• Clinical science

Hashimoto's thyroiditis (Chronic autoimmune thyroiditis)

Abstract

Hashimoto's disease is the most common form of autoimmune thyroiditis and the leading cause of hypothyroidism in the United States. Although currently thought to be due to chronic autoimmune-mediated lymphocytic inflammation of the thyroid tissue, the exact pathophysiology remains unclear. Patients are initially asymptomatic or hyperthyroid, progressing to hypothyroidism as the organ parenchyma is destroyed. Diagnosis is based on a combination of specific antibodies, thyroid function tests, and sonography of the thyroid. Treatment involves lifelong hormone replacement therapy with levothyroxine (L-thyroxine).

Epidemiology

  • Prevalence: : 5% in the US; Hashimoto's disease is the most common form of thyroiditis and the most frequent cause of hypothyroidism in the US.
  • Sex: > (7:1)
  • Age of onset: occurs in all age groups; , particularly in women aged 30–50 years

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

Pathophysiology

  • Unknown etiology: Genetic and environmental factors likely play a role.
  • Immunological mechanisms
  • Associations: often associated with Non-Hodgkin's lymphoma or autoimmune diseases
  • Certain factors may precipitate Hashimoto's thyroiditis (e.g., thyroid injury, stress or iodine), however, most remain hypothetical.

References:[1][4][5]

Clinical features

References:[3][6][2][1]

Subtypes and variants

Diagnostics

Anti-TPO antibodies are also elevated in 70% of patients with Graves disease!

References:[1][3][7][6][8]

Pathology

References:[9][1]

Differential diagnoses

References:[2][3][10][6]

The differential diagnoses listed here are not exhaustive.

Treatment

  • Levothyroxine (T4) replacement therapy
    • Life-long oral administration of L-thyroxine (T4)
    • Commence at a lower and more slow-acting dose with increasing severity of hypothyroidism because of the risk of cardiac side effects.
  • Life-long monitoring
    • Due to decline in T4 production with increasing age
    • Life-long monitoring of thyroid parameters (primarily TSH) is necessary to adjust treatment accordingly and avoid hyperthyroidism
  • Surgery is indicated in the presence of obstructive symptoms (e.g., dysphagia), malignancy, or may be considered for cosmetic reasons

References:[3]

Complications

References:[2][3][11]

We list the most important complications. The selection is not exhaustive.

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  • 5. Wiebolt J, Achterbergh R, Den boer A, et al. Clustering of additional autoimmunity behaves differently in Hashimoto's patients compared with Graves' patients. Eur J Endocrinol. 2011; 164(5): pp. 789–794. doi: 10.1530/EJE-10-1172.
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  • 8. Baloch ZW, Livolsi VA. Fine-needle aspiration of the thyroid: today and tomorrow. Best Pract Res Clin Endocrinol Metab. 2008; 22(6): pp. 929–939. doi: 10.1016/j.beem.2008.09.011.
  • 9. Le T, Bhushan V, Sochat M, Petersen M, Micevic G, Kallianos K. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical; 2014.
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  • 11. DeGroot LJ, Akamizu T. Hashimoto's Thyroiditis. http://www.thyroidmanager.org/chapter/hashimotos-thyroiditis/. Updated December 20, 2013. Accessed January 26, 2017.
  • Herold G. Internal Medicine. Cologne, Germany: Herold G; 2014.
last updated 12/05/2018
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