Thyroiditis
Introduction
Introduction to thyroiditis Thyroiditis is a thyroid disease characterized by inflammation, including infectious and non-infectious. The clinical classification of thyroiditis is diverse, and it is divided into acute suppurative thyroiditis, subacute thyroiditis and chronic thyroiditis according to the onset of disease. Subacute thyroiditis is further divided into subacute granulomatous thyroiditis (ie, methylene inflammation) and subacute lymphocytic thyroiditis (painless thyroiditis), which is further divided into sporadic thyroiditis and postpartum thyroiditis. . Chronic thyroiditis includes chronic lymphocytic thyroiditis (Hashimoto thyroiditis) and chronic fibrotic thyroiditis. According to the classification of pathogens, it can be divided into bacterial, viral, autoimmune, post-irradiation, parasitic, tuberculosis, syphilis and AIDS infections. The most common clinical thyroiditis is chronic lymphocytic thyroiditis and subacute granulomatous thyroiditis. Painful thyroiditis is often seen clinically. The most common pathogen is autoimmune thyroiditis. basic knowledge The proportion of sickness: 0.01% Susceptible people: no special people Mode of infection: non-infectious Complications: hyperthyroidism thyroiditis swelling
Cause
Cause of thyroiditis
Chronic lymphocytic thyroiditis (30%):
The etiology of Hashimoto's thyroiditis is thought to be the outcome of the interaction between genetic factors and a variety of internal and external environmental factors.
Subacute granulomatous thyroiditis (25%):
The cause is unknown. It is generally believed that because of viral infection, upper respiratory tract infections often occur 1-3 weeks before onset.
Subacute lymphocytic thyroiditis (25%):
The cause is unknown, and studies in recent years have been shown to be associated with autoimmunity.
Chronic lymphocytic thyroiditis
It is often found that the same family has several generations of the disease. The HLA gene partially determines genetic susceptibility, but this effect is not very strong, and there are certain differences between different populations. The production of thyroid autoantibodies is related to autosomal dominant inheritance. In Europe and North America, HLA-B8, DR3 and DR5 are more common in patients with this disease, and Japanese are more common in B35. Infection and dietary iodide are two environmental factors in the pathogenesis of Hashimoto's thyroiditis. The anti-Yersinia bacterial antibody in the serum of patients with Hashimoto's thyroiditis was higher than that of the normal control, indicating that the small intestine and colon infection of Yersinia is associated with this disease. Epidemiological studies have found that iodine deficiency and the incidence of Hashimoto's thyroiditis are high, and experimental studies have shown that iodine excess can cause thyroiditis in experimental animals with genetic susceptibility. The pathogenesis of Hashimoto's thyroiditis is immunomodulatory defects, which may be the abnormal number and quality of organ-specific T lymphocytes. Both cellular and humoral immunity are involved in the damage of the thyroid gland. There is a large amount of lymphatic and plasma cell infiltration in the thyroid tissue. Various thyroid autoantibodies, such as TGA, TMA and TRAb, are found in serum and thyroid tissue. The damage to thyroid cells can be self. Antibody-to-cell lysis and antibody-dependent lymphocyte killing can also be direct killing of sensitized lymphocytes to target cells. Some people call this disease autoimmune thyroiditis. The disease is often accompanied by other autoimmune diseases such as addison, pernicious anemia, Sjogren's syndrome, SLE and so on.
Subacute granulomatous thyroiditis
At the time of onset, the antibody titer of certain viruses in the serum of patients is increased, including mumps virus, Coxsackie virus, influenza virus, echovirus (ECHO), adenovirus and the like. It is also believed that autoimmunity is involved in the onset of the disease, and HLA-B35 may determine the patient's susceptibility to the virus. In the subacute phase of some patients, there are antibodies against TSH-R and sensitized T lymphocytes against thyroid antigen.
Subacute lymphocytic thyroiditis
Relevant evidences: the most prominent pathological feature of postpartum thyroiditis is lymphocytic infiltration; TMA in patients with serum increased, sporadic 50% positive, postpartum 80% positive; this disease often combined with other autoimmune diseases, such as Sjogren's syndrome, SLE, addison, etc.; postpartum type often 6 weeks postpartum, autoimmunity is inhibited during pregnancy, post-natal immune suppression is released in the rebound phase, 50% have a family history of AITD, HLA-DR3, DR4, DR5 more common.
Prevention
Thyroiditis prevention
1. Enhance the resistance, avoid upper respiratory tract infection and pharyngitis can help prevent this disease.
2. iodine-containing drugs should be avoided for women with a history of the disease to avoid induction of hypothyroidism.
3. This disease should be avoided when pregnant women should avoid excessive iodine intake, so as to prevent iodine transmission through the placenta, resulting in fetal TSH increased and then neonatal hypothyroidism.
Complication
Thyroiditis complications Complications hyperthyroidism thyroiditis swelling
1. If you are a woman in the reproductive period, you should try to avoid pregnancy during the period of thyroiditis, so as not to affect the development of the fetus in the abdomen.
2. Thyroiditis is the main inducer of many thyroid diseases. In addition to thyroid diseases such as Hashimoto's hyperthyroidism, Hashimoto's thyroiditis, and thyroid cysts, thyroiditis may cause retrosternal goiter and swelling. Part or all of the thyroid is below the sternum.
3. As the enlarged thyroid gland compresses surrounding organs, it can cause difficulty in breathing, swallowing discomfort, and superior vena cava compression syndrome.
4. Thyroiditis is caused by bacteria, viruses, etc., which cause swelling of the thyroid gland and nodular changes. It is called thyroiditis. It can be divided into acute, subacute and chronic types. Acute is caused by bacterial infection, accompanied by redness and swelling of the thyroid gland, fever, headache, and sometimes children with high fever, increased white blood cells, difficulty breathing, hoarseness and other symptoms.
Symptom
Symptoms of thyroiditis Common symptoms Cold nodules Thyroid nodules Thyroid spasm and smooth... Thyroid heart palpitations Thyroid peroxides... Goiter after childbirth
Chronic lymphocytic thyroiditis
Hashimoto's thyroiditis is the most common type of thyroiditis. In recent years, there has been an increasing trend. More than 90% of women are women, and men are younger than women. Women are 30-50 years old and have other diseases at other ages. The disease often has a family history of thyroid disease, sometimes combined with other autoimmune diseases.
The onset of the disease is insidious and often not noticed. Sometimes it is found by chance when you check your body, or when you have symptoms of hypothyroidism. The typical clinical manifestations are: middle-aged and elderly women, slow onset, long course of disease, diffuse enlargement of thyroid, hard and tough texture, painless or tender tenderness, smooth surface, nodules, local compression and systemic symptoms are not obvious. Occasionally, pharyngeal discomfort, normal or abnormal thyroid function. From the onset to the occurrence of thyroid dysfunction, it often takes a long time, hypothyroidism can occur, hyperfunction can also occur, and sometimes subacute thyroid inflammation can occur, but eventually develop hypothyroidism. The progression of Hashimoto's disease to hypothyroidism is related to many factors. Women are 5 times more likely to be men, and progress is faster after 45 years of age. Patients with high initial thyroid antibodies and elevated initial TSH progress rapidly. A 20-year follow-up study showed that antibody-positive patients progressed to a rate of hypothyroidism of 2.6% per year, and the incidence of hypothyroidism was 33% at the end of follow-up. The rate of hypothyroidism progressed to a rate of hypothyroidism of 2.1% per year. It is 27%.
In addition to the typical clinical manifestations described above, Hashimoto's disease has some special features. There are two cases of thyrotoxicosis in Hashimoto's disease: Hashitoxitosis and Hashimoto's pseudothyroid (transient hyperthyroidism). Hashimoto's hyperthyroidism refers to Hashimoto combined with hyperthyroidism, or Hashimoto with toxic diffuse goiter. Its clinical features are hyperthermia, hyperhidrosis, hand shake, weight loss and other symptoms of hyperthyroidism, thyroid enlargement, toughness, vascular murmur, invasive exophthalmos and sputum mucus edema thyroid antibody TMA, TGA Positive, TRAb positive, high thyroid iodine rate, multiple histological changes in Hashimoto's disease and toxic diffuse goiter, requiring regular antithyroid medication, the same course of treatment as the usual toxic diffuse goiter, However, surgery and iodine 131 treatment are not suitable because it is relatively prone to hypothyroidism. Hashimoto's pseudo-hyperthyroidism (transient hyperthyroidism) is caused by thyroid destruction and thyroid hormone release. The general symptoms are mild, the condition is easy to control, the thyroid iodine rate is reduced, and thyroid function is easy to appear after applying anti-thyroid drugs. Rapid decline.
Subacute granulomatous thyroiditis
More common in middle-aged women aged 20-50, women are 3-6 times more likely to be male, the incidence of seasonal and regional. Pre-existing symptoms of upper respiratory tract infection 1-3 weeks before onset. Typical clinical manifestations are divided into hyperthyroidism, transition, hypothyroidism, and recovery. During the second to sixth weeks of onset, the hyperthyroidism is the early stage of the disease. The prominent feature is the gradual or sudden pain of the thyroid gland. The swallowing is worse, and there may be radiation pain in the back of the neck, behind the ears, and even in the ipsilateral arm. Obviously swollen, hard and tender, only a part of one side or one side at the beginning, will soon affect both sides, may have nodules. With systemic symptoms such as fever, discomfort, and fatigue, sometimes the body temperature can reach 39 degrees or more. There may be symptoms of hyperthyroidism such as transient heat, palpitations, excessive sweating, and irritability. Generally, the 50% peak occurs within 1 week and the duration is <2-4 weeks. The examination may have a mild to moderate increase in white blood cells, a significant increase in ESR, generally 40 mm/h or more, a decrease in the five T3 and T4 levels of the thyroid function, a decrease in the TSH, and a decrease in the thyroid iodine rate. Ultrasound showed thyroid enlargement, internal hypoechoic area, local tenderness, blurred borders, low blood flow in hypoechoic, and abundant peripheral blood supply. Isotope scanning shows that the image is incomplete or unevenly developed, and sometimes a leaf is defective. Thyroid biopsy has characteristic multinucleated giant cells or granulomatous changes. During the transition period and hypothyroidism (interim period), the above abnormalities gradually weakened, and the self-limiting nature was mostly relieved for several weeks to several months, and some did not appear hypothyroidism, and directly entered the recovery period. During the recovery period (late stage), the patient's clinical symptoms improved, the goiter and nodules disappeared, and no sequelae remained. Very few become permanent hypothyroidism. The whole course of disease lasts for 2-4 months, and some last for more than half a year, with an annual recurrence rate of 2%. On one side of the individual patient, the lesion is close to the recovery period, and on the other side, the lesion appears, causing clinical manifestations and lesions to undulate and prolong the course.
Subacute lymphocytic thyroiditis
The incidence of this disease has increased in recent years, 2/3 is 30-40 years old women. Mainly manifested as mild to moderate hyperthyroidism, can have heart palpitations, fear of heat, sweating, fatigue, weight loss and so on. The thyroid gland is slightly enlarged or normal, but there is no endocrine exophthalmos and anterior mucus edema, lack of thyroid vascular murmur. Thyroid follicle destruction, blood circulation T3, T4 increased. ESR is normal or slightly elevated. TGA and TMA are mildly moderately elevated in 80% postpartum and 50% loose. Ultrasound showed diffuse or focal hypoechoic. The thyroid iodine rate decreased. A thyroid biopsy reveals that diffuse or focal lymphocytic infiltration has diagnostic value for this disease. Hyperthyroidism lasts no more than 3 months, after which it is often followed by hypothyroidism, and a few become permanent hypothyroidism.
Examine
Examination of thyroiditis
Chronic lymphocytic thyroiditis
1. Thyroid function is normal or low, and thyroid function is related to different stages of Hashimoto's disease development. Most thyroid function is normal, and the function of the elderly is reduced. Sometimes the thyroid function is hyperactive and the duration is variable.
2. Thyroglobulin antibody (TGA) and thyroid microsomal antibody (TMA) are significantly increased, and can last for a long time, 80% for several years, or even more than 10 years. Two antibodies have special significance for the diagnosis of this disease. The diagnosis of Hashimoto's disease is superior to TGA in TMA, and 50% can be diagnosed only with TMA.
3. The thyroid iodine rate can be normal, elevated or decreased. Nuclide scans are unevenly distributed, irregularly sparse and concentrated, with unclear boundaries or cold nodules.
4. Ultrasound of the thyroid shows diffuse enlargement, thickening of the spot, diffuse ultrasound and low echo, uneven distribution.
5. Thyroid biopsy has the formation of lymphocytes and lymphoid follicles, which may have eosinophils and fibrosis.
Subacute granulomatous thyroiditis
The examination may have a mild to moderate increase in white blood cells, a significant increase in ESR, generally 40 mm/h or more, a decrease in the five T3 and T4 levels of the thyroid function, a decrease in the TSH, and a decrease in the thyroid iodine rate.
Ultrasound showed thyroid enlargement, internal hypoechoic area, local tenderness, blurred borders, low blood flow in hypoechoic, and abundant peripheral blood supply.
Isotope scanning shows that the image is incomplete or unevenly developed, and sometimes a leaf is defective.
Thyroid biopsy has characteristic multinucleated giant cells or granulomatous changes.
During the transition period and hypothyroidism (interim period), the above abnormalities gradually weakened, and the self-limiting nature was mostly relieved for several weeks to several months, and some did not appear hypothyroidism, and directly entered the recovery period.
Subacute lymphocytic thyroiditis
ESR is normal or slightly elevated. TGA and TMA are mildly moderately elevated in 80% postpartum and 50% loose.
Ultrasound showed diffuse or focal hypoechoic. The thyroid iodine rate decreased.
A thyroid biopsy reveals that diffuse or focal lymphocytic infiltration has diagnostic value for this disease.
Diagnosis
Diagnosis and diagnosis of thyroiditis
Chronic lymphocytic thyroiditis
All middle-aged women, slowly developing goiter, nodules and toughness should be suspected, with typical clinical manifestations, as long as TMA, TGA positive can be diagnosed, clinical manifestations are not typical, high titer TMA, TGA can be diagnosed, ie The two antibody radioimmunoassay method is >60% twice in a row. When there is hyperthyroidism, the high titer antibody lasts for more than half a year. When clinically suspected, the antibody is negative or not high, and if necessary, a biopsy can be performed, and the diagnosis value is confirmed.
Typical cases are not difficult to diagnose based on clinical signs and symptoms and laboratory and imaging examinations. However, it is necessary to make a differential diagnosis with the following diseases: Hashimoto's disease may have diffuse or nodular changes, which need to be differentiated from nodular goiter or adenoma, but nodular goiter and adenoma have normal thyroid function, antibody drops Higher degrees, not difficult to identify. When hyperfunction occurs, it is necessary to identify whether it is a simple toxic diffuse goiter or a Hashimoto's hyperthyroidism, or a Hashimoto pseudo-hyperthyroidism. Hypertrophic thyroid gland in toxic diffuse goiter, TGA and TMA titers are low or short duration; Hashimoto's hyperthyroidism has both Hashimoto's disease and toxic diffuse goiter; Hashimoto's pseudothyroid disease is short, thyroid Reduced iodine intake, prone to hypothyroidism. Hashimoto's disease occasionally occurs when the thyroid gland rapidly increases, and it needs to be differentiated from methylene inflammation when it is painful. The latter has the characteristics of fever, rapid blood sedimentation, and low antibody. Hashimoto's disease may be associated with lymphoma, papillary carcinoma, etc., and biopsy for histopathological examination is helpful for identification.
Subacute granulomatous thyroiditis
The diagnosis of this disease is mainly based on clinical manifestations and laboratory tests. According to the patient's thyroid enlargement, pain, hard, with systemic symptoms, history of upper respiratory tract infection before the onset, rapid blood sedimentation, high T3, T4 and reduced thyroid iodine rate can be diagnosed. If the thyroid biopsy has giant cells and granuloma, further support for diagnosis.
The disease needs to be differentiated from the following diseases: thyroid cyst or adenoma-like nodules can cause thyroid enlargement, pain, but no fever, erythrocyte sedimentation rate, normal thyroid function, and dark liquid area under ultrasound. Hashimoto's disease is sometimes painful, but there is no erythrocyte sedimentation rate, fever, and TMA and TGA are significantly increased. Thyroid cancer Although the texture of thyroid nodules is similar to methylene inflammation, it is very hard, but no clinical symptoms, no tenderness, unpleasant erythrocyte sedimentation rate, nodules persist, will not become soft or disappear, and if necessary, thyroid biopsy will be identified. Painless thyroiditis without pain and thyroid tenderness, no history of viral infection, erythrocyte sedimentation, pathological lymphocytic infiltration (see Table 1). Acute suppurative thyroiditis can have high fever and pain, but the blood picture is high, local fluctuations, and antibiotic treatment is effective.
Subacute lymphocytic thyroiditis
Diagnosis is based on clinical performance and laboratory tests.
The disease is differentiated from subacute granulomatous thyroiditis, which has pain and tenderness, low recurrence rate, is associated with viral infection, erythrocyte sedimentation rate is significantly increased, and biopsy is granulomatous. An important means of identifying toxic diffuse goiter is that the thyroid iodine absorption rate increases, and invasive exophthalmos, anterior tibial mucinous edema, persistent hyperthyroidism and thyroid receptor antibody positive are helpful for the diagnosis of the latter. When Hashimoto's hyperthyroidism, thyroid iodine increased or normal, pathology has eosinophil formation.
