Riedel's thyroiditis treated with tamoxifen

A 46-year-old woman with clinical diagnosis of Riedel's thyroiditis was admitted to our Department, presenting with dyspnea, dysphagia, fatigue, and hoarseness. Previously, she had been diagnosed with Hashimoto's thyroiditis and hypothyroidism. The disease had a progressive course and had lasted for a year before the definitive diagnosis of Riedel's thyroiditis was confirmed and treated with methylprednisolone, 12 mg daily, without success. We started therapy with tamoxifen, 10 mg twice a day, together with methylprednisolone, 16 mg daily, and L-thyroxin substitution therapy. The follow-up lasted for one year. Treatment with tamoxifen led to a significant subjective improvement and objective changes, confirmed by regular clinical examinations, ultrasonography, and computed tomography of the neck. After 8 months of therapy, the patient had no compression symptoms and goiter decreased in estimated weight from 105 g to 63 g according to ultrasound measurements. The patient underwent partial thyroidectomy at 10 months after diagnosis of Riedel's thyroiditis. Histopathology confirmed the diagnosis of Riedel's thyroiditis. Our report indicates that tamoxifen can be a valuable drug therapy in the treatment of Riedel's thyroiditis.

Multifocal fibrosclerosis: a case of thyroiditis and bilateral lacrimal gland involvement

A patient with invasive fibrous thyroiditis (Riedel's thyroiditis), dysphagia, and bilateral lacrimal gland involvement is described. Resolution of the thyroid mass and orbital swellings followed corticosteroid therapy. The unusual ocular features of this case are briefly discussed and the use of corticosteroid and other immunosuppressant therapy in multifocal fibrosclerosis is reviewed.

Association between lithium use and thyrotoxicosis caused by silent thyroiditis

OBJECTIVE

To determine the incidence of silent thyroiditis in lithium users and characterize lithium-associated thyrotoxicosis.

DESIGN

Retrospective record review.

PATIENTS

400 consecutive patients (300 with Graves' disease and 100 with silent thyroiditis) who underwent radioiodine scanning of the thyroid.

MEASUREMENTS

Odds of lithium exposure.

RESULTS

The odds of lithium exposure were increased 4.7-fold in patients with silent thyroiditis compared with those with Graves' disease (95% CI: 1.3, 17). Lithium-associated silent thyroiditis occurred with an incidence rate of approximately 1.3 cases per 1000 person-years, and lithium-associated thyrotoxicosis occurred with an incidence rate of approximately 2.7 cases per 1000 person-years, higher than the reported incidence rates of silent thyroiditis (< 0.03-0.28 cases per 1000 person-years) and of thyrotoxicosis (0.8-1.2 cases per 1000 person-years) in the general population.

CONCLUSION

Thyrotoxicosis caused by silent thyroiditis might be associated with lithium use.

Tamoxifen therapy in steroid resistant Reidel's thyroiditis

Riedel's thyroiditis is a rare chronic inflammatory disorder characterised by extensive fibrosis of the thyroid gland and sometimes the surrounding tissues. We report a case of Riedel's Thyroiditis in a middle aged female presenting with goitre, stridor and dyspnoea. She initially responded to corticosteroid treatment and subsequently to Tamoxifen. The rationale for these treatments are discussed.

Multifocal idiopathic fibrosclerosis manifesting with Riedel's thyroiditis

OBJECTIVE

To discuss our experience with a case of Riedel's thyroiditis manifesting in conjunction with several other fibrosclerotic lesions.

METHODS

We describe a case of multifocal fibrosclerosis and its response to glucocorticoid therapy.

RESULTS

A 46-year-old man with dyspnea, dysphagia, and hoarseness was found to have Riedel's thyroiditis, sclerosing cholangitis, retroperitoneal fibrosis, and renal cortical fibrosis. Treatment with high-dose glucocorticoids in the early stages of the disease and maintenance therapy with low-dose glucocorticoids in later stages of the disease had a beneficial effect. Serial follow-up assessments with determination of the erythrocyte sedimentation rate and computed tomographic imaging of the abdomen and thorax are recommended for monitoring of disease activity.

CONCLUSION

Glucocorticoids are currently the treatment of choice for progressive multifocal fibrosclerosis. Accumulation of further clinical data is needed to determine more precise treatment strategies.

[Thyroiditis in children. Personal observations]

Enlargement of the thyroid gland, local tenderness and thyroid function disorder are common symptoms of thyroiditis. Hashimoto's thyroiditis (chronic lymphocytic thyroiditis) is the most common form of thyroiditis in children. This disease is a frequent cause of acquired hypothyroidism. Hashimoto's thyroiditis (HT) is characterised by infiltration of the thyroid gland by lymphocytes, gradual destruction of the gland and production of various thyroid autoantibodies, mainly antimicrosomal (ATM) and antithyroglobulin antibodies (ATGL). 54 children (45 girls and 9 boys) aged from 11 to 18 with confirmed or suspected HT were observed. The clinical diagnosis of HT was confirmed by fine needle aspiration biopsy (FNAB) in 27 patients. In one case HT was histologicaly confirmed after thyroid surgery. FNAB was not carried out in 19 patients and in 7 cases FNAB was thyroiditis negative. All patients were positive for ATM and/or ATGL. Initially 24 patients were euthyroid. Hypothyroidism was recognized in 8 children, subclinical hypothyroidism in 11 children. One patient was hyper- thyroid. 51 patients were treated with l-thyroxin. Ultrasonography revealed variable thyroid abnormality in all patients: hyperplasia in 38 patients, multinodular goiter or solitary nodule in 15 patients. 8 children suffered from associated disease: 5 patients from allergy, 1 patient from trombocytopenia, 1 from alopecia areata, 1 from secondary amenorrhea. Follow up examination of children with HT must be continued due to the risk of hypothyroidism or neoplastic disease of thyroid.

[Thyroid tuberculosis--a clinical case]

We present the case of a 38-year-old male patient with tuberculosis of the thyroid; the diagnosis was established on histological examination after surgery.

Ob-Gyn interactive case challenge--a case of sadness and anxiety 9 months postpartum

If you were the primary care provider, how would you diagnose and treat postpartum anxiety and depression in this young, first-time mother? After a normal, uncomplicated pregnancy, this 27-year-old woman developed anxiety and depressed mood, which she was still struggling to control 9 months after the birth of her child. Among the diagnostic possibilities to consider are occult malignancy, diabetes mellitus, and thyroid disorder, as well as major depression/anxiety disorder and postpartum depression.

Cerebral venous sinus thrombosis: a late sequel of invasive fibrous thyroiditis

Riedel's invasive fibrous thyroiditis (IFT) is a rare disease of unknown etiology characterized by a dense fibrosis involving the thyroid gland and its surrounding tissues. Clinically, patients present with a stony hard goiter frequently associated with compressive symptoms. Involvement of the surrounding neck structures by IFT can lead to various clinical sequelae. We report the case of a 55-year-old woman with known IFT who developed thrombosis in the right internal jugular vein that progressed to the right sigmoid, transverse, and superior sagittal sinuses. IFT could have predisposed to cerebral venous sinus thrombosis by causing venous stasis, vascular damage and possibly a hypercoagulable state. To our knowledge, this is the first report of cerebral venous sinus thrombosis that developed as a complication of IFT.

Postpartum psychosis and postpartum thyroiditis

The term postpartum psychosis refers to a group of severe and heterogeneous disorders with psychotic symptoms that occur most frequently in the context of a mood disorder during the postpartum period. We report a case of 'postpartum psychosis' possibly associated with postpartum thyroiditis in a 29 year-old woman. The appearance of psychotic symptoms was chronologically related to the onset of postpartum thyroiditis and resolution of psychosis synchronized with the achievement of biochemical euthyroidism. The patient had typical symptoms of 'classic postpartum psychosis' (a historical term not included in DSM-IV, but used frequently by many physicians to describe diagnostic and therapeutic challenges posed by puerperal psychoses). Three months postpartum, the patient began to believe that she was pregnant with the Christ child, although she was not pregnant. Her delusions resolved around the 'pregnancy' and harm to her 'unborn' child. She also believed that her child (Jesus) was going to be killed. Other key symptoms included hallucinations, mixed mood symptoms, agitation and transient disorientation. Her DSM-IV diagnosis on admission was major depression with psychotic features and her discharge diagnosis (most likely diagnosis) was psychotic disorder due to thyrotoxicosis caused by postpartum thyroiditis. The differential diagnosis of co-occurring psychosis and postpartum thyroiditis can be examined relative to four possibilities: (1) psychosis due to thyrotoxicosis caused by postpartum thyroiditis; (2) a coincidence (no association between psychosis and postpartum thyroiditis); (3) precipitation of psychotic symptoms and disorientation related to a postpartum thyroiditis in a woman with a pre-existing mood disorder; or (4) both psychosis and thyroiditis caused by a pre-existing defect in autoimmunity. The authors stress the importance of early diagnosis and prompt treatment of postpartum psychosis. They discuss the indications for thyroid screening in postpartum psychoses. Further research is needed to clarify the nosology and mechanisms of severe postpartum disorders and to elucidate treatment-relevant and etiologically-distinct subsets of postpartum psychosis.

Silent thyroiditis after excision of a thymoma

A 61-year-old man developed thyrotoxicosis after excision of a thymoma. His laboratory examination showed an increased level of thyroid hormone and a low thyroidal iodine uptake. No thyroidal autoantibody was detected. With the diagnosis of silent thyroiditis, he was treated with propranolol. He became euthyroid after 2 months. Thymoma often accompanies an autoimmune disease as a paraneoplastic syndrome, and an immunological mechanism is thought to be involved in the onset of silent thyroiditis. This case suggests the involvement of an immunological mechanism in the pathogenesis of silent thyroiditis.

Riedel's thyroiditis presenting with hypothyroidism and hypoparathyroidism: dramatic response to glucocorticoid and thyroxine therapy

Riedel's thyroiditis is a rare fibro-inflammatory process originating in the thyroid gland with progressive extension and invasion of surrounding tissues. Patients frequently present with a stony hard thyroid mass suggestive of anaplastic carcinoma. We report a striking case of Riedel's thyroiditis associated with hypothyroidism, hypoparathyroidism and bilateral vocal cord paralysis. A dramatic response to high dose prednisone and levothyroxine therapy was seen, with recovery of parathyroid and vocal cord function. Our case suggests that early initiation of combination therapy may be important, particularly in the presence of severe disease.

Efficacy and safety of iodine in the postpartum period in an area of mild iodine deficiency

BACKGROUND

Iodine deficiency (even moderate) plays a major role in pregnancy associated goiter development, which is only party reversible after pregnancy. The prevalence of post partum thyroiditis is reported to be slightly lower in areas of iodine deficiency. Thus iodine supplementation may be effective in decreasing pregnancy associated increase in thyroid volume, but enhances the risk of increasing the prevalence of thyroid dysfunction in the post partum period. Therefore, we evaluated the effect of iodine supplementation (with two different doses: 50 microg and 250 microg) on the prevalence of post partum thyroiditis and the decrease in thyroid volume up to 8 months post partum in an area of mild iodine deficiency.

PATIENTS AND METHODS

Thyroid volume of 56 women was evaluated 5 days and 3 months after delivery (study I). In an intervention study (Study II) 70 women were randomized to receive 50 or 250 microg of potassium iodide for a period of 8 months post partum beginning five days after delivery. Thyroid volume, the echogenecity of the thyroid gland, thyroid hormone parameters (T4, T3, fT4, TSH) and thyroid antibodies (TPO and Tg-Ab) were measured 5 days, 3 and 8 months after delivery.

RESULTS

A total number of 11 women developed postpartum thyroid dysfunction: 4 women developed manifest thyroid dysfunction (3 hyperthyroidism and 1 hypothyroidism) 3 months post partum. The remaining seven had subclinical hypo- or hyperthyroidism. All changes were clinically mild and transient as evidenced by normalization of thyroid hormone parameters on reexamination at 8 months. Among the eleven, 6 women in the 50 microg iodine group and 5 women of the 250 microg iodine group developed thyroid dysfunction, suggesting that the iodine dose did not affect post partum thyroiditis. The administration of only 50 microg iodine was associated with a significant fall of thyroid size already 3 months after delivery (25.4 +/- 1.5 ml (mean +/- sem) to 18.2 +/- 1.25 p <0.001). The application of 250 microg iodine was equally effective. 8 months post partum a slight but further decrease could be demonstrated. On the other hand, in study I no significant reduction in thyroid volume was observed in women receiving no supplementary iodine (thyroid volume at delivery 29 +/- 2.2 ml; at 3 months 27.5 +/- 3.0 ml.

CONCLUSION

The administration of supplementary iodine (up to 250 microg) to an unselected population, residing in an area of mild iodine deficiency, in the post partum period is save as indicated by a prevalence of 5.7% manifest thyroid dysfunction. These changes are clinically mild and transient. Even the amount of 50 microg of iodine supplementation seems to by very efficient in reducing pregnancy associated increments in thyroid volume.

Corticosteroid therapy in Riedel's thyroiditis

We report a case of Riedel's thyroiditis presenting with a systemic illness, life-threatening stridor and a stony hard goitre. Diagnosis was confirmed by open thyroid biopsy. Treatment with corticosteroid resulted in a dramatic improvement. A possible autoimmune mechanism in the pathogenesis of Riedel's thyroiditis is discussed.

Management of the patient with thyroid disease

The nursing care of patients with thyroid problems requires an understanding of the disease process so that a through history is obtained to facilitate diagnosis, treatment, and patient education. To understand the pathophysiology of thyroid diseases, thyroid hormone synthesis, transport, and metabolic effects, as well as the regulation of thyroid function by the hypothalamic-pituitary feedback system have been reviewed. Frequently used thyroid laboratory measures and diagnostic tests are outlined herein. The focus of this article has been the assessment and management of thyroid diseases commonly encountered in an ambulatory setting: goiter, hypothyroidism, hyperthyroidism, thyroiditis, and thyroid nodules. Proper assessment and management of patients with thyroid disorders are cost effective and have significant impact on the health and well-being of our patients.

Riedel's thyroiditis: treatment with tamoxifen

BACKGROUND

Riedel's thyroiditis is an often disabling disease with clinical and histologic similarity to several other fibrous inflammatory disorders. Surgical treatment alone is often unsatisfactory in permanently alleviating airway compression, dysphagia, neck immobility, pain, or chronic fatigue syndrome. Investigation of drugs shown to be of benefit in the treatment of related fibrous disorders in which hormonal factors or inflammatory deregulation appear to be important is indicated. Tamoxifen has not been previously used in the treatment of Riedel's thyroiditis.

METHODS

Four patients with clinical and histologic diagnoses of Riedel's thyroiditis were evaluated before and after treatment with tamoxifen. Each had progressive symptomatic disease of 3 to 16 years' duration despite one or more surgical procedures and steroid therapy. Subjective improvement was noted in all cases, and objective changes were confirmed by periodic physical and computed tomographic examinations.

RESULTS

Patients have been monitored for 1 to 4 years with subjective improvement in 100% and objective disease regression ranging from 50% to 100% in all patients. One patient had complete regression within 6 months, and another had more than 50% regression within 3 months. All have returned to predisease activity levels. There were no significant side effects of the therapy.

CONCLUSIONS

Tamoxifen has proved to be the most effective drug therapy available for managing Riedel's thyroiditis. Our studies suggest that this is unrelated to antiestrogen activity. Tamoxifen's effectiveness may be caused by a mechanism by which it stimulates the release of transforming growth factor-beta, which may inhibit the fibroblastic proliferation characteristic of Riedel's thyroiditis.

Failure of plasmapheresis, corticosteroids and thionamides to ameliorate a case of protracted amiodarone-induced thyroiditis

We report a case of amiodarone-induced thyrotoxicosis of protracted duration, unresponsive to conventional thionamide therapy, with therapy limited by severe adverse drug reactions. Other treatment modalities included high dose corticosteroids, plasmapheresis, lithium and perchlorate. Temporary amelioration was achieved following plasmapheresis; however, this and other measures were unsuccessful in controlling the thyrotoxicosis, which deteriorated to thyroid storm. Histopathologically, a degenerative, inflammatory thyroiditis was evident. We discuss the limitations of conventional drug therapy and the lack of a sustained response to plasmapheresis. The failure of high doses steroids to alter the course of illness and to completely suppress the thyroidal inflammatory process is highlighted. A potential role for renal and hepatic impairment in the observed protracted course of amiodarone-induced thyrotoxicosis is suggested.

Hypopituitarism associated with transient diabetes insipidus followed by an episode of painless thyroiditis in a young man

A 16-year-old male complained of a headache and a high fever followed by polyuria. The endocrinological studies showed he had hypopituitarism and central diabetes insipidus, and magnetic resonance imaging (MRI) revealed a pituitary mass. Diabetes insipidus gradually improved and hydrocortisone treatment was begun at three months after onset, but a month later painless thyroiditis developed. An MRI demonstrated a spontaneous shrinkage of the pituitary mass nine months after onset. Lymphocytic hypophysitis followed by painless thyroiditis was the most probable diagnosis, although it is very uncommon especially among men.

Thyroiditis. A disease with many faces

Inflammatory conditions of the thyroid are commonly encountered in clinical practice. Older and middle-aged women are most often affected, and the clinical course may be acute, subacute, or chronic. Differentiating the various forms of thyroiditis can be difficult, because they often mimic other disease processes and each other. Diagnosis requires an awareness of the distinguishing characteristics of each type of thyroiditis as well as the overlapping features.

Acute suppurative thyroiditis caused by Salmonella enteritidis

Acute suppurative thyroiditis in a 47-year-old diabetic woman is reported. Diagnosis was suspected by clinical examination and confirmed by ultrasound, CT-scan and cytological examination. A rare causative agent was isolated--Salmonella enteritidis. No signs of nodular goiter or connection with piriform sinus were found. In spite of our efforts, the source and route of infection remained unclear. However, the haematogenic route seems to be the most plausible. Surgical drainage and antibiotics brought about a complete recovery. Partial lesion of the gland required transitory administration of levothyroxine.