Subacute Thyroiditis

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Subacute Thyroiditis

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Subacute thyroiditis is a self-limited thyroid condition associated with a triphasic clinical course of hyperthyroidism, hypothyroidism, and return to normal thyroid function. Subacute thyroiditis may be responsible for 15-20% of patients presenting with thyrotoxicosis and 10% of patients presenting with hypothyroidism. Recognizing this condition is important; because it is self-limiting, no specific treatment, such as antithyroid or thyroid hormone replacement therapy, is necessary in most patients. (See Presentation, Workup, and Treatment.)

In general, the following three forms of subacute thyroiditis are recognized:

Subacute granulomatous thyroiditis – Also known as subacute painful or de Quervain thyroiditis (see the image below)^[1]

Subacute lymphocytic thyroiditis – Also known as subacute painless thyroiditis

Subacute postpartum thyroiditis

Although the etiology appears to be different for the three subtypes, the clinical courses are the same. High thyroid hormone levels result from the destruction of the thyroid follicle and the release of preformed thyroid hormone into the circulation, with thyrotoxicosis consequently developing. (The high thyroid hormone levels are not a function of new thyroid hormone synthesis and secretion.) This phase lasts 4-10 weeks. (See Pathophysiology and Etiology.)

The thyrotoxic phase undergoes spontaneous remission in 4-8 weeks. At this time, the thyroid is depleted of colloid and is now incapable of producing thyroid hormone, resulting in hypothyroidism. The hypothyroid phase may last up to 2 months. Often, the hypothyroidism is mild, and no thyroid hormone therapy is required unless the patient has signs or symptoms of hypothyroidism. As the follicles regenerate, the euthyroid state is restored. Depending on the etiology, 90-95% of patients return to normal thyroid function. (See Prognosis.)

Subacute granulomatous thyroiditis

Subacute granulomatous thyroiditis is the most common cause of a painful thyroid gland. This condition is also known as painful subacute thyroiditis, de Quervain thyroiditis, and migratory thyroiditis (this last because the pain can shift to different locations in the thyroid). It is a transient inflammation of the thyroid, the clinical course of which is highly variable. Most patients have pain in the region of the thyroid, which is usually diffusely tender, and some have systemic symptoms. Thyrotoxicosis often occurs initially, sometimes followed by transient hypothyroidism. Complete recovery in weeks to months is characteristic. Some patients will clinically note only one phase—thyrotoxic or hypothyroid—while others will note both. (See the Table, below.)

Table. Characteristic Course of Subacute Granulomatous Thyroiditis (Open Table in a new window)

Parameters

Stage 1

Stage 2

Stage 3

Stage 4

Symptoms

Thyrotoxicosis

Euthyroid

Hypothyroid

Euthyroid (recovery)

T4, T3

Elevated

Normal

Decreased

Normal

TSH

Decreased

Normal

Elevated

Normal

T4 = thyroxine

T3 = triiodothyronine

TSH = thyroid-stimulating hormone

For patient education information, see the Thyroid and Metabolism Center, as well as Thyroid Problems.

Destruction of follicular epithelium and loss of follicular integrity are the primary events in the pathophysiology of subacute granulomatous thyroiditis. Thyroglobulin (TG), thyroid hormones, and other iodinated compounds are released into the blood, often in quantities sufficient to elevate the serum thyroxine (T4) and triiodothyronine (T3) concentrations and suppress thyroid-stimulating hormone (TSH) secretion. This state lasts until the stores of TG are exhausted or until healing occurs. Thyroidal iodine uptake and new hormone synthesis temporarily ceases because of the low level of TSH.

As inflammation subsides, the thyroid follicles regenerate and thyroid hormone synthesis and secretion resume. In some patients, several months are required for thyroid hormone synthesis to return to a normal rate; during that period, clinical hypothyroidism may be evident.

The hypermetabolic effect of thyrotoxicosis is the same, regardless of cause. Thyrotoxicosis affects every organ system, because thyroid hormones made in the thyroid travel via the circulation to reach every cell in the body. Thyroid hormone is necessary for normal growth and development, and it regulates cellular metabolism.

Excess thyroid hormone causes an increase in metabolic rate that is associated with increased total body heat production, increased cardiovascular activity (eg, increased heart contractility, heart rate, vasodilation) to remove heat to the periphery and remove metabolic wastes, and perspiration to cool the body.

The major symptoms of thyrotoxicosis include palpitations, nervousness, sweating, hyperdefecation, and heat intolerance. Women often note a reduction in menstrual flow, or oligomenorrhea. Common signs of thyrotoxicosis include the following:

Weight loss despite increased appetite

Lid lag and stare

Sinus tachycardia

Atrial fibrillation or high-output failure (in elderly persons)

Fine tremor

Muscle weakness

Synergism occurs between thyrotoxicosis and the adrenergic system, with increases in nervousness, stare, tremor, and tachycardia.

The manifestations of thyrotoxicosis vary among patients. Younger patients tend to exhibit more sympathetic activations (eg, anxiety, hyperactivity, tremor), while older patients have more cardiovascular symptoms (eg, dyspnea, atrial fibrillation) and unexplained weight loss. The clinical manifestation of thyrotoxicosis does not always correlate with the extent of the biochemical abnormality.

A retrospective study by Gül et al suggested that papillary thyroid carcinoma is more prevalent in subacute thyroiditis than has previously been indicated. While one report found the rate of papillary thyroid carcinoma to be 0.4% in subacute thyroiditis, and another found no cases of such carcinomas in patients with the condition, the prevalence in this study was 4.4% (6 out of 137 patients).^[2]

The causes of subacute thyroiditis, other than those of subacute granulomatous thyroiditis, are not entirely clear.

The most accepted etiology for this condition is a viral illness.^[3]Viral particles have never been identified within the thyroid, but episodes often follow upper respiratory infections and are associated with falling postconvalescent viral titers of various viruses, including influenza, adenovirus, mumps, and coxsackievirus. The occurrence of subacute granulomatous thyroiditis in the course of novel H1N1 influenza infection has been reported from Greece.^[4]

De Quervain thyroiditis is not associated with autoimmune thyroiditis. The transient presence of autoantibodies (eg, inhibitory immunoglobulins that bind to TSH, antibodies that block thyroid stimulation, thyroid antimicrosomal antibodies, thyroglobulin [TG] antibodies) has been noted in the acute phase of the disease, but this has been attributed to a virally induced autoimmune response and has not been implicated in the pathologic process. (Viral inclusion bodies are not observed in thyroid tissue in subacute granulomatous thyroiditis.)

It is unclear, however, whether the destructive thyroiditis in De Quervain patients is caused by direct viral infection of the gland or by the host’s response to the viral infection.

In contrast to autoimmune thyroid disease, the immune response in subacute granulomatous thyroiditis is not self-perpetuating; therefore, the process is limited.

HLA-B35

A genetic predisposition to the development subacute granulomatous thyroiditis clearly exists; risk for developing the disease in patients with human leukocyte antigen (HLA)–Bw35 is 6-fold that of the general population.^[5]In one study, as many as 72% of patients with subacute thyroiditis manifested HLA-Bw35.

A proposed etiologic mechanism suggests that the disease results from a viral infection that provides an antigen, one that is either viral or that results from virus-induced host tissue damage, that uniquely binds to HLA-B35 molecules on macrophages. The antigen–HLA-B35 complex activates cytotoxic T lymphocytes that damage thyroid follicular cells, because these cells have some structural similarity to the infection-related antigen.

In Japanese patients, an association seems to exist between subacute granular thyroiditis and HLA-B67. In a study, 87% of Japanese patients with subacute thyroiditis had either HLA-B35 or HLA-B67. Research indicates that HLA-B67 is associated with a greater risk of developing a hypothyroid phase than is HLA-Bw35.

Growth factors

The role of growth factors in the development of subacute thyroiditis has received some attention. In the granulomatous stage of subacute thyroiditis, growth factor–rich monocytes and/or macrophages infiltrating follicular lumina are thought to trigger the granulomatous reaction, with this reaction probably being mediated by vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), platelet-derived growth factor (PDGF), and transforming growth factor beta 1 (TGF-β1) produced by the stromal cells.

In the regenerative phase, endothelial growth factor (EGF) mediates follicular regeneration through its mitogenic effect on thyrocytes, along with cofactors. In addition, the decreased expression of TGF-β1, a fibrogenic factor, contributes to thyroid tissue repair. VEGF and bFGF may be responsible for angiogenesis in both stages.

This condition most likely is autoimmune in nature. Patients develop an autoimmune goiter and permanent hypothyroidism more often than they do with subacute granulomatous thyroiditis. An HLA association may be present, suggesting a genetic predisposition to subacute lymphocytic thyroiditis.

Certain drug exposures relating to excess iodine and cytokines may cause this form of silent thyroiditis. These drugs include amiodarone (iodine-rich), interferon alfa, interleukin 2, and lithium. Cases of thyroiditis resulting from these drugs are typically treated in a similar way.

Amiodarone

Amiodarone has multiple established effects on thyroid function. One of the 2 types of amiodarone-induced thyrotoxicosis is a destructive subacute lymphocytic thyroiditis. This form of thyroiditis is more common in men, likely due to the higher prevalence of amiodarone therapy in men. Subacute lymphocytic thyroiditis typically occurs after more than 2 years of amiodarone therapy.^[6]

Interferon alfa

Up to 5% of patients taking interferon alfa may experience subacute lymphocytic thyroiditis. This condition is detected biochemically, after 3 months of therapy, more often than it is found clinically. Subacute lymphocytic thyroiditis in patients taking interferon alfa is associated with an increased antithyroid antibody concentration.

Interleukin 2

Although case reports exist that interleukin 2 is associated with subacute lymphocytic thyroiditis, its causative role is less established than that of interferon alfa.

Lithium

Lithium is a well-known cause of either subclinical or clinical hypothyroidism, as well as of goiter. Because of lithium’s ability to inhibit the release of thyroid hormone, it has been used as a treatment for thyrotoxicosis. However, reports exist of lithium-associated thyrotoxicosis due to a subacute lymphocytic thyroiditis, with the classic picture of hyperthyroidism, absent neck tenderness, and low radioactive iodine uptake.

Subacute lymphocytic thyroiditis can occur during lithium administration, as well as up to 5 months following discontinuation of lithium therapy. Increased thyroid antibodies in lithium users and a direct toxic effect of lithium have been proposed as possible mechanisms.

This condition is likely autoimmune in nature.^[7]Patients develop an autoimmune goiter and permanent hypothyroidism more often than they do with subacute granulomatous thyroiditis. In iodine-sufficient countries, such as the United States, postpartum thyroiditis occurs in approximately 5-8% of pregnant women. In Japan where the diet is rich in iodine, nearly 20% of pregnancies are associated with this condition.

Patients with positive test results for thyroid autoantibodies either before their pregnancy or during the third trimester are at much higher risk of developing postpartum thyroiditis.

Cigarette smoking is also associated with an increased incidence of postpartum thyroiditis. Once patients have an episode of subacute postpartum thyroiditis, they are likely to have additional episodes following each pregnancy.

Other causes of subacute thyroiditis, or at least conditions that have been associated with the disease, include the following:

Radioiodine therapy for Graves disease can result in transient thyroidal inflammation, causing thyroiditis

Subacute thyroiditis also has been described following external radiation to the neck

Subacute thyroiditis has presented as a paraneoplastic manifestation of renal cell carcinoma

An association between subacute thyroiditis and febrile neutrophilic dermatoses (Sweet syndrome) has been reported

Concurrence of giant cell arteritis has been reported in patients with classic de Quervain thyroiditis

Subacute thyroiditis has been described after bone marrow transplantation for chronic granulocytic leukemia

Subacute granulomatous thyroiditis occurs in less than 5% of all patients with thyroid pathology, although estimates indicate that together, the 3 forms of subacute thyroiditis account for 20-25% of thyrotoxicosis cases. De Quervain thyroiditis tends to have a seasonal and geographic distribution and is most common during the summer and fall. It tends to follow viral epidemics.

A systematic review of all cases of subacute granulomatous thyroiditis diagnosed between 1960 and 1997 in Olmsted County, Minnesota, revealed an age- and sex-adjusted annual incidence of 4.9 cases per 100,000 population.^[8]

Postpartum thyroiditis has an incidence of 5.4% in the general population. An isolated hypothyroid phase occurs in 48% of women with the condition, while isolated thyrotoxicosis is found in 30% patients, and a presentation of hyperthyroidism followed by hypothyroidism is seen in 22% of them.^[9]

As is the case for most thyroid diseases, de Quervain thyroiditis appears more frequently in females, with a female-to-male ratio of 3-5:1. Subacute lymphocytic thyroiditis occurs twice as often in women as it does in men.

Postpartum thyroiditis occurs 1-6 months after giving birth. If a woman has postpartum thyroiditis with one baby, all other pregnancies are likely to be associated with this condition.

Subacute lymphocytic thyroiditis can occur in any age group, while postpartum thyroiditis occurs in women of childbearing age.

Subacute granulomatous thyroiditis usually occurs in adults (ie, aged 20-60 y), with the incidence peaking in the fourth and fifth decades of life. It is rare in the first decade and relatively infrequent in people older than 50 years, although it has been reported in extreme age groups.^[10]Occurrence during pregnancy has been reported as well.^[11]

The prognosis is excellent in 90-95% of patients who experience subacute thyroiditis. Approximately 5-10% of patients have permanent thyroid dysfunction, usually hypothyroidism, after an episode of subacute thyroiditis. Permanent goiter and thyroid dysfunction occur most frequently after postpartum thyroiditis.

Thyrotoxicosis from subacute thyroiditis is brief, usually lasting no longer than 6-8 weeks. Patients can be extremely thyrotoxic during this period and can appear extremely ill, but concerns regarding left ventricular hypertrophy and osteoporosis are not as great as those associated with conditions of permanent hyperthyroidism. However, sudden-onset thyrotoxicosis and severe thyrotoxicosis can be associated with atrial arrhythmia and congestive heart failure (CHF).

This condition generally resolves completely in more than 90-95% of patients. No special thyroidal follow-up is needed. Morbidity is caused during the initial phase by pain, which usually prompts the patient to consult a physician. Hyperthyroidism, usually a mild, transient form, occurs in approximately 50% of patients with subacute granulomatous thyroiditis; in up to half of all patients, hypothyroidism may later develop.

Acute complications

When acute complications do occur, they can include the following:

Severe hyperthyroidism – May be observed during the inflammatory phase

Severe anterior neck pain over the thyroid – Usual treatment is nonsteroidal therapy, but emerging studies suggest that prednisolone 15 mg/day with a taper of 5 mg every 2 weeks is safe and effective to quickly reduce pain; in a study of prednisolone use by Kubota et al, most patients had resolution of symptoms by 6-8 weeks, although the longest period of therapy was 40 weeks^[12]

Multiple system organ failure – May complicate the course of the disease in exceptionally rare cases

Pancreatitis or splenomegaly – Associated with de Quervain thyroiditis in case reports only

Vocal cord paralysis – Occurs occasionally in cases with severe thyroid gland inflammation

Cerebral venous thrombosis – has been reported in some cases; in one case, the patient was a heterozygous carrier for the G20210A mutation of the prothrombin gene, which predisposed her to this complication

Long-term complications

Permanent hypothyroidism is the most frequent long-term complication of de Quervain thyroiditis. It is observed in less than 5-10% of the patients and requires thyroid replacement therapy.

Disease recurrence has been documented in occasional cases (up to 20% of cases in some series). Recurrence is more frequent in the first year but has been reported even 30 years after the initial diagnosis. The risk of recurrence cannot be correlated with initial thyroid function, inflammatory syndrome, or ultrasonographic aspect (ie, thyroid volume, echogenicity).

Occasionally, patients have recurrent episodes of painless thyrotoxicosis.^[13]No treatment exists to prevent the recurrences except subtotal thyroidectomy. However, this condition generally resolves completely in more than 90-95% of patients. Patients with goiters or permanent thyroid dysfunction should be monitored with a thyroid examination and thyroid function tests every 6 months.

Usually, repeat episodes occur after each pregnancy; no known treatment exists to prevent these. Patients may have a residual goiter and thyroid hypofunction after postpartum thyroiditis, because this condition is associated with chronic autoimmune thyroiditis. Patients should be observed routinely for goiter enlargement and thyroid hypofunction every 6-12 months.

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Parameters

Stage 1

Stage 2

Stage 3

Stage 4

Symptoms

Thyrotoxicosis

Euthyroid

Hypothyroid

Euthyroid (recovery)

T4, T3

Elevated

Normal

Decreased

Normal

TSH

Decreased

Normal

Elevated

Normal

T4 = thyroxine

T3 = triiodothyronine

TSH = thyroid-stimulating hormone

Stephanie L Lee, MD, PhD Associate Professor, Department of Medicine, Boston University School of Medicine; Director of Thyroid Health Center, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center; Fellow, Association of Clinical Endocrinology

Stephanie L Lee, MD, PhD is a member of the following medical societies: American College of Endocrinology, American Thyroid Association, Endocrine Society