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Key Features

Essentials of Diagnosis

  • Autoimmune thyroiditis (Hashimoto) most common thyroiditis

  • Thyroid function tests variable

  • Antithyroperoxidase or antithyroglobulin antibodies usually high in autoimmune thyroiditis

General Considerations

  • Classification

    • Autoimmune (Hashimoto) thyroiditis (chronic lymphocytic thyroiditis)

      • Most common thyroid disorder in the United States

      • Due to autoimmunity

      • Frequency increased by dietary iodine supplementation

      • Certain drugs can trigger autoimmune thyroiditis: alemtuzumab, amiodarone, denileukin diftitox, interferon-alpha, interleukin-2, ipilimumab, lenalidomide, lithium, thalidomide, tremelimumab, and tyrosine kinase inhibitors

      • Associated with other autoimmune diseases, eg, inflammatory bowel disease, pernicious anemia, Sjögren syndrome, vitiligo, and celiac disease (gluten enteropathy)

      • Rarely associated with other autoimmune conditions such as alopecia areata, hypophysitis, encephalitis, membranous nephropathy myocarditis, or primary pulmonary hypertension

    • Subacute thyroiditis (de Quervain thyroiditis, granulomatous thyroiditis, and giant cell thyroiditis)

      • Relatively common

      • Believed to be caused by viral infection

    • Infectious (suppurative) thyroiditis: rare, caused by pyogenic organisms, usually during systemic infection

    • Postpartum thyroiditis (autoimmune): causes transient hyperthyroidism followed by hypothyroidism

    • Riedel thyroiditis (also known as invasive fibrous thyroiditis, Riedel struma, woody thyroiditis, ligneous thyroiditis, and invasive thyroiditis)

      • Rarest form

      • Usually a manifestation of a multifocal systemic fibrosis syndrome

      • May occur a thyroid manifestation of IgG4-related systemic disease

  • Thyroiditis commonly occurs in patients with hepatitis C

Demographics

  • Autoimmune (Hashimoto) thyroiditis

    • Often familial, varies by kindred and by race

    • Six times more common in women

  • Antithyroid antibodies in US adolescents and adults found in

    • 3% of men and 13% of women

    • 25% of women over age 60 years

    • 14% of whites

    • 11% of Mexican Americans

    • 5% of blacks

  • Subacute thyroiditis accounts for 5% of clinical thyroid disease

  • Riedel thyroiditis usually affects middle-aged or elderly women

  • 40% of women and 20% of men exhibit focal thyroiditis at autopsy

Clinical Findings

Symptoms and Signs

Autoimmune (Hashimoto) thyroiditis

  • Thyroid gland usually diffusely enlarged, firm, and finely nodular

  • One lobe may be asymmetrically enlarged, raising concern for neoplasm

  • Neck tightness; pain and tenderness not usually present

  • Mild dry mouth (xerostomia) or dry eyes (keratoconjunctivitis sicca) related to Sjögren syndrome in ~33%

  • Diplopia due to coexistent myasthenia gravis

  • Manifestations of other autoimmune diseases listed above

Subacute thyroiditis

  • Acute, usually painful, thyroid enlargement, with dysphagia

  • Pain may radiate to ears

  • Low-grade fever and fatigue

  • If no pain, called "silent thyroiditis"

  • May persist for weeks or months

  • May be associated with malaise

Infectious (suppurative) thyroiditis

  • Severe pain, tenderness, redness, and fluctuation in the region of the thyroid gland

Riedel thyroiditis

  • Enlargement often asymmetric

  • Gland is stony hard and adherent to neck structures, causing dysphagia, dyspnea, pain, and hoarseness

  • Related conditions include

    • Retroperitoneal fibrosis

    • Fibrosing mediastinitis

    • Sclerosing cervicitis

    • Subretinal fibrosis

    • Sclerosing cholangitis

Differential Diagnosis

  • Benign multinodular goiter

  • Iodine-deficient (endemic) ...

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