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

Riedel's thyroiditis: report of 7 patients and review of literature

Riedel's thyroiditis is a rare inflammatory-sclerosing thyroid disease, and its aetiology remains unknown. After a surgical biopsy to establish the diagnosis, the treatment of Riedel's thyroiditis is still challenging in most patients. The aim of this article is to report seven patients with Riedel's thyroiditis seen in a department of Endocrinology and Metabolic diseases over a period of 24 years, and based on the patient's data and the review of the literature to discuss the indications of surgery, glucocorticoids, tamoxifen and immunosuppressive drugs in the personalized treatment of patients with Riedel's thyroiditis.

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.

Antibody Response to Canine Parvovirus Vaccination in Dogs with Hypothyroidism Treated with Levothyroxine

(1) Background: No information is available on how dogs with hypothyroidism (HypoT) respond to vaccination. This study measured pre- and post-vaccination anti-canine parvovirus (CPV) antibodies in dogs with HypoT treated with levothyroxine and compared the results to those of healthy dogs. (2) Methods: Six dogs with HypoT and healthy age-matched control dogs (n = 23) were vaccinated against CPV with a modified-live vaccine. Hemagglutination inhibition was used to measure antibodies on days 0, 7, and 28. The comparison of the vaccination response of dogs with HypoT and healthy dogs were performed with univariate analysis. (3) Results: Pre-vaccination antibodies (≥10) were detected in 100% of dogs with HypoT (6/6; 95% CI: 55.7–100) and in 100% of healthy dogs (23/23; 95% CI: 83.1–100.0). A ≥4-fold titer increase was observed in none of the dogs with HypoT and in 4.3% of the healthy dogs (1/23; CI_95%: <0.01–22.7). Mild vaccine-associated adverse events (VAAEs) were detected in 33.3% of the dogs with HypoT (2/6; 95% CI: 9.3–70.4) and in 43.5% (10/23; 95% CI: 25.6–63.2) of the healthy dogs. (4) Conclusions: There was neither a significant difference in the dogs’ pre-vaccination antibodies (p = 1.000), or vaccination response (p = 0.735), nor in the occurrence of post-vaccination VAAEs (p = 0.798). The vaccination response in dogs with levothyroxine-treated HypoT seems to be similar to that of healthy dogs.

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.

Riedel's Thyroiditis: Report of Two Cases and Literature Review

Riedel's thyroiditis is a rare entity consisting of a fibrotic process of the thyroid which can generate gland destruction, infiltration of cervical structures and even airway obstruction. It has been associated with systemic fibrotic disorders, autoimmune diseases, and more recently with spectrum of diseases related to excess of Immunoglobulin G type 4 (IgG4). Two cases of Riedel's thyroiditis by IgG4, confirmed by immunohistochemistry and was managed surgically with favorable results during the follow-up time, are presented. These case descriptions highlight the diagnostic challenge of this disease, describe the response with surgical management, and make a brief update on the subject.

Early Hypoparathyroidism Reversibility with Treatment of Riedel's Thyroiditis

BACKGROUND

Riedel's thyroiditis (RT) is a rare, fibroinflammatory condition which induces gradual thyroid gland destruction and adjacent soft-tissue fibrous infiltration. About one- seventh of RT cases are associated with hypoparathyroidism, necessitating long-term therapy for symptomatic hypocalcemia. The reversibility of the parathyroid hormone deficit has not been fully described.

PATIENT FINDINGS

A 40-year-old woman with no prior history of thyroid disease presented with a six month history of progressive thyroid enlargement complicated by worsening dysphagia and positional dyspnea. Her past medical history was remarkable only for retroperitoneal fibrosis. Physical examination revealed a large, hard, non-mobile goiter. Thyroid indices while maintained on levothyroxine were normal, but marked asymptomatic hypocalcemia with an inappropriately normal parathyroid hormone level was noted. Thyroid imaging and fine needle aspiration were consistent with RT. Isthmectomy and subsequent serial corticosteroid and tamoxifen treatment led to rapid symptom improvement. Serum calcium and parathyroid hormone levels returned to the reference range within three months.

SUMMARY

We describe a case of RT in which hypoparathyroidism resolved after treatment targeted the mechanical compression and the fibroinflammatory milieu of the patient's thyroidal disease.

CONCLUSIONS

RT can be associated with hypoparathyroidism that is clinically silent at presentation. Mechanical decompression of the goiter and immunomodulatory therapy can reverse the fibrosclerotic process and lead to rapid recovery of parathyroid gland function, as in this patient. However, in most cases hypoparathyroidism is persistent and requires continued treatment to prevent symptomatic hypocalcemia.

Benign conditions of the thyroid gland

Infectious and autoimmune diseases account for the majority of benign conditions of the thyroid gland. They are usually diagnosed and followed by clinical examination and laboratory analyses, but when imaged, ultrasonography and computed tomography are the modalities of choice. In particular, fine needle aspiration under ultrasound guidance may be invaluable for diagnostic and therapeutic purposes.

A rare case of Reidel thyroiditis with associated vocal cord paralysis: CT and MR imaging features

Reidel thyroiditis is extremely rare and not only involves the thyroid gland but usually extends to neighboring structures in the neck. A rare complication of this disease is entrapment of the recurrent laryngeal nerve causing a vocal cord paralysis. In fact, to our knowledge, this is likely the only benign thyroid disease to cause such a paralysis. We present a case of a 57-year-old woman with Reidel thyroiditis and a recurrent laryngeal nerve paralysis. The CT and MR imaging features are presented as well as a brief review of this disease.

Riedel’s thyroiditis: impact and strategy of a challenging surgery

BACKGROUND

No surgical standard for Riedel's thyroiditis (RT) is established. Salvage surgery follows severe cervical and compressive airway symptoms or strong suspicion of malignancy. Obscured planes and multi-infiltrative extension prevent sufficient surgery with considerate complications. No alternative definitive treatment is available. In failing conservative treatment, the role of surgery in RT remains unclear.

MATERIALS AND METHODS

Clinical manifestation, treatment, outcome and follow-up in a unique series of eight consecutive patients with RT are presented.

RESULTS

Seven female patients and one male patient with cervical tumor growth or thyroiditis underwent four total and three sub-total thyroidectomies, respectively, one patient declined remedial surgery. Complications were one bilateral laryngeal nerve palsy and one transient hypoparathyroidism. Histology confirmed RT with perithyroidal extension and excluded malignancy in all. Symptomatic relief of cervical and airway obstruction was achieved in all. Follow-up revealed two extensive mediastinal RT recurrences 1 and 6 years after surgery.

CONCLUSION

Favourable symptomatic outcome and alleviation of steroids in the majority render surgery for RT valuable when conservative treatment fails. However, more radical procedures show no advantages and recurrences are not prevented. The demanding technique in RT requires special surgical expertise and highly recommends intra-operative neuromonitoring.

Glucocorticoid receptor subunit gene expression in thyroid gland and adenomas

The present study was undertaken to investigate whether the glucocorticoid receptor -alpha (GR-alpha) and -beta (GR-beta) mRNA may be expressed in thyroid gland. Ten normal thyroid gland and 14 follicular adenomas were studied using a real-time fluorescent quantitative RT-PCR (FQ-RT-PCR) method. The results demonstrated that there was a lower expression of GR-alpha mRNA (x10(6) GR-alpha cDNA copies/microg total RNA) in thyroid adenoma (1.27+/-0.26) than that in normal thyroid gland (3.53+/-1.22) (p < 0.001). The expression of GR-beta mRNA was lower in all the thyroid tissues. Of note, there was a significant difference in GR-beta mRNA expression (x10(4) GR-beta cDNA copies/microg total RNA) between thyroid adenoma (80.8+/-13.9) and thyroid gland (1.78+/-0.59) (p < 0.001). The GR-alpha/GR-beta ratios in thyroid adenoma and normal thyroid gland were 1.67+/-0.68 and 207.57+/-84.41 respectively (p < 0.001). These results revealed, for the first time, that both GR-alpha and GR-beta mRNA expression were detectable in both thyroid gland and adenomas tissues. We therefore conclude that down-regulation of GR-alpha and up-regulation of GR-beta mRNA expression may play an important role in the thyroid adenomas.

An unusual form of Riedel's thyroiditis: a case report and review of the literature

We report the case of a 36-year old woman with a history of long-term fever associated with a biologic inflammatory syndrome that was not corrected by several courses of corticosteroid treatment. The only remarkable result during previous investigations was the presence of a positive Epstein-Barr virus (EBV) serology. Clinical examination revealed an heterogenous thyroid with a nodule on the right lobe. Serum thyrotropin (TSH) concentration was normal. The levels of antiperoxidase antibodies and thyrocalcitonin were normal. Ultrasound examination of the neck showed a 3-cm hypoechogenous nodule in the right lobe of the thyroid. A total thyroidectomy was performed. Histopathologic findings led to the diagnosis of Riedel's thyroiditis. We observed a dramatic improvement after surgery with absence of fever and normalization of inflammatory parameters. The role of EBV infection in the process of this unusual form of Riedel's thyroiditis 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.

A Case of Riedel’s Thyroiditis Treated with Tamoxifen: Another Successful Outcome

OBJECTIVE

To report a case of Riedel's thyroiditis, which was successfully treated with tamoxifen.

METHODS

We present the clinical, laboratory, and imaging findings and describe the clinical course of a patient with Riedel's thyroiditis.

RESULTS

A 40-year-old woman presented with hypothyroidism and a large goiter, which was unresponsive to hormone replacement therapy. Magnetic resonance imaging confirmed the presence of an enlarged thyroid gland, more pronounced on the right than on the left. The patient had progressive discomfort attributable to compressive symptoms in the neck. Surgical exploration of the neck disclosed a hard, immobile thyroid mass, which could not be resected because of adherence to surrounding structures. Biopsy of the thyroid and of the muscles of the neck revealed Riedel's thyroiditis. Treatment with tamoxifen, in a dosage of 20 mg twice a day for more than 1(1/2) years, completely resolved the neck mass (substantiated by follow-up magnetic resonance imaging) and relieved the signs and symptoms of compression of the neck.

CONCLUSION

Tamoxifen treatment is effective in resolving the mass and compression in Riedel's thyroiditis.

Positron emission tomography as an aid in the diagnosis and follow-up of Riedel's thyroiditis

We describe the usage of positron emission tomography (PET) as an aid in the initial diagnosis and follow-up of Riedel's thyroiditis. A 41-year-old patient was admitted for an enlarged and tender thyroid gland in association with severe systemic symptoms of inflammation. Imaging with fluorine-18 fluorodeoxyglucose (FDG) and PET demonstrated an intensive uptake of FDG in both lobes of the thyroid gland as an indication of severe inflammation. The diagnosis of Riedel's thyroiditis was confirmed by the histological findings of biopsy specimens taken during a palliative thyroid resection. The inflammatory symptoms and local pain dramatically disappeared after commencement of high-dose corticosteroid therapy. A follow-up PET scan after 2 weeks of corticosteroid treatment showed a 60% decrease in the uptake of FDG in the thyroid. This indicates that FDG metabolic activity can also be used to assess a patient's response to therapy in Riedel's thyroiditis.

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.

Riedel's thyroiditis and retroperitoneal fibrosis in multifocal fibrosclerosis: positron emission tomographic findings

PURPOSE

The authors describe F-18 fluorodeoxyglucose positron emission tomographic (FDG PET) imaging features of Riedel's thyroiditis and retroperitoneal fibrosis in a patient with multifocal fibrosclerosis.

MATERIALS AND METHODS

A 41-year-old woman in whom Riedel's thyroiditis had been diagnosed 7 months earlier was examined for fatigue, anorexia, and lower back pain, irradiating to the abdomen. Abdominal sonography and computed tomography showed a retroperitoneal mass. A biopsy of this mass showed histopathologic findings of retroperitoneal fibrosis. FDG PET was performed to evaluate the activity of the retroperitoneal fibrosis and to screen for other areas of fibrosclerosis.

RESULTS

The FDG-PET images showed an intense hypermetabolic abdominal mass surrounding the aorta and increased glucose metabolism in the thyroid. No other sites of abnormal FDG metabolism were noted. These abnormalities disappeared after 4 months of steroid therapy.

CONCLUSIONS

Sites of multifocal fibrosclerosis can be demonstrated by FDG PET, probably as a result of active inflammation involving lymphocytes, plasma cells, and fibroblast proliferation. FDG PET can help to establish the diagnosis of multifocal fibrosclerosis and evaluate the activity and patient response to corticosteroid therapy.

MR findings with dynamic evaluation in Riedel's thyroiditis

We reported the findings on MRI in a patient with proven Riedel's thyroiditis. The lesion was seen as slightly heterogeneous hypointensity on both T1- and T2-weighted images and had a mild enhancement after administration of gadpentate dimeglumine (Gd-DTPA). Dynamic MR study showed gradual increase in signal intensity of the lesion. These findings were different from those of thyroid neoplasms and were considered to reflect the mixture of inflammatory cells infiltration and fibrosis of Riedel's thyroiditis.

Tamoxifen therapy in steroid-resistant Riedels disease

Riedels 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 Riedels 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 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.

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.

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.