Hashimoto Thyroiditis

Original Editors - Kerri Falk and Tori Kute Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Amelia Cantrell, Kerri Falk, Elaine Lonnemann, Lucinda hampton, Kim Jackson, Admin, Tori Kute, 127.0.0.1 and WikiSysop

Introduction

Hashimoto thyroiditis is an autoimmune disease. In this condition the thyroid cells are destroyed via cell and antibody-mediated immune action. In developed countries it is the most common cause of hypothyroidism, whereas worldwide the most common cause is a deficient dietary intake of iodine.

Epidemiology

After age six, Hashimoto is the most common cause of hypothyroidism in those areas of the world where iodine intake is adequate.

• The incidence is estimated to be 0.8 per 1000 per year in men and 3.5 per 1000 per year in women.
• Studies suggests genetic genetic factors play a role and to a lesser degree environmental and sex hormone influences.
• The prevalence of thyroid disease, in general, increases with age.

Etiology

There are many factors that may play a role in acquiring Hashimoto’s disease, these factors include;

• Genes - Some people are more apt to Hashimoto's disease due to their genes. Researchers are continuing to work on finding the gene or genes that are involved
• Gender - Sex hormones are thought to take part in the cause. This may assist in explaining why Hashimoto's disease affects more women than men.
• Pregnancy - Pregnancy affects the thyroid. Some women have thyroid problems after having a baby, which usually go away. But about 20 percent of these women develop Hashimoto's disease in later years. This suggests that pregnancy might trigger thyroid disease in some women.
• Too much iodine and some drugs may bring about the onset of thyroid disease in people susceptible to acquiring it.
• Radiation exposure has been shown to trigger autoimmune thyroid disease. This includes radiation from the atomic bomb in Japan, the nuclear accident at Chernobyl, and radiation treatment of Hodgkin's disease.

BupaHealth UK. How a thyroid gland can become underactive.

Other Autoimmune Disease Associations

People with other autoimmune diseases are more likely to develop Hashimoto’s disease. The opposite is also true—people with Hashimoto’s disease are more likely to develop other autoimmune diseases. These diseases include

• Vitiligo, a condition in which some areas of the skin lose their natural color.
• Rheumatoid arthritis, a disease that causes pain, swelling, stiffness, and loss of function in the joints when the immune system attacks the membrane lining the joints.
• Addison’s Disease, in which the adrenal glands are damaged and cannot produce enough of certain critical hormones.
• Diabetes Mellitus type I, in which the pancreas is damaged and can no longer produce insulin, causing high blood glucose, also called blood sugar.
• Pernicious Anemia, a type of anemia caused by not having enough vitamin B12 in the body. In anemia, the number of red blood cells is less than normal, resulting in less oxygen carried to the body’s cells and extreme fatigue.
• Celiac Disease, a form of gastrointestinal gluten sensitivity, an autoimmune disorder in which people cannot tolerate gluten because it will damage the lining of the small intestine and prevent adsorption of nutrients. Gluten is a protein found in wheat, rye, and barley and in some products.
• Autoimmune Hepatitis, or nonviral liver inflammation, a disease in which the immune system attacks liver cells.

Characteristics/Clinical Presentation

Hashimoto Thyroiditis does not present with any unique signs and symptoms. “The condition progresses very slowly over many years, people with Hashimoto’s thyroiditis may not have any symptoms early on. Many of the signs and symptoms mimic general hypothyroid conditions. 

Signs and Symptoms:

• Painless thyroid enlargement
• Gland is sometimes easily palpable
• Fatigue and lethargy
• Cold intolerance
• Pale, dry skin
• Constipation
• Hoarseness
• Dysphagia
• Weight gain
• Myalgia and stiffness
• Proximal muscle weakness
• Excess or prolonged menstrual bleeding
• Increased PMS symptoms
• Depression

Without treatment the signs and symptoms increase in severity and include:

• Goiter: If the goiter is allowed to increase in size it can lead to "dysphagia and respiratory distress."
• Constipation
• Myxedema

As the disease progresses neurological involvement including:

• Difficulty learning
• Forgetfulness

Medications

The central component of treatment for hypothyroidism is thyroid hormone replacement. The drug used commonly is titrated levothyroxine sodium administered orally. Note the formation of thyroxine varies worldwide and there can be problems with absorption in patients with disorders of the gastric mucosa.

Diagnosis

Hashimoto’s thyroiditis is usuallt diagnosed when patients present with symptoms of hypothyroidism, often along with a goiter on physical examination. Laboratory testing of hypothyroidism shows elevated thyroid stimulating hormone (TSH) with or without a low thyroid hormone (Free thyroxine [Free T4]) levels.

Medical Management

According to the NIH,” Treatment generally depends on whether the thyroid is damaged enough to cause hypothyroidism. Health care providers may choose to treat Hashimoto’s disease to reduce the size of the goiter, or choose not to treat and simply monitor their patients for disease progression.
Hashimoto’s disease, is treated with synthetic thyroxine. Health care providers prefer to use synthetic T4, such as Synthroid, rather than synthetic T3, because T4 stays in the body longer, ensuring a steady supply of thyroid hormone throughout the day
Health care providers routinely test the blood of patients taking synthetic thyroid hormone and adjust the dose as necessary, typically based on the result of the TSH test. Hypothyroidism can almost always be completely controlled with synthetic thyroxine, as long as the recommended dose is taken every day as instructed”

Physical Therapy Management

Physical therapy is not standard treatment for patients with this disorder. Physical therapists should know to screen for it.  Physical therapists also need to be aware of the disease because they may have a patient that has Hashimoto Thyroiditis as a co-morbidity.

A physical therapy screening for Hashimoto Thyroiditis should include:

• Subjective questioning
• Upper and/or lower quarter clearing exam - depending on the patient's complaints
  
• MMT - for the specific muscle(s)/area
• ROM - for the specific muscle(s)/area
• Special tests - for the specific joint/area
• Palpation - thyroid and any other areas that are suspected as the cause of the symptoms
• Any other measure that the physical therapist deems necessary for the patient's specific complaints
  

If the above screening does not indicate a musculoskeletal issue, the physical therapist should refer the patient to the appropriate health care provider.

Alternative/Holistic Management

Supplements:

• Selenium: Research has found that it aids in the regulation of T3 and T4 hormones.

• Probiotics: Aid in the support of gastrointestinal health

• Vitamin D

• B vitamins: Are important for maintaining energy and metabolic function.