This document discusses various types of thyroid disorders including simple goiter, thyroiditis, drug-induced thyroiditis, and autoimmune thyroiditis. Simple goiter is usually asymptomatic and caused by iodine deficiency or goitrogen intake. Thyroiditis can be acute from infections, subacute from viruses, or chronic from autoimmunity. Drug-induced thyroiditis is caused by medications like amiodarone and interferons. Autoimmune thyroiditis involves lymphocytic infiltration and can lead to hypothyroidism.

1. SIMPLE GOITRE
&
THYROIDITIS

2. SIMPLE GOITRE
 Other names:-
 Diffuse non-toxic
 Colloid
 Juvenile (teenagers)
 Characteristics:-
 Soft, symmetrical, diffuse
 NO nodularity, tenderness, bruit, LNE
 TFT normal
 NO anti-thyroid Ab

3. SIMPLE GOITRE
 Age group:-
 15-25 years most common
 Causes:-
 Pregnancy
 Puberty
 Iodine deficiency
 Goitrogen intake – Cabbage, cauliflower
 Inherited thyroid hormone dysgenesis:-
 Iodine transport, thyroglob synthesis, organification,
coupling, iodide regeneration

4. SIMPLE GOITRE
 Clinical features:-
 Asymptomatic mainly
 Noticed by others, self
 Cosmetic concern
 Localised pain & swelling (Spont bleed)
 Large goitre -
 Tracheal compression
 Esophageal compression

5. SIMPLE GOITRE
 Examination:-
 Diffuse, symmetrical enlargement
 Soft, nontender
 NO nodules, LNE
 Pemberton’s sign – raise arms, then
 Facial congestion
 Faintness
 Ext jugular vein compression
 Substernal goitre

6. SIMPLE GOITRE
 Investigations:-
 TFT – r/o hypo/hyper
 Normal
 Normal T3 & TSH, low T4 (Iod def, more T4→T3)
 Anti-TPO Ab – r/o autoimmune thyroid disease
 Urinary Iodine - <10 mcg/dL = Iodine def
 USG – If nodularity suspected

7. SIMPLE GOITRE
 Treatment:-
 Juvenile/ pregnancy –
 TFT normal, NO Rx. Usually regress spontaneously
 Iodine deficiency –
 Iodine
 Thyroxine
 Surgery –
 Tracheal compression
 Thoracic outlet obstruction
 Cosmetic
 Radioiodine –
 Follow-up for hypothyroidism

8. SIMPLE GOITRE
 Recurrent episodes –
 Fibrosis
 Nodule formation - MNG
 Autonomous function – toxic nodule

9. THYROIDITIS

10. CAUSES
 Acute
 Bacterial infection:
 Staphylococcus, Streptococcus, and Enterobacter
 Fungal infection:
 Aspergillus, Candida, Coccidioides, Histoplasma, and Pneumocystis
 Radiation thyroiditis after 131I treatment
 Amiodarone (may also be subacute or chronic)
 Subacute
 Viral (or granulomatous) thyroiditis
 Silent thyroiditis (including postpartum thyroiditis)
 Mycobacterial infection
 Chronic
 Autoimmunity: focal thyroiditis, Hashimoto's thyroiditis, atrophic
thyroiditis
 Riedel's thyroiditis
 Parasitic thyroiditis:
 Echinococcosis, strongyloidiasis, cysticercosis
 Traumatic: after palpation

11. SUPPURATIVE THYROIDITIS
 Rare
 Suppuration –
 Bacterial
 Fungal
 Associated –
 Pyriform sinus (4th brachial pouch)
 Long standing goitre
 Degeneration of malignancy

12. SUPPURATIVE THYROIDITIS
 Clinical
 Thyroid pain – ref to throat, ear
 Fever, dysphagia
 Erythema over thyroid
 Small, tender, asymmetric goitre
 Differentials
 Thyroiditis – subacute, chronic
 Haemorrhage into cyst
 Malignancy
 Amiodarone induced thyroiditis
 Amyloidosis

13. SUPPURATIVE THYROIDITIS
 Investig –
 TC & ESR ↑
 FNAC – polymorph infiltration
 Specimen gram stain, C&S
 CT, USG – abscess
 Treatment –
 Antibiotics, antifungals
 Surgery –
 Abscess
 Compressive symptoms (trachea, esophagus, jugular
veins)

14. SUPPURATIVE THYROIDITIS
 Complications –
 Tracheal compression
 Retropharyngeal abscess
 Esophageal compression
 Septicaemia
 Mediastinitis
 Jugular vein thrombosis

15. DRUG INDUCED
 Interferons –
 IFN-α
 IL-2
 Amiodarone
 Can result in –
 Painless thyroiditis
 Grave’s
 Hypothyroidism
 Risk factor –
 Anti-TPO Ab+ve before Rx

16. AMIODARONE INDUCED
 Acute, subacute, chronic
 Class III antiarrhythmic
 Structure related = thyroid hormone
 39% Iodine (wt)
 Stored in adipose (>6 mths for levels ↓)
 Actions –
 ↓ T4 release
 Inhibit deiodinase
 Weak thyroid hormone antagonist

17. AMIODARONE INDUCED
 Effects –
 A/c transient ↓ thyroid function
 Persistent hypothyroid (women, anti-TPO Ab)
 Thyrotoxic (incipient Grave’s, MNG, Jod-Basedow)
 TFT –
 Initial T4 ↓
 Then T4 ↑, T3 ↓ & thyroid effect ↓
 Wolff-Chaikoff escape, deiodinase inhib, thyroxine inhib
 TSH initial ↑ , then N/↓

18. AMIODARONE INDUCED - Rx
 Hypothyroid – Levothyroxine
 Hyperthyroid – complex
 Stop drug (often impractical)
 Type I –
 Preclinical Grave’s, MNG
 Anti-thyroid high dose
 Type II –
 Destructive thyroiditis
 Iodinated oral contrast (↓formation, conversion, action)
 Glucocorticoid
 Lithium
 Near-total thyroidectomy

19. SUBACUTE THYROIDITIS
 Synonyms –
 de Quervain’s
 Granulomatous
 Viral (lots of viruses)
 Mimic pharyngitis
 30-50 years, women:men = 3:1

20. SUBACUTE THYROIDITIS
 Pathophysiology –
 Patchy inflammatory infiltrate
 Multinucleate giant cells
 Granuloma, fibrosis
 Disrupt + destroy thyroid follicles
 Stages –
 1 = Destruction (Tg,T3,T4 release. Hyperthyroidism)
 2 = Depletion (T3,T4 fall. Hypothyroidism)
 3 = Recovery (TFT slowly returns to normal)

21. SUBACUTE THYROIDITIS
 Clinical –
 Painful, symmetric goitre (ref to jaw, ear)
 Fever +/-, malaise
 Thyrotoxicosis
 URTI
 o/e Exquisitely tender goitre
 Uncommon –
 Permanent hypothyroidism
 Rare –
 Prolonged course with multiple relapses

22. SUBACUTE THYROIDITIS
 Investigations –
 TFT –
 1 = T3 & T4 ↑↑, TSH ↓↓
 2 = T3 & T4 ↓↓, TSH ↑↑
 3 = TFT normal
 ESR ↑
 TC ↑/N

23. SUBACUTE THYROIDITIS
 Treatment –
 Aspirin – 600mg 4-6 hrly
 NSAIDs
 Glucocorticoid –
 Severe local/systemic symptoms
 Taper 6-8 weeks
 β-blocker – hyperthyroidism
 Levothyroxine – hypothyroidism (low dose)
 TFT 2-4 weekly (hyper, hypo, normo)

24. SUBACUTE THYROIDITIS
 Silent thyroiditis –
 Synonyms – painless, postpartum
 3 stages – hyper, hypo, normo
 Recovery norm
 Assoc – TPO +ve, type 1 DM
 ESR normal
 Severe thyrotoxicosis – propranolol
 Hypothyroidism – levothyroxine
 TFT annually – monitor for hypothyroidism

25. AUTOIMMUNE THYROIDITIS
 Focal –
 Seen on autopsy
 Asymptomatic
 Hashimoto’s –
 Lymphocytic infiltration
 Large, irregular, painless goitre
 Atrophic –
 More fibrosis
 Less lymphocytic infiltrate
 Distorted architecture

26. AUTOIMMUNE THYROIDITIS
 Main mechanism –
 T-lymphocytic injury
 Clinical –
 Goitre – Hashimoto’s
 Hypothyroidism – atrophic, late Hashimoto’s
 Children –
 Rare
 Slow growth, delayed facial development

27. AUTOIMMUNE THYROIDITIS
 Investigations –
 TFT –
 Clinical/subclinical hypothyroidism
 Anti-TPO Ab marker
 FNAC –
 Lymphocytic infiltrate (Hashimoto’s)
 More fibrosis (atrophic)
 USG –
 Heterogenous enlargement (Hashimoto’s)
 Atrophied gland (atrophic)
 No nodules

28. AUTOIMMUNE THYROIDITIS
 Treatment –
 Monitor TFT regularly
 Levothyroxine if hypothyroid

29. REIDEL’S THYROIDITIS
 Rare
 Middle-aged women
 Pathophysiology –
 Dense fibrosis
 Normal architecture lost
 Gland size enlargement
 Dysfunction uncommon

30. REIDEL’S THYROIDITIS
 Clinical –
 Insidious, painless, hard, nontender goitre
 Compression –
 Esophagus
 Trachea
 Neck veins
 Recurrent laryngeal nerves
 Associated idiopathic fibrosis –
 Retroperitoneal, biliary tree
 Mediastinal, lung
 Orbit

31. REIDEL’S THYROIDITIS
 Diagnosis –
 Open biopsy
 Treatment –
 Surgical decompression
 Thyroxine if hypothyroid
 Tamoxifen (no evidence)