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Journal of Endocrinology, Metabolism and Diabetes of

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A case of Riedel's thyroiditis

a b
Carolyn Droste MB BCh, FCP (SA), Cert Endocrinol , L Nokoane MB BCh , K R L Huddle MB BCh, FCP
c c
(SA), FRCP & R Shires BSc, MB BCh, PhD, FRCP
a
Division of Endocrinology, Department of Medicine, Chris Hani Baragwanath Hospital and
University of the Witwatersrand, Johannesburg
b
Department of Anatomical pathology, National Health Laboratory Service and University of the
Witwatersrand, Johannesburg
c
Division of Endocrinology, Department of Medicine, Chris Hani Baragwanath Hospital and
University of the Witwatersrand
Published online: 14 Aug 2014.

To cite this article: Carolyn Droste MB BCh, FCP (SA), Cert Endocrinol, L Nokoane MB BCh, K R L Huddle MB BCh, FCP (SA), FRCP &
R Shires BSc, MB BCh, PhD, FRCP (2007) A case of Riedel's thyroiditis, Journal of Endocrinology, Metabolism and Diabetes of South
Africa, 12:2, 72-74, DOI: 10.1080/22201009.2007.10872160

To link to this article: http://dx.doi.org/10.1080/22201009.2007.10872160

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 case report

A case of Riedel’s thyroiditis

Division of Endocrinology, Department of Medicine, Chris Hani Baragwanath Hospital and

University of the Witwatersrand, Johannesburg
Carolyn Droste, MB BCh, FCP (SA), Cert Endocrinol
Department of Anatomical Pathology, National Health Laboratory Service and University of
October 2007, Vol. 12, No. 2

the Witwatersrand, Johannesburg

L Nokoane, MB BCh
Division of Endocrinology, Department of Medicine, Chris Hani Baragwanath Hospital and
University of the Witwatersrand
JEMDSA

K R L Huddle, MB BCh, FCP (SA), FRCP

R Shires, BSc, MB BCh, PhD, FRCP

72 Riedel’s thyroiditis is a rare disorder that mainly affects middle-aged women. Dense fibrosis disrupts the
normal thyroid architecture and replaces the normal thyroid architecture, and can extend beyond the thyroid
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capsule.

This is the first report of a case of Riedel’s thyroiditis associated with systemic, multifocal fibrosis in a black
South African patient.

Case report
A 53-year-old black woman was admitted to Chris
Hani Baragwanath Hospital, Johannesburg, with
ascites. She had been diagnosed as hypothyroid the
previous year, the cause thought to be Hashimoto’s
thyroiditis. She had been treated with thyroxine,
but at the time of admission was clinically and
biochemically hypothyroid (free T4 3.3 pmol/l, TSH
>150 mIU/l). Examination revealed a small, firm goitre
which moved well on swallowing. She was mildly
proptotic. An ascitic tap was performed and the fluid
found to be chylous with a triglyceride concentration
of 3.17 mmol/l. Urea and electrolyte testing on
admission revealed that she was in renal failure (urea
32.4 mmol/l, creatinine 1 676 µmol/l). Serum calcium
and phosphate values were within normal limits.
An abdominal ultrasound scan showed her to have
bilateral hydronephrosis and a multifibroid uterus.
Gynaecological opinion was that the enlarged uterus
was unlikely to account for the hydronephrosis. An
attempted nephrostomy on the right side failed, but
was successful on the left side. Subsequently, an
intravenous haemodialysis catheter was inserted, but
following her second dialysis session, she developed a
right-sided hemiplegia and expressive aphasia. A non-
contrast computed tomography (CT) scan of the brain
showed a watershed infarct with cerebral oedema. Her
level of consciousness deteriorated further and she
died 22 days after admission.
A postmortem examination, performed with her
family’s permission, revealed the following:
1. A
 destroyed thyroid gland that had been replaced
by fibrous tissue, with lymphocyte and plasma cell
infiltration, in keeping with Riedel’s thyroiditis (Fig.
1, A, B and C).
2. Extensive perivascular fibrosis of the lungs.
3. Mediastinal fibrosis.
4. E
 xtensive retroperitoneal fibrosis, with fibrosis
surrounding the ureters bilaterally and encasing the
left kidney (Fig. 1, D).
5. A right perinephric abscess.
Discussion
Fibrous or Riedel’s thyroiditis was originally described
in 1896 as a ‘specific inflammation of mysterious
nature producing an iron hard tumefaction of the
thyroid’. It is an extremely rare condition, making
up only 0.03 - 0.98% of surgical thyroid diseases. It
is characterised by a chronic inflammatory process
which often extends beyond the thyroid gland to the
surrounding tissues, resulting in hypoparathyroidism,
hoarseness due to recurrent laryngeal nerve
involvement, and tracheal compression with stridor.
The fibrosis may extend down into the mediastinum
and also involve the anterior chest wall.1
The fibrotic process is, in fact part of a systemic,
multifocal fibrosclerotic disorder that may affect many
distant sites including the retroperitoneal space, the
retro-orbital area and the biliary tree.2 Our patient

pg72-76.indd 72 10/29/07 2:56:05 PM


A
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B plasma cells and eosinophils. Once the diagnosis has
C Alternatively, however, the multifocal nature of
D risk of trauma to neck structures. Therapy with
Fig. 1. A: Postmortem specimen of the patient’s thyroid gland
showing complete replacement of the gland by avascular fibrous
tissue. B: Haematoxylin and eosin (H&E) section through a
normal thyroid gland. Note the follicles filled with colloid. C:
H&E section through the patient’s thyroid gland. The normal
architecture has been completely obliterated by dense hyaline
fibrous tissue with a lymphocyte and plasma cell infiltrate.
D: Postmortem specimen of the patient’s right kidney and
surrounding tissue demonstrating the abundant retro-peritoneal
fibrosis encasing the kidney.
pg72-76.indd 73
had thyroid, retroperitoneal, mediastinal and lung
involvement, with the retroperitoneal fibrosis being
the likely cause of her chylous ascites.
Fibrous thyroiditis characteristically presents as a
non-tender, hard anterior neck mass which is adherent
to the adjacent soft tissues and consequently may
October 2007, Vol. 12, No. 2
JEMDSA
fail to move on swallowing. Regional lymph nodes
are sometimes enlarged so that the clinical picture
may suggest a carcinoma. Depending on the extent
of the perithyroidal soft-tissue involvement the
patient may have stridor, hoarseness, dysphagia or
hypoparathyroidism.1,3,4 Despite the extensive fibrosis,
hypothyroidism occurs in only 30 - 40% of patients.
Radio-iodine thyroid scanning shows either low or
heterogeneous uptake. Computed tomography and
ultrasound scanning may be useful to delineate the
extent of the fibrosis.
73
Fine-needle aspiration may be performed to exclude
carcinoma, if suspected. However, in cases of
fibrous thyroiditis, the cell yield is often very low. In
such circumstances an open biopsy may therefore
be necessary to make a definitive diagnosis.
Macroscopically, the thyroid tissue is hard, pale
and avascular. Histology shows dense hyalinised
fibrous tissue with a sparse infiltrate of lymphocytes,
been established, the patient should be evaluated
to exclude other sites that may be involved by the
multifocal fibrosclerotic process. Fibrosis of the
thyroid gland may also be seen in Hashimoto’s
thyroiditis, but to a far lesser extent, and does not
extend to surrounding tissues.5
The aetiology is uncertain, but the chronic
inflammatory infiltrate and vasculitis evident in the
fibrous tissue, as well as the presence of antithyroid
antibodies in the sera of two-thirds of these patients,
suggest an underlying autoimmune mechanism.
the disease is also compatible with a disorder of
the fibroblast.6 No link between drugs and Riedel’s
thyroiditis has been shown.3
Treatment is directed at both the hypothyroidism
and the fibrosclerotic manifestations. Limited surgery
is performed to relieve any tracheal or oesophageal
obstruction, if present, but more invasive surgery
should not be performed as the tissue planes are
often obscured by fibrosis, with a consequent high
corticosteroids and tamoxifen has been reported to
be helpful in a small number of patients.4,7,8 Owing to
the rarity of this condition, no clinical trials have been
performed on the efficacy of these drugs. Without
therapy, however, the condition is usually progressive,
albeit slowly, and empiric medical therapy is therefore
probably justified.
10/29/07 2:56:35 PM
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Conclusion
This is the first reported case of a black patient in
sub-Saharan Africa presenting with Riedel’s thyroiditis
accompanied extensive fibrosis.
1. Volpe R. Fibrous (Riedel’s) thyroiditis. In: Werner SC, Ingbar SH, eds. The Thyroid. A
Fundamental and Clinical Text. Hagerstown: Harper & Row, 1978: 1009-1012
2. De Lange WE, Freling NJ, Molenaar WM, Doorenbos H. Invasive fibrous thyroiditis
(Riedel’s struma): a manifestation of multifocal fibrosclerosis? A case report with
review of the literature. Q J Med 1989; 72: 709-717.
October 2007, Vol. 12, No. 2
case report
JEMDSA
A pituitary macroadenoma presenting with
74 hyponatraemia
Division of Endocrinology, Groote Schuur Hospital, Cape Town
J A Dave, PhD, FCP (SA), Cert Endocrinol (SA)
L Varkel, MB ChB
Division of Neurosurgery, Groote Schuur Hospital
P Semple, FCS Neurol (SA), MMed
Division of Endocrinology, Groote Schuur Hospital
N S Levitt, MD, FCP (SA)
A non-functional pituitary macroadenoma commonly
presents with headaches and/or visual field defects,
which may even extend to blindness. Although
symptoms are often present before diagnosis they
are frequently not appreciated because they are
nonspecific, require a focused history and are
therefore erroneously attributed to other causes.
Hyponatraemia is a common electrolyte disturbance
with many different causes, but is rarely due to
hypopituitarism. Yet hyponatraemia is potentially
life-threatening, requiring a prompt diagnosis and
initiation of appropriate therapy. In the setting
of hypopituitarism this may merely be hormone
replacement, obviating the need for meticulous fluid
replacement to avoid central pontine myelinolysis
(CPM).
We report on a patient presenting with hyponatraemia
secondary to hypoadrenalism and hypothyroidism due
to a pituitary macroadenoma.
Case report
A 67-year-old man presented to the medical
emergency department with a 2-week history of left-
sided lower abdominal pain and constipation. He did
not complain of vomiting but did have a 1-year history
of weight loss. There was no significant past medical
history and he was not taking any medication.
pg72-76.indd 74
3. Schwaegerle SM, Bauer TW, Esselstyn CB Jr. Riedel’s thyroiditis. Am J Clin Pathol
1988; 90: 715-722.
4. Lo JC, Loh KC, Rubin AL, et al. Riedel’s thyroiditis presenting with hypothyroidism
and hypoparathyroidism: dramatic response to glucocoricoid and thyroxine therapy.
Clin Endocrinol 1998; 48: 815-818.
5. Meissner WA. Pathology. In: Werner SC, Ingbar SH, eds. The Thyroid. A Fundamental
and Clinical Text. Hagerstown: Harper & Row, 1978: 444-479.
6. Zimmermann-Belsing T, Feldt-Rasmussen U. Riedel’s thyroiditis: an autoimmune or
primary fibrotic disease? J Intern Med 1994; 235: 271-274.
7. Vaidya B, Harris PE, Barrett P, Kendall-Taylor P. Corticosteroid therapy in Riedel’s
thyroiditis. Postgrad Med J 1997; 73: 817-819.
8. Few J, Thompson NW, Angelos P, et al. Riedel’s thyroiditis: treatment with tamoxifen.
Surgery 1996; 120: 993-998.
Clinical examination revealed a well-looking patient
who was not confused, was apyrexial, and had normal
hydration, a blood pressure of 167/92 mmHg with
no postural drop, a pulse rate of 54 beats/min and
a respiratory rate of 18 breaths/min. Apart from
mild tenderness in the left lower abdomen, systemic
examination was unremarkable. Since the patient was
an elderly man with a change in bowel habits and loss
of weight, the concern at this stage was that he might
have a bowel malignancy and he was admitted to the
emergency medical admission ward.
The findings on baseline biochemical investigation
were as follows: sodium 108 mmol/l (normal 135 - 141
mmol/l), potassium 4.5 mmol/l (3.3 - 5.3 mmol/l), urea
1.5 mmol/l (2.6 - 7.0 mmol/l), creatinine 46 µmol/l (60 -
120 µmol/l), urinary sodium on a random urine sample
149 mmol/l, haemoglobin 10.2 g/dl (13.0 - 17.0 g/dl),
mean cell volume 103.8 fl (79.1 - 98.9 fl), white cell
count 4.42×109/l (4.00 - 10.00×109/l), platelets 191×109/l
(137 - 373×109/l). A chest radiograph was normal.
A working diagnosis of syndrome of inappropriate
antidiuretic hormone secretion (SIADH) was made and
the patient was placed on fluid restriction. Since his
chest radiograph was normal a magnetic resonance
image (MRI) scan of the brain was done and showed a
well-defined pituitary lesion measuring 18 mm by 18
mm, compatible with a pituitary macroadenoma (Fig.
1). The patient was then referred to the endocrine
10/29/07 2:56:36 PM