Autoimmune thyroiditis - Clinicals, Diagnosis, and Management

Endocrinology, Metabolism and Nutrition

Clinicals - History

Fact Explanation
Asymptomatic Some patients can be asymptomatic. Asymptomatic
Some patients can be asymptomatic.
Feeling of fullness in the neck Some patients may not notice the goiter but complain of tightness or fullness in the neck. Feeling of fullness in the neck
Some patients may not notice the goiter but complain of tightness or fullness in the neck.
Goiter Patients often complain of painless diffuse enlargement of the thyroid gland. Goiter
Patients often complain of painless diffuse enlargement of the thyroid gland.
Symptoms of hypo or hyperthyroidism In young children poor growth or short stature are the usual complains. Amenorrhea either primary or secondary and delayed puberty are presenting complains in adolescents. Constipation, lethargy, and cold intolerance are other symptoms of hypothyroidism.
Children with hyperthyroidism often have poor attention, hyperactivity and restlessness. Other complains are heat intolerance, palpitations, nervousness weight loss and loose stools.
Hashimoto’s thyroiditis presents with either hypo or euthyroidism. Patients with postpartum thyroiditis present after about three months of delivery with symptoms of hyperthyroidism. One to two months later they develop hypothyroidism and subsequently become euthyroid. Subacute lymphocytic thyroiditis can present with hypo, hyper and euthyroidism. Graves’ disease presents with symptoms of hyperthyroidism and ophthalmological manifestations like protrusion of the eyes as proptosis, painful opthalmoplegia and chemosis.
Symptoms of hypo or hyperthyroidism
In young children poor growth or short stature are the usual complains. Amenorrhea either primary or secondary and delayed puberty are presenting complains in adolescents. Constipation, lethargy, and cold intolerance are other symptoms of hypothyroidism.
Children with hyperthyroidism often have poor attention, hyperactivity and restlessness. Other complains are heat intolerance, palpitations, nervousness weight loss and loose stools.
Hashimoto’s thyroiditis presents with either hypo or euthyroidism. Patients with postpartum thyroiditis present after about three months of delivery with symptoms of hyperthyroidism. One to two months later they develop hypothyroidism and subsequently become euthyroid. Subacute lymphocytic thyroiditis can present with hypo, hyper and euthyroidism. Graves’ disease presents with symptoms of hyperthyroidism and ophthalmological manifestations like protrusion of the eyes as proptosis, painful opthalmoplegia and chemosis.
Risk factors of autoimmune diseases Patients with Down syndrome, Turner syndrome and autoimmune disorders (type 1 diabetes, Addison disease, vitiligo, pernicious anemia, premature ovarian failure) are at high risk of autoimmune thyroiditis. Risk factors of autoimmune diseases
Patients with Down syndrome, Turner syndrome and autoimmune disorders (type 1 diabetes, Addison disease, vitiligo, pernicious anemia, premature ovarian failure) are at high risk of autoimmune thyroiditis.
Positive family history of autoimmune thyroid diseases Some autoimmune diseases have a positive family history. Post-partum thyroiditis and Hashimoto’s thyroiditis have a genetic basis hence a positive family history. Positive family history of autoimmune thyroid diseases
Some autoimmune diseases have a positive family history. Post-partum thyroiditis and Hashimoto’s thyroiditis have a genetic basis hence a positive family history.

Clinicals - Examination

Fact Explanation
Goiter Thyroid gland is enlarged to a size of two to three times of the normal gland. In Hashimoto’s thyroiditis and in post partum thyroiditis the thyroid gland is diffusely and symmetrically enlarged, non-tender and firm in consistency. Goiter may not be felt in patients with hypothyroidism. Goiter
Thyroid gland is enlarged to a size of two to three times of the normal gland. In Hashimoto’s thyroiditis and in post partum thyroiditis the thyroid gland is diffusely and symmetrically enlarged, non-tender and firm in consistency. Goiter may not be felt in patients with hypothyroidism.
Signs of hypothyroidism These include slow growth rate, obesity, bradycardia, cold dry skin, coarse hair, coarse facies, myxedema, cognitive impairment, macroglossia and delayed relaxation of the deep tendon reflexes. Signs of hypothyroidism
These include slow growth rate, obesity, bradycardia, cold dry skin, coarse hair, coarse facies, myxedema, cognitive impairment, macroglossia and delayed relaxation of the deep tendon reflexes.
Signs of hyperthyroidism Patients have tremor, warm and sweaty palms, and irregularly irregular pulse. Signs of hyperthyroidism
Patients have tremor, warm and sweaty palms, and irregularly irregular pulse.
Examination of the eyes Thinning of the lateral part of the eye brows is seen in hypothyroidism. Proptosis, lid lag, lid retraction, chemosis and painful ophthalmoplegia are seen in Graves’ disease. Examination of the eyes
Thinning of the lateral part of the eye brows is seen in hypothyroidism. Proptosis, lid lag, lid retraction, chemosis and painful ophthalmoplegia are seen in Graves’ disease.
Examination of the cardiovascular system Bradycardia and pericardial effusions are detected in hypothyroidism. Hyperthyroidism causes atrial fibrillation hence irregularly irregular pulse. Examination of the cardiovascular system
Bradycardia and pericardial effusions are detected in hypothyroidism. Hyperthyroidism causes atrial fibrillation hence irregularly irregular pulse.

Investigations - Diagnosis

Fact Explanation
Full blood count Often shows no abnormality with normal white cell counts. Hypothyroid patients can have normocytic anemia. Full blood count
Often shows no abnormality with normal white cell counts. Hypothyroid patients can have normocytic anemia.
Erythrocyte sedimentation rate (ESR) ESR is within normal range. Erythrocyte sedimentation rate (ESR)
ESR is within normal range.
Thyroid function test Serum thyroid stimulating hormone (TSH) levels are increased in hypothyroidism and suppressed in hyperthyroidism. Hashimoto’s thyroiditis present with either hypo or euthyroidism so TSH levels will be either high or normal. Subclinical hypothyroidism (normal T4 and raised TSH) is another finding in Hashimoto’s thyroiditis. TSH is low in postpartum thyroiditis. Thyroid function test
Serum thyroid stimulating hormone (TSH) levels are increased in hypothyroidism and suppressed in hyperthyroidism. Hashimoto’s thyroiditis present with either hypo or euthyroidism so TSH levels will be either high or normal. Subclinical hypothyroidism (normal T4 and raised TSH) is another finding in Hashimoto’s thyroiditis. TSH is low in postpartum thyroiditis.
Antithyroid peroxidase (antithyrocellular, antimicrosomal) antibody Elevated antibody level is the most sensitive investigation to diagnose Hashimoto’s thyroiditis and elevated levels are found in about 90% to 95% of affected patients. Patients with postpartum thyroidism also have elevated levels of antithyroid peroxidase antibodies. Antithyroid peroxidase (antithyrocellular, antimicrosomal) antibody
Elevated antibody level is the most sensitive investigation to diagnose Hashimoto’s thyroiditis and elevated levels are found in about 90% to 95% of affected patients. Patients with postpartum thyroidism also have elevated levels of antithyroid peroxidase antibodies.
Antithyroglobulin antibodies This is elevated in some patients and not sensitive as the assessment of antithyroid peroxidase antibody levels. Antithyroglobulin antibodies
This is elevated in some patients and not sensitive as the assessment of antithyroid peroxidase antibody levels.
Thyroid-stimulating immunoglobulins Thyroid-stimulating immunoglobulins are elevated in Graves’ disease. Thyroid-stimulating immunoglobulins
Thyroid-stimulating immunoglobulins are elevated in Graves’ disease.
Radioactive iodine thyroid scanning Uptake of radioiodine can be reduced, normal or high in autoimmune thyroiditis. This depends on the number of viable follicles. Increased uptake of radioactive iodine is seen in Graves’ disease. Radioactive iodine thyroid scanning
Uptake of radioiodine can be reduced, normal or high in autoimmune thyroiditis. This depends on the number of viable follicles. Increased uptake of radioactive iodine is seen in Graves’ disease.
Thyroid ultrasonography Ultrasound scan helps in diagnosing an autoimmune etiology. When combined with Doppler flow it can detect increased perfusion of the gland as seen in Graves’ disease. Thyroid ultrasonography
Ultrasound scan helps in diagnosing an autoimmune etiology. When combined with Doppler flow it can detect increased perfusion of the gland as seen in Graves’ disease.
Fine-needle thyroid aspiration Lymphocytic infiltration of the thyroid gland and the presence of Askanazy (Hürthle) cells is suggestive of Hashimoto thyroiditis. In subacute lymphocytic thyroiditis cytology is similar to Hashimoto’s thyroiditis but there is no fibrosis. Fine-needle thyroid aspiration
Lymphocytic infiltration of the thyroid gland and the presence of Askanazy (Hürthle) cells is suggestive of Hashimoto thyroiditis. In subacute lymphocytic thyroiditis cytology is similar to Hashimoto’s thyroiditis but there is no fibrosis.
Serum prolactin levels Although not routinely assessed serum prolactin levels are elevated in hypothyroidism. Serum prolactin levels
Although not routinely assessed serum prolactin levels are elevated in hypothyroidism.

Investigations - Management

Fact Explanation
Serum TSH Patients should be euthyroid. Raised TSH levels indicated hypothyroidism and suppressed TSH levels indicated hyperthyroidism. Thyroid function tests should be done annually in patients with Hashimoto’s thyroiditis, and after one month of altered levothyroxine doses. Serum TSH
Patients should be euthyroid. Raised TSH levels indicated hypothyroidism and suppressed TSH levels indicated hyperthyroidism. Thyroid function tests should be done annually in patients with Hashimoto’s thyroiditis, and after one month of altered levothyroxine doses.
Ant thyroid peroxidase antibodies Risk of permanent hypothyroidism is higher with elevated antibody levels. Ant thyroid peroxidase antibodies
Risk of permanent hypothyroidism is higher with elevated antibody levels.
Fine needle aspiration cytology Development of rapidly enlarging solitary nodule in previously diagnosed Hashimoto’s thyroiditis should raise the suspicion of primary lymphoma of the thyroid. FNAC will aid in diagnosing or excluding the malignancy. Fine needle aspiration cytology
Development of rapidly enlarging solitary nodule in previously diagnosed Hashimoto’s thyroiditis should raise the suspicion of primary lymphoma of the thyroid. FNAC will aid in diagnosing or excluding the malignancy.
Full blood count Normocytic anemia is found in hypothyroidism. Full blood count
Normocytic anemia is found in hypothyroidism.
ECG Shows atrial fibrillation. ECG
Shows atrial fibrillation.
Serum electrolytes Hyponatremia is seen in association with hypothyroidism. Serum electrolytes
Hyponatremia is seen in association with hypothyroidism.
Lipid profile In hypothyroidism low-density lipoprotein and triglycerides are elevated. Lipid profile
In hypothyroidism low-density lipoprotein and triglycerides are elevated.
Anti-thyroid peroxidase antibodies Although not routinely screened, women with raised anti-thyroid peroxidase antibodies have about 25% risk of developing postpartum thyroiditis. Therefore at risk females (females with type1 diabetes mellitus, positive family history of autoimmune thyroid disease) can be screened. Females with a history of post-partum thyroiditis and elevated levels of anti-thyroid peroxidase antibodies are at high risk of recurrence in subsequent pregnancies as well. Anti-thyroid peroxidase antibodies
Although not routinely screened, women with raised anti-thyroid peroxidase antibodies have about 25% risk of developing postpartum thyroiditis. Therefore at risk females (females with type1 diabetes mellitus, positive family history of autoimmune thyroid disease) can be screened. Females with a history of post-partum thyroiditis and elevated levels of anti-thyroid peroxidase antibodies are at high risk of recurrence in subsequent pregnancies as well.

Management - Supportive

Fact Explanation
Health education Patients should be educated about the disease prognosis. Females with postpartum thyroiditis should be educated about the risk of recurrence in subsequent pregnancies. Thyroxin tablets should be taken regularly and early in the morning on empty stomach. Health education
Patients should be educated about the disease prognosis. Females with postpartum thyroiditis should be educated about the risk of recurrence in subsequent pregnancies. Thyroxin tablets should be taken regularly and early in the morning on empty stomach.
Conservative management Asymptomatic and euthyroid patients may not require any treatment but regular follow up. Conservative management
Asymptomatic and euthyroid patients may not require any treatment but regular follow up.
Management of myxedema coma This is a life threatening complication of hypothyroidism. Commonly occur in elderly women. Patients may need ventilator support in intensive care units. Electrolyte replacement, temperature control and hemodynamic support can be given. Some may require corticosteroids. Detection and treatment of precipitating cause is also important in management. Management of myxedema coma
This is a life threatening complication of hypothyroidism. Commonly occur in elderly women. Patients may need ventilator support in intensive care units. Electrolyte replacement, temperature control and hemodynamic support can be given. Some may require corticosteroids. Detection and treatment of precipitating cause is also important in management.

Management - Specific

Fact Explanation
Levothyroxine Patients with hypothyroidism (TSH levels more than 10 mcU per mL) should be prescribed levothyroxine to make them euthyroid. Supplementation of thyroid hormone is used in patients with goiters even they are euthyroid to prevent further enlargement of the goiter. 1.6 mcg per kg per day is the initial dose. Then dose titrations are made. Elderly patients and patients with cardiovascular comorbidities should be prescribed 25 or 50 mcg daily as the starting dose. Levothyroxine
Patients with hypothyroidism (TSH levels more than 10 mcU per mL) should be prescribed levothyroxine to make them euthyroid. Supplementation of thyroid hormone is used in patients with goiters even they are euthyroid to prevent further enlargement of the goiter. 1.6 mcg per kg per day is the initial dose. Then dose titrations are made. Elderly patients and patients with cardiovascular comorbidities should be prescribed 25 or 50 mcg daily as the starting dose.

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