History

Fact Explanation
Asymptomatic Some patients can be asymptomatic. [2]
Feeling of fullness in the neck Some patients may not notice the goiter but complain of tightness or fullness in the neck. [2]
Goiter Patients often complain of painless diffuse enlargement of the thyroid gland. [1]
Symptoms of hypo or hyperthyroidism [2] 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. [2] 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. [2] Subacute lymphocytic thyroiditis can present with hypo, hyper and euthyroidism. [1] Graves’ disease presents with symptoms of hyperthyroidism and ophthalmological manifestations like protrusion of the eyes as proptosis, painful opthalmoplegia and chemosis. [4,5]
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. [1]
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. [1,7]
References
  1. ARCHANA BINDRA, GLENN D. BRAUNSTEIN. Thyroiditis. Am Fam Physician. [online] 2006 May 15;73(10):1769-1776. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2006/0515/p1769.html
  2. JOHN SLATOSKY, BENJAMIN SHIPTON, HANEY WAHBA. Thyroiditis: Differential Diagnosis and Management. Am Fam Physician. [online] 2000 Feb 15;61(4):1047-1052. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2000/0215/p1047.html
  3. ARMENGOL MP, JUAN M, LUCAS-MARTíN A, FERNáNDEZ-FIGUERAS MT, et al. Thyroid Autoimmune Disease : Demonstration of Thyroid Antigen-Specific B Cells and Recombination-Activating Gene Expression in Chemokine-Containing Active Intrathyroidal Germinal Centers Am J Pathol [online] 2001 Sep, 159(3):861-873 [viewed 15 May 2014] Available from: doi:10.1016/S0002-9440(10)61762-2
  4. WEETMAN AP, MCGREGOR AM, HALL R. Ocular manifestations of Graves' disease: a review. J R Soc Med [online] 1984 Nov, 77(11):936-942 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1440185
  5. GILLILAND IC. The Eye in Graves' Disease Postgrad Med J [online] 1964 Dec, 40(470):720-721 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2482801
  6. TOMER Y, HUBER A. The etiology of autoimmune thyroid disease: a story of genes and environment. J Autoimmun [online] 2009 May-Jun, 32(3-4):231-9 [viewed 15 May 2014] Available from: doi:10.1016/j.jaut.2009.02.007
  7. AMORY JOHN K, HIRSCH IRL B. Hyperthyroidism from autoimmune thyroiditis in a man with type 1 diabetes mellitus: a case report. Array [online] 2011 December [viewed 15 May 2014] Available from: doi:10.1186/1752-1947-5-277

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. [1,2] 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. [3]
Signs of hyperthyroidism Patients have tremor, warm and sweaty palms, and irregularly irregular pulse. [7,8]
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. [5,6]
Examination of the cardiovascular system Bradycardia and pericardial effusions are detected in hypothyroidism. [3] Hyperthyroidism causes atrial fibrillation hence irregularly irregular pulse. [4]
References
  1. ARCHANA BINDRA, GLENN D. BRAUNSTEIN. Thyroiditis. Am Fam Physician. [online] 2006 May 15;73(10):1769-1776. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2006/0515/p1769.html
  2. JOHN SLATOSKY, BENJAMIN SHIPTON, HANEY WAHBA. Thyroiditis: Differential Diagnosis and Management. Am Fam Physician. [online] 2000 Feb 15;61(4):1047-1052. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2000/0215/p1047.html
  3. DAVID Y. GAITONDE, KEVIN D. ROWLEY, LORI B. SWEENEY. Hypothyroidism: An Update. Am Fam Physician. [online] 2012 Aug 1;86(3):244-251. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2012/0801/p244.html
  4. N J, FRANCIS J. Atrial Fibrillation and Hyperthyroidism Indian Pacing Electrophysiol J [online] , 5(4):305-311 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1431605
  5. WEETMAN AP, MCGREGOR AM, HALL R. Ocular manifestations of Graves' disease: a review. J R Soc Med [online] 1984 Nov, 77(11):936-942 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1440185
  6. GILLILAND IC. The Eye in Graves' Disease Postgrad Med J [online] 1964 Dec, 40(470):720-721 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2482801
  7. COOPER DAVID, MCDERMOTT MICHAEL, WARTOFSKY LEONARD. Hyperthyroidism. The Journal of Clinical Endocrinology & Metabolism [online] 2006 July, 91(7):0-0 [viewed 15 May 2014] Available from: doi:10.1210/jcem.91.7.9996
  8. PEARCE EN. Diagnosis and management of thyrotoxicosis BMJ [online] 2006 Jun 10, 332(7554):1369-1373 [viewed 15 May 2014] Available from: doi:10.1136/bmj.332.7554.1369

Differential Diagnoses

Fact Explanation
Other causes of thyroiditis Characteristically autoimmune thyroiditis, drug induced thyroiditis (amiodarone, interferon-alfa, interleukin-2,lithium) and idiopathic fibrotic thyroiditis (Riedel's thyroiditis) are painless but thyroiditis secondary to infection, radiation, or trauma is painful. postpartum thyroiditis is another possible differential diagnosis. [1]
Primary thyroid lymphoma This is a common complication of Hashimoto’s thyroiditis but also seen in normal population. Appearance of rapidly enlarging nodule is suggestive of a primary thyroid lymphoma. [2]
Papillary carcinoma of the thyroid gland Malignant proliferation of the thyroid gland should also be considered as a differential diagnosis. Fine needle aspiration cytology will aid in diagnosis. [3]
Multi-nodular goiter [4] Clinically undetectable multi-nodular goiter may be palpated as a diffuse enlargement of the gland. Patients sometimes present with hyperthyroidism secondary to a toxic nodule. [5]
References
  1. ARCHANA BINDRA, GLENN D. BRAUNSTEIN. Thyroiditis. Am Fam Physician. [online] 2006 May 15;73(10):1769-1776. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2006/0515/p1769.html
  2. THIEBLEMONT C, MAYER A, DUMONTET C, BARBIER Y, CALLET-BAUCHU E, et al. Primary thyroid lymphoma is a heterogeneous disease. J Clin Endocrinol Metab [online] 2002 Jan, 87(1):105-11 [viewed 15 May 2014] Available from: doi:10.1210/jcem.87.1.8156
  3. LIVOLSI VA. Papillary thyroid carcinoma: an update. Mod Pathol [online] 2011 Apr:S1-9 [viewed 15 May 2014] Available from: doi:10.1038/modpathol.2010.129
  4. AMORY JOHN K, HIRSCH IRL B. Hyperthyroidism from autoimmune thyroiditis in a man with type 1 diabetes mellitus: a case report. Array [online] 2011 December [viewed 15 May 2014] Available from: doi:10.1186/1752-1947-5-277
  5. NADA AHMED, MOHAMED AHMED ASHRAF, VILALLONGA RAMON, ARMENGOL MANUEL, MOUSTAFA IBRAHIM. A Giant Euthyroid Endemic Multinodular Goiter with No Obstructive or Compressive Symptoms. Case Reports in Medicine [online] 2011 December, 2011:1-3 [viewed 15 May 2014] Available from: doi:10.1155/2011/620480

Investigations - for Diagnosis

Fact Explanation
Full blood count Often shows no abnormality with normal white cell counts. [3] Hypothyroid patients can have normocytic anemia. [4]
Erythrocyte sedimentation rate (ESR) ESR is within normal range. [3]
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. [1]
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. [1]
Antithyroglobulin antibodies This is elevated in some patients and not sensitive as the assessment of antithyroid peroxidase antibody levels. [2]
Thyroid-stimulating immunoglobulins Thyroid-stimulating immunoglobulins are elevated in Graves’ disease. [4]
Radioactive iodine thyroid scanning Uptake of radioiodine can be reduced, normal or high in autoimmune thyroiditis. This depends on the number of viable follicles. [1,3] Increased uptake of radioactive iodine is seen in Graves’ disease. [6]
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. [7]
Fine-needle thyroid aspiration Lymphocytic infiltration of the thyroid gland and the presence of Askanazy (Hürthle) cells is suggestive of Hashimoto thyroiditis. [1,5] In subacute lymphocytic thyroiditis cytology is similar to Hashimoto’s thyroiditis but there is no fibrosis. [1]
Serum prolactin levels Although not routinely assessed serum prolactin levels are elevated in hypothyroidism. [6]
References
  1. ARCHANA BINDRA, GLENN D. BRAUNSTEIN. Thyroiditis. Am Fam Physician. [online] 2006 May 15;73(10):1769-1776. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2006/0515/p1769.html
  2. PEARCE ELIZABETH N., FARWELL ALAN P., BRAVERMAN LEWIS E.. Thyroiditis. N Engl J Med [online] 2003 June, 348(26):2646-2655 [viewed 15 May 2014] Available from: doi:10.1056/NEJMra021194
  3. JOHN SLATOSKY, BENJAMIN SHIPTON, HANEY WAHBA. Thyroiditis: Differential Diagnosis and Management. Am Fam Physician. [online] 2000 Feb 15;61(4):1047-1052. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2000/0215/p1047.html
  4. DAVID Y. GAITONDE, KEVIN D. ROWLEY, LORI B. SWEENEY. Hypothyroidism: An Update. Am Fam Physician. [online] 2012 Aug 1;86(3):244-251. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2012/0801/p244.html
  5. ARMENGOL MP, JUAN M, LUCAS-MARTíN A, FERNáNDEZ-FIGUERAS MT, et al. Thyroid Autoimmune Disease : Demonstration of Thyroid Antigen-Specific B Cells and Recombination-Activating Gene Expression in Chemokine-Containing Active Intrathyroidal Germinal Centers Am J Pathol [online] 2001 Sep, 159(3):861-873 [viewed 15 May 2014] Available from: doi:10.1016/S0002-9440(10)61762-2
  6. GINSBERG J. Diagnosis and management of Graves' disease. CMAJ [online] 2003 Mar 4, 168(5):575-85 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12615754
  7. RABER WOLFGANG, GESSL ALOIS, NOWOTNY PETER, VIERHAPPER HEINRICH. Thyroid Ultrasound Versus Antithyroid Peroxidase Antibody Determination: A Cohort Study of Four Hundred Fifty-One Subjects. Thyroid [online] 2002 August, 12(8):725-731 [viewed 15 May 2014] Available from: doi:10.1089/105072502760258712

Investigations - Fitness for Management

Fact Explanation
Full blood count Normocytic anemia is found in hypothyroidism. [1]
ECG Shows atrial fibrillation. [2]
Serum electrolytes Hyponatremia is seen in association with hypothyroidism. [1]
Lipid profile In hypothyroidism low-density lipoprotein and triglycerides are elevated. [1]
References
  1. DAVID Y. GAITONDE, KEVIN D. ROWLEY, LORI B. SWEENEY. Hypothyroidism: An Update. Am Fam Physician. [online] 2012 Aug 1;86(3):244-251. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2012/0801/p244.html
  2. N J, FRANCIS J. Atrial Fibrillation and Hyperthyroidism Indian Pacing Electrophysiol J [online] , 5(4):305-311 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1431605

Investigations - Followup

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. [1]
Ant thyroid peroxidase antibodies Risk of permanent hypothyroidism is higher with elevated antibody levels. [1]
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. [2]
References
  1. ARCHANA BINDRA, GLENN D. BRAUNSTEIN. Thyroiditis. Am Fam Physician. [online] 2006 May 15;73(10):1769-1776. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2006/0515/p1769.html
  2. JOHN SLATOSKY, BENJAMIN SHIPTON, HANEY WAHBA. Thyroiditis: Differential Diagnosis and Management. Am Fam Physician. [online] 2000 Feb 15;61(4):1047-1052. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2000/0215/p1047.html

Investigations - Screening/Staging

Fact Explanation
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. [1]
References
  1. LAZARUS JH, PREMAWARDHANA LD. BEST PRACTICE NO 184 Screening for thyroid disease in pregnancy J Clin Pathol [online] 2005 May, 58(5):449-452 [viewed 15 May 2014] Available from: doi:10.1136/jcp.2004.021881

Management - General Measures

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. [1] Thyroxin tablets should be taken regularly and early in the morning on empty stomach. [4]
Conservative management Asymptomatic and euthyroid patients may not require any treatment but regular follow up. [2]
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. [3]
References
  1. ARCHANA BINDRA, GLENN D. BRAUNSTEIN. Thyroiditis. Am Fam Physician. [online] 2006 May 15;73(10):1769-1776. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2006/0515/p1769.html
  2. JOHN SLATOSKY, BENJAMIN SHIPTON, HANEY WAHBA. Thyroiditis: Differential Diagnosis and Management. Am Fam Physician. [online] 2000 Feb 15;61(4):1047-1052. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2000/0215/p1047.html
  3. DAVID Y. GAITONDE, KEVIN D. ROWLEY, LORI B. SWEENEY. Hypothyroidism: An Update. Am Fam Physician. [online] 2012 Aug 1;86(3):244-251. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2012/0801/p244.html
  4. VIRGINIA POOLE ARCANGELO, ANDREW M. PETERSON. Pharmacotherapeutics for Advanced Practice: A Practical Approach. Lippincott Williams & Wilkins, 2006, pp. 701.

Management - Specific Treatments

Fact Explanation
Levothyroxine Patients with hypothyroidism (TSH levels more than 10 mcU per mL) should be prescribed levothyroxine to make them euthyroid. [1,2] 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. [3,4]
References
  1. ARCHANA BINDRA, GLENN D. BRAUNSTEIN. Thyroiditis. Am Fam Physician. [online] 2006 May 15;73(10):1769-1776. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2006/0515/p1769.html
  2. GILLETT M. Subclinical Hypothyroidism: Subclinical Thyroid Disease: Scientific Review and Guidelines for Diagnosis and Management Clin Biochem Rev [online] 2004 Aug, 25(3):191-194 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1880829
  3. JOHN SLATOSKY, BENJAMIN SHIPTON, HANEY WAHBA. Thyroiditis: Differential Diagnosis and Management. Am Fam Physician. [online] 2000 Feb 15;61(4):1047-1052. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2000/0215/p1047.html
  4. DAVID Y. GAITONDE, KEVIN D. ROWLEY, LORI B. SWEENEY. Hypothyroidism: An Update. Am Fam Physician. [online] 2012 Aug 1;86(3):244-251. [viewed 15 May 2014] Available from: http://www.aafp.org/afp/2012/0801/p244.html