Painful Hashimoto's thyroiditis

The Old and the New in Subacute Thyroiditis: An Integrative Review

Subacute thyroiditis (SAT) is the most common cause of neck pain and thyrotoxicosis. Although this disease was recognized already by the end of the 18th century, new concepts regarding pathogenesis have emerged in recent years. Moreover, in the last two years, literature on SAT has increased significantly due to articles describing the possible connection with coronavirus disease 2019 (COVID-19). This integrative review depicts old and new concepts of this disease, proposing a detailed overview of pathogenesis, a practical approach to diagnosis and treatment, and a thorough description of the latest discoveries regarding the association of SAT with COVID-19.

Local symptoms of Hashimoto's thyroiditis: A systematic review

OBJECTIVE

Hashimoto's thyroiditis (HT) is the most common type of thyroid disease and can cause many different manifestations. The local symptoms of HT are an under-studied area of research. Therefore, the purpose of this study was to investigate the local symptoms of HT and their prevalence.

METHODS

A systematic review was performed to find articles in PubMed that discuss the local symptoms of HT. Relevant vocabulary terms and key terms included: autoimmune thyroid disease (AITD), hyperthyroidism, hypothyroidism, neck, throat, pharynx, airway, esophagus, breathe, swallow, globus, sleep apnea, symptoms, and quality of life. Two investigators independently screened the eligible studies.

RESULTS

A total of 54 articles fulfilled the inclusion criteria. Of these, 25 were clinical studies, 24 were case reports, and five were reviews. These clinical studies and case reports included a total of 2660 HT patients. There were eight local symptoms related to HT: neck pain (0.02%~16%), voice changes (7%~30%), throat discomfort (20%~43.7%), shortness of breath (28%~50%), dysphagia (29%), goiter-related symptoms (69.44%), sleep apnea, and generally defined compressive symptoms. Due to the use of different outcome measures among all the studies, a meta-analysis of the data could not be performed.

CONCLUSION

Goiter symptoms, which are an item on the ThyPRO scales, are the most frequent local symptoms in HT patients, and include neck pain, voice changes, throat discomfort, and dysphagia. These local symptoms should be identified in the clinic and included in the early diagnosis and management of HT, as well as evaluated further to understand their relevance in the pathogenesis of HT.

Role of Total Thyroidectomy in Painful (Symptomatic) Hashimoto's Thyroiditis: Descriptive Study

Hakura Hashimoto described Hashimoto's Thyroiditis (HT) in 1912. In HT, there occurs formation of antibodies against the self (thyroid), which causes enlargement of the thyroid gland as a whole and decreased thyroid hormone levels. Most of the patients with HT are given medical line of management (hypo/hyperthyroidism). The indications for surgical line of management for HT are due to pressure symptoms over the trachea and oesophagus, pain in the thyroid gland and for chance of malignancy. Surgical treatment gives complete relief from pain and pressure symptoms and also prevents the risk of malignancy. To evaluate the outcome and complications of total thyroidectomy in painful (symptomatic) Hashimoto's thyroiditis. It was a Hospital based Descriptive study conducted in tertiary care teaching hospital by ENT Department, Sri Manakula Vinayagar Medical College and Hospital, Pondicherry from Nov 2017 to May 2019. Sample size was 30. All patients with symptomatic (painful) HT was given trail of medical therapy (steroids and NSAIDS), following repeated attempts of failed medical therapy, surgical management (total thyroidectomy) was preferred. Visual Analog Scale (VAS) was used to assess the pain grading pre and post operatively. MS Excel and SPSS trial version 20 software was used to analyze the data. The Wilcoxan Signed Ranked test was used as test of significance to identify the difference between ordinal variables. In this study, all the 30 patients had pain as the predominant symptom. Visual Analog Scale was used to grade the pain in all the patients preoperatively and 2 weeks postoperatively. All the patients had significant reduction in the pain following total thyroidectomy, when compared to pre-operative VAS grading. Total thyroidectomy is the technique of choice in surgical treatment of symptomatic Hashimoto's thyroiditis (pain, tenderness and pressure symptoms) which warrants a radical and definitive control of the disease, without any risk of relapse and without the side effects of medical management. Moreover in longstanding cases of HT, the risk of malignant transformation is prevented due to total thyroidectomy. In experienced hands it assures total relief of compressive and painful symptoms and low incidence of/nil major complications.

A Rare Case of Painful Goiter Secondary to Pediatric Hashimoto's Thyroiditis Requiring Thyroidectomy for Pain Control

Hashimoto's thyroiditis (HT) usually presents as painless thyroid swelling. Painful pediatric HT is a rare condition with limited literature on pain management. We report a 15-year-old female who presented with 4 weeks history of fatigue, malaise and progressive, painful midline thyroid swelling. There was no difficulty in swallowing, no fever or recent upper respiratory infection symptoms. Exam was remarkable for diffusely enlarged, very tender, and non-nodular thyroid. Thyroid function tests, C-reactive protein, and complete blood count were normal. Ultrasound revealed diffusely enlarged non-nodular, non-cystic gland with mild increased vascularity. Diagnosis of HT was confirmed by biopsy and thyroid antibodies. Over a 6 week period, pain management with ibuprofen, levothyroxine, corticosteroid, gabapentin and amitriptyline was unsuccessful. Ultimately, total thyroidectomy resulted in complete resolution of thyroid pain. We can conclude that thyroidectomy may be considered for the rare case of painful HT in children.

Should neck pain in a patient with Hashimoto's thyroiditis be underestimated? A case and review of the literature

Hashimoto's Thyroiditis (HT) is an autoimmune disease and the most frequent cause of hypothyroidism. Subacute thyroiditis (SAT) overlapping HT is a rare entity. A 69-year-old female patient with HT and multinodular goiter has been followed on levothyroxine replacement therapy for 7 years. She presented with neck pain radiating to the right ear persisting for 2 months. She was prescribed analgesics and antibiotics by other physicians during that period, which did not work. Her vital signs were stable with no tachycardia or fever. The right lobe of the thyroid gland was tender on palpation. Her TSH level was 3.94 mIU/ml, ESR 23 mm/h, CRP 3.2 mg/l, WBC 4900/μl at presentation. Thyroid ultrasonography revealed a hypoechoic area over the tender lobe. Power Doppler imaging revealed almost no blood flow in that area. She was started on methylprednisolone 32 mg/day. At day 10 of therapy, her symptoms had completely resolved. Ultrasonography repeated showed that the hypoechoic area had disappeared. Glucocorticoid dosage was tapered and stopped. Emergence of subacute thyroiditis in a case with preexisting Hashimoto's thyroiditis is a quite rare condition, but should be kept in mind along with a painful attack of HT in the differential diagnosis.

A Case of Painful Hashimoto Thyroiditis that Mimicked Subacute Thyroiditis

Hashimoto thyroiditis (HT) is an autoimmune thyroid disorder that usually presents as a diffuse, nontender goiter, whereas subacute thyroiditis (SAT) is an uncommon disease that is characterized by tender thyroid enlargement, transient thyrotoxicosis, and an elevated erythrocyte sedimentation rate (ESR). Very rarely, patients with HT can present with painful, tender goiter or fever, a mimic of SAT. We report a case of painful HT in a 68-year-old woman who presented with pain and tenderness in a chronic goiter. Her ESR was definitely elevated and her thyroid laboratory tests suggested subclinical hypothyroidism of autoimmune origin. ^99mTc pertechnetate uptake was markedly decreased. Fine needle aspiration biopsy revealed reactive and polymorphous lymphoid cells and occasional epithelial cells with Hürthle cell changes. Her clinical symptoms showed a dramatic response to glucocorticoid treatment. She became hypothyroid finally and is now on levothyroxine therapy.

Extent of hypoechogenic area in the thyroid is related with thyroid dysfunction after subacute thyroiditis

OBJECTIVE

To gain an insight into risk factors for hypothyroidism after subacute thyroiditis (SAT), we examined the correlation between initial laboratory and ultrasonographic findings and sequential thyroid dysfunction among treatment modalities.

PATIENTS

We reviewed retrospectively the medical records of 252 patients (26 men and 226 women) with SAT who consecutively visited our thyroid clinic at Kuma Hospital for at least 6 months from 1996 through 2004.

RESULTS

Throughout the course, 135 patients (53.6%) developed transient or permanent hypothyroidism. Levels of TSH were most often elevated (greater than 5 IU/ml) 2 months after SAT onset regardless of treatment, and 97.0% of patients who showed transient or permanent hypothyroidism clustered within 6 months from onset. During follow-up, patients treated with prednisone (PSL) were more likely to have normal thyroid function than patients not treated or those receiving anti-inflammatory drug therapy. In patients who developed hypothyroidism with PSL treatment or without treatment, the rates of bilateral hypoechogenic areas (HEA) were 6-fold higher than those of unilateral HEA. Moreover, permanent hypothyroidism occurred in 5.9% of patients, and all patients with permanent hypothyroidism presented initially with bilateral HEA and had consequently small thyroid size with or without abnormal autoimmunity.

CONCLUSIONS

The rates of thyroid dysfunction after SAT were significantly lower in patients receiving PSL. Extent of HEA in the thyroid, but not laboratory findings, may be a possible marker for developing thyroid dysfunction after SAT.