Hashimoto Thyroiditis


Article Author:
Dana Mincer


Article Editor:
Ishwarlal Jialal


Editors In Chief:
Alexandra Caley
Sameh Boktor


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
5/5/2019 10:15:19 PM

Introduction

Hashimoto thyroiditis is an autoimmune disease that destroys thyroid cells by cell and antibody-mediated immune processes. It is the most common cause of hypothyroidism in developed countries. In contrast, worldwide, the most common cause of hypothyroidism is an inadequate dietary intake of iodine. This disease is also known as chronic autoimmune thyroiditis and chronic lymphocytic thyroiditis. The pathology of the disease involves the formation of antithyroid antibodies that attack thyroid tissue, causing progressive fibrosis. The diagnosis is often challenging and does not occur until later on in the disease process. The most common laboratory findings demonstrate an elevated thyroid-stimulating hormone (TSH) and low thyroxine (T4) levels coupled with increased anti-thyroid peroxidase (TPO) antibodies. However, earlier on the in the course of the disease, patients may exhibit signs, symptoms, and laboratory findings of hyperthyroidism or normal values. This is because the destruction of the thyroid gland cells may be intermittent.Women are more often affected. The female-to-male ratio is at least 10:1. Although some sources cite diagnosis happening more so in the fifth decade of life, most women are diagnosed between the ages of 30 to 50 years old. Conventional treatment occurs with levothyroxine at the recommended dose of 1.6 to 1.8 mcg/kg/day. The T4 converts to T3, which is the active form of thyroid hormone in the human body. Excessive supplementation can lead to deleterious and morbid effects, including but not limited to arrhythmias (the most common being atrial fibrillation and osteoporosis. In this chapter, we review the pathogenesis, diagnosis, and management of Hashimoto's thyroiditis.[1][2]

Etiology

The etiology of Hashimoto's disease is very poorly understood. Most patients have developed antibodies to a variety of thyroid tissues, the most common of which is anti-thyroid peroxidase (anti-TPO). Many also form antithyroglobulin (anti-Tg) and TSH receptor blocking antibodies (TBII). There is a small subset of the population, no more than 10%  with the clinically evident disease, that are serum antibody-negative. Positive TPO antibodies presage the clinical syndrome.[3][4]

It can be part of the Polyglandular Auto-Immune syndrome type 2 with auto-immune adrenal deficiency and type-1 DM.

Ruggeri et al. found that Hashimoto's disease is associated with a variety of different nonthyroidal autoimmune diseases (NSAIDs) and a diagnosis in adulthood made these even more prevalent.

Epidemiology

After age six, Hashimoto's is the most common cause of hypothyroidism in the United States and in those areas of the world where iodine intake is adequate. The incidence is estimated at 3.5 per 1000 per year in women and 0.8 per 1000 per year in men. Twin studies have shown an increased concordance of autoimmune thyroiditis in monozygotic twins as compared with dizygotic twins. Danish studies have demonstrated concordance rates of 55% in monozygotic twins, compared with only 3% in dizygotic twins. This data suggests that 79% of predisposition is due to genetic factors, allotting 21% for environmental and sex hormone influences. The prevalence of thyroid disease, in general, increases with age.

Pathophysiology

The development of Hashimoto's disease is thought to be autoimmune with lymphocyte infiltration and fibrosis as typical features. The current diagnosis is based on clinical symptoms correlating with laboratory results of elevated TSH with normal to low thyroxine levels. It is interesting to note, however, that there is little evidence demonstrating a role for antithyroid peroxidase (anti-TPO) antibody in the pathogenesis of autoimmune thyroid disease (AITD). Anti-TPO antibodies can fix complement and, in vitro, have been shown to bind and kill thyrocytes. However, to date, there has been no correlation noted in human studies between the severity of disease and level of anti-TPO antibody concentration in serum. We do however know that positive serum anti-TPO antibody concentration is correlated with the active phase of the disease. Other theories implicated immune complexes, containing thyroid directed antibodies, as culprits of thyroid destruction.

Histopathology

On pathologic examination, there can appear to be diffuse, symmetric enlargement of the thyroid. The capsule is often intact with a prominent pyramidal lobe. When cut, the surface is similar to that of lymph nodes, with a tannish, yellow color. Interlobular fibrosis may or may not be present. Atrophy may also occur. In some patients, the gland may become nodular or asymmetric. However, necrosis or calcification does not occur and would suggest a different diagnosis.

History and Physical

The organ system manifestations of Hashimoto's thyroiditis are varied due to the nature of the disease. Initially patient's may have bouts of hyperthyroid symptoms, as the initial destruction of thyroid cells may lead to increase releases of thyroid hormone into the bloodstream. Eventually, however, enough destruction is caused by the antibody response that patients exhibit symptoms of hypothyroidism. These symptoms are insidious and variable and may affect almost any organ system in the body. The classic skin characteristic associated hypothyroidism is myxedema, which refers to the edema-like skin condition caused by increased glycosaminoglycan deposition. This, however, is uncommon and only occurs in severe cases. Skin can be scaly and dry, especially on the extensor surfaces, palms, and soles.  Histologic examination reveals epidermal thinning. Increased dermal mucopolysaccharides cause water retention and in turn, pale colored skin. The rate of hair growth slows, and hair can be dry, coarse, dull, and brittle. Diffuse or partial alopecia is not uncommon. Decreased thyroid function can increase peripheral vascular resistance by as much as 50% to 60% and reduce cardiac output by as much as 30% to 50%. Bradycardia may result from a loss of chronotropic action of thyroid hormone directly on the sinoatrial cells. However, most patients have few symptoms directly referable to the cardiovascular system. Fatigue, exertional dyspnea, and exercise intolerance are likely related to a combination of limited pulmonary and cardiac reserve in addition to decreased muscle strength or increased muscle fatigue. Hypothyroid rats have been shown to have decreased endurance. Biochemical changes in this population have shown decreased muscle oxidation of pyruvate and palmitate, increased utilization of glycogen stores, and diminished fatty acid mobilization. Muscle weakness and myopathy are important features.

The presentation may also be subclinical. Early symptoms may include constipation, fatigue, dry skin, and weight gain. More advanced symptoms may include: cold intolerance, decreased sweating, nerve deafness, peripheral neuropathy, pressure symptoms in the neck from goiter enlargement such as voice hoarseness, decreased energy, depression, dementia, memory loss, muscle cramps, joint pain, hair loss, apnea, and menorrhagia. Physical findings may include cold, dry skin, facial edema particularly periorbital as well as nonpitting edema involving the hands and feet, brittle nails, bradycardia, delayed relaxation phase of tendon reflexes, elevated blood pressure, slow speech, ataxia, and macroglossia. Furthermore, patients can have an accumulation of fluid in the pleural and pericardial cavities rarely. Myxoedema coma is the severest clinical presentation and has to be managed as an endocrine emergency within patient care.

Evaluation

Hashimoto thyroiditis laboratory studies are as follows. Thyroid-stimulating hormone (TSH) is raised due to Hashimoto thyroiditis causing primary hypothyroidism. Free T4 is low. Low total T4 or free T4 level in the presence of an elevated TSH level confirms the diagnosis of primary hypothyroidism. T3 levels have no place in the diagnosis of hypothyroidism. Presence of anti-thyroid peroxidase and anti-thyroglobulin antibodies suggests Hashimoto's thyroiditis, however, 10%  of patients may be antibody negative. Anemia is present in 30% to 40%. There can be decreased glomerular filtration rate (GFR), renal plasma flow, and renal free water clearance with resultant hyponatremia. Creatine kinase is frequently elevated. Prolactin levels may be elevated. Elevated total cholesterol, LDL, and triglyceride levels can occur. A thyroid ultrasound assesses thyroid size, echotexture, and whether thyroid nodules are present; however, it is usually not necessary for diagnosing the conditioning the majority.[5][6]

Treatment / Management

The mainstay of treatment for hypothyroidism is thyroid hormone replacement. The drug of choice is titrated levothyroxine sodium administered orally. It has a half-life of 7 days and can be given daily.  It should not be given with iron, calcium supplements, aluminum hydroxide, and proton pump inhibitors to avoid optimum absorption and is best taken early in the morning on an empty stomach for optimum absorption. Lower doses should be used in patients with cardiovascular diseases and the elderly. However, in pregnancy, the dose of thyroxine needs to be increased by 30%. There is less evidence-based medicine to support an autoimmune/anti-inflammatory diet. The theory behind the inflammation has to do with leaky gut syndrome, where there is an insult to the gut mucosa, which allows penetrance of proteins that do not typically enter the bloodstream via transporters in the gut mucosa. It is theorized that a response similar to molecular mimicry occurs, and antibodies are produced against the antigens. Unfortunately, the antigen may be very structurally similar to thyroid peroxidase, leading to antibody formation against this enzyme. The concept of an autoimmune diet is based on healing the gut and decreasing the severity of the autoimmune response. Much further research is warranted on this topic before it becomes mainstream.

Pearls and Other Issues

Hashimoto's thyroiditis (HT) is one of the most frequent autoimmune diseases and has been reported to be associated with gastric disorders in 10% to 40% of patients. About 40% of patients with autoimmune gastritis also present with Hashimoto's thyroiditis, according to research by Cellini et al. Chronic autoimmune gastritis (CAG) is characterized by the partial or complete disappearance of parietal cells leading to impairment of hydrochloric acid and intrinsic factor production. The patients go on to develop hypochlorhydria-dependent iron-deficient anemia, leading to pernicious anemia, and severe gastric atrophy.

Thyrogastric syndrome was first described in the 1960s when thyroid autoantibodies were found in a subset of patients with pernicious anemia and atrophic gastritis. The latest guidelines have incorporated the two aforementioned autoimmune disorders into a syndrome now known as a polyglandular autoimmune syndrome (PAS). This is characterized by two or more endocrine and nonendocrine disorders. The thyroid gland develops from the primitive gut, and therefore the thyroid follicular cells share similar characteristics with parietal cells of the same endodermal origin. For example, both are polarized and have apical microvilli which house enzymatic activity, and both can concentrate and transport iodine across the cell membrane via the sodium/iodide symporter. Iodine not only plays an essential role in the production of thyroid hormone, but it also is involved in the regulation of gastric mucosal cell proliferation and acts as an electron donor in the presence of gastric peroxidase and assists in the removal of free oxygen radicals.

It is important to note that due to the pharmaceutical formation of thyroxine available worldwide, there can be problems with absorption in patients with disorders of the gastric mucosa. Most levothyroxine is obtained by the salification with sodium hydroxide, making sodium levothyroxine. The absorption of T4 occurs in all areas of the small intestine and ranges from 62% to 84% of the ingested dose. Decreased gastric acid secretion can disrupt this percentage and may cause issues with decreased absorption of most pharmaceutical grade forms of levothyroxine, except for liquid-based or soft gel formations.

Clinically, it is important to note the association of thyroid and gastric autoimmune diseases. The presence of iron-deficient anemia and thyroxine absorption issues should encourage a further diagnostic workup.

Enhancing Healthcare Team Outcomes

Hashimoto thyroiditis is a life long disorder with no cure; thus it is best managed by a multidisciplinary team that includes an endocrinologist, internist, primary care provider, and an internist. The key is to follow up on the levels of thyroid hormone. Empirically prescribing one standard dose of levothyroxine may lead to hormone toxicity in some people. In addition, some patients may develop lymphoma and thus a regular examination of the neck area is highly recommended.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Hashimoto Thyroiditis - Questions

Take a quiz of the questions on this article.

Take Quiz
A 65-year-old female with presents for evaluation of fatigue. She states she has recently felt fatigued, with cold intolerance, and constipation. She is concerned that something is wrong, as years ago she used to have constant diarrhea and now she feels constipated all the time. Physical exam reveals a small thyroid on palpation. Which of the following is most likely to be present in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is false about Hashimoto disease?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male presents with an enlarging, painless thyroid nodule. Bloodwork shows an elevated thyroid stimulating hormone level and is positive for anti-thyroid peroxidase and anti-thyroglobulin antibodies. Histological exam shows dense lymphoplasmacytic infiltrate with the formation of lymphoid follicles. What is this patient at risk for developing?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female has been complaining of a feeling of fullness around her neck area but denies any pain. Blood work reveals the presence of anti-thyroglobulin antibodies and a high titer of anti-thyroid peroxidase. She denies any family history. This patient may have which of the following conditions?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is a FALSE statement regarding Hashimoto thyroiditis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not true of Hashimoto thyroiditis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true of Hashimoto disease?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Elevated levels of antibody to thyroglobulin are commonly seen in which condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is NOT a sign or symptom of Hashimoto thyroiditis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What should be assessed first in a patient suspected of hypothyroidism due to Hashimoto thyroiditis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with complaints of fatigue is found to have antibodies to thyroglobulin and thyroid peroxidase. She may have which of the following conditions?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 40-year-old nurse presents with constipation, fatigue, dry skin, cold intolerance, and weight gain. She is taking no medications and never had any surgery. Her thyroid is not palpable and not tender. T4 and T3 levels are low and thyroid stimulating hormone (TSH) is elevated. What is the most likely cause of her condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Antimicrosomal antibodies are most likely to be found in which condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
The majority of patients with Hashimoto disease initially have which finding?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In the long term, Hashimoto patients are prone to developing which of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common type of thyroiditis in the U.S.?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not true regarding Hashimoto thyroiditis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is expected to be elevated in Hashimoto thyroiditis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following disorders can present as a hypo, hyper, or euthyroidism state?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common cause of hypothyroidism in the United States?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the true statement.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the histologic findings usually seen with Hashimoto thyroiditis.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 40-year-old woman is found to have nontender enlargement of the thyroid. Free T3 and T4 are normal while TSH is minimally elevated. There are antithyroid peroxidase antibodies and no antibodies to the TSH receptor. What is the most probable diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 14-year-old girl presents with a goiter. She was born and raised in the United States. She has no symptoms and no other physical findings. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which statement is most accurate regarding Hashimoto thyroiditis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
The thyroid enlargement of Hashimoto's thyroiditis is due to:



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A young female is seen in the clinic after being diagnosed with subclinical hypothyroidism. The physician orders additional blood work, which reveals the presence of serum anti-thyroid peroxidase antibodies. If left untreated, this patient is most likely going to progress to which of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 34-year-old female with a past medical history of gluten sensitivity and eosinophilic esophagitis presents with complaints of exhaustion. She is a second-year medical resident and a single mother of 1 child who is six years old. Her family history is significant for a father with psoriatic arthritis, currently on biologic agents for control; a paternal aunt with psoriatic and rheumatoid arthritis; a maternal grandmother with hypothyroidism; and a maternal grandfather with osteoarthritis. The patient says she has been working 70 to 80 hours per week in the hospital, sleeping 4 to 5 hours per night, and is under extreme stress in both her professional and personal life. She recently was sent to a psychiatrist who evaluated her and started her on lisdexamfetamine and bupropion; however, she does not wish to continue these medications. Her review of symptoms is positive for "feeling swollen," puffy face, recent new onset shortness of breath with exertion, and decreased exercise tolerance. What is the next appropriate step in the evaluation of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 36-year-old female comes to your office to get a second opinion. She has not been happy with her primary care doctor, who wants her to get an MRI of her brain and see an endocrinologist due to an elevated prolactin level. She says she does not have money for the test and specialist copay right now. Upon further questioning, she reveals a past medical history of recently diagnosed thyroid disease for which she has started taking levothyroxine one week ago, migraine headaches, and gluten sensitivity. She has her recent laboratory results with her that reveal TSH 9, T4 0.3, T3 2.5, anti-TPO 1000, and prolactin 51. Which of the following is the most appropriate next course of action?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 44-year-old female presents to your clinic with fatigue and weakness. She states that over the past 2 years she has been feeling increasingly tired and having difficulty with her everyday tasks. She also has gained 15 pounds despite trying to lose weight. Her past medical history is significant for Sjogren syndrome, which was diagnosed 20 years ago and has been treated medically. On physical exam, she has dry skin, notable hair loss, and nonpitting lower extremity edema. Her neck exam reveals a rubbery, nontender goiter. Her thyroid-stimulating hormone levels are increased. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Hashimoto Thyroiditis - References

References

Eghtedari B,Correa R, Levothyroxine 2019 Jan;     [PubMed]
Tagoe CE,Sheth T,Golub E,Sorensen K, Rheumatic associations of autoimmune thyroid disease: a systematic review. Clinical rheumatology. 2019 Mar 29;     [PubMed]
Leung AKC,Leung AAC, Evaluation and management of the child with hypothyroidism. World journal of pediatrics : WJP. 2019 Apr;     [PubMed]
Yuan J,Sun C,Jiang S,Lu Y,Zhang Y,Gao XH,Wu Y,Chen HD, The Prevalence of Thyroid Disorders in Patients With Vitiligo: A Systematic Review and Meta-Analysis. Frontiers in endocrinology. 2018;     [PubMed]
Liu M,Murphy E,Amerson EH, Rethinking screening for thyroid autoimmunity in vitiligo. Journal of the American Academy of Dermatology. 2016 Dec;     [PubMed]
Yoo WS,Chung HK, Recent Advances in Autoimmune Thyroid Diseases. Endocrinology and metabolism (Seoul, Korea). 2016 Sep;     [PubMed]
Kostoglou-Athanassiou I,Ntalles K, Hypothyroidism - new aspects of an old disease. Hippokratia. 2010 Apr;     [PubMed]
Singh G,Jialal I, Polyglandular Autoimmune Syndrome, Type II (Carpenters, Schmidt) 2019 Jan;     [PubMed]
Ruggeri RM,Trimarchi F,Giuffrida G,Certo R,Cama E,Campennì A,Alibrandi A,De Luca F,Wasniewska M, Autoimmune comorbidities in Hashimoto's thyroiditis: different patterns of association in adulthood and childhood/adolescence. European journal of endocrinology. 2017 Feb;     [PubMed]
Brix TH,Hegedüs L,Gardas A,Banga JP,Nielsen CH, Monozygotic twin pairs discordant for Hashimoto's thyroiditis share a high proportion of thyroid peroxidase autoantibodies to the immunodominant region A. Further evidence for genetic transmission of epitopic     [PubMed]
Williams DE,Le SN,Godlewska M,Hoke DE,Buckle AM, Thyroid Peroxidase as an Autoantigen in Hashimoto's Disease: Structure, Function, and Antigenicity. Hormone and metabolic research = Hormon- und Stoffwechselforschung = Hormones et metabolisme. 2018 Dec;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of CNS-Public Community Health. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for CNS-Public Community Health, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in CNS-Public Community Health, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of CNS-Public Community Health. When it is time for the CNS-Public Community Health board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study CNS-Public Community Health.