Hashimoto’s Thyroiditis: Symptoms, Causes, and Treatments

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Hashimoto’s thyroiditis is chronic autoimmune inflammation of the thyroid with lymphocytic infiltration. Findings include painless thyroid enlargement and symptoms of hypothyroidism. Diagnosis involves demonstration of high titers of thyroid peroxidase antibodies. Lifelong L-thyroxine replacement is typically required.

Hashimoto’s thyroiditis is believed to be the most common cause of primary hypothyroidism in North America. It is twice as prevalent among women. Incidence increases with age and in patients with chromosomal disorders, including Down, Turner’s, and Klinefelter’s syndromes. A family history of thyroid disorders is common.

Hashimoto’s thyroiditis, like Graves’ disease, is sometimes associated with other autoimmune disorders, including Addison’s disease (adrenal insufficiency), type 1 diabetes mellitus, hypoparathyroidism, vitiligo, premature graying of hair, pernicious anemia, connective tissue diseases (eg, RA, SLE, Sjogren’s syndrome), and Schmidt’s syndrome (Addison’s disease, diabetes, and hypothyroidism secondary to Hashimoto’s thyroiditis). There may be an increased incidence of thyroid tumors, rarely thyroid lymphoma. Pathologically, there is extensive infiltration of lymphocytes with lymphoid follicles and scarring.

Symptoms and Signs

Patients complain of painless enlargement of the thyroid or fullness in the throat. Examination reveals a nontender goiter that is smooth or nodular, firm, and more rubbery than the normal thyroid. Many patients present with symptoms of hypothyroidism, but some present with hyperthyroidism.

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Diagnosis

  • Thyroxine (T4)
  • Thyroid-stimulating hormone (TSH)
  • Thyroid autoantibodies

Testing consists of measuring T4, TSH, and thyroid autoantibodies; early in the disease T4 and TSH levels are normal and there are high levels of thyroid peroxidase antibodies and less commonly of antithyroglobulin antibodies. Thyroid radioactive iodine uptake may be increased, perhaps because of defective iodide organification together with a gland that continues to trap iodine. Patients later develop hypothyroidism with decreased T4, decreased thyroid radioactive iodine uptake, and increased TSH. Testing for other autoimmune disorders is warranted only when clinical manifestations are present.

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Treatment

Occasionally, the hypothyroidism is transient, but most patients require lifelong thyroid hormone replacement, typically L-thyroxine 75 to 150 μg po once/day.

Medicine can replace hormones that your body doesn’t make. It is inexpensive, very effective, and available in many doses to properly treat each patient. The goal is to provide the body with enough hormone so that it works normally.

The medicine, called synthetic thyroid hormone or levothyroxine, should be taken daily because the body needs a new supply each day. Regular blood tests will ensure the right dose. The right dose of the synthetic hormone has no side effects.

Doses that are too high may cause palpitations, nervousness, shakiness, bone loss, and increased bowel movements. These symptoms should prompt blood tests to check whether the dose should be changed.

Patients should start feeling better within a few weeks after starting thyroid medicine.

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