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Thyroiditis

Overview
Presentation
DDx
Workup
Treatment
Medication
Updated: Sep 04, 2015

Background

Pathophysiology
Epidemiology
Prognosis
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References

Background
The broad category of thyroiditis includes the following inflammatory diseases of
the thyroid gland: (1) acute suppurative thyroiditis, which is due to bacterial
infection; (2) subacute thyroiditis, which results from a viral infection of the gland;
and (3) chronic thyroiditis, which is usually autoimmune in nature. In childhood,
chronic thyroiditis is the most common of these 3 types. The second form of
thyroiditis, Riedel struma, is rare in children. Secondary thyroiditis may be due to
the administration of amiodarone to treat cardiac arrhythmias or the
administration of interferon-alpha to treat viral diseases.

Three multinuclear, giant cell

granulomas observed in a fine-needle aspiration biopsy of the thyroid; from a patient with thyrotoxicosis
from lymphocytic or subacute granulomatous thyroiditis.

Pathophysiology
Acute suppurative thyroiditis is rare in childhood because the thyroid is
remarkably resistant to hematogenously spread infection. Most cases of acute
thyroiditis involve the left lobe of the thyroid and are associated with a
developmental abnormality of thyroid migration and the persistence of a pyriform
sinus from the pharynx to the thyroid capsule. The usual organisms responsible
include Staphylococcus aureus, Streptococcus hemolyticus, and pneumococcus.
Other aerobic or anaerobic bacteria may also be involved.
Subacute thyroiditis is generally thought to be due to viral processes and usually
follows a prodromal viral illness. Various viral illnesses may precede the disease,
including mumps, measles, influenza, infectious mononucleosis, adenoviral or
Coxsackievirus infections, myocarditis, or the common cold. Other illnesses or
situations associated with subacute thyroiditis include catscratch
fever,sarcoidosis, Q fever, malaria, emotional crisis, or dental work. The disease
is more common in individuals with human leukocyte antigen (HLA)Bw35.
Because chronic thyroiditis in children is usually due to an autoimmune process,
it is HLA-associated, similar to other autoimmune endocrine diseases. The
specific alleles in the atrophic and goitrous forms of the disease vary. The
histologic disease picture varies, but lymphocytic thyroid infiltration is the
hallmark of the disease and frequently obliterates much of the normal thyroid
tissue. Follicular thyroid cells may be small or hyperplastic. The degree of fibrosis
among patients also widely varies. Children usually have hyperplasia with
minimal fibrosis. The blood contains autoantibodies to thyroid peroxidase and,
frequently, autoantibodies to thyroglobulin. Autoimmune thyroiditis is also
frequently part of the polyglandular autoimmune syndromes.

Epidemiology
Frequency
United States

Studies in the United States and Western Europe report a prevalence of 1.2% in
individuals aged 11-18 years. Approximately 25% of adults with type 1
diabeteshave thyroiditis, about one half of whom have hypothyroidism.
Approximately 10% of children with type 1 diabetes have antithyroid antibodies.
Thirteen of 121 children with vitiligo were also found to have subsequent
evidence of autoimmune thyroiditis.[1] The disease is also more common in
children with Down syndromeor Turner syndrome. Acute suppurative thyroiditis is
rare in Western nations. Subacute thyroiditis is rare in childhood.
International
The prevalence of chronic autoimmune thyroiditis varies depending on screening
procedures. A Greek study showed a prevalence of thyroid antibodies as high as
12.5% in some areas. Few data are available regarding the incidence of the
various forms of thyroiditis in the non-Western world. Acute thyroiditis is more
common in geographic areas where antibiotic use is less prevalent.

Mortality/Morbidity
Long-term morbidity or mortality from thyroiditis is uncommon. Patients with
autoimmune thyroiditis frequently develop hypothyroidism and require lifelong
treatment. Patients with subacute thyroiditis may briefly have hyperthyroidism but
usually regain normal thyroid function. Patients with acute thyroiditis generally
maintain normal thyroid function.

Sex
The pediatric male-to-female ratio for autoimmune thyroiditis ranges from 1:2 to
1:6. This is low when compared with the 90% female predominance in adults. [2, 3, 4]

Prognosis
Acute thyroiditis
Recovery is usually complete, and thyroid function returns to normal.

Subacute thyroiditis
This self-limiting disease may last 2-7 months.

Chronic autoimmune thyroiditis

Permanent hypothyroidism is the main complication. Approximately 20% of
children with subclinical hypothyroidism enter remission and become
euthyroidism.[4]
Clinical Presentation

History
Acute thyroiditis

A history of acute illness, including fever, chills, neck pain, sore throat, hoarseness,
and dysphagia, is common.

Neck pain is frequently unilateral and radiates to the mandible, ears, or occiput. Neck
flexion reduces the severity of the pain. The pain worsens with neck hyperextension.
Subacute thyroiditis

Neck tenderness and swelling may occur.

Occasionally, the initial symptoms are those of hyperthyroidism.
Systemic symptoms such as weakness, fatigue, malaise, and fever are usually low
grade.
Chronic autoimmune thyroiditis
Chronic autoimmune thyroiditis is observed in the following 3 patterns:

Goiter that is usually diffuse and nontender: Systemic illness is not evident. The
thyroid gland is frequently 2-3 times its normal size and may be larger. The patient, parent,
or physician may discover the goiter.

Symptoms of hypothyroidism: In children, this frequently includes poor growth or

short stature. Adolescent girls may have primary or secondary amenorrhea. Boys may
have delayed puberty. Because the disease develops slowly, the patient or parent may not
notice other signs of hypothyroidism, including constipation, lethargy, and cold intolerance.
The child with diabetes may have decreasing insulin requirement.

Symptoms of hyperthyroidism: These may include poor attention span, hyperactivity,

restlessness, heat intolerance, or loose stools.
Asymptomatic thyroiditis
Asymptomatic thyroiditis with or without thyroid function abnormalities may also be
discovered upon routine screening of children at high risk; these include children with Down
syndrome or Turner syndrome and children with other autoimmune endocrine disorders (eg,
type 1 diabetes, Addison disease, vitiligo).
Celiac disease
The prevalence of celiac disease is increased in those with autoimmune thyroid disease and
comorbidities such as type 1 diabetes and Down syndrome.[5]

Physical
Acute thyroiditis

The patient may have a fever of 38-40C.

Acute illness may be evident.
Neck tenderness is present, and the swollen thyroid gland is tender. The swelling and
tenderness may be unilateral. Erythemas develop over the gland, and regional
lymphadenopathy may develop as the disease progresses. Abscess formation may occur.
Subacute thyroiditis

The patient may have signs of systemic illness, such as low-grade fever and
weakness.

Signs of hyperthyroidism, including increased pulse rate, widened pulse pressure,

fidgeting, tremor, nervousness, tongue fasciculations, brisk reflexes (possibly with clonus),
weight loss, and warm moist skin, may be present.

The thyroid gland may be enlarged and tender, with tenderness exacerbated by neck
extension.
Chronic autoimmune thyroiditis

Initially, an enlarged, lumpy, bumpy, and nontender thyroid is often present. The
gland may not be enlarged, particularly in children who have profound hypothyroidism.

Signs of hypothyroidism include slow growth rate, weight gain, slow pulse, cold dry skin,
coarse hair and facial features, edema, and delayed relaxation of the deep tendon
reflexes.
Signs of hyperthyroidism are occasionally present early in the disease.

Causes
Acute suppurative thyroiditis is more common in poorer geographic areas where antibiotic
use is less prevalent. It usually occurs in children with embryologic abnormalities such as a
persistent thyroglossal duct or brachial cleft cysts.
Chronic autoimmune thyroiditis is more common in developed countries with increased
iodine intake.
Children with Down syndrome or Turner syndrome and those who have type 1 diabetes or
another autoimmune endocrine disease are at particular risk of chronic thyroiditis.

Differential Diagnoses

Hyperthyroidism

Hypothyroidism

Pediatric Hyperthyroidism

Pediatric Hypothyroidism

Laboratory Studies
Acute thyroiditis
See the list below:

Laboratory abnormalities in acute thyroiditis reflect the acute systemic

illness.
Findings include leukocytosis with a left shift and an increased
sedimentation rate.
Thyroid function test results are within the reference range.

Subacute thyroiditis
See the list below:

The primary laboratory abnormalities are consistent with abnormal thyroid

function. Initially, the thyroid-stimulating hormone (TSH) level is suppressed,
and the free thyroxine (T4) level is increased. As the disorder progresses,
transient or sometimes permanent hypothyroidism may develop.

The WBC count is usually within the reference range but may be mildly
elevated. High-sensitivity C-reactive protein levels are usually elevated in
subacute thyroiditis.

Chronic thyroiditis
See the list below:

Laboratory abnormalities reflect thyroid function abnormality and

evidence of autoimmunity.
TSH levels are increased in children with subclinical and overt
hypothyroidism. Free T4 levels are within the reference range in the former and
low in the latter. In children with hyperthyroidism, TSH levels are suppressed.
Many children have normal thyroid function and normal TSH levels.
Antithyroid peroxidase (antithyrocellular, antimicrosomal) antibody levels
elevated above the reference range are the most sensitive indicator of thyroid
autoimmunity. Many children also have antithyroglobulin antibodies, although
this is less sensitive and less specific.

Imaging Studies
Radioactive iodine thyroid scanning
See the list below:

Radioactive iodine thyroid scanning is not necessary for acute suppurative

thyroiditis because the results are normal and do not aid in diagnosis. A scan
may be helpful after diagnosis to identify a persistent thyroglossal duct as a
route for infection.
This test is also unnecessary for chronic thyroiditis because the results can
be misleading and may show increased uptake consistent with Graves disease,
a multinodular goiter, or a hypofunctioning or hyperfunctioning nodule.
Radioactive iodine thyroid scanning is helpful in patients with
hyperthyroidism who are thought to have subacute thyroiditis because the
extremely low uptake is consistent with the thyrocellular destruction in
progress.

Thyroid ultrasonography
See the list below:

Thyroid ultrasonography is useful in revealing abscess formation in

patients with acute thyroiditis.
The degree of hypoechogenicity on ultrasonography is related to the
degree of thyroid dysfunction but its clinical use in chronic thyroiditis is
questionable and does not alter management in children with chronic
thyroiditis.[6]
The overall of specificity of thyroid ultrasonography to identify specific
concerns is questionable. A study in Germany found thyroid ultrasonography

abnormalities in 40% of a random adult population, including nodules in 35.6%.

[7]

Medical Care
Acute thyroiditis

Acute thyroiditis requires immediate parenteral antibiotic therapy before abscess

formation begins. For initial antibiotic therapy, administer penicillin or ampicillin to cover
gram-positive cocci and the anaerobes that are the usual causes of the disease.
In patients who are allergic to penicillin, cephalosporins are appropriate.
Patients with acute thyroiditis may require inpatient care to complete 10-14 days
of antibiotics.
Subacute thyroiditis

Subacute thyroiditis is self-limiting; therefore, the goals of treatment are to relieve

discomfort and to control the abnormal thyroid function. The discomfort can usually be
relieved with low-dose aspirin (divided every 4-6 h). In the rare cases that aspirin does
not relieve the discomfort, administer prednisone for 1 week and then taper.
Propranolol can be used to reduce signs and symptoms of hyperthyroidism.
Low-dose levothyroxine may be necessary in some patients who develop
hypothyroidism.
Chronic autoimmune thyroiditis

Treatment for chronic autoimmune thyroiditis depends on the results of the

thyroid function tests. Patients with overt hypothyroidism who have high thyroidstimulating hormone (TSH) and low free T4 levels require treatment with levothyroxine.
The dose is age dependent. TSH levels should be monitored and the dose should be
adjusted to maintain levels within the reference range.
The treatment of subclinical hypothyroidism in patients with elevated TSH and
normal free T4 levels is controversial. These children may enter a remission phase and
may not have permanent hypothyroidism. This appears to be a minority of subjects.
One study found that 4 of 14 subjects had normalization of TSH after a follow-up of 312 years. Most pediatric endocrinologists recommend treatment of subclinical
hypothyroidism during childhood to ensure normal growth and development. If
thyroxine administration may not be permanently required, treatment may be stopped
once the patient has completed pubertal development, and thyroid function then can
be reassessed. Guidelines for the diagnosis and management of subclinical thyroid
disease have been established.
The use of thyroxine treatment in patients with a goiter due to autoimmune
thyroiditis who have normal TSH and free T4 levels is even more controversial. Some
studies have suggested that treatment may decrease gland size, [8, 9] but other studies
suggest that reduction in gland size is likely only in children with initially elevated TSH
levels.[4]

Surgical Care

In acute thyroiditis, surgery may be necessary to drain the abscess and to correct the
developmental abnormality responsible for the condition.
The surgical service consulted depends on the institution and the physician who has the
most experience with thyroid surgery. Options include the following:

Pediatric surgery
Otolaryngology
A specialized endocrine surgery service

Consultations
Acute thyroiditis: Consulting with a pediatric infectious disease specialist may be useful
for selecting appropriate antibiotic therapy.
Subacute and chronic thyroiditis: Consulting with a pediatric endocrinologist should be
considered in treating children with these disorders. This is particularly true if the child
has experienced poor growth possibly due to hypothyroidism, has symptoms of overt
hyperthyroidism, or has a discrete thyroid nodule.

Diet
No dietary limitations are necessary.

Activity
Children with overt hyperthyroidism or hypothyroidism have poor exercise tolerance.
These children usually limit their own activity. As treatment progresses and thyroid
function levels return to normal, their exercise tolerance should increase.

Long-Term Monitoring
Subacute thyroiditis

This is a self-limiting disease that may last 2-7 months.

During this time, monitor thyroid function and adjust medications as needed.
Chronic autoimmune thyroiditis

Outpatient care involves monitoring thyroid function tests. Patients with normal
thyroid function test results should be examined every 6 months to ensure that they do
not develop hypothyroidism. After a year, these visits may be annual.
Children who require thyroxine therapy should undergo thyroid function tests
every 3-12 months, depending on age. More frequent testing is required in younger
children. Thyroid-stimulating hormone (TSH) and free T4 levels should be checked 1
month after any change in dosage.

Medication

Procedures
Fine-needle thyroid aspiration
See the list below:

This procedure is advocated by some to document the presence of thyroid

lymphocytic infiltration in autoimmune thyroiditis. Histologic results are predictive of thyroid
function; however, the results can be misinterpreted and can lead to unnecessary thyroid
surgery.
Reserve this test for patients in whom underlying malignancy is suggested by a
discrete thyroid nodule.
In patients with acute thyroiditis, needle aspiration can be used to obtain material for
culture, enabling appropriate antibiotic therapy.

Antibiotics
Class Summary
These agents are used to treat acute suppurative thyroiditis. First-line antibiotic choices
to treat acute thyroiditis include parenteral penicillin or ampicillin. These drugs cover
most of the gram-positive cocci and anaerobes that cause the disease.
View full drug information

Penicillin G (Pfizerpen)

Antibiotic with activity against gram-positive, some gram-negative, and some anaerobic
bacteria. Penicillin binds to PBPs, inhibiting bacterial cell wall growth.
View full drug information

Ampicillin (Principen)

Penicillin antibiotic with activity against gram-positive and some gram-negative bacteria.
Binds to PBPs, inhibiting bacterial cell wall growth.

Anti-inflammatory drugs

Class Summary
These drugs are used to decrease discomfort in patients with subacute thyroiditis.
View full drug information

Aspirin (Anacin, Bayer)

Most patients respond well to aspirin as a first-line therapy. Treats mild to moderate pain.
Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating
thromboxane A2.
View full drug information

Prednisone (Sterapred)

Used when aspirin is ineffective in controlling discomfort in patients with subacute

thyroiditis. May decrease inflammation by reversing increased capillary permeability and
suppressing PMN activity.

Beta-adrenergic blocking agents

Class Summary
Many signs and symptoms of hyperthyroidism are due to increased beta-adrenergic
sensitivity. In particular, these include the hemodynamic abnormalities of tachycardia
and hypertension. Beta-adrenergic blockade can reduce many of these symptoms.
These agents are the DOC in treating cardiac arrhythmias that result from
hyperthyroidism. These agents control cardiac and psychomotor manifestations within
minutes.
View full drug information

Propranolol (Inderal)

Can be immediately initiated in patients with hyperthyroidism due to either subacute

thyroiditis or autoimmune thyroiditis. Because of the self-limiting nature of these
situations, they may be the only drugs needed.

Hormones
Class Summary

These agents are used to treat hypothyroidism due to autoimmune thyroiditis. Use
thyroid-stimulating hormone (TSH) levels to monitor dose and keep them within the
reference range.
View full drug information

Levothyroxine (Levothroid, Levoxyl, Synthroid)

Levothyroxine is a synthetic form of thyroxine involved in normal growth, metabolism,

and development.