Riedel's thyroiditis association with IgG4-related disease.

CONTEXT: IgG4-positive (+) plasma cells have been reported in both Riedel's thyroiditis (RT) and Hashimoto's thyroiditis (HT). These cells are the hallmark of IgG4-related disease (IgG4-RD). OBJECTIVE: We sought to determine whether RT is part of IgG4-RD spectrum. DESIGN, SETTING AND PATIENTS: This was a case-control study performed at a tertiary medical centre. We included RT cases from the period 1958 to 2008 that had sufficient paraffin-embedded tissue for IgG4 immunostaining. Controls were patients with HT, age and gender matched, with similar pathology criteria. MAIN OUTCOME MEASURE: The main outcome measures were the intensity of the IgG4 staining and the clinical and histological correlates with IgG4-RD. RESULTS: Six pairs of RT and HT were analysed. The mean age was 44·7 years. In both groups, 5/6 cases had positive IgG4 staining. The mean number of IgG4 + cells/ HPF, normalized to the degree of inflammation, was 3·2 ± 3·0 SD (RT) vs 0·9 ± 0·7 (HT), P = 0·15, for fibrotic areas and 2·1 ± 2·3 SD vs 1·0 ± 0·8 (P = 0·39) for areas with lymphoid aggregates. We found the number of IgG4 +  cells in RT to be inversely correlated with the duration of disease (P = 0·046). Three RT cases had associated comorbidities from the IgG4-RD spectrum while none of the HT cases had such conditions. CONCLUSIONS: Riedel's thyroiditis is a component of IgG4-RD with the density of the IgG4 +  lymphocytic infiltrate being time dependent. In this small study, we did not identify differences in IgG4 infiltration between RT and HT, minimizing the utility of this marker in RT diagnosis.

[Inflammatory diseases of the thyroid gland]. / Entzündungen der Schilddrüse.

This review article deals with the classification, clinical features and morphology of thyroiditis. These inflammatory diseases account for approximately 20 % of all thyroid diseases. The vast majority of cases of thyroiditis are of immunogenic origin while non-immunogenic thyroiditis (caused by pathogens or iatrogenic) is a rarity.

Multifocal fibrosing thyroiditis: report of 55 cases of a poorly recognized entity.

During the course of our consultation activity, we have recognized a peculiar form of thyroiditis in which multiple foci of fibrosis, most of which were associated with reactive atypia of the surrounding follicles, are present. We have referred to this condition, both in our consultation reports and in the third series of A.F.I.P. Fascicle on Tumors of the Thyroid Gland, as "multifocal fibrosing thyroiditis" or (less frequently) "multifocal sclerosing thyroiditis," which are descriptive terms that highlight the benign/inflammatory nature of the process, its multiplicity, and its unknown pathogenesis. The aim of this study is to better define the morphologic features of this process and correlate it with some clinical data. With this purpose, the consultation files of one of the authors (J.R.) were searched for cases coded as multifocal fibrosing thyroiditis or multifocal sclerosing thyroiditis in a 20-year period ranging from January 1989 to December 2009. A total of 55 cases were identified that displayed the above-listed features. There were 51 (93%) female and 4 (7%) male patients (F/M=12.75), with ages ranging between 15 and 71 years (mean age, 47.03 y; median age, 44.5 y). Microscopically, multiple foci of fibrosis were identified in all cases, their number ranging from 2 to 51 per case (mean number, 16), with a mean diameter of 3 mm (range: 0.36 to 15.1 mm). Although heterogenous in shape and size, the individual foci were rather similar to each other in composition, being characterized by a fibrotic poorly cellular center that merged with a cellular peripheral zone. Some of the follicular structures present at the periphery of the scar and-to a lesser extent-those entrapped inside it underwent complex reactive and regenerative (atypical) changes that simulated malignancy. We discuss the differential diagnosis with other benign and malignant thyroid conditions and speculate about its pathogenesis and possible relationship with papillary thyroid microcarcinoma.

Thyroiditis: an integrated approach.

Thyroiditis is a general term that encompasses several clinical disorders characterized by inflammation of the thyroid gland. The most common is Hashimoto thyroiditis; patients typically present with a nontender goiter, hypothyroidism, and an elevated thyroid peroxidase antibody level. Treatment with levothyroxine ameliorates the hypothyroidism and may reduce goiter size. Postpartum thyroiditis is transient or persistent thyroid dysfunction that occurs within one year of childbirth, miscarriage, or medical abortion. Release of preformed thyroid hormone into the bloodstream may result in hyperthyroidism. This may be followed by transient or permanent hypothyroidism as a result of depletion of thyroid hormone stores and destruction of thyroid hormone-producing cells. Patients should be monitored for changes in thyroid function. Beta blockers can treat symptoms in the initial hyperthyroid phase; in the subsequent hypothyroid phase, levothyroxine should be considered in women with a serum thyroid-stimulating hormone level greater than 10 mIU per L, or in women with a thyroid-stimulating hormone level of 4 to 10 mIU per L who are symptomatic or desire fertility. Subacute thyroiditis is a transient thyrotoxic state characterized by anterior neck pain, suppressed thyroid-stimulating hormone, and low radioactive iodine uptake on thyroid scanning. Many cases of subacute thyroiditis follow an upper respiratory viral illness, which is thought to trigger an inflammatory destruction of thyroid follicles. In most cases, the thyroid gland spontaneously resumes normal thyroid hormone production after several months. Treatment with high-dose acetylsalicylic acid or nonsteroidal anti-inflammatory drugs is directed toward relief of thyroid pain.

Combined mycophenolate mofetil and prednisone therapy in tamoxifen- and prednisone-resistant Reidel's thyroiditis.

BACKGROUND: Mycophenolate mofetil is a recently identified therapy for disorders associated with systemic fibrosis, but has never been reported in the treatment of Reidel's thyroiditis. We report the first case of Reidel's thyroiditis that became resectable after treatment with mycophenolate and prednisone. SUMMARY: A 27-year-old woman presented to an outside hospital with thyromegaly associated with compressive symptoms. The patient underwent a neck exploration with thyroid biopsy that revealed evidence of fibrosing variant Hashimoto's thyroiditis. The patient was then treated with tamoxifen and prednisone at an outside hospital without resolution. After initial evaluation she underwent an open thyroid wedge biopsy that revealed Reidel's thyroiditis. She was subsequently treated with both 1 g mycophenolate twice daily and 100 mg prednisone daily. The patient experienced immediate subjective improvement of compressive symptoms and objective decrease in mass size at 30 days, as seen by serial computed tomography examination. By 90 days of therapy the mass had decreased to a size small enough to allow subtotal thyroidectomy, which was completed over two staged procedures. CONCLUSIONS: Reidel's thyroiditis remains a primarily surgical disease. Patients who are not surgical candidates have been treated with tamoxifen and prednisone with equivocal results. Our report is the first to suggest the combination of mycophenolate and prednisone as a viable treatment option for patients with Reidel's thyroiditis.

Revisión histórica de la tiroiditis / Historial review of thyroiditis

La inflamación de la glándula tiroides, tiroiditis, puede presentarse por tres causas principales: autoinmune, infecciosa y secundaria a fármacos. Entre las tiroiditis de base autoinmune destacan: tiroiditis de Hashimoto, descubierta en el año 1912 por el japonés Dr. Hakaru Hashimoto, reportándola como "struma lymplhomatosa" en su artículo "Notes of lymphomatous in the thyroid gland"; tiroiditis Silente o indolora, reportada en el año 1977 por Nobuyuki Amino et al en su artículo "Transient post-partum hypothyroidism: fourteen cases with autoimmune thyroiditis" luego del estudio de 14 casos de tiroiditis post-parto; tiroiditis de Riedel, enfermedad descubierta en 1883 por Bernhard Riedel, publicado en 1896 una descripción de dos casos usando el nombre de "eisenharte struma", posteriormente estudiada por investigadores como Woolner et al (1957) y por Schwaegerle et al (1988). Entre las tiroiditis de base infecciosa se han descrito dos tipos: tiroiditis aguda o supurada infecciosa originada por bacterias, hongos, o parásitos, siendo predominante en individuos con cierto grado de inmunosupresión; tiroiditis de Quervain, descubierta por Fritz de Quervain, quien en 1902 presenta ante el Congreso de la Sociedad Alemana de Cirugía su trabajo titulado "Ueber acute, nicht eiterige thyreoiditis" (tiroiditis subaguda no supurativa), y es para 1904 que pública su trabajo "Die akute nicht eiterige thyreoiditis und die betelingung der schilddrüse an akuten intoxikationen und infektionen überhaupt", que luego llevaría el nombre del investigador. Por último se encuentran las tiroiditis secundarias a fármacos como amiodarona y litio, cuyos componentes han sido responsables de la inflamación de la glándula tiroidea.

Inflammation of the thyroid gland, also called thyroiditis, can occur by three main causes autoimmune, infectious and secondary to drugs. Thyroiditis of autoimmune origin include: Hashimoto's thyroiditis, discovered in 1912 by japanese Dr. Hakaru Hashimoto who reported it as "struma lymphomatosa" in his article "Notes of lymphomatous in the thyroid gland"; Silent or painless thyroiditis, reported in 1977 by Nobuyuki Amino et al in their article "Transient postpartum hypothyroidism: fourteen cases with autoimmune thyroiditis" after studying 14 cases of postpartum thyroiditis; Riedel thyroiditis, a disease discovered in 1883 by Bernhard Riedel, who published in 1896 a description of two cases using the name "eisenhart struma" to describe this new form, later developed by researchers Woolner et al (1957) and Schwagerle et al (1988). Among the infectious thyroiditis there have been desribed two types: acute or suppurative thyroiditis caused by infectious bacteria, fungi, parasites, being individuals with a degree of immunosuppression the main risk group; De Quervain's thyroiditis, disecovered by Fritz de Quervain, who in the Congress of the German Society of Surgery of 1902 presented his work entitled "ueber acute, nicht eiterige tryreoiditis" (non suppurative subacute thyroiditis), and by 1904 published his work entitled "Die akute nicht eiterige thyreoiditis und die beteilingung der schilddrüse an akuten intoxikationen und infektionen überhaupt", named later after him. Finally thyroiditis secondary to drugs such as amiodarone and lithium, whose components are responsible for inflammation of the thyroid gland.

Tireoidite / Thyroiditis

As tireoidites são doenças inflamatórias da tireóide. Consistem um grupo variado de patologias correlacionadas que apresentam, ao mesmo tempo,características comuns e diferenças importantes.Este artigo tem como proposta fazer uma breve revisão sobre as principais tireoidites, apresentando sua classificação, suas manifestações clínicas e laboratoriais e o tratamento de cada subgrupo.

[What diagnosis can be made by the pathologist in a case of sclerosing thyroiditis?]. / Quel diagnostic l'anatomopathologiste peut-il porter en présence d'une thyroïdite sclérosante ?

The pathology of thyroiditis seems well-established with a recognized classification based on clinical and pathological features. However, problems of differential diagnosis remain between both Riedel's and Quervain's thyroiditis and sclerosing Hashimoto's thyroiditis: these entities sometimes lack the characteristic histological pattern, and the clinico-biological data are not always available to the pathologist. We re-examined 18 cases of thyroiditis with sclerosis, retrieved from our files, diagnosed as Riedel's thyroiditis in five cases, Quervain's thyroiditis in five other cases and sclerosing Hashimoto thyroiditis in eight cases. Only two diagnosed cases of Riedel's thyroiditis were pathognomic. Three cases of Quervain's thyroiditis and four cases of sclerosing Hashimoto's thyroiditis presented a slight or moderate extension of the fibrosis in perithyroidal soft-tissues, raising the differential diagnosis of an incipient Riedel's thyroiditis. A definite diagnosis of the type of thyroiditis with sclerosis remains difficult, because all three pathologies present common points. In cases with a characteristic pattern, the diagnosis is straightforward. However, it appears in our study that half of the diagnoses remain ambiguous, because of the existence of histological features common to different entities. In these cases, we think the diagnosis of sclerosing thyroiditis NOS would be more appropriate, the histology not being sufficiently characteristic to make a more specific diagnosis.

Hyperthyroidism.

Thyrotoxicosis is a condition resulting from elevated levels of thyroid hormone. In this article, the authors review the presentation, diagnosis, and management of various causes of thyrotoxicosis.

Espectro clinicopatológico de las tiroiditis

El espectro clinicopatológico de las tiroiditis abarca, desde la rara tiroiditis aguda o supurativa hasta la más rara tiroiditis de Riedel. Las tiroiditis subaguda y silente (y su variante postpartum) también son enfermedades no comunes, mientras que la tiroiditis crónica autoinmune o enfermedad de Hashimoto resulta la tiroiditis y la enfermedad autoinmune órgano específica más frecuente, responsable de la mayor parte de los casos de hipotiroidismo. Efectivamente, en las áreas geográficas no deficientes en yodo, la mayor parte de los desórdenes tiroideos se deben a enfermedad autoinmune. La autoinmunidad como fenómeno primario juega un papel trascendente en la etiopatogenia de la tiroiditis crónica autoinmune, la tiroiditis silente-postpartum y la tiroiditis de Riedel y, sólo un rol secundario en la tiroiditis subaguda. Posiblemente, las infecciones virales causan la tiroiditis subaguda, mientras que los gérmenes piógenos y hongos son responsables de la tiroiditis supurativa. Las tiroiditis autoinmunes y la tiroiditis subaguda se acompañan comúnmente de disfunción tiroidea. Se conoce como “tiroiditis destructiva” al proceso inflamatorio tiroideo acompañado de destrucción y tirotoxicosis transitoria.

En estos casos, la disfunción tiroidea adopta usualmente el patrón de “tiroiditis bifásica”, en la que secuencialmente, la tirotoxicosis pasajera va seguida de hipotiroidismo transitorio y recuperación. Desórdenes con diferente etiopatogenia, como la tiroiditis subaguda, la tiroiditis silente y la enfermedad de Hashimoto, son responsables de los fenómenos fisiopatológicos similares que dan origen a la tiroiditis bifásica. El dolor en la tiroides adquiere relevancia en la tiroiditis subaguda y en la tiroiditis supurativa y, sólo raramente, está presente en la tiroiditis silente o en la exacerbación aguda de la enfermedad de Hashimoto. En la mayor parte de los casos, es posible establecer el diagnóstico de la tiroiditis mediante la historia clínica, las pruebas de función tiroidea y los estudios isotópicos y ecosonográficos. La biopsia tiroidea por aspiración con aguja fina permite resolver los casos dudosos. Esta revisión del “Espectro clínico-patológico de las tiroiditis”, resulta una síntesis de la información bibliográfica y la experiencia lograda con las tiroiditis a través de un enfoque clínico integral.

Clinical-pathological spectrum of thyroiditis comprises from the rare acute o suppurative thyroiditis as far as the rarest Rieldel’s thyroiditis. Also, subacute and silent thyroiditis (and it postpartum variant) are non common diseases, while autoimmune chronic thyroiditis or Hashimoto’s disease results the most frequent thyroiditis and organ-specific autoimmune disorder, that is responsible for most part of hypothyroidism cases. Effectively, in iodine-replete geographic areas, most persons with thyroid disorders have autoimmune disease. Autoimmunity as primary phenomenon plays a transcendent role in etiopathogeny of chronic autoimmune thyroiditis, silent-postpartum thyroiditis and Riedel’s thyroiditis and only a secondary role in subacute thyroiditis. Probably, viral infections cause subacute thyroiditis, while pyogenic germs and fungus are responsible for suppurative thyroiditis. Commonly, autoimmune and subacute thyroiditis are associated with thyroid dysfunction. It is known as “destructive thyroiditis”, the thyroidal inflammatory process that is joined to destruction and transient thyrotoxicosis.

Usually, thyroid dysfunction in these cases adopt “biphasic thyroiditis” pattern, in which sequentially, transient thyrotoxicosis is followed by transient hypothyroidism and recovery. Disorders with different etiopathogeny as subacute thyroiditis, silent thyroiditis and Hashimoto’s thyroiditis are responsible of similarly physiopathologic phenomenons that originated biphasic thyroiditis. Pain in the thyroidal gland is relevant in subacute and suppurative thyroiditis and, rarely is present in silent thyroiditis or in acute exacerbation of Hashimoto’s thyroiditis. In most of the cases, it is possible to establish the diagnosis of thyroiditis through clinical history, thyroidal function tests, isotopic studies and ecosonography. Thyroid fine needle biopsy resolves doubtful cases. This review about “Clinical-pathological spectrum of thyroiditis”, results from the synthesis of bibliographic information and the experience obtained with thyroiditis through and integral clinic focus.

Thyroid disorders. Part II: hypothyroidism and thyroiditis.

Part II of the series on thyroid disorders discusses hypothyroidism and thyroiditis that may be found in dental patients. An overview of the conditions is presented. Presenting signs and symptoms, laboratory tests used to diagnose hypothyroidism and thyroiditis, and their medical management is discussed. The dental management of patients with hypothyroidism is discussed in detail. The dentist by detecting the early signs and symptoms of hypothyroidism and thyroiditis can refer the patient for medical diagnosis and treatment and avoid potential complications of treating patients with uncontrolled disease. Patients with thyroiditis may have a short period of being hyperthyroid and it may be best to avoid routine dental treatment during that period. Patients with suppurative thyroiditis should not receive routine dental treatment during the acute stage of the disease. The end stage of Hashimoto's thyroiditis results in hypothyroidism. Central nervous system depressants, sedatives, or narcotic analgesics must be avoided in patients with severe hypothyroidism because significant respiratory depression may occur. In addition, myxedematous coma, particularly in elderly hypothyroid patients, can be precipitated by central nervous system depressants, infection, and possibly stressful dental procedures. In medically well-controlled patients the dental treatment plan is not affected and most dental procedures can be offered to these patients.

The clinical and physiological spectrum of interferon-alpha induced thyroiditis: toward a new classification.

Interferon-alpha (IFNalpha) is a major treatment modality for several malignant and nonmalignant diseases, especially hepatitis C. Prospective studies have shown that up to 15% of patients with hepatitis C receiving IFNalpha develop clinical thyroid disease, and up to 40% were reported to develop thyroid antibodies. Some of these complications may result in discontinuation of interferon therapy. Thus, interferon induced thyroiditis (IIT) is a major clinical problem for patients receiving interferon therapy. IIT can be classified as autoimmune type and non-autoimmune type. Autoimmune IIT may manifest by the development of thyroid antibodies without clinical disease, or by clinical disease which includes both autoimmune hypothyroidism (Hashimoto's thyroiditis) and autoimmune thyrotoxicosis (Graves' disease). Non-autoimmune IIT can manifest as destructive thyroiditis or as hypothyroidism with negative thyroid antibodies. Early detection and therapy of these conditions is important in order to avoid complications of thyroid disease such as cardiac arrhythmias. While it is not clear which factors contribute to the susceptibility to IIT, recent evidence suggests that genetic factors, gender, and hepatitis C virus infection may play a role. In contrast, viral genotype and therapeutic regimen do not influence susceptibility to IIT. The etiology of IIT is unknown and may be secondary to immune modulation by IFNalpha and/or direct effects of interferon on the thyroid. In this review we discuss the clinical and pathophysiological aspects of IIT, and we are proposing a new, etiology-based classification of IIT, as well as an algorithm for diagnosis and treatment of IIT.

Tiroiditis de Hashimoto en niños y adolescentes con bocio / Hashimoto´s thyroiditis in children and adolescents with goiter

Se denomina bocio al aumento de tamaño de la glándula tiroidea, que da lugar a un abultamiento en la región anterior del cuello, el agrandamiento de los lóbulos laterales de la tiroides debe ser superior al tamaño de la falange distal del dedo pulgar del paciente. La tiroiditis de Hashimoto es la inflamación crónica de la tiroides de origen autoinmunitario; cursa con bocio y puede provocar hipotiroidismo existe un hipotiroidismo, este se desarrolla en forma paulatina. El tratamiento del paciente hipotiroideo consiste en la administración de levotiroxina.

[Inflammatory diseases of the thyroid gland. Epidemiology, symptoms and morphology]. / Entzündliche SchilddrüsenerkrankungenEpidemiologie, Klinik und Morphologie.

Inflammation of the thyroid gland makes up approximately 20% of all thyroid diseases. According to the clinical course, thyroiditis has been subdivided into acute, subacute, and chronic forms. Recent classifications are based on the fact that the majority of thyroiditis cases have an autoimmune background. The most common form of this disease is autoimmune thyroiditis (AIT), with or without subclinical/manifest hypothyroidism; less common forms of autoimmune thyroiditis comprise subacute granulomatous (de Quervain's) thyroiditis, postpartum thyroiditis, silent ("painless") thyroiditis, and invasive-sclerosing thyroiditis (Riedel's thyroiditis). Non-autoimmune thyroiditis is very rare (acute suppurative thyroiditis, radiation thyroiditis). Thyroiditis is both clinically and morphologically an important differential diagnosis of thyroid tumours. The present paper deals with the epidemiology, clinical course, and morphology of thyroiditis, knowledge of which is essential for the examination of cytological and histological thyroid specimens.

Algunos aspectos de la tiroiditis / Some aspects of the tiroiditis

Se presenta una revisión de la tiroiditis donde se incluye su definción, clasificación, diagnóstico y el tratamiento de los casos de tiroiditis aguda, subaguda y crónica.