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Thyroid/parathyroid » General
Hashimoto's Thyroiditis
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Presentation A 31 years old female presents overweight, fatigue, constipation and dry skin. Laboratory features revealed increased levels of TSH, decreased levels of T3, T4 and increased levels of TPO anti. A cervical ultrasound is requested.
 
 
Caption: Transverse sonogram of the thyroid gland.
Description: Transverse ultrasonography reveals a heterogeneous and coarse ecotexture of the enlarged thyroid gland with linear fibrosis. A hypercoecogenic nodule is seen in the right lobe.
 
 
Caption: Longitudinal sonogram of the right lobe of the thyroid gland.
Description: Longitudinal view of the enlarged right thyroid lobe reveals a coarse and heterogeneous ecotexture with linear fibrosis. A hypercoecogenic nodule is seen.
 
 
Caption: Longitudinal sonogram of the left lobe of the thyroid gland.
Description: Longitudinal view of the enlarged left thyroid lobe reveals a coarse and heterogeneous ecotexture with linear fibrosis.
 
 
Caption: Transverse sonogram of the thyroid gland. Power Doppler view.
Description: Power Doppler view showing increased vascularity in the thyroid gland.
 
Differential Diagnosis
De Quervain thyroiditis
Autoimmune Thyroid Disease and Pregnancy
Hashimoto Thyroiditis
Thyroid Lymphoma
Thyroid Nodule

 
Final Diagnosis Hashimoto Thyroiditis
 
Discussion
Hashimoto's thyroiditis, also known as chronic lymphocytic thyroiditis and Hashimoto's disease, is an autoimmune disease in which the thyroid gland is gradually destroyed. Early on there may be no symptoms. Over time the thyroid may enlarge forming a painless goiter. Some people eventually develop hypothyroidism with its accompanying weight gain, feeling tired, constipation, depression, and general pains. After many years the thyroid typically shrinks in size. Potential complications include thyroid lymphoma1.

It is difficult to reliably sonographically differentiate Hashimoto thyroiditis from other thyroid pathology. 
Ultrasound features can be variable depending on the severity and phase of disease2,6:

- Diffusely enlarged thyroid gland with a heterogeneous echotexture is a common sonographic presentation7.
- The presence of hypoechoic micronodules (1-6mm) with surrounding echogenic septations is also considered to have a relatively high positive predictive value4,5. This appearance may be described as pseudonodular or a giraffe pattern.
- Colour Doppler study usually shows normal or decreased flow, but occasionally there might be hypervascularity similar to a thyroid inferno.
- Prominent reactive cervical nodes may be present, especially in level VI, but they have normal morphologic features.
- Patients are at higher risk for papillary thyroid carcinoma, so a discrete nodule should be considered for biopsy.

In some situations, large nodules may be present, which may be referred to as nodular Hashimoto thyroiditis8.

Overt, symptomatic thyroid dysfunction is the most common complication, with about 5% of persons with subclinical hypothyroidism and chronic autoimmune thyroiditis progressing to thyroid failure every year. Transient periods of thyrotoxicosis (over-activity of the thyroid) sometimes occur, and rarely the illness may progress to full hyperthyroid Graves' disease with active orbitopathy (bulging, inflamed eyes). Rare cases of fibrous autoimmune thyroiditis present with severe dyspnea (shortness of breath) and dysphagia (difficulty swallowing), resembling aggressive thyroid tumors – but such symptoms always improve with surgery or corticosteroid therapy. Primary thyroid B cell lymphoma affects fewer than one in a thousand persons, and it is more likely to affect those with long-standing autoimmune thyroiditis9.

 
Case References
1. Hiromatsu, Y; Satoh, H; Amino, N (2013). "Hashimoto's thyroiditis: history and future outlook". Hormones (Athens, Greece). 12 (1): 12–8. PMID 23624127.
2. Langer JE, Khan A, Nisenbaum HL et-al. Sonographic appearance of focal thyroiditis. AJR Am J Roentgenol. 2001;176 (3): 751-4. AJR Am J Roentgenol (full text) - Pubmed citation
3. Intenzo CM, Capuzzi DM, Jabbour S et-al. Scintigraphic features of autoimmune thyroiditis. Radiographics. 21 (4): 957-64. Radiographics (full text) - Pubmed citation
4. Yeh HC, Futterweit W, Gilbert P. Micronodulation: ultrasonographic sign of Hashimoto thyroiditis. J Ultrasound Med. 1996;15 (12): 813-9. J Ultrasound Med (abstract) - Pubmed citation
5. Set PA, Oleszczuk-raschke K, Von lengerke JH et-al. Sonographic features of Hashimoto thyroiditis in childhood. Clin Radiol. 1996;51 (3): 167-9. - Pubmed citation
6. Moon HJ, Kim EK, Kim MJ et-al. Lymphocytic thyroiditis on fine-needle aspiration biopsy of focal thyroid nodules: approach to management. AJR Am J Roentgenol. 2009;193 (4): W345-9. doi:10.2214/AJR.09.2413 - Pubmed citation
7. Takashima S, Matsuzuka F, Nagareda T et-al. Thyroid nodules associated with Hashimoto thyroiditis: assessment with US. Radiology. 1992;185 (1): 125-30. Radiology (abstract) - Pubmed citation.
8. Anderson L, Middleton WD, Teefey SA et-al. Hashimoto thyroiditis: Part 2, sonographic analysis of benign and malignant nodules in patients with diffuse Hashimoto thyroiditis. AJR Am J Roentgenol. 2010;195 (1): 216-22. doi:10.2214/AJR.09.3680 - Pubmed citation.
9. Fabrizio Monaco (2012). Thyroid Diseases. Taylor and Francis. p. 78. ISBN 9781439868393.

 
Technical Details
Ultrasound scanner. - Voluson 730 PRO. General Electric.
Transducer. – 10 - 12MHz linear array
Scanning in both transverse and longitudinal planes.

 
Follow Up Hypothyroidism was treated with levothyroxine, whose dose depended on laboratory results.
 
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