Let us now move on to thyroiditis with hyperthyroidism.
We’ve officially completed our discussion
Let’s get into the group of diseases characterized
by thyroid inflammation.
Chronic lymphocytic, the most common...
Now, this is interesting.
Hashimoto, most common cause of primary hypothyroidism
in the US.
So, why is it under hyperthyroidism?
Because of the following.
Whenever you have inflammation, -itis, inflammation
of the thyroid, there’s every possibility
that the colloid…
Can you picture the colloid for me?
The homogenous eosinophilic central region
of your thyroid cell that stores your, harbours
my thyroid hormones.
Any time there’s inflammation, that colloid
You may then release your T3, T4 into circulation
in great quantity.
Welcome to thyroid storm.
There’s every possibility with any one of
these thyroiditises that the patient may present
initially with hyperthyroidism and that’s
the topic that we’re sticking with here.
Do not ever forget that.
Chronic lymphocytic thyroiditis.
Acute bacterial (suppurative) thyroiditis
– rare, but still possible.
What’s subacute mean?
De Quervain, granulomatous thyroiditis.
Once again, destruction release of… Colloid
releasing T3, T4 excessively.
We’ll talk about this post-partum especially,
We’ll see that coming up.
Take a look at the “iod” in amiodarone.
And doesn’t that resemble iodine?
You may be using this as an antiarrhythmic
drug specifically and technically comes under
However, you know it has all classes of antiarrhythmic
Point is, the iodine, with amiodarone, some
patients will respond with hyperthyroid type
of presentation, whereas other patients may
present with hypo.
I wish to be very clear here that the functioning
or the side effect of amiodarone could either
be hypo or hyper.
You really want to pay attention how is your
And we have what’s called Riedel’s thyroiditis.
Rare, but must know.
Let’s take a look at painful thyroiditis.
Infectious (suppurative) thyroiditis and deal
with acute specifically.
Presents with abscess formation.
Thinking about bacteria.
Gram-positive or gram-negative organism and
gaining access most commonly and usually in
children via fistula from the piriform sinus
adjacent to the larynx, or via hematogenous
spread in an immonucompromised patient.
So, if it’s a child, it would be through
a fistula, through a sinus.
If it’s an adult, you’re thinking more
about an immunocompromised patient.
Acute – rare, but still keep in mind.
A suppurative thyroiditis.
Remember, if you have a bacterial infection,
it’ll usually be painful lymphadenopathy
and it may present as painful thyroiditis.
Chronic thyroiditis usually caused by Aspergillus,
Pneumocystis in immunocompromised patients
that you’re quite familiar with.
Sudden (acute) onset of neck pain, usually
unilateral with fever.
Well, behind your thyroid gland is oesophagus
– may then constrict it, therefore result
in obstruction, dysphagia.
And whenever you have bacterial infection,
you expect it to be, or even any type of infection,
Differential – haemorrhage into the thyroid
nodule and subacute thyroiditis are your differentials
that you want to keep in mind.
Continuing discussion of painful thyroiditis
and here are some important differentials.
Infectious thyroiditis – you would expect
to find abscess.
So, therefore, you would expect to find a
fluid-filled type of structure within the
thyroid gland resulting in, or diagnosing
your patient more or less with bacterial.
Whereas subacute thyroiditis, as a differential,
diffusive heterogeneity and low intensity
So, diffuse heterogeneity, meaning to say
that here on ultra-sound instead of finding
a homogenous type of structure, it would be
Then thyroid gland is going to be affected.
Abscess is localised in one region.
Fine needle aspiration (FNA).
Infectious thyroiditis – fluid collection
with microbes, so you want to see as to…
You want to culture the organisms that you
would expect to find within your perhaps abscess.
If it’s subacute, maybe.
Remember, this is more chronic in nature,
so therefore you would expect to find more
of a granulomatous type of inflammation, so
therefore, you’d expect to find multinucleated
Any type of granuloma.
Treatment – well, depends.
IV antibiotic and ultimately you’re thinking
about draining your abscess.
Important points of properly managing a patient
who’s presenting with hyperthyroidism, but
is painful thyroiditis.
Acute, subacute, ultra-sound, FNA.
Painful thyroiditis – differentials.
We’ll put together granulomatous and DeQuervain
thyroiditis, so this is much longer.
Usually here you’re not going to find bacterias
Acute – bacterial, abscess, ultra-sound,
localised lesions that you’d find in your
Subacute – viral infections: MUMPS, coxsackie.
Often preceding in upper respiratory tract
infection, strongly associated with HLA-B35.
Limited, painful, tender.
More common in women.
Typically 3-6 weeks of pain and thyrotoxicosis.
What does that mean?
Hyperthyroidism followed by several months
of hypothyroidism and recovery is going to
Now, let’s get into further continuum of
It’s initially there might be destruction
You might have increase of your T3, T4 and
at some point things are going to slow down
and upon recovery, because this is viral,
may result in normal euthyroidic function.
Because it’s painful thyroiditis and you’re
thinking about viral, you are thinking about
symptomatic treatment and anti-inflammatories.
FNA – focal destruction of your thyroid
tissues by granulomatous inflammation.
And what kind of cells are you going to find
Multinucleated giant cells.
Clinical note – radiation thyroiditis may
manifest 5-10 days.
You’re looking at approximately week post-radioiodine
treatment of Grave’s disease.
So, even if you’re thinking about perhaps
giving your patient radioactive iodine, there’s
every possibility that may result in what’s
known as radiation thyroiditis.
Keep that in mind.
I’d like to show you a graph here with the
continuum of thyroiditis.
Up until this point, I’ve been talking to
you about how you may destroy the colloid
releasing T3, T4, but as the sequence takes
place for thyroiditis, then what do you want
You can have a patient initially with hyperthyroidism.
Take a look at X-axis on the graph.
If it’s hyperthyroidism, you’d expect
your T3, T4 to be high.
Take a look at the blue line.
And you find that to be elevated.
If you find your T3, T4 to be elevated, then
if you are thinking about diagnosis radioactive
iodine, which is the red line, when you have
such T3, T4 elevated, what is your TSH level?
Take a look at the green line, in specifically
Increased T3, T4, decreased TSH.
Welcome to thyroiditis.
Here, because of decreased TSH activity on
the thyroid gland.
What about your radioactive iodine uptake?
It is decreased, because you don’t have
as much receptor activity.
Through thyroiditis, this is not Grave’s
disease, this is not Hashimoto, even though
Hashimoto could present a little bit like
This is thyroiditis, subacute.
Then you go through euthyroid phase.
So, what does that mean?
Now, you have levels of your thyroid gland
or thyroid receptors for your thyroid hormones
which are decreasing.
As the thyroid hormone levels are decreasing,
take a look at the blue line, then you would
expect your TSH to be rising along with it.
You’d expect your radioactive iodine to
With continuous destruction of your thyroid
gland, maybe because of viral infections,
then you expect your thyroid hormones to depress
even further so you get into your third segment
on your X-axis, your hypothyroid.
Notice here, please, that your T3, T4 decreased.
Therefore, you would expect to find an increase
in TSH and, thus, you expect increased activity
of your TSH receptors and your radioactive
iodine is being taken up in greater quantity.
Once the viral infection has been passed,
then you go into a state of euthyroidism.
Welcome to recovery.
Notice now that at any point in time in a
patient, so you’re looking at approximately
3-6 weeks of hyperthyroidism, maybe state
of euthyroid, maybe state of hypo and then
with the viral, you’d expect it to be recovery.
Obviously, such a thing would not be taking
place with Hashimoto.
You will see.
Silent lymphocytic thyroiditis.
1-5% of your cases of hyperthyroidism.
Once again, release of your T3, T4.
Any woman non-post-partum or man a who’s
had symptoms of mild hyperthyroidism for less
than 2 months.
This is painless, silent, lymphocytic.
That’s short and has a small diffuse goiter
and no thyroid enlargement.
That’s your definition of a painless, silent
Autoimmune – could be a variant and could
be a variant of what’s known as your Hashimoto,
but in milder form.
Meds – interferon-?, interleukin-2, lithium
– may also result in destruction of your
thyroid; may present as silent, painless thyroiditis.
Phasic course similar to subacute – what
does that mean to you?
Meaning to say that you would be in a state
of hyperthyroidism, maybe euthyroid and unfortunately
25% of your patient may actually remain hypothyroid
Post-partum, so, now, a pregnant woman is
Thyroiditis occurs within one year after parturition
or after spontaneous or induced abortion.
Patient may present with, once again, hyperthyroid,
Similar clinical pathogenetically to painless
However, differs from painless thyroiditis
in that more patients have elevated levels
of serum anti-thyroid antibody or anti-, let’s
say thyroglobulin, or anti-thyroid peroxidise;
TPO stands for thyroid peroxidise, increasing
likelihood of permanent thyroid disease later.
So, couple of things that you want to keep
in mind here as you walk through your painless
thyroiditis is, well, similarly talk about
However, along with this, there might be issues
with autoimmune, meaning to say they were
referring to our Hashimoto perhaps.