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Swelling of thyroid gland, sometimes causing pressure symptoms in acute and subacute forms; painless enlargement and rubbery firmness in chronic form Thyroid function tests variable Serum antithyroperoxidase and antithyroglobulin antibody levels usually elevated in Hashimoto s thyroiditis
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1 Hashimoto s thyroiditis The thyroid gland is usually diffusely enlarged, firm, and finely nodular One thyroid lobe may be asymmetrically enlarged, raising concerns about neoplasm Although patients may complain of neck tightness, pain and tenderness are not usually present About 10% of cases are atrophic, the gland being fibrotic, particularly in elderly women Systemic manifestations are mostly related to ambient levels of thyroid hormone However, depression and chronic fatigue are more common in such patients, even after correction of hypothyroidism About one-third of patients have mild dry mouth (xerostomia) or dry eyes (keratoconjunctivitis sicca) of an autoimmune nature related to Sj gren s syndrome It may be associated with myasthenia gravis, which is usually of mild severity, mainly affecting the extraocular muscles and having a relatively low incidence of detectable AChR Ab or thymic disease Hashimoto s thyroiditis is sometimes associated with adrenal insufficiency (Schmidt s syndrome) and other endocrine deficiencies as part of polyglandular autoimmunity Thyroiditis is also more common in patients with other autoimmune conditions, such as inflammatory bowel disease or celiac disease (10%) Hashimoto s thyroiditis is very rarely associated with myocarditis, encephalopathy, or membranous
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Thyroiditis may be classified as follows: (1) chronic lymphocytic thyroiditis due to autoimmunity (also called Hashimoto s thyroiditis), (2) subacute thyroiditis, (3) suppurative thyroiditis, and (4) Riedel s thyroiditis Hashimoto s thyroiditis is an autoimmune condition and the most common thyroid disorder in the United States Elevated serum levels of antithyroid antibodies are found in 3% of men and 13% of women Women over the age of 60 years have a 25% incidence of elevated serum levels of antithyroid antibodies The incidence of Hashimoto s thyroiditis varies by kindred and by race; in persons older than 12 years
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nephropathy Women with gonadal dysgenesis (Turner s syndrome) have a 15% incidence of significant thyroid dysfunction by age 40 years Thyroiditis is also commonly seen in patients with hepatitis C Women with Hashimoto s thyroiditis have an increased risk of miscarriage in the first trimester of pregnancy Painless postpartum thyroiditis refers to autoimmune thyroiditis that occurs soon after delivery in 72% of women Women in whom postpartum thyroiditis develops have a 70% chance of recurrence after subsequent pregnancies It occurs most commonly in women who have high levels of thyroid peroxidase antibody in the first trimester of pregnancy or immediately after delivery It is also more common in women with other autoimmunity or a family history of Hashimoto s thyroiditis There is some evidence that the autoimmunity may be triggered by the accumulation of fetal cells in the maternal thyroid during pregnancy, a condition known as microchimerism Postpartum thyroiditis is typically accompanied by hyperthyroidism that begins 1 6 months after delivery and persists for only 1 2 months Then, hypothyroidism tends to develop in affected women beginning 4 8 months after delivery Although 80% of affected women subsequently recover normal thyroid function, permanent hypothyroidism eventually develops in about 50% within 7 years Permanent hypothyroidism is more common in women who are multiparous or who have had a spontaneous abortion Painless sporadic thyroiditis is thought to be a subacute form of Hashimoto s thyroiditis that is similar to painless postpartum thyroiditis except that it is not related to pregnancy It accounts for about 1% of cases of thyrotoxicosis Thyrotoxic symptoms are usually mild; a small, nontender goiter may be palpated in about 50% of such patients High serum thyroid peroxidase antibody concentrations are found in only 50% of such patients The course is similar to painless postpartum thyroiditis 2 Subacute thyroiditis Subacute thyroiditis also called de Quervain s thyroiditis, granulomatous thyroiditis, and giant cell thyroiditis is relatively common, accounting for about 5% of clinical thyroid disease It usually presents as an acute, usually painful enlargement of the thyroid gland, often with dysphagia The pain may radiate to the ears Patients usually manifest a low-grade fever and fatigue The manifestations may persist for weeks or months and may be associated with malaise In patients who experience pain, it is called painful subacute thyroiditis If there is no pain, it is called silent thyroiditis Subacute thyroiditis often follows an upper respiratory infection and its incidence peaks in the summer A viral etiology has been proposed but not firmly established Thyrotoxicosis develops in 50% of affected patients and tends to last for several weeks Subsequently, hypothyroidism develops that lasts 4 6 months Normal thyroid function typically returns within 12 months, but persistent hypothyroidism develops in 5% of patients Young and middle-aged women are most commonly affected 3 Suppurative thyroiditis Suppurative thyroiditis is caused by an infection of the thyroid gland, usually bacterial However, low-grade mycobacterial, fungal, and parasitic (eg, Pneumocystis jiroveci) infections have been described, fre-
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