Richard M. Jordan, MD, Regional Dean,

heehawultraMécanique

22 févr. 2014 (il y a 3 années et 7 mois)

60 vue(s)

Richard M. Jordan, MD, Regional Dean,

School of Medicine

Texas Tech Health Sciences Center at Amarillo


Subacute

Thyroiditis



(
DeQuervain’s

Thyroiditis,
Granulomatous Thyroiditis, Giant Cell Thyroiditis
) A Post Viral
Syndrome with Thyroid Pain



Painless
Thyroiditis



(
Subacute

Lymphocytic Thyroiditis, Silent
Thyroiditis
)
Probable Variant of Autoimmune (Hashimoto’s)
Thyroiditis. Excludes Women with Painless Thyroiditis
Occurring within 1 Year of Delivery.



Postpartum Thyroiditis


Probable Variant of Autoimmune
Thyroiditis, Similar to Painless Thyroiditis But Occurring
Postpartum.



Drug Induced Thyroiditis



Amiodarone
, Lithium, Interleukin
-
2,
Denileukin

Diffitoxin
,



Radiation Induced


Occurs Post Radioactive Iodine Treatment





Preceding Viral Infection with Sore Throat, Fever,
Myalgias


May occur in Clusters


Damage to the Thyroid Follicles with Release of Thyroid
Hormone


Goiter with Neck Pain


Can Radiate to Jaw or Ear


Elevated Sedimentation Rate, Elevated Thyroglubulin


Triphasic Course


Hyperthyroidism to Hypothyroidism
to Euthyroidism


Permanent Hypothyroidism may develop in 10
-
15%

Acute viral infection

Presents with viral prodrome, thyroid tenderness, and hyperthyroid symptoms




Pathology


Disruption and Collapse of the Thyroid Follicles


Infiltration with Inflammatory Cells


Neutrophils


Lymphocytes


Histiocytes


Multinucleated “Giant” Cell
s




Suppressed Radioactive Iodine Update in
Hyperthyroid Phase



Sedimentation Rate approximately > 50 mm/h



Treatment


NSAIDS or Steroids, Beta Blocker



in Hyperthyroid Phase



Probable Variant of Autoimmune (Hashimoto’s) Thyroiditis



Sedimentation Rate is Normal or Slightly Elevated



May have Elevated
Antithyroid

Peroxidase (TPO) Levels



Thyroglobulin Levels Are Elevated



Pathology
-
Lymphocytic Infiltration which Persists in Recovery



Clinical Course
-
Similar to
Subacute

Thyroiditis;
Hyperthyroidism
(Usually Mild) Followed by Recovery or Hypothyroidism



Permanent Hypothyroidism Develops in 20
-
50%



Hyperthyroidism
-
Mild may require no therapy. If
Symptomatic give beta
-
bockers



Hypothyroidism
-
If Symptomatic or TSH>10mU/L
give thyroid hormone replacement



Monitor for the development of hypothyroidism


Painless Thyroiditis vs Factitious Thyrotoxicosis



Painless Thyroiditis

Factitious Thyrotoxicosis




Goiter Small Usually Absent


Thyroglobulin Elevated Undetectable


Occupation Not Specific Access to Thyroid Hormone




Variant of Autoimmune (Hashimoto’s)
Thyroiditis


Follows Delivery


Autoimmune Damage to the Follicles with
Release of Thyroid Hormone


Painless with Small Goiter


Variable
Triphasic

Course


Suppressed Radio Iodine Uptake


Sedimentation Rate
-
<30 mm/h



Prevalence


7 to 10 Percent of All Pregnancies


Most Common Variety of Hyperthyroidism Associated with


Pregnancy


Risk Factors


Elevated TPO Antibodies


50% Will Develop Postpartum Thyroiditis


Type I Diabetes Mellitus


25% Will Develop Postpartum Thyroiditis


Postpartum Thyroiditis with Prior Pregnancy




Pathology


Lymphocytic Infiltration, Disruption of Follicles, Germinal Centers


Variant of Hashimoto’s Thyroiditis



Course


25%
-

Classic
Triphasic

Response


35%
-

Only Hyperthyroidism


40%
-

Only
Hypothyroidism



Persistent Hypothyroidism


After 4 years 25 to 50% have hypothyroidism or
Goiter or Both


56
% with a Hypothyroid Phase Develop Permanent
Hypothyroidism



Patients with
Postpartum
Hypothyroidism


Require
Yearly Screening






Postpartum


Graves’ Disease


Goiter Small
, No Bruit



Small
to Large, Bruit Present


Course


Mild
, Short Duration


Mild
to Severe, Long
Duration


Opthalmopathy


Absent





May
Be Present


Iodine Uptake


Low




Normal
to Elevated


TSI



Absent




Present



*
TSI
-
Thyroid Stimulating Immunoglobulin








Hyperthyroid Phase


Beta Blocker



Hypothyroid Phase


Thyroid
Hormone



Selenium During Pregnancy in TPO
Positive Patients


Hypothyroidism
-
Iodine Induced


Overt Hypothyroidism


5%


Subclinical Hypothyroidism


25%



Hyperthyroidism


3
-
5%


Type 1
-

(
Jod
-
Basedow
, Iodine
-
Induced)
,


Underlying MNG, Graves’ Disease


Type 2


Chemical Destructive Thyroiditis



I
123

Uptake
is Usually Suppressed in Both Types


Of the
I
123

Detectable Type 1 is Likely


Presence of the Diffuse Goiter, MNG or TSI
suggests Type 1


Color Flow Doppler


Increased Flow (increased vascularity)


Type 1


Decreased Flow (absent vascularity)


Type
2


Interpretation Difficult



Type 1


Thionamides

(
Methimazole

or PTU)




Radioactive Iodine (If I123 Uptake is Detectable)


Thyroidectomy (Failure of Other Options)


Type
2




Prednisone 40 mg daily for 6 to 12 weeks


Uncertain If Type 1 or Type 2
(Usually the Case)


Start Prednisone 40 mg and
Methimazole

40 M
g daily


Measure
Thyroid Function in 6 weeks


If Improved Taper
Methimazole


If Unimproved Taper Prednisone



Type 1


Thionamides

(
Methimazole

or PTU)



Radioactive Iodine (If I
123

Uptake is Detectable)



Thyroidectomy (Failure of other options)


Type 2


Prednisone 40 mg daily for 6 to 12 weeks




Uncertain if Type 1 or Type 2
(Usually the Case)


Start
Prenisone

40 mg and
Methimazole

40 Mg daily


Measure Thyroid Function in 6 weeks


If Improved Taper
Methimazole


If Unimproved Taper Prednisone






Interferon Alfa
-
10% Hypothyroidism,
Painless Thyroiditis, or Graves Disease


Interleukin 2% Painless Thyroiditis


Lithium
-
Painless Thyroiditis But
Hypothyroidism more common


Denileukin

Difitox