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quently in patients with AIDS Suppurative thyroiditis is quite rare, since the thyroid is resistant to infection, largely due to its high iodine content Affected patients usually are febrile and have severe pain, tenderness, redness, and fluctuation in the region of the thyroid gland It tends to affect patients with preexistent thyroid disease It is also more likely to affect patients who are immunosuppressed or infirm 4 Riedel s thyroiditis Riedel s thyroiditis is also called invasive fibrous thyroiditis, Riedel s struma, woody thyroiditis, ligneous thyroiditis, and invasive thyroiditis It usually causes hypothyroidism and may cause hypoparathyroidism as well It is the rarest form of thyroiditis and is found most frequently in middle-aged or elderly women Enlargement is often asymmetric; the gland is stony hard and adherent to the neck structures, causing signs of compression and invasion, including dysphagia, dyspnea, pain, and hoarseness It is usually a manifestation of a multifocal systemic fibrosis syndrome, with anterior neck symptoms predominating Related conditions include retroperitoneal fibrosis, fibrosing mediastinitis, sclerosing cervicitis, subretinal fibrosis, and biliary tract sclerosis It may respond to therapy with tamoxifen (see Treatment, below)
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With hyperthyroidism due to subacute thyroiditis or Hashimoto s thyroiditis, serum FT4 levels tend to be proportionally higher than T3 levels, since the hyperthyroidism is due to the passive release of stored thyroid hormone, which is predominantly T4; this is in contrast to Graves disease and toxic nodular goiter, where T3 is relatively more elevated Because T4 is less active than T3, the hyperthyroidism seen in thyroiditis is usually less severe Serum levels of TSH are suppressed in hyperthyroidism due to thyroiditis Thyroid autoantibodies are most commonly demonstrable in Hashimoto s thyroiditis but may also be present in the other types of thyroiditis Patients with Hashimoto s thyroiditis and clinically evident disease usually have increased circulating levels of antithyroid peroxidase (90%) or antithyroglobulin (40%) antibodies Antithyroid antibodies decline during pregnancy and are often undetectable in the third trimester Once Hashimoto s thyroiditis has been diagnosed, monitoring of these antibody levels is not necessary The serum TSH level is elevated if thyroid hormone is not elaborated in adequate amounts by the thyroid gland The ESR is markedly elevated, and antithyroid antibodies are low, which helps differentiate this form of thyroiditis from others Aspiration biopsy is usually not required but shows characteristic giant multinucleated cells Patients with Hashimoto s thyroiditis who have a thyroid nodule should have an ultrasound-guided fine-needle aspiration (FNA) biopsy, since the risk of papillary thyroid cancer is about 8% in such nodules In suppurative thyroiditis, the leukocyte count and ESR are usually elevated; when suspected, an FNA biopsy with Gram stain and culture is required
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Ultrasound in cases of Hashimoto s thyroiditis typically shows a gland with characteristic diffuse heterogeneous density and
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If the thyroid gland is only minimally enlarged and the patient is euthyroid (with normal TSH levels), regular observation is in order, since hypothyroidism may develop subsequently often years later (See Hypothyroidism section) In one study involving 21 patients with Hashimoto s thyroiditis and subclinical hypothyroidism, simvastatin (20 mg orally daily) improved thyroid function over 8 weeks, possibly by stimulating apoptosis of certain types of lymphocytes In another study, selenium selenite (200 mcg daily orally for 3 months) reduced the serum levels of antithyroperoxidase antibodies by 49% versus a 10% reduction in the placebo arm The long-term effectiveness of statins or selenium therapy on the course of Hashimoto s thyroiditis is unknown Hyperthyroidism may develop in patients with Hashimoto s thyroiditis due to the release of stored hormone by the thyroid, which is caused by inflammation This condition has variably been termed hashitoxicosis or painless sporadic thyroiditis; it is known as postpartum painless thyroiditis when it occurs in women after delivery Such patients may have only mild thyrotoxicosis and may not require therapy Patients who are more symptomatic may be treated with propranolol (see Subacute Thyroiditis); they should have a 24-hour 123I thyroid uptake and scan to determine whether Graves disease may be present In patients with low RAI uptake, propranolol is continued; sodium ipodate or iopanoic acid may also be given in doses of 500 mg daily orally until the patient is euthyroid to block the peripheral conversion of T4 to T3 Patients having low RAI uptake do not respond to thiourea medication Because RAI is excreted in breast milk, nursing mothers having RAI scanning should always be scanned with 123I, since it is less toxic than 131I; breast milk must be pumped and discarded for 2 days after 123I scanning
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hypoechogenicity Ultrasonography of the thyroid helps distinguish thyroiditis from multinodular goiter or thyroid nodules that are suspicious for malignancy It is also helpful in guiding FNA biopsy of small suspicious thyroid nodules Color-flow Doppler ultrasonography can help distinguish thyroiditis from Graves disease, since patients with Graves disease have a hypervascular thyroid gland, whereas in thyroiditis there is normal or reduced vascularity RAI uptake and scan may be helpful in determining the cause of hyperthyroidism, distinguishing thyroiditis from Graves disease, since patients with subacute thyroiditis exhibit a very low RAI uptake In patients with chronic Hashimoto s thyroiditis (euthyroid or hypothyroid), RAI uptake may be normal or high with uneven uptake on the scan; scanning is not useful in making the diagnosis
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