Combined mycophenolate mofetil and prednisone therapy in tamoxifen- and prednisone-resistant Reidel's thyroiditis

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.

Reshaping the Concept of Riedel's Thyroiditis into the Larger Frame of IgG4-Related Disease (Spectrum of IgG4-Related Thyroid Disease)

Recently, Riedel's thyroiditis (RT) was assimilated into the larger spectrum of immunoglobulin IgG4-related disease (IgG4-RD) in addition to a particular frame of IgG4-related thyroid disease (IgG4-RTD), underlying IgG4-RT, IgG4-associated Hashimoto's thyroiditis (and its fibrotic variant), and IgG4-related Graves's disease. Our objective was to overview recent data on RT, particularly IgG4-RD and IgG4-RTD. The case and study- sample analysis (2019-2023) included 293 articles and selected 18 original studies: nine single case reports (N = 9, female/male = 2/1, aged: 34-79 years, 5/9 patients with serum IgG4 available data, 2/5 with high serum IgG4) and four case series (N = 21; 4/5 series provided data on IgG4 profile, 3/21 had serum IgG4 assays, and 2/3 had abnormally high values). IgG4-RD and thyroid findings were analyzed in three cohorts (N = 25). Another two studies (N = 11) specifically addressed IgG4-RTD components. On presentation, the patients may have hypothyroidism, transitory thyrotoxicosis, goiter, long-term history of positive anti-thyroid antibodies, and hypoechoic ultrasound thyroid pattern. The 5-year analysis (N = 66) showed the rate of serum IgG4 evaluation remained low; normal values do not exclude RT. Mandatory histological and immunohistochemistry reports point out a high content of IgG4-carrying plasma cells and IgG4/IgG ratio. Unless clinically evident, histological confirmation provides a prompt indication of starting corticoid therapy since this is the first-line option. Surgery, if feasible, is selective (non-responders to medical therapy, emergency tracheal intervention, and open/core needle biopsy). Current open issues are identifying the role of serum IgG4 assays in patients with IgG4-RD, finding out if all cases of RT are IgG4-mediated, applying IgG4-RTD criteria of differentiation among four entities, and providing an RT/IgG4-RTD guideline from diagnosis to therapy. It remains that the central aim of approaching RT in daily practice is the early index of suspicion in order to select patients referred for further procedures that provide enough histological/immunohistochemistry material to confirm RT and its high IgG4 burden.

Reidel's Thyroiditis, a Diagnostic and Management Challenge: A Case Report and Review of the Literature

Riedel's thyroiditis is a very rare inflammatory condition. It affects not only the thyroid gland but also the adjacent vital structures. It may also be associated with different forms of systemic fibrotic disorders. The exact etiology is unknown, but currently, the most favorable opinion is that it is a localized form of the systemic fibrotic process. We report the case of a 38-year-old woman, presented with a 10-month history of progressive hypothyroidism, dysphonia, and dysphagia. A Doppler ultrasound study revealed massive thyroid enlargement with multiple Eu TIRADS 3 and 4 nodules. Fine needle aspiration was noncontributive on two occasions. A hard subtotal thyroidectomy was performed. Pathological study confirmed Riedel's thyroiditis with the presence of IgG4 antibodies in immunohistochemistry. The patient was successfully treated with levothyroxine replacement and corticosteroid therapy with rapid resolution of obstructive symptoms. The case descriptions highlight the diagnostic challenge of this disease, describe the response to surgical management and corticosteroid therapy, and give a short review of the subject.

Long-Term Outcomes of Tamoxifen Citrate Therapy and Histo- and Immunopathological Properties in Riedel Thyroiditis

BACKGROUND

Riedel thyroiditis (RT) is a rare form of thyroiditis; thus, data about the disease course and treatment options are limited. Therefore, we aimed to assess the clinical, serological, radiological, and histopathological features, as well as short- and long-term follow-up of RT patients under glucocorticoid (GC) and tamoxifen citrate (TMX). Parameters related to IgG4-related diseases (IgG4-RD) were also investigated.

METHODS

Eight patients with RT diagnosed between 2000 and 2019 were enrolled. Data were collected in a retrospective and prospective manner. The diagnosis was confirmed with histopathological features in all patients. Results of the treatment with GCs on short- to mid-term, followed by TMX in the long term, were evaluated.

RESULTS

The mean age at diagnosis was 40.5 ± 6.8 years; female predominance was observed (F/M:7/1). Parameters related to IgG4-RD, like increase in IgG4 serum levels, total plasmablast counts, and IgG4+ plasmablasts, were negative in most of our patients in both active and inactive states of the disease. Likewise, an increased ratio of IgG4/IgG-positive plasma cells >40% could only be observed in 2 cases. GCs followed by TMX were given to the patients with an over-all median follow-up time of 67 (8-216) months. All the patients considerably improved clinically and had a reduction in the size of the mass lesion on GCs, followed by TMX therapy. None of the patients had a recurrence under TMX therapy for a median period of 18.5 (7-96) months.

CONCLUSION

Even though RT is suggested to be a member of IgG4-RD, serologic or histological evidence of IgG4 elevation or positivity is only useful for diagnosis and follow-up of RT. The diagnosis should be based on clinical and radiological evidence and confirmed by histopathology. GCs are effective for initial treatment, and TMX is a successful and safe therapeutic option for long-term maintenance therapy.

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.

SUCCESSFUL USE OF RITUXIMAB IN A CASE OF RIEDEL THYROIDITIS RESISTANT TO TREATMENT WITH PREDNISONE AND TAMOXIFEN

Objective

Riedel thyroiditis (RT) is a rare disorder with high morbidity and limited treatment options. We describe a case resistant to conventional treatment with corticosteroids and tamoxifen, which subsequently responded to rituximab.

Methods

Surgical pathology with hematoxylin and eosin staining was initially performed to confirm diagnosis, followed by IgG4 immunostaining and IgG4 serology in the setting of refractory RT, given its association with IgG4-related disease. Response to treatment was monitored subjectively as well as objectively with serial computed tomography scans.

Results

A 51-year-old female with history of Hashimoto thyroiditis presented with compressive neck symptoms. Imaging was suggestive of a multinodular goiter with a large right thyroid nodule. Total thyroidectomy was planned, however intraoperative findings of a densely adherent thyroid with disruption of resection planes led to early termination of surgery. Biopsies obtained during surgery showed benign thyroid tissue with chronic lymphocytic thyroiditis, dense fibrous scar tissue, and benign lymph nodes, confirming the diagnosis of RT. The patient had minimal symptomatic improvement with chronic prednisone as high as 60 mg daily with tamoxifen at 30 mg twice a day. She subsequently received 4 doses of intravenous rituximab at 375 mg/m² every 3 weeks, resulting in significant subjective improvement of her compressive symptoms as well as an objective decrease in size of the thyroid mass as seen on a subsequent computed tomography scan.

Conclusion

Evidence regarding etiology and management of RT is limited. We present a case of refractory RT treated with rituximab with resultant symptomatic improvement, thus providing further evidence for use of rituximab in resistant cases.

IgG4-related disease in endocrine practice

IgG4-related disease is a set of symptoms resulting from a chronic, usually multiple organ inflammatory condition which affects various organs. It consists of lymphoplasmacytic infiltrations with attendant fibrosis and deep vein thrombosis. Frequently observed tissue lesions are accompanied by elevated IgG4 levels in serum. The etiopathogenesis of the lesions is of multifactor character and the clinical manifestation of the disease is highly diverse. The diagnostic process is based on the patient's medical history, clinical examination and additional tests, including a histopathological examination of the infected organ's tissues. Almost forty different locations of the disease have been reported, including disorders of the endocrine system. IgG4-related endocrinopathies are quite rare. However, it is likely that the diagnosis is under-reported due to lack of awareness of this clinical entity. Despite increasing interest in the subject, there are not enough reliable studies evaluating the link between IgG4-RD and endocrine disorders.

Riedel's thyroiditis: clinical presentation, treatment and outcomes

BACKGROUND

Riedel´s thyroiditis (RT) is a rare inflammatory disease of the thyroid gland, causing compression and fibrosis of adjacent tissues. Typically the goiter is hard and firm. Hoarseness, dyspnea, and dysphagia may be present.

METHODS

We retrospectively reviewed all patients known by us with RT in addition to all patients with appropriate ICD-10 codes evaluated at the Karolinska University Hospital 2003-2015. Clinical, biochemical, and histological data of patients with RT were recorded in detail. Histological preparations were re-examined when available.

RESULTS

RT was diagnosed in six patients. Five were females and the median age at first presentation was 50 years (25-81 years). Median follow-up time was 3.75 years (1-22 years). At diagnosis five had hypothyroidism. Four had extrathyroidal manifestations, and one of these had also distant fibrosis. One patient had a clear IgG4/IgG ratio over 40%. One patient was treated with tracheostomy, one with isthmectomy and one with total thyroidectomy. Four had been treated with glucocorticoids, four with tamoxifen, and two with both drugs. One had also been treated with mycophenolate mofetil combined with Rituximab. At the end of follow-up four was doing fine, one had recurrent episodes of inflammation and one had died of possible complications to RT.

CONCLUSION

It is important to recognize RT and give adequate treatment. Steroids are still the mainstay of therapy but other medications against fibrosclerosis can be considered. Wakefulness of other fibrosing manifestations is essential. Immunohistochemistry can show whether IgG-4 plasma cells are increased which could lead to fibrosis in other organs.

Rituximab: a novel treatment for refractory Riedel's thyroiditis

This case report reviews the rare condition of Riedel's thyroiditis via a patient case. The report highlights the difficulties that one may encounter when managing such a case in regards to patient symptoms, side effects of medications and the relapsing nature of the condition. The case report also highlights novel treatment in the treatment of Riedel's thyroiditis, rituximab, how this works and the resolution of symptoms that we have achieved with our patient on this treatment.

Learning points

Riedel's thyroiditis is characterised by chronic inflammation, which causes dense fibrosis in the thyroid gland.Riedel's thyroiditis can present with neck pain, dysphagia and dyspnoea with a firm, non-tender mass found on examination.Riedel's thyroiditis is part of the IgG4-related systemic disorders.Rituximab is a monoclonal antibody that works against the protein CD20.

Immunoglobulin G4-Related Thyroid Diseases

Immunoglobulin G4-related disease (IgG4-RD) is a new disease category involving many organ systems, including the endocrine system in general and the thyroid in particular. Since an initial association was made between hypothyroidism and autoimmune (IgG4-related) pancreatitis, more forms of IgG4-related thyroid disease (IgG4-RTD) have been recognized. Four subcategories of IgG4-RTD have so far been identified: Riedel thyroiditis (RT), fibrosing variant of Hashimoto thyroiditis (FVHT), IgG4-related Hashimoto thyroiditis, and Graves disease with elevated IgG4 levels. Although a male predominance is seen for IgG4-RD in general, RT and FVHT have a female preponderance. The pathogenesis of IgG4-RD is not completely understood; however, genetic factors, antigen-antibody reactions, and an allergic phenomenon have been described. Diagnosis of IgG4-RD requires a combination of clinical features, serological evidence, and histological features. Histology is the mainstay of diagnosis, with IgG4 immunostaining. Although serum IgG4 levels are usually elevated in IgG4-RD, raised serum IgG4 is neither necessary nor adequate for diagnosis. Imaging supports the diagnosis and is a useful tool in disease monitoring. Management of IgG4-RTD is both medical and surgical. Steroids are the first-line treatment and may produce a swift response. Tamoxifen and rituximab are second-line agents used in steroid-resistant patients. Surgical debulking is carried out in RT solely as a procedure to relieve obstruction. Other endocrine associations described with IgG4-RD are hypophysitis and Hashimoto encephalopathy. IgG4-RTD is an uncommon disease entity, and prompt diagnosis and treatment can improve outcomes.

Riedel's Thyroiditis Mimicking as Anaplastic Thyroid Carcinoma: Unusual Presentation

Riedel's thyroiditis is a rare inflammatory process which not only involves thyroid gland but also the surrounding vital structures. It may also be associated with various forms of systemic fibrotic disorders. The exact etiology is not known, but currently most favored view is that of a localized form of systemic fibrotic process. We report a case of Riedel's thyroiditis in a patient, highlighting a rare presentation mimicking anaplastic carcinoma. Clinical awareness of such presentation of Riedel's thyroiditis would enhance our ability to make this diagnosis promptly. Apart from avoiding or minimizing aggressive surgical intervention, awareness of such clinical entity may avoid complications and hence morbidity. Our case also highlights the difficulty in histological diagnosis which is very important to rule out malignancy and avoiding any major surgical intervention fraught with complications. Good response to high dose steroids as seen in our case is the current accepted treatment of choice.