J Korean Endocr Soc.  2008 Dec;23(6):438-443. 10.3803/jkes.2008.23.6.438.

A Case of Painful Hashimoto's Thyroiditis Successfully Treated with Total Thyroidectomy

• Kim HK
• Shin HJ
• Kang HC

• KMID: 1965998
• DOI: http://doi.org/10.3803/jkes.2008.23.6.438

Abstract

Painful Hashimoto's thyroiditis (HT) is a subtype of HT characterized by thyroid pain with overt elevation in inflammatory markers and thyroid autoantibodies. The differential diagnosis of painful HT with subacute granulomatous thyroiditis is often difficult because initial clinical findings are very similar. Findings that favor the diagnosis of painful HT include preceding history of chronic goiter or autoimmune thyroid diseases, a high titer of thyroid autoantibodies, and repeated painful attacks even with chronic glucocorticoid therapy. Surgery is often needed to relieve the thyroid pain.

Keyword

Hashimoto's thyroiditis; subacute thyroiditis; thyroidectomy

MeSH Terms

Autoantibodies
Diagnosis, Differential
Goiter
Thyroid Diseases
Thyroid Gland
Thyroidectomy
Thyroiditis
Thyroiditis, Subacute
Autoantibodies

Figure

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  Fig. 1 Moderate diffuse goiter is evident on initial presentation. The thyroid was exquisitely tender and very hard on palpation.

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  Fig. 2 Findings of thyroid ultrasonography (US) and computed tomography (CT) of the neck. A. Panoramic US shows diffuse goiter with hypoechic thyroid parenchyme with multiple ill-defined hypoechoic nodules (arrowheads). B. Intranodular vascularity is not visible on power doppler US. C and D. Pre- and post-contrast CT shows uneven enhancement of the thyroid with no discrete nodular lesions.

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  Fig. 3 Results of the cytologic examination. A. The smear is composed of lymphocytes and aggregate of follicular cells (Pap, ×100). B. High power view shows oxyphilic cells with abundant cytoplasm and prominent nucleoli (Pap, ×400).

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  Fig. 4 Serial follow-up of inflammatory markers and serum TSH shows the clinical response of the patient with therapy with glucocorticoids and levothyroxine.

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  Fig. 5 Histology confirms the diagnosis of Hashimoto's thyroiditis. A. The glandular architecture is destructed with dense lymphocytic infiltration and thick fibrous bundles (H&E stain, ×100). B. A typical germinal center is observed with destruction of normal follicular structure of the thyroid gland (H&E stain, ×100).

Reference

1. Dayan CM, Daniels GH. Chronic autoimmune thyroiditis. N Engl J Med. 1996. 335:99–107.

2. Pearce EN, Farwell AP, Braverman LE. Thyroiditis. N Engl J Med. 2003. 348:2646–2655.

3. Meier DA, Nagle CE. Differential diagnosis of a tender goiter. J Nucl Med. 1996. 37:1745–1747.

4. Doniach D, Hudson RV, Roitt IM. Human auto-immune thyroiditis: clinical studies. Br Med J. 1960. 1:365–373.

5. Ishihara T, Mori T, Waseda N, Ikekubo K, Akamizu T, Imura H. Pathological characteristics of acute exacerbation of Hashimoto's thyroiditis--serial changes in a patient with repeated episodes. Endocrinol Jpn. 1986. 33:701–712.

6. Zimmerman RS, Brennan MD, McConahey WM, Goellner JR, Gharib H. Hashimoto's thyroiditis. An uncommon cause of painful thyroid unresponsive to corticosteroid therapy. Ann Intern Med. 1986. 104:355–357.

7. Ishihara T, Mori T, Waseda N, Ikekubo K, Akamizu T, Imura H. Histological, clinical and laboratory findings of acute exacerbation of Hashimoto's thyroiditis-comparison with those of subacute granulomatous thyroiditis. Endocrinol Jpn. 1987. 34:831–841.

8. Leung AK, Hegde K. Hashimoto's thyroiditis simulating De Quervain's thyroiditis. J Adolesc Health Care. 1988. 9:434–435.

9. Shigemasa C, Ueta Y, Mitani Y, Taniguchi S, Urabe K, Tanaka T, Yoshida A, Mashiba H. Chronic thyroiditis with painful tender thyroid enlargement and transient thyrotoxicosis. J Clin Endocrinol Metab. 1990. 70:385–390.

10. Gourgiotis L, Al-Zubaidi N, Skarulis MC, Papanicolaou DA, Libutti SK, Alexander HR Jr, Merino MJ, Sarlis NJ. Successful outcome after surgical management in two cases of the "painful variant" of Hashimoto's thyroiditis. Endocr Pract. 2002. 8:259–265.

11. Kon YC, DeGroot LJ. Painful Hashimoto's thyroiditis as an indication for thyroidectomy: clinical characteristics and outcome in seven patients. J Clin Endocrinol Metab. 2003. 88:2667–2672.

12. Ohye H, Fukata S, Kubota S, Sasaki I, Takamura Y, Matsuzuka F, Amino N, Kuma K, Miyauchi A, Kakudo K. Successful treatment for recurrent painful Hashimoto's thyroiditis by total thyroidectomy. Thyroid. 2005. 15:340–345.

13. Kasagi K. Painful Hashimoto's thyroiditis. Intern Med. 2006. 45:351–352.

14. Thomas CG Jr, Rutledge RG. Surgical intervention in chronic (Hashimoto's) thyroiditis. Ann Surg. 1981. 193:769–776.

15. Rotondi M, Chiovato L, Romagnani S, Serio M, Romagnani P. Role of chemokines in endocrine autoimmune diseases. Endocr Rev. 2007. 28:492–520.

16. Schafers M, Sorkin L. Effect of cytokines on neuronal excitability. Neurosci Lett. 2008. 437:188–193.

17. Nishihara E, Ohye H, Amino N, Takata K, Arishima T, Kudo T, Ito M, Kubota S, Fukata S, Miyauchi A. Clinical characteristics of 852 patients with subacute thyroiditis before treatment. Intern Med. 2008. 47:725–729.

18. Yeh HC, Futterweit W, Gilbert P. Micronodulation: ultrasonographic sign of Hashimoto thyroiditis. J Ultrasound Med. 1996. 15:813–819.