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Hashimoto's Thyroiditis

Chronic Lymphocytic Thyroiditis

Hashimoto’s thyroiditis is an inflammatory disorder which is autoimmune in origin. It is also known as chronic autoimmune thyroiditis, as lymphocytic infiltration is seen in the thyroid. Hurthle cell formation is also seen.


Presentation

Generally it is asymptomatic in mild and moderate disease conditions but the symptoms are noticeable as the condition worsens. Some common symptoms are mentioned below [7]:

Goiter
  • A clearly enlarging goiter was observed before the diagnosis of lymphoma in 3 patients.[ncbi.nlm.nih.gov]
  • In advanced stages, a goiter can interfere with proper breathing and swallowing.[endocrineweb.com]
  • The patient was a 24-year-old man who underwent subtotal thyroidectomy due to compression symptoms caused by goiter and was diagnosed with HT postoperatively based on pathological examinations two years previously.[ncbi.nlm.nih.gov]
  • Background Resistance to thyroid hormone (RTH) commonly presents with goiter, attention deficit hyperactivity disorder (ADHD), short stature and tachycardia.[ncbi.nlm.nih.gov]
  • A 33 year old female presented with history of goiter for one year. Fine needle aspiration cytology (FNAC) of the swelling revealed cytological features suggestive of medullary carcinoma of thyroid.[ncbi.nlm.nih.gov]
Thyroid Nodule
  • The presence of any thyroid nodules with US and cytopathologic features was analyzed. The malignancy rate was also determined. RESULTS: Thyroid nodules were in 20 of the 89 patients (22.4%).[ncbi.nlm.nih.gov]
  • The study included 46 women with thyroid nodules and HT and 60 women with thyroid nodules without HT (controls) who underwent a fine needle aspiration biopsy (FNAB).[ncbi.nlm.nih.gov]
  • The study included 138 malignant and 292 benign thyroid nodules confirmed by cytological or histopathological results.[ncbi.nlm.nih.gov]
  • US-FNA demonstrated an effective method for diagnosis of subcentimeter thyroid nodules with a low nondiagnostic rate in our study.[ncbi.nlm.nih.gov]
  • In the differential diagnosis of thyroid nodules, ultrasound-guided fine-needle biopsy is an effective method to distinguish Hashimoto's thyroiditis from other thyroid disorders.[ncbi.nlm.nih.gov]
Cold Intolerance
  • Symptoms Common symptoms of the disease are dry skin, weight gain, cold intolerance, voice hoarseness, pressure symptoms in the neck from thyroid enlargement, tiredness, weight gain and hair thinning.[symptoma.com]
  • Critical Essential Core Tested Community Questions (2) Sorry, this question is for PEAK Premium Subscribers only (M1.EC.39) A 46-year-old Caucasian female presents with cold intolerance, weight gain, and constipation.[medbullets.com]
  • Symptoms of Hashimoto's thyroiditis include dry skin, fatigue, constipation, cold intolerance, hair loss, irregular periods, weight gain and the development of a goiter.[livestrong.com]
  • Hypothyroidism is when your thyroid gland doesn't produce enough thyroid hormone, and it can have some pretty nasty side effects: weight gain, sleepiness, cold intolerance, constipation, swelling, decreased heart rate, and heavy periods, to name a few[self.com]
  • This precipitates non-specific symptoms such as: Fatigue Weight gain Cold intolerance Joint or muscle pain Constipation Dry skin and hair Heavy menstrual periods Difficulty conceiving Depression Impaired memory Bradycardia Additionally, the inflammation[news-medical.net]
Myxedema
  • Abstract Myxedema coma (MC) is a rare, but often fatal endocrine emergency. The majority of cases that occur in elderly women with long-standing primary hypothyroidism are caused by particular triggers.[ncbi.nlm.nih.gov]
  • Myxedema Severe untreated hypothyroidism leads to myxedema, a condition characterized by the following: Heart failure Seizures Loss of consciousness Death.[innerbody.com]
  • Myxedema coma: In its severest form, untreated hypothyroidism may result in a rare life-threatening condition called myxedema or myxedema coma . There is mental slowing, profound lethargy, and ultimately coma . This is a life-threatening emergency.[emedicinehealth.com]
  • […] some costal areas  Diagnosis Low FT4, High TSH (Primary, check for antibodies) Low FT4, Low TSH (Secondary or Tertiary, TRH stimulation test, MRI)  Treatment Levothyroxine (T4) due to longer half life Treatment prevents bone loss, cardiomyopathy, myxedema[slideshare.net]
  • Myxedema (severe hypothyroidism): People with Hashimoto's thyroiditis sometimes develop this rare, life-threatening form of hypothyroidism. Learn More About Hashimoto's Thyroiditis Symptoms Learn More About Hashimoto's Thyroiditis Treatment[everydayhealth.com]
Fever
  • A 47-year-old Filipino woman with a 30-year history of an asymptomatic anterior neck mass developed painful, erythematous annular plaques on her arms with associated fever. Skin biopsy confirmed the diagnosis of Sweet's syndrome.[ncbi.nlm.nih.gov]
  • […] thyroiditis [ thi″roi-di tis ] inflammation of the thyroid gland, usually characterized by such symptoms as sore throat, fever, and painful enlargement of the gland. atrophic thyroiditis a type of autoimmune thyroiditis with atrophy of the follicles and[medical-dictionary.thefreedictionary.com]
  • It usually causes fever and pain in the neck, jaw or ear.[nhs.uk]
  • A patient with increased size of the gland, asymmetrical enlargement or associated B symptoms (20% of NHL can have symptoms of fevers, nightsweats or weight loss) should be evaluated for lymphoma and this includes an ultrasound guided fine-needle aspiration[clinicaladvisor.com]
Hoarseness
  • Symptoms Common symptoms of the disease are dry skin, weight gain, cold intolerance, voice hoarseness, pressure symptoms in the neck from thyroid enlargement, tiredness, weight gain and hair thinning.[symptoma.com]
  • Anyone who has a hoarse voice, constipation, a puffy and pale face, dry skin, and feels tired for no clear reason should see a doctor. Causes Hashimoto's disease is an inflammation of the thyroid gland.[medicalnewstoday.com]
  • Voice hoarseness Slow speech Impairment in memory function Peripheral neuropathy - This may be a mononeuropathy (as exemplified by carpal tunnel syndrome) or a polyneuropathy resulting from the involvement of several peripheral nerves, manifesting as[emedicine.medscape.com]
  • Signs that your thyroid isn’t working properly include: constipation dry, pale skin hoarse voice high cholesterol depression lower body muscle weakness fatigue feeling sluggish cold intolerance thinning hair irregular or heavy periods problems with fertility[healthline.com]
  • Do you feel like you have a lump in your throat that you can’t swallow, making your voice hoarse, causing problems swallowing, or causing a tight feeling in your throat? You may have Hashimoto’s disease, a common cause of hypothyroidism.[holtorfmed.com]
Alopecia
  • Alopecia areata is an autoimmune disease associated with other autoimmune diseases such as thyroid disorders, anemia, and other skin disorders.[ncbi.nlm.nih.gov]
  • Two years later, she presented with weight loss, knee and elbow arthritis, alopecia, leukopenia, and positive ANA and dsDNA autoantibody confirming the diagnosis of JSLE.[ncbi.nlm.nih.gov]
  • There is often hair loss (alopecia) and the skin becomes dry and flaky.[endocrinesurgeon.co.uk]
  • Alopecia areata, totalis and universalis. Chronic active hepatitis. [ 10 ] Polymyalgia rheumatica and giant cell arteritis. Primary biliary cirrhosis. Rheumatoid arthritis, Sjögren's syndrome, systemic lupus erythematosus.[patient.info]
  • . SIGNS- dry coarse skin, cool peripheral extremities; puffy face,hands and feet;diffuse alopecia; bradycardia; peripheral edema;delayed tendon reflex relaxation;carpal tunnel syndrome; serous cavity effusions. 16.  Agenesis Thyroid destruction Hashimoto[slideshare.net]
Urticaria
  • In this case report we describe a 49 year-old man who presented with chronic urticaria, angioedema and soft stool consistency.[ncbi.nlm.nih.gov]
  • BACKGROUND: Chronic spontaneous urticaria (CSU) may be associated with autoimmune thyroid diseases, and the Autologous Serum Skin Test (ASST) is an autoreactivity marker.[ncbi.nlm.nih.gov]
  • Leslie J De Groot,MD Second Response BY DR ANTHONY WEETMAN -My understanding is that chronic urticaria has been reported to be more frequent in autoimmune thyroid disease and thyroid antibodies occur in up to 27% of patients with urticaria (J Allergy[endotext.org]
  • The AITD may also be associated with chronic urticaria 26 and, rarely, glomerulonephritis. 27 Clinical Manifestations Thyroid hormones play an important role in childhood growth and are involved in the maturation and metabolism of certain organs such[touchendocrinology.com]
  • Chronic urticaria in patients with autoimmune thyroiditis: Significance of severity of thyroid gland inflammation.[cytojournal.com]
Neck Mass
  • A 47-year-old Filipino woman with a 30-year history of an asymptomatic anterior neck mass developed painful, erythematous annular plaques on her arms with associated fever. Skin biopsy confirmed the diagnosis of Sweet's syndrome.[ncbi.nlm.nih.gov]
  • We describe a unique DSPTC patient, an 18-year-old woman who presented with a neck mass that grew slowly for 2 years. The palpable neck mass was nontender, well defined, firm, and unmovable.[ncbi.nlm.nih.gov]
Round Face
  • At clinical examination, she presented with bradycardia, pale and round face, pseudohypertrophy of calf muscles and no pitting edema of the limbs.[ncbi.nlm.nih.gov]
Seizure
  • These include: Infertility, miscarriage, and giving birth to an infant with birth defects High cholesterol Severe cases can result in heart failure, seizures, coma, and death.[medicalnewstoday.com]
  • Myxedema Severe untreated hypothyroidism leads to myxedema, a condition characterized by the following: Heart failure Seizures Loss of consciousness Death.[innerbody.com]
  • […] hypothyroidism from Hashimoto’s disease can cause other health problems, including: Infertility Miscarriage Giving birth to a baby with birth defects High cholesterol Very rarely, severe underactive thyroid, called myxedema, can lead to: Heart failure Seizures[womenshealth.gov]

Workup

Routine thyroid function tests and thyroid antibody tests are the blood tests used to diagnose Hashimoto’s thyroiditis. The thyroid peroxidase antibody test is more sensitive than the thyroglobulin antibody test and is the preferred test for confirming autoimmune thyroid disease. If a thyroid nodule is present, an ultrasound examination may be performed [8]. In patients with a dominant nodule, a fine-needle aspiration biopsy should be performed to exclude malignancy.

Liver Biopsy
  • Detection of antinuclear antibodies at a titer of 1/800, anti-SSA, anti-SSB, anti-GP210, anti-microsomial and p-ANCA anti-myeloperoxydase antibodies along with renal, salivary and liver biopsy led to a diagnosis of MPA associated with PBC, Sjogren's syndrome[ncbi.nlm.nih.gov]

Treatment

In patients with Hashimoto’s thyroiditis, the goal of treatment is to maintain level of thyroid hormones throughout the life. This can be achieved by administering a proper dose of levothyroxine sodium orally. Dietary supplement of selenium along with levothyroxine sodium is also recommended by the FDA. Gluten-free diet is also proved to reduce the level of circulating anti-thyroid peroxidise and other thyroid-related serum antibodies [9].

Prognosis

Patients with hypothyroidism need lifelong thyroid hormone replacement. Euthyroid patients with Hashimoto’s thyroiditis may have an increased risk of developing hypothyroidism and rarly hyperthyroidism. Though unusual, patients with chronic thyroiditis may change from a hypothyroid to a euthyroid state or to a hyperthyroid state because of the development of stimulating thyroid stimulating hormone (TSH) receptor autoantibodies of Graves disease [6].
In a prospective study of 82 women with subclinical hypothyroidism followed over a mean of 9.2 years, risk factors for overt thyroid failure were identified based on initial evaluation. The incidence of overt hypothyroidism was increased in patients positive for thyroperoxidase antibodies (58.5% vs 23%) and impaired thyroid reserve (53% vs 38%), as determined by the degree increase in T3 levels after thyroid-releasing hormone (TRH) administration.

Etiology

Inflammation of the thyroid gland due to this autoimmune disease leads to insufficient amount of thyroid hormones (T3 and T4) in the body which is responsible for metabolism [2]. Excess intake of iodine may impart toxicity to thyrocytes, induce thyroglobulin antigenicity and block the hormone synthesis by the thyroid gland.

Epidemiology

Hashimoto’s thyroiditis can affect all age groups including children. It is approximately 7 times more common in women, with its peak onset usually between the ages of 30 to 50 years. On an average 1 in 1000 people are affected by this disease. It is prevalent in geographic areas where dietary iodine intake is high [3].

Sex distribution
Age distribution

Pathophysiology

Though there are no sufficient studies reporting the mechanism of induction of the condition by excess iodine in the body, the same may be explained by the oxygen free radical release mechanism upon the enzymatic reaction of thyroid peroxidise and thereby increasing the immunogenicity of thyroglobulin [4].

In Hashimoto’s thyroiditis gradual destruction of follicles in the thyroid gland occurs when antibodies are produced against thyroglobulin and thyroid peroxidase. Activation of cytotoxic T-lymphocytes followed by cell-mediated immune response is the major cause for thyrocyte destruction. The thyroid gland becomes enlarged and lobulated. Antibodies such as TSH receptor-blocking antibodies, anti-thyroid peroxidise and antithyroglobulin can be found in the systemic circulation.

Glandular hyperplasia results due to the decreased ability of the thyroid gland to produce hormones. Also, the replacement of normal cells by fibrous and lymphoid tissue occurs. Histopathological studies indicate the presence of diffuse lymphocyte infiltration by both B cells and cytotoxic T cells [5]. In patients with Hashimoto’s thyroiditis, thyrocytes express the Fas gene, which causes thyroid apoptosis by interaction with the Fas ligand present on the surface of the thyrocyte.

Prevention

It is not possible to prevent Hashimoto’s thyroiditis as it an autoimmune disease.

Summary

Hashimoto’s thyroiditis is named after the Japanese discoverer, Hakaru Hashimoto. It is the most common cause of primary hypothyroidism [1]. Family history of this autoimmune disease, selenium deficiency, stress and smoking are the major contributing factors for this disease. Hashimoto’s thyroiditis is initiated by environmental factors in genetically predisposed persons.

Patient Information

The thyroid gland is a butterfly-shaped organ that is found in the front part of your neck. Thyroid hormones regulate body temperature, heart rate, and weight gain or loss.

Definition

Hashimoto’s thyroiditis is an autoimmune thyroid disorder that occurs when the immune system attacks the thyroid gland. It can be seen in all age groups including children but more common in women of age group 30 to 50 years. Though it cannot be prevented, it can be managed well by maintaining thyroid hormone levels in your body.

Cause

Destruction of thyroid gland due to autoimmune response of the body is the major cause for Hashimoto’s thyroiditis, leading to inadequate level of thyroid hormones in your body. It is prevalent in geographic areas where dietary iodine intake is high.

Symptoms

Common symptoms of the disease are dry skin, weight gain, cold intolerance, voice hoarseness, pressure symptoms in the neck from thyroid enlargement, tiredness, weight gain and hair thinning. Other symptoms are depression, sleeplessness, memory loss, deafness, constipation, joint pain, muscle pain, slow heart beat and irregular periods in women.

Diagnosis

Thyroid hormone levels in the body are obtained by blood tests. An ultrasound uses sound waves to show pictures of your thyroid on a monitor. A thyroid scan shows how well your thyroid is working. You may be given a dye before the pictures are taken to help caregivers see the pictures better. Fine needle biopsy is a procedure where a small needle is used to take a sample of your thyroid gland for tests [10].

Treatment

Maintaining the normal thyroid hormone level in the body is the basis of treatment. In addition, gluten-free diet and intake of dietary selenium also help to reduce the level of circulating thyroid specific antibodies.

References

Article

  1. Tomer Y, Huber A. The etiology of autoimmune thyroid disease: a story of genes and environment. J Autoimmun. Mar 21 2009
  2. Wiebolt J, Achterbergh R, den Boer A, et al. Clustering of additional autoimmunity behaves differently in Hashimoto's patients compared with Graves' patients. Eur J Endocrinol. May 2011;164(5):789-94.
  3. Vanderpump MP, French JM, Appleton D. The prevalence of hyperprolactinaemia and association with markers of autoimmune thyroid disease in survivors of the Whickham Survey cohort. Clin Endocrinol (Oxf). Jan 1998;48(1):39-44. 
  4. Huber A, Menconi F, Corathers S, et al. Joint genetic susceptibility to type 1 diabetes and autoimmune thyroiditis: from epidemiology to mechanisms. Endocr Rev. Oct 2008;29(6):697-725.
  5. Fava A, Oliverio R, Giuliano S, et al. Clinical evolution of autoimmune thyroiditis in children and adolescents. Thyroid. Feb 18 2009
  6. Vestgaard M, Nielsen LR, Rasmussen AK, et al. Thyroid peroxidase antibodies in pregnant women with type 1 diabetes: impact on thyroid function, metabolic control and pregnancy outcome. Acta Obstet Gynecol Scand. 2008;87(12):1336-42.
  7. z. Interferon alpha treatment and thyroid dysfunction. Endocrinol Metab Clin North Am. Dec 2007;36(4):1051-66; x-xi.
  8. Menconi F, Monti MC, Greenberg DA, et al. Molecular amino acid signatures in the MHC class II peptide-binding pocket predispose to autoimmune thyroiditis in humans and in mice. Proc Natl Acad Sci U S A 2008; 105:14034.
  9. Ban Y, Tozaki T, Tobe T, et al. The regulatory T cell gene FOXP3 and genetic susceptibility to thyroid autoimmunity: an association analysis in Caucasian and Japanese cohorts. J Autoimmun 2007; 28:201.
  10. Tomer Y, Barbesino G, Greenberg DA, et al. Mapping the major susceptibility loci for familial Graves' and Hashimoto's diseases: evidence for genetic heterogeneity and gene interactions. J Clin Endocrinol Metab 1999; 84:4656. 

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Last updated: 2019-07-11 20:48