Thyroiditis
•Download as PPTX, PDF•
0 likes•463 views
Diagnosis of thyroiditis with emphasis on ultrasound features. It is important to differentiate between different types of thyroiditides as each type has a different management strategy.
More Related Content
What's hot
What's hot (20)
Similar to Thyroiditis
Similar to Thyroiditis (20)
Recently uploaded
Recently uploaded (20)
Thyroiditis
- 1. Thyroiditis Basic concepts, diagnosis Durr-e-Sabih MBBS. MS. FRCP. FANMB. FAIUM Multan Ultrasound Service Multan-Pakistan dsabih@yahoo.com
- 2. The great mimicker • Goitre or no goitre • Painless or painful • Thyrotoxic, hypothyroid or euthyroid or all three in sequence Hamburger, J. I. (1986). The various presentations of thyroiditis. Diagnostic considerations. Ann Intern Med 104 (2): 219-224.
- 3. Thyroiditis Gland Inflammation Acute (release of intrathyroidal T4) Chronic Hypothyroid Thyrotoxic Euthyoid Hypothyroid + Euthyroid
- 4. Thyroiditis Gland Inflammation Acute (release of intrathyroidal T4) Chronic Hypothyroid Thyrotoxic Euthyoid Hypothyroid + Euthyroid
- 5. Natural history acute and chronic thyroiditis Time
- 6. Thyroiditis, major types Hashimoto’s thyroiditis Painless lymphocytic thyroiditis Postpartum thyroiditis Drug-induced thyroiditis Subacute thyroiditis Suppurative thyroiditis Radiation thyroiditis Traumatic Riedel’s thyroiditis Pearce, E.N., A.P. Farwell, and L.E. Braverman, Thyroiditis. N Eng J Med, 2003. 348(26): p. 2646-55.
- 7. Thyroiditis, major types Hashimoto’s thyroiditis Painless lymphocytic thyroiditis Postpartum thyroiditis Drug-induced thyroiditis Subacute thyroiditis Suppurative thyroiditis Radiation thyroiditis Traumatic Riedel’s thyroiditis Pearce, E.N., A.P. Farwell, and L.E. Braverman, Thyroiditis. N Eng J Med, 2003. 348(26): p. 2646-55. Painless Painful
- 8. Thyroiditis, major types Hashimoto’s thyroiditis Painless lymphocytic thyroiditis Postpartum thyroiditis Drug-induced thyroiditis Subacute thyroiditis Suppurative thyroiditis Radiation thyroiditis Traumatic Riedel’s thyroiditis Pearce, E.N., A.P. Farwell, and L.E. Braverman, Thyroiditis. N Eng J Med, 2003. 348(26): p. 2646-55. Painless Painful
- 9. Ultrasound evaluation of the thyroid • Parenchyma o Echogenicity, texture, focal disease • Vascularity o Parenchymal vascularity o Superior and/or inferior thyroidal artery Doppler
- 10. The normal thyroid • Echogenic and homogenous (no nodules) • Avascular or sparsely vascular* Ralls, P. W., D. S. Mayekawa, et al. (1988). "Color-flow Doppler sonography in Graves disease: "thyroid inferno"." American Journal of Roentgenology 150(4): 781-784.
- 11. The Normal thyroid looks like the normal submandibular gland or slightly more echogenic SMG T
- 13. The inflamed thyroid • Less common features in brackets o Hypoechoic, diffuse (or focal) o Micronodular (or Macronodular) o Avascular (or Hypervascular)
- 14. Hashimoto’s thyroiditis (Chronic lymphocytic thyroiditis) •Diffusely enlarged or normal sized. •Progressive destruction leads to permanent hypothyroidism •Propensity to develop lymphoma in thyroid Anderson L, et al. Hashimoto thyroiditis: sonographic analysis of benign and malignant nodules in patients with diffuse Hashimoto thyroiditis. AJR Am J Roentgenol. 2010 Jul;195(1):216-22. doi: 10.2214/AJR.09.3680. PMID: 20566819.
- 15. Natural history Normal range Rare Hashitoxicosis * * Shahbaz A ;et al. Prolonged Duration of Hashitoxicosis in a Patient with Hashimoto's Thyroiditis: A Case Report and Review of Literature. Cureus. 2018 Jun 14;10(6):e2804. doi: 10.7759/cureus.2804.
- 16. Ultrasound features in Hashimoto’s thyroiditis • Mildly enlarged • Hypoechoic somewhat heterogeneous • Micronodulation presents as very small hypoechoic nodules (1-7mm) hypoechoic nodules surrounded by an echogenic septa. • The nodules can be hyperechogenic and the intervening septa can be hypoechoic Giraffe-hide pattern.
- 17. Atypical nodules • Atypical nodules can be large and very bright in a hypoechoic background, the white-knight nodule. • Atypical nodules can also be hypoecohic and even complex at times. • These can be palpable and also mimic malignant nodules. • All types of calcification can be seen.
- 18. Vascularity in Hashimoto’s thyroiditis • Typically increased (thyroid inferno), this can also be focal (focal thyroid inferno).
- 19. Ultrasound
- 21. Giraffe skin
- 22. Thyroid inferno with thyroiditis
- 23. Nodules in Hashimoto’s thyroiditis (FNA +ve) 60 mm
- 24. End-stage small thyroid after Hashimoto’s thyroiditis
- 25. Painless lymphocytic thyroiditis • A variant of Hashimoto’s thyroiditis. • There is a mild goitre, transient thyrotoxicosis, followed by hypothyroidism and then resolution with a euthyroid status. • It can sometimes be drug induced.
- 26. Natural history, subacute, postpartum and painless thyroiditis Normal range
- 27. Painless lymphocytic thyroiditis • It should be suspected in anyone with a short history of thyrotoxicosis (<2 months) and no or minimal goitre. • There is no ophthalmopathy or pretibial myxoedema. • Ultrasound features are similar to those seen in Hashimoto’s thyroiditis. • Avascular or hypovascular.
- 28. Post partum thyroiditis • In relation to pregnancy or abortion and usually occurs within one year of delivery (or abortion). • Might present with exacerbation of previous Graves disease in a few women. Antithyroid antibodies are high. • There is propensity to recur after subsequent pregnancies
- 29. Natural history, subacute, postpartum and painless thyroiditis Normal range
- 30. Post partum thyroiditis • Grey-scale ultrasound features are similar to Hashimoto’s thyroiditis. • Vascularity can be reduced during destructive thyrotoxic phase and increased during hypothyroid phase when increased TSH induces hyperactivity of the remaining thyroid follicles.
- 31. Drug induced thyroiditis • History of drug intake should prompt a workup of thyroid function. Thyroid antibodies might or might not be present and absence should not exclude the possibility of thyroiditis • Can result in both thyrotoxicosis (Amiodarone, interferon etc) or hypothyroidism (Amiodarone, Lugol’s iodine, lithium).
- 32. • Can cause hypothyroidism as well as thyrotoxicosis • Gray scale features similar to Hashimoto’s thyroiditis • Blood flow is a distinguishing point • In a thyrotoxic patient on Amiodarone, if there is no blood flow, this means thyroiditis • Increased blood flow might be due to Grave’s disease triggered by Amiodarone Drug induced thyroiditis (Amiodarone induced thyroiditis) Gilbert H. Daniels et al. Imaging “Thyroiditis”: A Primer for Radiologists., Current Problems in Diagnostic Radiology, 2020. https://doi.org/10.1067/j.cpradiol.2020.09.012.
- 33. Natural history, drug induced thyroiditis Normal range 20% will revert to euthyroid , treatment needed for others Most patients with no pre-existing thyroid conditions will revert to euthyroid if
- 34. Subacute thyroiditis (Dequervain’s thyroiditis) • Pain front of the neck, often following a viral infection. The pain might radiate to the ears, jaw or chest. There is a small goitre that feels knobbly and hard. • ESR is high • There is thyrotoxicosis in the early stages but thyroid uptake is very low
- 35. Subacute thyroiditis (Dequervain’s thyroiditis) • Ultrasound shows irregular, unencapsulated, poorly marginated, hypoechoic areas in the thyroid. • Vascularity is reduced in the acute stage and might be slightly increased during the recovery phase. • The vascularity even when present appears more peripheral and the central areas of the nodules tend to be avascular.
- 36. Subacute thyroiditis (Dequervain’s thyroiditis) • The process might start as a focal disease in one lobe, rapidly extending or involving the other lobe too within a week or so. • The ultrasound features might become less obvious and even resolve completely as the disease resolves. This might appear similar or even identical to a thyroid malignancy.
- 38. Subacute Rt Lt
- 39. Suppurative thyroiditis • Very rare. Bacterial or other infection of the thyroid. • Presents with fever, pain and tender goitre. • With tuberculous infection fever or pain might be absent or mild. • The abscess might rarely extend beyond the thyroid too.
- 40. Suppurative thyroiditis • Early cases can present with ill defined hypoechoic areas before purulent material has formed but later classic irregular complex abscesses can be seen with increased peripheral vascularity . • Ultrasound guided aspiration is confirmatory.
- 41. Thyroid abscess
- 42. Radiation thyroiditis • Typically after a patient of thyrotoxicosis has been treated with radio-iodine. • Pain and tenderness in the front of neck as inflammatory changes develop. • There might be a transient increase in hyperthyroidism as the stored thyroxine is released as a result of radiation induced injury. • This is usually a self limiting process.
- 44. Fibrous thyroiditis • Fibrous thyroiditis (Riedel’s thyroiditis or invasive thyroiditis), is a rare disease marked by extensive fibrosis of the thyroid gland that extends into adjacent tissues. • It can be associated with retroperitoneal fibrosis as part of a more widespread fibrosis process.
- 45. Fibrous thyroiditis • Patients present with neck discomfort and a goitre that is diffuse very hard and fixed. • Sometimes the front of neck becomes hard and the goitre cannot be palpated separately. • Very high antibody levels are found.
- 46. Riedel’s thyroiditis Journal of Ultrasound in Medicine, Volume: 28, Issue: 2, Pages: 267-271, First published: 01 February 2009, DOI: (10.7863/jum.2009.28.2.267)
- 47. Grave disease • Many experts consider Grave disease as part of thyroiditis spectrum. • Autoimmune condition leading to over production of thyroid hormones and clinical manifestations of thyrotoxicosis , eye and peripheral signs (proptosis, lid lag, pretibial myxoedema etc).
- 48. Grave disease • Grey scale ultrasound shows a mildly enlarged, uniformly hypoechoic thyroid. Some cases might show heterogeneous texture and micronodulation. • It is usually very vascular on Doppler an appearance called the thyroid inferno.
- 49. Grave disease • Both the grey scale features and colour Doppler appearance might also be seen in Hashimoto’s thyroiditis. • Spectral Doppler of superior or inferior thyroid artery blood flow velocitimetry can help to differentiate between the two. • Variable cut off ranging from 40 cm/sec to 87 cm/sec. High sensitivity and positive predictive values obtained. Peng, X. et al. Mean peak systolic velocity of superior thyroid artery for the differential diagnosis of thyrotoxicosis: a diagnostic meta-analysis. BMC Endocr Disord 19, 56 (2019). https://doi.org/10.1186/s12902-019-0388-x
- 50. Grave disease
- 52. Take home • Thyroiditis usually: o Hypoechoic background o Focally hypoechogenic o Micro nodularity common • macronodularity uncommon o Parenchymal vascularity decreased in all except Hashimoto’s where it is markedly increased o Velocimetry normal in all thyroidites
- 54. Short digression • Thyrotoxicosis: nonspecific and refers to excess thyroid hormones in blood (Grave’s disease, exogenous hormone intake, destructive thyroiditis, medicines) • Hyperthyroidism: conditions where thyroid shows increased production of thyroid hormones that are released in blood (Grave’s disease, hyperfunctioning adenoma, toxic MNG, Jod Basedow’s disease)
- 55. Short digression • Every hyperthyroidism has thryotoxicosis but every thyrotoxicosis is not due to hyperthyroidism.
- 56. Gilbert H. Daniels et alImaging “Thyroiditis”: A Primer for Radiologists., Current Problems in Diagnostic Radiology, 2020. https://doi.org/10.1067/j.cpradiol.2020.09.012. Proposed algorithm for incorporating clinical information into sonographic interpretation and formulate diagnostic conclusions in most thyroid diffuse conditions. AIT, amiodarone induced thyrotoxicosis; CFD, color flow Doppler. Note that AIT-I is at all effects a form of Graves’ disease, or toxic multinodular goiter complicated or precipitated by amiodarone, while AIT-II is a form of painless subacute thyroiditis also complicated or precipitated by amiodarone. Grey boxes indicate conditions in which the radioactive iodine uptake is high or normal. Conditions in white boxes display zero uptake.
- 59. Type of thyroid vascularity • type 0 (or normal pattern): flow seen only in the major vessels and not in the parenchyma or a few small vascular areas seen in the subcapsular regions. • Type I: mildly increased colour flow; seen in the major vessels but also within the parenchyma with a patchy distribution. This tends to be difficult to identify and the impression remains indeterminate. • type II: clearly increased colour flow Doppler signal with patchy distribution; • Type III. markedly increased colour flow Doppler signals with diffuse homogeneous distribution Vitti, P., T. Rago, et al. (1995). "Thyroid blood flow evaluation by color-flow Doppler sonography distinguishes Graves’ disease from Hashimoto’s thyroiditis. Journal of Endocrinological Investigation 18(11): 857-861.
- 60. Recognizing Normal on YOUR Machine 1 2 3
- 61. Thyroiditis, major types Hashimoto’s thyroiditis Painless lymphocytic thyroiditis Postpartum thyroiditis Drug-induced thyroiditis Subacute thyroiditis Suppurative thyroiditis Radiation thyroiditis Traumatic Riedel’s thyroiditis Pearce, E.N., A.P. Farwell, and L.E. Braverman, Thyroiditis. N Eng J Med, 2003. 348(26): p. 2646-55. Painless Painful
- 62. Thyroiditis is a group of inflammatory thyroid disorders
Editor's Notes
- Ladies and gentlemen, greetings from Pakistan. For the non-thyroidologist, dealing with thyroiditis can really be challenging, even daunting with so many types and so many clinical manifestations within each type. The topic of thyroiditis is complex, confusing but my effort today would be to demystify the concepts and organize the features in a way that would make your diagnosis somewhat more precise, the next time you encounter such a patient.
- In a more acute setting, there is destruction of the thyroid and the stored hormones are released into the blood leading to thyrotoxicosis, as the hormones are metabolized and intrathyroidal hormone stores deplete, the patient can become euthyroid and then hypothyroid… in some cases there is healing, the thyrocyte integrity is restored and a euthyroid state reverts, or the patient might remain permanently hypothyroid if there is excessive thyroid tissue destruction and not enough is left behind to establish a euthyroid state
- In chronic gland inflammation and destruction, the thyroid hormone leakage is not a problem, the major pathology is replacement of thyroid tissue by fibrosis following inflammation, there is no sudden thyrotoxicosis, on the contrary, there is gradual onset of hypothyroidism, this is the common endpoint of Hashimoto’s thryoidits and the hypothyroidism tends to be permanent
- There are many types of thyroidites, if just diagnose “thyroiditis” as a physician or radiologist or nuclear medicine physician, you have not done your job
- If you have gone one step further and diagnosed panful or painless thyroiditis, it is still not enough … it is essential that the exact etiology be identified as well and this be reported because each type has a different management. There is no management for thyroiditis but each type of thyroiditis can be managed.
- If you have gone one step further and diagnosed panful or painless thyroiditis, it is still not enough … it is essential that the exact etiology be identified as well and this be reported because each type has a different management. There is no management for thyroiditis but each type of thyroiditis can be managed.
- We now have the background in place, lets come to the topic …. Lets start with ultrasound of the normal thyroid. Like everywhere else, ultrasound evaluation includes assessment of parenchyma with emphasis on echogenicity, texture and focal disease and evaluation of vascularity with emphasis on parenchymal vascularity and also spectral evaluation of the superior and inferior thyroidal arteries
- The normal thyroid is echogenic, more so than the muscles around it, it has a homogenous texture and is relatively avascular
- The thyroid echogenicity and texture are very similar to the submandibular salivary gland
- This slide shows the normal parenchymal vascularity, depending on machine sensitivity, no vascularity or only very sparse vascularity is seen in normal thyroid substance
- Inflamed thyroid is usually hypoechoic, this can be diffuse or focal, there can be a non-uniform micronodular texture but large nodules can also be seen. Large nodules can be hypoechoic or hyperechoic. The vascularity is usually decreased but can be increased markedly in Hashimoto’s thyroiditis.
- Hashimoto’s thyroiditis is the most common form of thyroiditides and the most common cause of hypothyroidism in areas that that have adequate dietary iodine. Most patients present with hypothyroidism or subclinical hypothyroidism is discovered incidentally. The thyroid tends to be enlarged and firm, it tends to be diffuse. These patients are at higher risk of lymphoma of the thyroid and departmental guidelines should include ultrasound follow-up and new focal lesions should have an FNA done.
- Hashimoto’s thyroiditis is usually of insidious onset and the patient becomes permanently hypothyroid. Rarely some patients might become euthyroid with treatment. Some patients might have thyrotoxicosis, this is called hashitoxicosis
- On ultrasound, typically, the gland is enlarged and hypoechoic, there might be micronodules on this background.
- In this slide image 1 is a normal thyroid, see how the gland is uniformly echogenic, there are no nodules. Image 2 and 3 are typical Hashimoto’s thyroiditis, with slightly enlarged rubbery on palpation and hypoechoic on ultrasound with some hypoechoic nodules with thin echogenic septa in between, this is most easily seen in image 3.
- The images on these slides show giraffe skin pattern. This is suggestive of thyroiditis, most likely Hashimoto’s thyroiditis.
- A feature that distinguishes Hashimoto’s thyroiditis from the next commonest subacute thyroiditis is vascularity, being hypervascular in thyroiditis but hypovascular in subacute thyroiditis… some times the vascularity of Hashimotos thyroiditis is indistinguishable from Grave disease but we will talk about this later.
- Larger thyroid nodules can have bizarre appearance. All of these are confirmed cases of Hashimoto’s thyroiditis
- Long standing thyroiditis results in a small gland, usually these are hypothyroid. Even if the gland is shrunken, you might pick up unexpected vascularity.
- Thyroiditis of recent onset, of about 2 months or less should prompt a search for painless thyroiditis
- Subacute thyroiditis, post partum thyroiditis and painless thyroiditis follow a similar course of early destruction with rapid onset of thyrotoxicosis, as the stored hormones get depleted the patient usually becomes hypothyroid but in most cases the disease eventually runs its course and the patient reverts to an euthyroid status by 12-18 months of onset of symptoms.
- Subacute thyroiditis, post partum thyroiditis and painless thyroiditis follow a similar course of early destruction with rapid onset of thyrotoxicosis, as the stored hormones get depleted the patient usually becomes hypothyroid but in most cases the disease eventually runs its course and the patient reverts to an euthyroid status by 12-18 months of onset of symptoms.
- Withdrawing the drug alone might help in about 20%cases of Amiodarone induced toxicosis, for others a specific diagnosis of the type of toxicosis is needed
- 32 Yr male, fever, pain front of neck radiating upwards, loss of appetite. Hard goitre. ESR 118mm; T4 high TSH very low. No uptake on thyroid scan. TPOAB mildly raised and ATG markedly raised
- Very rare, in my 40 years I have seen only one case with a frank abscess, this was Kochs so the presentation was atyipical, without high fever, just a painful goitre with frankly fluid areas within
- Allow me to digress a little here, the terms thyrotoxicosis and hyperthyroidism are often used interchangeably and might have similar major clinical features, but these refer to somewhat different etiologies and management strategies.
- It is important to differentiate between the two conditions because in hyperthyroidism you want to decrease the rate of hormone production, but when there is leakage of stored thyroid hormones you need to either stop leakage or reducethe peripheral action of the hormones
- Hashimoto’s thyroiditis is usually of insidious onset and the patient becomes permanently hypothyroid. Rarely some patients might become euthyroid with treatment. There are occasional cases reported where a patient with Hashimoto thyroiditis became thyrotoxic after pregnancy as postpartum thyroiditis superimposed on a Hashimoto hypothyroid background. Subacute thyroiditis, post partum thyroiditis and painless thyroiditis follow a similar course of early destruction with rapid onset of thyrotoxicosis, as the stored hormones get depleted the patient usually becomes hypothyroid but in most cases the disease eventually runs its course and the patient reverts to an euthyroid status by 12-18 months of onset of symptoms. Drug induced thyroiditis can present with thyrotoxicosis or hypothyroidism but once the offending drug is stopped, the patient usually becomes euthyroid Radiation thyroiditis presents with exacerbation of symptoms in an already hyperthyroid patient who has been treated with radio-iodine
- Thyroid vascularity can increase in some pathological conditions and although several grades of hypervascularity are described these are very subjective
- Each machine displays texture differently. It is important that you familiarize yourself with how your machine displays thyroid texture. In this slide, all images are of my thyroid, acquired within 12 hours, but you will agree that the texture is different in each image. This difference is most marked between images 1 and 3. if you were used to seeing smooth images as in number 3, and were suddenly confronted with image 1, I would not blame you for thinking this to be heterogeneous….This underscores the importance of being familiar with how your machine displays texture.
- To divide these into those that are associated with pain and those that are painless.
- The name is helpful, thyroiditis, meaning inflammatory thyroid disorders. The term thyroiditis is not too helpful on its own… we will discuss this in a little more detail after a few slides.