Riedel's thyroiditis associated with Hashimoto's thyroiditis, hypoparathyroidism, and retroperitoneal fibrosis

IgG4-related sclerosing thyroiditis (Riedel-Struma): a review of clinicopathological features and management

We present a thorough review of the literature on Riedel thyroiditis (RT) with emphasis on aetiology, diagnosis and management, using the PubMed, Sinomed, and China National Knowledge Infrastructure databases. Although the exact aetiology of RT remains obscure, the histopathological features are consistent with a localized form of IgG4-related systemic disease (IgG4-RSD). Nevertheless, IgG4-RSD as a systemic fibroinflammatory disorder per se rarely affects the thyroid in the context of multiorgan manifestations. The initial diagnosis of RT is based on clinical history and imaging, but confirmation by histopathological examination is mandatory. In contrast to the historical surgical approach, glucocorticosteroid therapy is currently considered first line therapy, in line with the RT currently being viewed as a manifestation of, or analogous to, IgG4-RSD. For disease relapse, immunomodulatory agents (azathioprine, methotrexate, rituximab) can be used.

IgG4-Related Retroperitoneal Fibrosis: A Rare Association With Riedel's Thyroiditis

Idiopathic retroperitoneal fibrosis is a rare fibro-inflammatory disease that can be associated with other IgG4-related diseases (IgG4-RDs). It is exceedingly uncommon to encounter this condition in a patient with Riedel's thyroiditis (RT), another disease in the IgG4-RD family. We present the case of a 53-year-old man with a history of RT who presented for severe localized lower abdominal and suprapubic pain due to obstructive uropathy from extensive retroperitoneal fibrosis. The biopsy of the mass demonstrated fibro-inflammatory tissue, and its immunohistochemistry was notable for IgG4-positive plasma cells. This case highlights the challenge associated with the diagnosis and management of this rare manifestation of IgG4-RD. In a patient with a history of any form of IgG4-RDs, providers should be vigilant for any signs or symptoms that suggest the development of fibrosis in other organs.

Riedel Thyroiditis

CONTEXT

Riedel thyroiditis (RT) is a rare inflammatory autoimmune disease that is often a clinically diagnostic dilemma because of its insidious presentation and nonspecific symptoms.

OBJECTIVE

The aim of the present systematic review and meta-analysis is to clarify the presentation, management, and outcomes of RT.

STUDY SELECTION

A systematic search of PubMed/MEDLINE and Web of Science was conducted to identify relevant reports published up to September 2019.

DATA EXTRACTION

First author, country, patient sex, ethnicity, presentation, biochemical status, duration of symptoms, histology, treatment, follow-up duration, and short- and long-term outcomes.

DATA SYNTHESIS

Data from 212 RT patients were retrieved. The mean age was 47 years with a predominantly female population (81%). Neck swelling (89%), dyspnea (50%), and neck pain (41%) were the most common presenting symptoms. Inflammatory markers were elevated in 70% to 97% and thyroid antibody positivity was present in less than 50%. Up to 82% underwent surgical intervention, with the most common being total thyroidectomy in 34% of individuals. Glucocorticoids were used in 70% of individuals with median duration 3 months. Prognosis was reasonable with 90% having resolution or improvement of symptoms.

CONCLUSIONS

This analysis is the largest and most comprehensive to date of RT and provides clinicians with vital information on the common presentation features that may alert to the diagnosis and highlight management options.

Clinicopathological features of Riedel's thyroiditis associated with IgG4-related disease in Japan

Riedel's thyroiditis (RT) is a rare chronic fibrosing disorder characterized by a hard, infiltrative lesion in the thyroid gland, which is often associated with multifocal fibrosclerosis. Immunoglobulin G4-related disease (IgG4-RD) is typified by infiltration of IgG4-positive plasma cells into multiple organs, resulting in tissue fibrosis and organ dysfunction. In order to evaluate the clinicopathological features of RT and its relationship with IgG4-RD, we performed a Japanese literature search using the keywords "Riedel" and "Riedel's thyroiditis." We used the electronic databases Medline and Igaku Chuo Zasshi, the latter of which is the largest medical literature database in Japan. The diagnosis of RT was based on the presence of a fibroinflammatory process with extension into surrounding tissues. Only 10 patients in Japan fulfilled RT diagnostic criteria during the 25-year period between 1988 and 2012. Two patients with confirmed IgG4/IgG immunohistochemical findings demonstrated 43 and 13 IgG4-positive plasma cells per high-power field, respectively, and the IgG4-positive/IgG-positive plasma cell ratios of 20% and less than 5%. Of the 10 patients with RT, two received glucocorticoids, one of whom experienced marked shrinkage of the thyroid lesion. One patient had extra-thyroid involvement in the form of retroperitoneal fibrosis. Although the clinicopathological features of RT suggest that IgG4-RD may be the underlying condition in some cases, further investigation is needed to clarify the etiology of RT in relation to IgG4-RD.

Atypical Presentation of Riedel's Thyroiditis: Multifocal Nodular Fibrosis and Resolution with Levothyroxine

BACKGROUND

Riedel's thyroiditis is characterised by chronic inflammatory invasive fibrosclerosis of the thyroid gland, surrounding structures, and extrathyroidal fibrosis. We present a case of Riedel's thyroiditis associated with nodular fibrosis of the lungs and liver.

CASE

A 40-year-old woman presented with a 3-month history of neck swelling, difficulty swallowing and breathlessness on exertion. Core biopsy of the goitre revealed dense fibrous tissue with mixed chronic inflammatory cells. A staging computed tomography scan revealed a large thyroid mass encasing the oesophagus and compressing the trachea, multiple bilateral pulmonary nodules with no evidence of lymphadenopathy, and multiple suspicious nodular lesions in the liver. A thorascopic biopsy of a lung lesion in its entirety revealed a hyalinising lung lesion with no evidence of malignancy. Following the introduction of levothyroxine replacement, symptomatic improvement occurred in parallel with improvements in imaging.

CONCLUSION

To our knowledge, this is the first description of Riedel's thyroiditis presenting with nodular extrathyroidal fibrosis, and which showed resolution following institution of levothyroxine.

Invasive fibrous thyroiditis (Riedel thyroiditis): the Mayo Clinic experience, 1976-2008

BACKGROUND

Invasive fibrous thyroiditis (IFT) is the rarest form of thyroiditis, and reports are often limited to case reports and small case series. In this study, we aimed to summarize our institutional experience with IFT since 1976.

METHODS

We retrospectively reviewed the cases of all patients with IFT evaluated at Mayo Clinic, Rochester, Minnesota, from 1976 through 2008, with special emphasis on clinical presentation, associated risk factors, associated comorbid conditions, complications, and treatment.

RESULTS

Twenty-one patients met our inclusion criteria of (i) IFT confirmed by pathologic review at our institution and (ii) evidence of extension of fibrosis outside the thyroid capsule. Most patients (17, 81%) were women (mean age, 42 years). Presenting symptoms included pain (24%), dysphagia (33%), vocal cord paralysis (29%), and tracheal narrowing (48%). Three patients had associated hypoparathyroidism. Sixteen (76%) had a history of tobacco use, and 10 (48%) were current smokers. Fibrosing mediastinitis was present in four, orbital fibrosis in one, retroperitoneal fibrosis in three, and pancreatic fibrosis in one (38% had extracervical fibrotic processes). Eighteen patients had partial thyroidectomy, 7 (39%) of whom had surgical complications involving vocal cords and parathyroid. Two required tracheostomy. Thirteen had corticosteroid therapy; six received tamoxifen. There was no cause-specific mortality, and the fibrotic process stabilized or partially resolved in all patients.

CONCLUSIONS

IFT often is associated with a systemic extracervical fibrotic process and tobacco use. Attempted thyroid resection often results in postoperative complications. Long-term follow-up showed no deaths from IFT and showed stability of the thyroiditis.

Profile of Hashimoto's Thyroiditis in Sri Lankans: Is There an Increased Risk of Ancillary Pathologies in Hashimoto's Thyroiditis?

Hashimoto's thyroiditis has been reported to be associated with many neoplastic and nonneoplastic thyroid pathologies. This retrospective study aims to determine the demographic profile of Hashimoto's thyroiditis in Sri Lankans, document ancillary pathologies in Hashimoto's thyroiditis, and determine whether there is an increased risk of occurrence of malignancies, benign neoplasms, and nonneoplastic benign lesions in Hashimoto's thyroiditis by comparing with thyroids showing multinodular goiters, follicular adenomas, and colloid nodules. The mean age of Hashimoto's thyroiditis is 43.3 years with the majority in the 41 to 60 year age group and a female to male ratio of 10.3 : 1. This study revealed a statistically significant increase of thyroid malignancies in association with Hashimoto's thyroiditis. The association of Papillary carcinoma, Non-Hodgkin's lymphoma, and Hurthle cell adenoma with Hashimoto's thyroiditis was statistically significant.

A case of Riedel's thyroiditis with pleural and pericardial effusions

Riedel's thyroiditis (RT) is a rare type of chronic thyroiditis of unproven etiology and definite treatment. It can be associated with retroperitoneal, mediastinal, orbital, and hepatic fibrosis. Symptoms arise mainly due to compression of neighboring structures. Surgery is usually required for a definite diagnosis and decompression to relieve the symptoms. Glucocorticoids and tamoxifen are commonly used agents for the pharmacotherapy. We hereby describe the development of pleural and pericardial effusions during the clinical course of an RT case. A 39-year-old woman suffering from neck compression symptoms was admitted to the hospital. After a decompression isthmectomy, RT was diagnosed. She responded well to glucocorticoid therapy after surgery. However, symptoms reoccurred shortly after glucocorticoid withdrawal and the disease process extended to the mediastinum. Tamoxifen was started and the neck and mediastinal mass regressed and her symptoms disappeared considerably for more than 6 months. However, she was readmitted with severe dyspnea and chest pain. Further investigation revealed an exudative pleural and pericardial effusion and mediastinal enlargement. A thorough evaluation of the patient's effusions did not disclose any specific etiological insult. The patient was symptom-free with a considerable reduction of the soft tissue mass and no effusions, and treated successfully with colchicine, azathioprine, and glucocorticoids. To the best of our knowledge, this is the first case reported in the literature as an RT presenting with pleuropericardial effusions.

Idiopathic retroperitoneal fibrosis associated with Hashimoto's thyroiditis in an old-aged man

Idiopathic retroperitoneal fibrosis (IRPF) is a rare disease characterized by a retroperitoneal inflammatory proliferative fibrosing process. Hashimoto's thyroiditis is the most common inflammatory condition of the thyroid gland; and is a frequently-occurring autoimmune disorder manifesting predominantly in middle-aged women. We report a rare association of IRPF with Hashimoto's thyroiditis in a 67-year-old man demonstrating good response to steroid therapy.

Hashimoto's thyroiditis associated with idiopathic retroperitoneal fibrosis: case report and review of the literature

Idiopathic retroperitoneal fibrosis (IRF) is a rare disease of unknown origin, characterised by an inflammatory proliferative fibrosing process occurring in the retroperitoneum. Hashimoto's thyroiditis (HT) is a form of chronic thyroiditis that in some cases shows an extensive replacement of thyroid parenchyma by fibrous tissue. We report the rare association of IRF with HT in a 68-year-old woman presenting with pulmonary oedema, acute renal failure due to bilateral hydronephrosis and a firm diffuse goitre with hypothyroidism. The so far reported cases of IRF associated with chronic thyroiditis are reviewed, and the possible aetiopathogenetic link between these two entities is discussed.

Uso do tamoxifeno no tratamento da tireoidite de Riedel: relato de um caso

O tratamento da tireoidite de Riedel (TR) consiste em cirurgia nos casos de fibrose local limitada. Na maioria dos casos, entretanto, necessita-se do uso de agentes antiinflamatórios, como os glicocorticóides ou, nos casos de falha ou recidiva, o tamoxifeno pode ser útil. Relatamos um caso de TR em uma mulher negra de 55 anos, associada a hipotireoidismo e hipoparatireoidismo. Avaliamos o tratamento com tamoxifeno na dose de 20mg duas vezes ao dia, durante onze meses. Após sessenta dias de tratamento, a paciente não relatava os sintomas compressivos antes apresentados. Entretanto, em um seguimento de onze meses, houve pouca melhora objetiva avaliada por ultrassonografia e tomografia seriados de região cervical. O tamoxifeno pode ser útil na TR, principalmente quando o uso do glicocorticóide é contra-indicado. A duração ideal do uso desta terapia não está definida.

Steroid responsiveness in a case of Riedel's thyroiditis and retroperitoneal fibrosis

Riedel's thyroiditis is a rare chronic inflammatory disease of the thyroid characterised by an invasive fibrotic process. We present a lady with newly diagnosed hypothyroidism, rapidly enlarging hard, fixed goitre, strongly positive thyroid antibodies and raised erythrocyte sedimentation rate (ESR). A tru-cut biopsy confirmed Riedel's struma. Regression of the goitre and reduction of antibody titres occurred after starting prednisolone, which was stopped after 10 months. Six months later, she presented with renal failure due to retroperitoneal fibrosis that was successfully treated by reinstitution of steroids and ureteric stenting. Very high titres of thyroid antibodies and hypothyroidism predating development of goitre suggest coexistence of Hashimoto's thyroiditis and Riedel's thyroiditis. Tru-cut biopsy obviated the need for open thyroidectomy. A predominantly inflammatory as opposed to fibrotic thyroid histology may predict good response to steroids. Relapse following steroid withdrawal may not only be in the thyroid but also at other sites.

Hypoparathyroidism preceding Riedel's thyroiditis

We report the case of a woman who presented with primary hypoparathyroidism and who subsequently developed extensive Riedel's thyroiditis. To our knowledge, this is the first reported case of primary hypoparathyroidism preceding Riedel's thyroiditis. This observation suggests that Riedel's thyroiditis is part of a diffuse fibrotic process that may involve other organs, such as the parathyroid glands.

Hashimoto's thyroiditis and Graves' disease associated with retroperitoneal fibrosis

Retroperitoneal fibrosis is a rare disease of uncertain pathogenesis. However, its possible association with several immunopathologic conditions, the possibility of systemic involvement by the fibrous process, the presence of various autoantibodies, and the frequent response to immunosuppressive treatment all support an autoimmune pathogenesis. Riedel's thyroiditis is a rare disease the pathogenesis of which is also thought to be immune-mediated based on its optimal response to steroids; Riedel's thyroiditis is also frequently reported in association with retroperitoneal fibrosis. We describe here two cases of autoimmune thyroid disease associated with retroperitoneal fibrosis, the first with features of primary myxedema, the second of primary thyrotoxicosis. Histology of retroperitoneal fibrosis is documented and it is compatible with an immunopathologic condition. Thus, these two cases add further support to the hypothesis of an autoimmune pathogenesis of retroperitoneal fibrosis and indicate the importance of carefully monitoring for the development of other autoimmune disorders, i.e., of the thyroid gland, in patients with retroperitoneal fibrosis.

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.

Extensive sterile abscess in an invasive fibrous thyroiditis (Riedel's thyroiditis) caused by an occlusive vasculitis

Riedel's thyroiditis is a rare disease determined by an invasive fibrosclerotic transformation of the thyroid gland. It may be one manifestation of multifocal fibrosis with still unknown etiology. Because it mimics carcinoma, a biopsy must be performed to get the correct diagnosis. The condition is self-limiting when confined to the neck. Prognosis depends on the extent of extracervical fibrosclerosis. We present a patient with a huge cervical and mediastinal, unilateral thyroid mass expanding to the aortic curve, which led to tracheal deviation and compression with symptoms of stridor and dyspnea. These symptoms continued under a course of high-dose steroids; thus an operation was necessary to relieve the airway obstruction and limit inflammation. Intraoperative and pathological findings showed an inflammatory infiltration of the adjacent neck muscles and a sterile abscess caused by an occlusive vasculitis. Therefore, hemithyroidectomy had to be performed instead of a local limited resection.

Combined Riedel's Disease and Fibrosing Hashimoto's Thyroiditis: A Report of Three Cases with Two Showing Coexisting Papillary Carcinoma

Extensive sclerosis of the thyroid gland can be seen in both benign and malignant conditions. The benign sclerosing lesions of the thyroid include Riedel's disease and fibrosing Hashimoto's thyroiditis. Although these conditions usually occur separately, rarely can they occur simultaneously. In malignant lesions, papillary thyroid carcinoma and anaplastic carcinoma of the thyroid can be associated with extensive sclerosis leading to partial or total effacement of the tumor. We report on three cases that showed simultaneous occurrence of Riedel's disease and fibrosing Hashimoto's thyroiditis. Two of these cases also showed papillary carcinoma (one case of Warthin's-like papillary carcinoma and one case of classic type). All patients were females (age range 32-67 yr) and presented with elevated antithyroglobulin antibodies. Two patients presented with a solitary thyroid mass, and from these one had multiple bilateral neck nodes and a paravertebral mass. The third patient presented with a multinodular gland adherent to neck structures. All patients underwent total thyroidectomy. Histologic sections showed extensive replacement of the thyroid parenchyma with dense keloidal fibrosis, intermixed well-developed lymphoid follicles, and scattered lymphocytes and plasma cells. In all cases the fibrotic process extended beyond thyroid capsule with involvement of the perithyroidal soft tissues and skeletal muscle consistent with Riedel's disease. One case showed a classic papillary carcinoma with bilateral lymph node metastases, and the other showed a Warthin's-like papillary carcinoma. In both cases the papillary cancers were surrounded by dense sclerosis. Immunohistochemical stains for B- and T-markers and immunoglobulin light chains showed a polyclonal population of the lymphoid cells. The simultaneous occurrence of Riedel's disease and fibrosing Hashimoto's thyroiditis is rare and most likely represents a coincidental phenomenon, because both of these conditions are distinct clinicopathologic entities.

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.

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.

Simultaneous involvement of thyroid by Riedel's [correction of Reidel's] disease and fibrosing Hashimoto's thyroiditis: a case report

We report an unusual thyroid lesion showing histologic features of both Riedel's [corrected] disease and fibrosing Hashimoto's thyroiditis in a 57-year-old white female. The clinical presentation was hypothyroidism associated with a solitary firm to hard cold nodule replacing the entire right lobe of thyroid gland. Pathological examination demonstrated extensive replacement of the thyroid parenchyma with dense keloidal fibrosis, intermixed well-developed lymphoid follicles, scattered lymphocytes, and plasma cells. The fibrotic process extended into the perithyroidal soft tissues and skeletal muscle with complete obliteration of the thyroid capsule. These findings were consistent with Riedel's [corrected] disease. However, the immunohistochemical stains for B and T markers and immunoglobulin light chains showed an immunoprofile consistent with Hashimoto's thyroiditis. This combination of Riedel's [corrected] disease and fibrosing Hashimoto's thyroiditis is rare and coincidental, as both represent two distinct clinicopathological entities.

Hashimoto's thyroiditis associated with Riedel's thyroiditis and retroperitoneal fibrosis

This article describe the case of a 38-year-old woman with simultaneous involvement of the thyroid by Hashimoto's thyroiditis and Riedels's disease, associated with retroperitoneal fibrosis and lipidic endarteritis. According to a large review of the literature on the occurrence of this rare condition the difficulty in sharply defining the two thyroid processes is discussed. The chronology of the events is analyzed, and etiopathogenic hypotheses are listed with emphasis on the relationship between the vascular lesions and the onset of the fibrosing process.