Contents

Search

Hashimoto's thyroiditis; chronic lymphocytic thyroiditis; struma lymphomatosa; lymphadenoid goiter; primary myxedema

Hashimoto's thyroiditis is the first organ-specific autoimmune disease to be described. Etiology: 1) autoimmune 2) association with other autoimmune diseases: a) systemic lupus erythematosus - cutaneous lupus erythematosus b) Sjogren's syndrome c) rheumatoid arthritis d) pernicious anemia e) type 1 diabetes f) Grave's disease g) Addison's disease (Schmidt's syndrome) h) autoimmune hepatitis i) primary biliary cirrhosis Epidemiology: 1) most common cause of goitrous hypothyroidism in geographic regions with sufficient iodine 2) female to male ratio 5-7:1 3) incidence increases with age, but may occur in children [5] Pathology: 1) classic goitrous form: (most common form) a) intense infiltrate of lymphocytes admixed with plasma cells that virtually replace the thyroid parenchyma b) Askanazy cells 2) atrophic variant: (less common form) - fibrosis with a scant lymphoid infiltrate Genetics: 1) association with HLA-DR5 & HLA B8 with goitrous form 2) association with HLA-DR3 with atrophic variant 3) association with CTLA-4 [5] Clinical manifestations: 1) most patients are asymptomatic 2) incidental finding of painless, slowly enlarging thyroid 3) gland shrinks & becomes undetectable late in the disease 4) occasional-rare symptoms of mechanical compression 5) enlarged regional lymph nodes is uncommon 5) hypothyroidism a) 20% at presentation b) may be precipitated by a large iodine dose in the form of radiographic contrast [3] 6) hyperthyroidism (Hashitoxicosis) in 5% 7) euthyroid in 75% 8) may be associated with polyglandular failure 9) fatigue [11] Laboratory: 1) antibodies to thyroid peroxidase (anti-microsomal Ab) a) in 90%: titers > 1:2500 are diagnostic b) lower titers may be associated with other disorders c) titer not necessary unless diagnosis in question [3] 2) anti thyroglobulin (85%) - may be associated with other disorders 3) serum T3, serum T4, serum TSH related to stage of disease 4) antibodies to TSH receptor a) specific for autoimmune thyroid disease b) inhibitory rather than stimulatory antibodies as in Grave's disease c) rare cause of hypothyroidism [6] (no Loinc?) 5) other autoantibodies a) LMOD1 b) antibodies to the Na+/I- symporter (< 20%) Radiology: - scintigraphy reveals uniformly functioning thyroid tissue Complications: - Hashimoto encephalopathy - primary thyroid lymphoma Differential diagnosis: 1) thyroid carcinoma 2) primary thyroid lymphoma 3) subacute lymphocytic thyroiditis 4) diffuse goiter Management: 1) some patients do not require therapy 2) Hashimoto's disease may result in hypothyroidism, thus TSH should be monitored regularly 3) thyroxine may shrink symptomatic goiters through decreasing TSH production 4) surgery for symptoms of compression 5) euthyroid patients with Hashimoto's thyroiditis are sensitive to iodine exposure, which may result in a reversible form of hypothyroidism 6) total thyroidectomy may improve health-related quality of life & fatigue [11]

Interactions

disease interactions

Related

anti-thyroid peroxidase (microsomal) antibody thyroiditis

Specific

hashitoxicosis

General

autoimmune disease chronic thyroiditis (Riedel's thyroiditis, Hashimoto's thyroiditis)

Database Correlations

OMIM 140300 Entrez Gene 140805

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 473
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 646-50
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2018, 2022
  4. Williams Textbook of Endocrinology, 8th ed, JD Wilson & DW Foster (eds), WB Saunders Co, Philadelphia PA, 1992, pg 475
  5. UpToDate 2004 http://www.uptodate.com
  6. NEJM Knowledge+ Question of the Week. Sept 19, 2017 https://knowledgeplus.nejm.org/question-of-week/4350/
  7. De Luca F, Santucci S, Corica D, Pitrolo E, Romeo M, Aversa T. Hashimoto's thyroiditis in childhood: presentation modes and evolution over time. Ital J Pediatr 2013 Feb 1; 39:8 PMID: 23363471 Free PMC Article
  8. Zirilli G, Velletri MR, Porcaro F et al In children with Hashimoto's thyroiditis the evolution over time of thyroid status may differ according to the different presentation patterns. Acta Biomed. 2015 Sep 14;86(2):137-41. Review. PMID: 26422427
  9. Ajjan RA, Weetman AP. The Pathogenesis of Hashimoto's Thyroiditis: Further Developments in our Understanding. Horm Metab Res. 2015 Sep;47(10):702-10. Review. PMID: 26361257
  10. Pyzik A, Grywalska E, Matyjaszek-Matuszek B, Rolinski J Immune disorders in Hashimoto's thyroiditis: what do we know so far? J Immunol Res. 2015;2015:979167. Review. PMID: 26000316 Free PMC Article
  11. Guldvog I,Reitsma LC, Johnsen L et al Thyroidectomy Versus Medical Management for Euthyroid Patients With Hashimoto Disease and Persisting Symptoms: A Randomized Trial. Ann Intern Med. 2019. March 12. PMID: 30856652 https://annals.org/aim/article-abstract/2728199/thyroidectomy-versus-medical-management-euthyroid-patients-hashimoto-disease-persisting-symptoms