Thyroiditis
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Classification of the main thyroid diseases
| Type | Mechanism | Clinical presentation | Evolution |
|---|---|---|---|
| Hashimoto's thyroiditis (autoimmune chronic lymphocytic thyroiditis) | Auto-immune - cytotoxic T lymphocytes + anti-TPO + anti-TG antibodies → progressive destruction of thyroid follicles | Often asymptomatic for a long time + firm, painless goiter + progressively increasing TSH → subclinical then clinical hypothyroidism + woman aged 30-50 ++ + anti-TPO positive 95 % | Permanent hypothyroidism in 50 % of cases in 10-15 years + annual TSH monitoring + levothyroxine if TSH > 10 mUI/L + or 4-10 with symptoms |
| De Quervain thyroiditis (painful granulomatous subacute thyroiditis) | Probable post-viral (paramyxovirus + adenovirus + Coxsackie) → destructive granulomatous inflammation | Intense anterior cervical pain + radiating to jaw + ear + neck + fever ++ + asthenia + very high ESR and CRP + suppressed TSH (destructive hyperthyroidism) + very high thyroglobulin + white scintigraphy (no fixation) | Spontaneous resolution in 2-6 months → sequence: hyperthyroidism (4-8 wks) → euthyroidism → transient hypothyroidism → recovery + permanent hypothyroidism in 5-15 % + possible recurrences (5-10 %) |
| Postpartum thyroiditis | Auto-immune (post-partum immune rebound) - anti-TPO positive in 80 % + risk factor: T1D + lupus + pre-existing Hashimoto's disease | Appears within 12 months postpartum + often unrecognized + transient silent hyperthyroidism (2-6 months postpartum) then hypothyroidism (3-8 months postpartum) + postpartum depression + fatigue + palpitations | Resolution in 80 % of cases in 12-18 months + permanent hypothyroidism in 20-30 % at 5 years + if anti-TPO positive + risk of recurrence with each pregnancy |
| Silent thyroiditis (sporadic painless lymphocytic) | Auto-immune - similar to postpartum thyroiditis but without gestational link + anti-TPO positive in 50 % | Painless + moderate transient hyperthyroidism + possible goiter + white scintigraphy + TSH suppressed without very high FT4 | Spontaneous resolution in 2-4 months + permanent hypothyroidism in 20 % |
| Iatrogenic thyroiditis (cancer immunotherapy) | Immune activation by anti-PD1 (nivolumab + pembrolizumab) + anti-PD-L1 (atezolizumab) + anti-CTLA-4 (ipilimumab) → accelerated autoimmune thyroiditis | Initial transient hyperthyroidism (destruction) then permanent hypothyroidism in 30-50 % + often clinically silent + detected by systematic TSH monitoring + delay: 4-16 weeks after initiation | Hypothyroidism often permanent → lifelong levothyroxine in 30-50 % + rarely immunotherapy must be interrupted for thyroiditis (except severe forms) |
| Acute suppurative thyroiditis (bacterial) | Bacterial (Staphylococcus aureus + Streptococcus + Gram-negative) - hematogenous route or pyriformis fistula (child) | Intense neck pain + high fever + redness + local heat + dysphagia + dysphonia + leukocytosis ++ + very high CRP + functionally spared thyroid (euthy) | Emergency - IV antibiotics + surgical drainage if abscess + look for piriform sinus fistula in children |
| Riedel's thyroiditis (invasive fibrous) | Idiopathic invasive fibrosis (IgG4 disease spectrum) → invasion of adjacent cervical structures | Hard «woody» goiter + painless + fixed + dysphagia + dysphonia + stridor + tracheal compression + possible hypothyroidism + differential diagnosis thyroid cancer +++. | Rare + benign but invasive + corticosteroids + tamoxifen + decompressive surgery if necessary |
De Quervain thyroiditis - detailed management
- Diagnosis : classic triad = intense anterior cervical pain + SV > 50 mm/h (often > 80-100) + suppressed TSH with elevated FT4 + very high thyroglobulin (massive release) + white thyroid scintigraphy (almost no fixation - pathognomonic criterion) + anti-TPO usually negative (Hashimoto's distinction)
- NSAIDs (mild to moderate forms) : ibuprofen 400-600 mg × 3/d + or naproxen → analgesic + anti-inflammatory + duration 4-6 weeks → pain reduction + first-line treatment of choice
- Corticosteroids (severe or NSAID-refractory forms) : prednisone 40-60 mg/d × 2-4 weeks → gradual decrease over 4-8 weeks total → spectacular efficacy on pain (24-48 h) + caution: frequent relapse (30-40 %) on reduction of corticoids if decrease too rapid
- Beta-blockers (symptomatic hyperthyroid phase) : propranolol 20-40 mg × 2-3/d → control of adrenergic symptoms (palpitations + tremors + anxiety) → DO NOT use synthetic antithyroid drugs (hyperthyroidism is destructive + not productive)
- Levothyroxine (hypothyroid phase) : if symptomatic hypothyroidism or TSH > 10 + temporary in most cases → gradual cessation at 6-12 months + TSH check to verify recovery
Hashimoto's thyroiditis - monitoring and treatment
- Indications for levothyroxine treatment : TSH > 10 mUI/L (treatment recommended) + TSH 4-10 mUI/L with suggestive symptoms + or pregnant woman (target TSH 2.5 in 1st trimester. 2.5 + or anti-TPO positive with TSH > 4
- Monitoring without treatment : TSH annually if euthyroidism + anti-TPO positive → 2-5 % risk of hypothyroidism per year + no treatment only for anti-TPO positive without hypothyroidism + no gluten-free diet unless celiac confirmed
- Risk of thyroid lymphoma : slightly increased in Hashimoto's thyroiditis (risk × 3-67 depending on studies - very low absolute) → any cervical adenopathy + rapid increase in goitre + sudden pain → ultrasound + biopsy
Consult a physician if severe anterior cervical pain + fever + unusual fatigue + palpitations + or unexplained weight gain appear - a TSH assay + a VS + a CRP will help orient the diagnosis. Consult an emergency room if severe neck pain with high fever + local redness + difficulty swallowing or breathing suggests acute suppurative thyroiditis or tracheal compression (Riedel's thyroiditis). For a complete thyroid check-up and follow-up of thyroiditis, Clinique Omicron offers consultations at its points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's specialized physicians and nurse practitioners (NPs) diagnose the different types of thyroiditis (TSH + FT4 + anti-TPO + anti-TG + VS + CRP + thyroglobulin according to context), treat De Quervain's thyroiditis with NSAIDs or corticosteroids according to severity, initiate levothyroxine in Hashimoto's thyroiditis according to indications, monitor post-partum thyroiditis and iatrogenic thyroiditis under immunotherapy, and refer complex or refractory forms to endocrinology. Consultations are available at several points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The contents of this page are provided for information purposes only and do not replace the advice of a physician or endocrinologist. In De Quervain's thyroiditis, do not use synthetic antithyroid drugs - hyperthyroidism is destruction, not overproduction. Riedel's thyroiditis must be distinguished from thyroid cancer by biopsy - its hard, woody appearance may mimic neoplasia.
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