THYROIDITIS: causes, symptoms, diagnosis and therapy of thyroid inflammation

There thyroiditis it is an inflammation of the thyroid gland. There are many types of thyroiditis, each with a different course and cause. During thyroiditis there may be periods of increased release of thyroid hormones (thyrotoxicosis with hyperthyroidism), but usually most of the inflammatory pathologies of the thyroid lead to the development of thyroid dysfunction with hypothyroidism1.

What is a thyroiditis?

Thyroiditis is ainflammation of the thyroid tissue. There are many types of thyroiditis, each with a different course and cause. Acute thyroiditis has a bacterial infectious etiology and has a rapid course with a rapid return to normal thyroid function in most people. Subacute thyroiditis usually has a viral infectious etiology and develops over a few months. The thyroiditis chronic have a long duration, often resulting in permanent hypothyroidism which needs adequate replacement therapy with thyroid hormones.

Let's see the main forms of thyroiditis.

Acute infectious thyroiditis or suppurative thyroiditis

There acute thyroiditis, defined as "infectious thyroiditis" or "septic thyroiditis" or "suppurative or purulent thyroiditis", is an inflammatory disease of the thyroid gland, with an infectious etiology, caused from a'bacterial infection at the level of the thyroid gland. The infection can occur by blood or by diffusion by contiguity starting from an infectious process localized in the cervical area or at the level of the oropharyx (it can therefore also start from a trivial sore throat of bacterial origin). Fortunately nowadays it is very rare, as most bacterial infections are treated within the first days of their onset with adequate antibiotic therapy.

There symptomatology acute infectious thyroiditis is that of an acute febrile infection with elevated ESR, CRP and procalcitonin, leukocytosis and neutrophilia, and increased alpha globulin on protein electrophoresis. The thyroid is swollen (swollen) and shows signs of acute inflammation, with overlying skin that is hot, red and painful even if lightly touched.

There diagnosis it does not present difficulties, is clinical and can be confirmed by means of the blood tests described above. The therapy is based on antibiotics in the infectious forms, together with corticosteroids and anti-inflammatories to accelerate the "cooling" of the inflammation if the signs of inflammation are particularly important. 

Thyroiditis

Thyroiditis is inflammation of the thyroid gland: it can have viral, bacterial but, above all, autoimmune causes.

Acute non-infectious thyroiditis

They are very rare, they are also defined acute aseptic thyroiditis, caused by trauma or by irradiation, have the same symptoms as acute suppurative thyroiditis and are treated with anti-inflammatories and cortisone to reduce inflammation and speed up the resolution of symptoms.

De Quervain's subacute thyroiditis

Subacute thyroiditis or de Quervain's thyroiditis it is an inflammation of the thyroid gland, lasting from a few weeks to 3-6 months. De Quervain's subacute thyroiditis is likely caused by a viral infection, as it often occurs after an airway infection, and elevated levels of antibodies to numerous types of viruses are frequently found at peak clinical activity. such as influenza, parainfluenza, measles, enterovirus, rotavirus, EBV.

The disease begins with symptoms such as myalgia, pharyngitis, moderate fever and asthenia, to which the appearance of pain and swelling in the neck can be added. Sometimes the painful swelling moves from one lobe to another or in any case to different points of the same lobe of the gland, and for this reason it is also called "migrating thyroiditis".

In the initial stages of the disease a modest and in any case transient hyperthyroidism may appear caused by the sudden release into circulation of thyroid hormonesThe natural history of De Quervain's thyroiditis is characterized, in the absence of appropriate treatment, by relapses ("relapsing thyroiditis").

Initial thyrotoxicosis normally regresses after a few weeks, with thyroid function returning to normal in 95% of cases, while in the remainder 5% remains a hypothyroidism that will require treatment with replacement therapy (Eutirox). 


Hashimoto's chronic autoimmune thyroiditis

There Hashimoto's thyroiditis, called chronic thyroiditis or autoimmune thyroiditis is the most frequent thyroiditis, as well as the primary cause of hypothyroidism in adults. The disease has an autoimmune origin, characterized by a chronic infiltration of lymphocytes in the thyroid tissue and by the presence of antibodies to thyroid peroxidase and anti thyroglobulin facing right against the thyroid gland.

The presence of anti TPO and anti TG paradoxically helps diagnose Hashimoto's thyroiditis, given that these antibodies are positive singly or in pairs in more than 80% of patients with this pathology. Hashimoto's thyroiditis is divided into thyroiditis with goiter and thyroiditis with thyroid atrophy depending on whether or not the thyroid tissue is enlarged.

In its early stage, Hashimoto's thyroiditis can also have transient hyperthyroidism, called in by doctors hashitoxicosis, linked to the rapid release of thyroxine and triiodothyronine, the main thyroid hormones by damaged thyroid cells. With the passing of the weeks, however, the functioning thyroid tissue, increasingly scarce, will bring the thyroid function first in a state of subclinical hypothyroidism, i.e. with elevated TSH but still normal thyroid hormones, and finally in a real hypothyroidism with reduction of thyroid hormones , and significantly increased TSH.

Obviously in the first phase of the Hashimoto's thyroiditis, in case of temporary increase in circulating thyroid hormones, people may experience signs or symptoms such as heart pounding and rapid heartbeat, nervousness, irritability, restlessness, muscle weakness and aches, hand tremors, sleep disturbances from falling asleep, increased sweating, increased hunger and thirst, weight loss, diarrhea and loose stools, irregular menstruation with frequent and abundant bleeding, or on the contrary a total absence of the cycle.

But when the real develops hypothyroidism People with Hashimoto's thyroiditis may notice one or more of the following symptoms: tiredness and general exhaustion comma reduced heart rate or bradycardia, extrasystole, depressed mood, anxiety and panic attacks, lack of memory and concentration, dull dry hair , brittle, falling off more easily, dry and pasty skin, intolerance to cold, tendency to gain weight, constipation or constipation, tingling in the hands and forearms, menstrual cycle disturbances, decreased libido (sexual desire).

There therapy of the early stages of Hashimoto's thyroiditis it is substantially symptomatic, while hypothyroidism therapy is the classic replacement therapy with levothyroxine, an isoform of thyroxine, the main thyroid hormone, whose best known trade names are Eutirox and Tirosint. If treated properly, Hashimoto's thyroiditis leads to an absolutely normal life, and does not reduce life expectancy.

Chronic Riedel's thyroiditis

There Riedel's thyroiditis it is a rare chronic inflammation of the thyroid gland, characterized by the formation of sclerofibrotic tissue which progressively replaces the thyroid parenchyma and which can also extend to the surrounding structures such as trachea, neck muscles, pharynx.

It is a more frequent disease in women, clinically characterized by a thyroid of hard consistency and often increased size, in the absence of signs of inflammation such as fever or redness.

In the advanced stages of Riedel's thyroiditis, symptoms and signs of hypothyroidism are present, the greater the more the disease progresses. The diagnosis is clinical, clinical and radiological, and the etiological certainty is given by the execution of fine needle aspiration and cytological examination.

Therapy is surgical, with removal of the fibrotic thyroid, and pharmacological, with replacement therapy with thyroid hormones.

Postpartum silent thyroiditis

Silent postpartum thyroiditis is a thyroiditis characterized by inflammation of the thyroid gland that occurs between 2 months and a year and a half after the termination of a pregnancy.

It occurs in mothers after childbirth 5% and is characterized by the appearance of goiter with hyperthyroidism, followed by a transient period of hypothyroidism and, in most cases, the return to euthyroidism (i.e. normal thyroid function).

In a very low percentage of cases (0.2% of all pregnant women) postpartum silent thyroiditis determines the persistence of a picture of permanent hypothyroidism. From the point of view of blood tests, it is characterized by the presence of anti-thyroid antibodies and by the increase in inflammation indices (ESR, PCR). The differential diagnosis must exclude the presence of Graves-Basedow disease and, in the later stages, of Hashimoto's thyroiditis.

Women who have already had an episode of silent thyroiditis after childbirth may have relapses in subsequent pregnancies as well.

Thyroiditis Diagnosis

Thyroiditis is recognized by combining clinical signs and symptoms, blood tests and ultrasound and radiological data. First, the attending physician and / or endocrinologist specialist who follows you will carry out an accurate remote medical history (the history of your possible health problems), next medical history (what you have noticed in recent times and which has brought you to the doctor), physiological history (how are your relatives, how was your development, your growth, diet, and lifestyle habits) and drug history (any therapy and drugs that you take continuously or sporadically).

Secondly, a thorough examination with physical examination will be carried out, not limited only to the neck and the thyroid lodge but to the whole body. Finally, if you haven't done them, your doctor will prescribe you blood analysis including:

  • complete blood count with formula leukocyte
  • inflammation indices (ESR, PCR)
  • thyrotropin (TSH)
  • thyroid hormones: thyroxine (T4 and free fraction fT4), triiodothyronine (T3 and free fraction fT3)
  • anti-thyroid antibodies: antibodies to thyroid peroxidase (anti-TPO), anti thyroglobulin (anti-TG) and anti TSH receptor (anti r-TSH)

Based on the results of the first analyzes, if necessary, the endocrinologist will be able to deepen with other tests such as those relating to renal function, liver function, urinalysis and other hormones.

In acute thyroiditis, in subacute thyroiditis and Hashimoto in the initial stages, there will be elevated thyroid hormones, low TSH, increased phlogosis indices (high ESR, elevated CRP, leukocytosis with lymphocytosis and / or neutrophilia). In the late stages of thyroiditis, on the other hand, we will have a prevalence of hypothyroidism, with high TSH, low fT3 and fT4 and normalization of inflammation indices. Anti-thyroid antibodies are usually elevated, and with fluctuating values, in chronic autoimmune thyroiditis.

Symptoms of Thyroiditis

The thyroiditis they contain in the symptomatological procession a great amount of clinical manifestations and depend on the moment in which the pathology is taken into consideration. In acute thyroiditis and in the early stages of subacute thyroiditis and in Hashimoto's thyroiditis, it is not uncommon to find a state of thyrotoxicosis, with all symptoms of hyperthyroidism resulting from it:

  • heart pounding (feeling of heart in the throat or butterflies in the chest), tachycardia
  • mental instability with alternating crises of crying and laughter
  • increase in blood pressure
  • restlessness, nervousness, irritability
  • tremor of the hands
  • sleep disorders
  • muscle weakness,
  • myalgia (muscle pain)
  • urticaria with rashes
  • increased sweating, moist and warm skin
  • increased appetite and thirst
  • weight loss (weight loss)
  • loose stools
  • menstrual cycle disorders, with irregular cycles, menorrhagia or metrorrhagia or, in a minority of cases, disappearance of the menstrual cycle

In reality, most thyroiditis evolve sooner or later into a state of more or less marked thyroid hypofunction. In addition, the diagnosis of thyroiditis often occurs in the hypothyroidism phase, which is the one that lasts the longest and that leads people to see their doctor. The main symptoms of hypothyroidism they will be:

  • dry, brittle hair that falls out more easily
  • dry, pasty skin (myxedema)
  • constipation (constipation)
  • cold intolerance (people with hypothyroidism often admit that they are always cold)
  • weight gain (increase in body weight)
  • presence of nocturnal tingling and numbness in the hands and arms, due to an increased frequency of carpal tunnel syndrome
  • loss of hearing
  • menstrual cycle disorders with reduction or cycle or actual amenorrhea
  • decreased libido (decreased sexual desire)
  • asthenia, that is, great tiredness and exhaustion
  • drop in heart rate (often less than 60 beats per minute, bradycardia)
  • extrasystoles
  • dyslipidemias (increased cholesterol, hypertriglyceridaemia, reduction of HDL)
  • lack of memory and concentration
  • depressed mood, possible anxiety attacks and panic attacks
  • rarely, there is a real change of personality
  • apathetic facial expression (hypothyroid facies)
  • epileptic seizures, psychiatric symptoms and hallucinations, psychiatric symptoms in what is called Hashimoto's encephalopathy are very rare

Since most thyroiditis are of the autoimmune type (Hashiomoto's thyroiditis), often in addition to the symptoms related to the thyroid problem, there are signs and symptoms associated with other autoimmune diseases, which as we know often affect multiple body parts in the same body at the same time. person. Here we will have symptoms of autoimmune diseases such as:

  • pain, swelling and redness in the joints and muscles (typical of diseases such as rheumatoid arthritis, systemic lupus erythematosus SLE, spondyloarthritis, psoriatic arthritis)
  • muscle pain or myalgia (typical of connective tissue diseases, in particular polymyositis, SLE and myasthenia gravis)
  • hardening of the skin and connective tissues (typical of scleroderma, lupus and dermatomyositis)
  • various skin disorders (hives in hives, peeling and erythema in psoriasis)
  • dry mucous membranes (as in Sjögren's syndrome)
  • neurological symptoms (neuritis),
  • increased transaminases, increased bilirubin, jaundice, nausea and vomiting, signs of liver dysfunction in autoimmune hepatitis
  • anemia (pernicious autoimmune anemia)
  • nausea, vomiting, dyspepsia, diarrhea, abdominal pain, haematochezia or rectorrhagia, gastrointestinal problems in general (investigate the presence of celiac disease and / or IBD, i.e. chronic inflammatory bowel diseases such as ulcerative colitis and Crohn's disease)

Thyroiditis therapy

How thyroiditis is treated? Is there a remedy to resolve inflammatory thyroid status and thyroid dysfunction? Obviously, all thyroiditis can be treated in a more or less decisive way. Treatment changes according to the type of thyroid:

  • Acute infectious thyroiditis: since it is mainly of bacterial origin, the therapy is antibiotic and anti-inflammatory to reduce the symptoms of local thyroid inflammation. If there is an abscess it will need to be surgically drained.
  • De Quervain's subacute thyroiditis: the therapy of subacute thyroiditis is substantially symptomatic, i.e. aimed at soothing the important inflammatory symptoms through analgesics (paracetamol), non-steroidal anti-inflammatory drugs (NSAIDs) and, in the most important cases, cortisone drugs (prednisone is widely used). If necessary, beta-blocking drugs are also used to reduce some of the effects of hyperthyroidism (tachycardia, agitation, heart palpitations). In the late stages with evolution to thyroid hypofunction, instead, replacement therapy with thyroid hormones is used.
  • Chronic Hashimoto's thyroiditis: The therapy that people with chronic lymphocytic thyroiditis need above 95% is replacement therapy with L-T4 levothyroxine, which aims to maintain a low or suppressed TSH and thyroid hormones in the normal range.
  • Chronic Riedel's thyroiditis: therapy is surgical, with removal of the fibrotic tissue that has invaded the thyroid and / or surrounding tissues. In addition, of course, thyroid replacement therapy is used to compensate for the reduced production and secretion of thyroid hormones.
  • Silent thyroiditis and postpartum thyroiditis: the therapy will be aimed at compensating for the defective production and secretion of thyroid hormones.
1.
Smith T, Hegedüs L. Graves' Disease. N Engl J Med. 2017;376(2):185. [PubMed]
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