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

Hashimoto's Thyroiditis, also referred to as chronic lymphocytic thyroiditis or autoimmune thyroiditis, is a condition in which one's immune system attacks its own thyroid gland. Along with having an autoimmune basis, it appears to have a genetic disposition playing a factor in the etiology. The destruction is ultimately caused by "the infiltration of the gland by lymphocytes and antithyroid antibodies."The disease process causes the T3 and T4 serum levels to decrease, which triggers the pituitary gland to increase TSH production. The increased TSH levels causes the hyperfunction of the thyroidleading to goiter formation. Thyroid gland destruction can occur due to prolonged hyperfunction leading to eventual hypothyroidism. There is evidence that there is a genetic factor in being diagnosed with Hashimoto Thyroiditis. The disease is associated with the gene "HLA-DR3, which is also present in other autoimmune conditions." 

Youtube video----https://www.youtube.com/watch?v=oINxr8_nR_Y [last accessed 03/20/2017]

Prevalence

Hashimoto's (chronic) Thyroiditis "is the is the most common cause of hypothyroidism in the United States. It is primarily found in "middle-aged women” and leads to a genetic disposition. Affecting approximately women more than men at a 10:1 ratio. However, Hashimoto’s thyroiditis can be diagnosed at any age , and may affect men and children. The causative factor regarding the prevalence of antibodies is unknown, however there seems to be a familial correlation.

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

File:Goiter.jpg

Medications

Levothyroxine: "man-made form of T4 hormone." This medication "almost always"[3] needs to be taken for the rest of a person's life and in the same manner each day.[3] "Most people see a decrease in the size of the goiter and remain stable for years with treatment."6 The generic name of the drug is Levothyroxine, but it also goes by the brand names of Levothroid, Levoxyl, Synthroid, Tirosint, and Unithroidand it can also be administered orally in a liquid filled tablet, tablet, or in the form of a solution.

Diagnostic Tests/Lab Tests/Lab Values

Thyroid function tests can be performed.  The tests measure one's TSH and T4 levels.  If there is "an above normal level of TSH, it is a sign of an underactive thyroid."  This is because as the thyroid starts to fail the pituitary gland begins to produce an increased amount of TSH to get the thyroid to produce more thyroid hormone.  The thyroid is able to meet the increased demands for a time, and therefore tests will show normal T4 levels accompianed by slightly increased TSH levels.  This condition is referred to as "subclinical hypothyroidism."  As time goes on, "the damaged thyroid cannot keep up, and they T4 levels will drop below normal while the TSH levels will increase."   

Another test that is performed is the 'Antibody Test.'  This test looks for a specific antibody that is typically not found in individuals who do not have Hashimoto Thyroiditis, however, some people have the antibodies but have normal thyroid function.   

The patient may also have an ultrasonogram to help to differentiate this condition from another.

Etiology/Causes

Hashimoto Thyroiditis is caused when one's "immune system creates antibodies that damage [one's] thyroid gland."  The cause of the autoimmune disease is unknown, but there are some theories and factors that may play a role.

Theories:,

1. Virus or bacterium trigger
2. Genetic flaw
3. Gender
4. Pregnancy
5. Too much iodine and some drugs
6. Radiation exposure

BupaHealth. How a thyroid gland can become underactive. Available at: http://www.youtube.com/watch?v=2AFiMipv63k&feature=related [last acessed 3/3/11]

Systemic Involvement

The patient may present with the symptoms listed above that mimic musculoskeletal pain.

Medical Management (current best evidence)

The patient will take the synthetic hormone for their entire life, as discussed above.  The physician may see the patient to check the patient's "level of TSH after a few weeks of treatment."  According to the Mayo Clinic, the patient's physician will most likely check their TSH level every 6-12 months.  

Physical Therapy Management (current best evidence)

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 (current best evidence)

The information below was found on MayoClinic.com.  However, no peer reviewed evidence could be found to support or refute the use of this alternative management.

Natural extracts such as Armour Thyroid are sometimes used.  They contain "levothyroxine and triiodothyronine (T-3).  

Picture of Armour Thyroid.

Concerns regarding this supplement:

• Balance of T4 and T3 in animals is not the same as humans
• Exact amounts of T4 and T3 can vary due to the unpredictable amount in one's blood
  

Differential Diagnosis

Possible differential diagnoses:

• Euthyroid Sick Syndrome
• Hypopituitarism (Panhypopituitarism)
• Goiter
• Polyglandular Autoimmune Syndrome, Type I
• Goiter, Diffuse Toxic
• Polyglandular Autoimmune Syndrome, Type II
• Goiter, Lithium-Induced
• Thyroid Lymphoma
• Goiter, Nontoxic
• Goiter, Toxic Nodular
  

Other possible issues include:

• Addison disease
• Alopecia areata, totalis, and universalis
• Autoimmune gastritis (pernicious anemia)
• Chronic active hepatitis
• Idiopathic hypoparathyroidism
• Polymyalgia rheumatica and giant cell arteritis
• Primary biliary cirrhosis
• Primary ovarian or testicular failure
• Rheumatoid arthritis
• Sjögren syndrome
• Systemic lupus erythematosus
• Systemic sclerosis (scleroderma)
• Type 1 diabetes mellitus
• Vitiligo

Case Reports/ Case Studies

Hashimoto's Thyroiditis Case Study

A. M. McGregor, D. F. Roberts, and R. Hall.  A study of triplets with Hashimoto's thyroiditis.  Postgrad Med J. 1979 December; 55(650): 894–896.  Click here for article.

A Shuper, T Leathem, A Pertzelan, B Eisenstein, and M Mimouni.  Familial Hashimoto's thyroiditis with kidney impairment.   Arch Dis Child. 1987 August; 62(8): 811–814. Click here for article.

Jan van Schaik,1 Olaf M. Dekkers,2 Eleonora P. M. van der Kleij-Corssmit,2 Johannes A. Romijn,2 Hans Morreau,3 and Cornelis J. H. van de Velde1*.  Surgical Treatment for Unexplained Severe Pain of the Thyroid Gland: Report of Three Cases and Concise Review of the Literature.  Case Report Med. 2011; 2011: 349756.  Click here for article.

G. T. Ko, C. C. Chow, V. T. Yeung, H. Chan, and C. S. Cockram.  Hashimoto's thyroiditis, Sjogren's syndrome and orbital lymphoma.  Postgrad Med J. 1994 June; 70(824): 448–451.  Click here for article.

P L Vold and P J Weiss.  Rhabdomyolysis from tourniquet trauma in a patient with hypothyroidism.  West J Med. 1995 March; 162(3): 270–271.  Click here for article.

add links to case studies here (case studies should be added on new pages using the case study template)

Resources

American Thyroid Association.  http://www.thyroid.org/

Thyroid Federation International.  http://web.thyroid-fed.org/en/

Recent Related Research (from Pubmed)

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