrotoxicosis Thyrotoxicosis Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism: ↑ T3 and T4, ↓ TSH
    • Hypothyroid phase: ↓T3 and T4, ↑ TSH
    • Euthyroid phase: normal levels of T3, T4, and TSH
  • Ultrasonography:
    • Infectious thyroiditis presents with abscesses.
    • Subacute thyroiditis presents with diffuse heterogeneity and low vascular flow.
  • Fine-needle aspiration:
    • Infectious thyroiditis shows fluid collection with microbes.
    • Subacute thyroiditis shows multinucleated giant cell granulomas.
  • Thyroid peroxidase and thyroglobulin antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins will be present in Hashimoto’s thyroiditis.
  • Radioactive iodine uptake will usually be low.

Management

The type of therapy used will depend on which phase the patient presents or the specific cause of the condition.

  • Thyrotoxicosis Thyrotoxicosis Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism phase: antithyroid medication should not be used
    • Nonspecific beta-blockers block peripheral conversion of T4 to T3.
    • NSAIDs in the case of painful goiters (e.g., infectious thyroiditis)
  • Hypothyroid phase: lifelong oral administration of L-thyroxine
  • Riedel’s thyroiditis may require prednisolone and surgical relief of compressive symptoms.

Differential Diagnosis

The differential diagnosis of thyroiditis depends on the differentiation/recognition of the various conditions that can produce inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the thyroid gland Thyroid gland The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland. The following are the most common causes and their characteristic presentations.

  • Subacute thyroiditis (De Quervain’s thyroiditis): Patients present with hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism, followed by hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism and then recovery. During the hyperthyroid phase, the patient presents with neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain, a tender diffuse goiter Goiter A goiter is a chronic enlargement of the thyroid gland due to nonneoplastic growth occurring in the setting of hypothyroidism, hyperthyroidism, or euthyroidism. Morphologically, thyroid enlargement can be diffuse (smooth consistency) or nodular (uninodular or multinodular). Goiter, and elevated levels of T3 and/or T4.
  • Acute infectious thyroiditis with abscess formation is caused by gram-positive or gram-negative organisms, usually in immunocompromised patients. The organisms most commonly involved are staphylococci and streptococci. The patient presents with sudden onset of neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain and tenderness that is usually unilateral and accompanied by fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever and chills. Ordinarily, patients have a unilateral neck mass, which can fluctuate. Thyroid function is often normal, but thyrotoxicosis may be present.
  • Chronic infectious thyroiditis: usually presents as bilateral disease: The pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and tenderness are less prominent than in acute infections. Patients might present with hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism.
  • Radiation thyroiditis: Some patients with hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism treated with radioiodine develop thyroid pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and tenderness 5 to 10 days later due to a radiation-induced injury and necrosis of the thyroid follicular cells and associated inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation. Patients present with neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain and tenderness, which is usually mild and disappears in a few days. Transient exacerbation of hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism is possible.
  • Riedel’s thyroiditis: presents as neck discomfort or tightness with dysphagia or hoarseness and a diffuse, asymmetric goiter Goiter A goiter is a chronic enlargement of the thyroid gland due to nonneoplastic growth occurring in the setting of hypothyroidism, hyperthyroidism, or euthyroidism. Morphologically, thyroid enlargement can be diffuse (smooth consistency) or nodular (uninodular or multinodular). Goiter that is very hard, fixed, and often not clearly defined: Most patients with Riedel’s thyroiditis are euthyroid, and only a few are hypothyroid. Serum antithyroid antibody concentrations are often high in these patients.

References

  1. Hershman JM. (2020). Subacute thyroiditis (de Quervain thyroiditis; giant cell thyroiditis; granulomatous thyroiditis). Merck Manual Profession Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/thyroid-disorders/subacute-thyroiditis
  2. Hershman JM. (2020). Hashimoto thyroiditis (autoimmune thyroiditis; chronic lymphocytic thyroiditis). Merck Manual Profession Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/thyroid-disorders/hashimoto-thyroiditis
  3. Slatosky J, Shipton B, Wahba H. (2000). Thyroiditis: differential diagnosis and management. American Family Physician 61:1047–1054. https://pubmed.ncbi.nlm.nih.gov/10706157/
  4. Burman KD, Ross DS, Mulder JE. (2021). Overview of thyroiditis. Retrieved March 28, 2021, from https://www.uptodate.com/contents/overview-of-thyroiditis
  5. Burman KD, Ross DS, Mulder JE. (2021). Subacute thyroiditis. Retrieved March 28, 2021, from https://www.uptodate.com/contents/subacute-thyroiditis
  6. Burman KD, Ross DS, Mulder JE. (2021). Painless thyroiditis. Retrieved March 28, 2021, from https://www.uptodate.com/contents/painless-thyroiditis
  7. Burman KD, Ross DS, Mulder JE. (2021). Postpartum thyroiditis. Retrieved March 28, 2021, from https://www.uptodate.com/contents/postpartum-thyroiditis

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details