Hashimoto’s thyroiditis, also known as chronic lymphocytic thyroiditis, is an autoimmune disease.
1. Etiology
The disease is characterized by the detection of highly potent antithyroid antibodies in the blood and is therefore considered to be an autoimmune disease. In addition, the main evidence is that.
(1) The patient has a large infiltration of plasma cells and lymphocytes in the thyroid tissue, and lymphoid follicles may form.
(2) contact of lymphocytes with thyroid antigens leads to the formation of lymphoblasts and the production of mobile inhibitory factors and lymphocytotoxins, suggesting that the patient’s T cells have sensitizing activity and that their corresponding antigens are thyroid cell components.
(3) Similar autoantibodies to the thyroid gland can be detected in the blood of approximately 50% of the patient’s relatives.
(4) Patients or their relatives are susceptible to autoimmune diseases of other organs or tissues, such as Graves’ disease, autoimmune Addison’s disease, pernicious anemia, atrophic gastritis, insulin-dependent diabetes mellitus, systemic lupus erythematosus, etc.
(5) Better therapeutic response to immunosuppressants.
II. Pathology
The thyroid gland often shows a moderate diffuse lymphocytic infiltration, while there may be lymphoid follicle formation, plasma cell infiltration and rupture of the thyroid follicles. Some follicular cells show enlargement and eosinophilia, the so-called “Askanazy cells”. Some patients may have mucinous edema with a small or even inaccessible thyroid gland. The histological changes of the thyroid gland are similar to those described above, but with marked fibrous changes and reduced cellular infiltration.
Clinical manifestations
Chronic lymphocytic thyroiditis is most often seen in middle-aged adults, but can involve any age group. The incidence is significantly higher in women than in men, about 20:1. The onset of the disease is insidious and slow, and the thyroid gland is often found to be enlarged unintentionally, of medium size. Most goiters are symmetrical, with enlargement of the cone lobes, the surface of the gland may be lobulated, tough like rubber, thyroid function is mostly normal, but some patients may have hyperthyroidism, seen in young patients, called Hashimoto hyperthyroidism, and later hypothyroidism may appear, and a few have mucinous edema.
In adolescents, lymphocytic thyroiditis is predominantly diffusely enlarged with a smooth surface, while in middle-aged patients, the thyroid gland is moderately enlarged, moderately hard, less uniform, with a less smooth surface and a markedly elevated TGA and TMA. In a small number of patients, the thyroid gland is hard and difficult to distinguish from thyroid cancer or medullary thyroid cancer.
In the early stage of the disease, only TPOAb is positive and there are no clinical symptoms. In the late stage of the disease, hypothyroidism appears.
IV. Diagnostic methods
Basic tests
1. Thyroid function tests vary according to the course of the disease.
(1) Serum T4 and T3 are normal in the early stage, but TSH is elevated; in the later stage, serum T4 decreases, T3 is normal or decreases, and TSH is elevated.
(2) The iodine uptake rate of thyroid gland is normal or increased in the early stage, but can be suppressed by T3; in the later stage, the iodine uptake rate decreases and TSH is not increased by injection.
2. Immunological examination The titers of anti-thyroglobulin antibody (TGA) and anti-thyroid microsomal (peroxidase) antibody (TMA) in blood are significantly elevated, and both are diagnostic when they are greater than 50% (dual immunoassay method), which can last for several years or more than 10 years.
3. Other tests: increased sedimentation, up to 100 mm/h, decreased serum albumin, increased r-globulin.
Further tests
1. SPECT thyroid scan may be uniform or heterogeneous, and may appear as “cold nodules”.
For those with atypical clinical manifestations and low or negative antibody titers, fine-needle aspiration cytology or tissue biopsy may be used to confirm the diagnosis.
Diagnostic points
1. Middle-aged women with diffuse enlargement of the thyroid gland with a firm texture should be considered for this disease regardless of thyroid function.
2, serum TGA, TMA titers are significantly elevated (> 50%), the diagnosis can be basically confirmed.
3. For atypical clinical manifestations, antibody titers >= 60% for two consecutive times, and for those with hyperthyroidism, antibody titers >= 60 for more than six months.
4. The disease should be differentiated from thyroid cancer, which is antibody-negative. The incidence of thyroid cancer in this disease is reported to be 5%-17% in the literature.
V. Diagnosis
If a middle-aged woman has diffuse goiter, especially if it is accompanied by conus lobe enlargement, the disease should be suspected regardless of thyroid function. Further measurement of TMA and TGA can assist in the diagnosis, and potassium perchlorate excretion test has a reference value. Histological examination by thyroid puncture can clarify the diagnosis, and thyroid hormone test can also be used for treatment. Diagnosis of this disease should be distinguished from patients with thyroid cancer, subacute thyroiditis, simple goiter and nodular goiter, and other thyroid diseases.
VI. Characteristics
1. It is common in middle-aged women, with no obvious symptoms in the early stage and hypothyroidism symptoms in the late stage.
2. Moderate diffuse enlargement of the thyroid gland, often affecting the cone lobe, firm, lobulated, generally without pain and pressure.
3, increased blood sedimentation, elevated serum gammaglobulin, positive turbidity, flocculence test.
4. Thyroid iodine uptake rate of 131 iodine is normal or may be elevated, perchlorate excretion test is positive, thyroid tablet or T3 suppression test is positive in patients with elevated thyroid iodine uptake rate of 131 iodine (can be suppressed), serum TT3 and TT4 are normal or may be elevated in early stage, and may be decreased in late stage while serum TSH level is elevated, some patients may be positive for tr-ab.
5. Elevated serum immune complexes, elevated igg and iga levels, increased lymphocyte metastasis, increased percentage of adjuvant t lymphocytes, strong positive thyroid autoantibodies, and significantly elevated titers.
6, thyroid fine needle aspiration cytology examination shows abundant lymphocytes, also visible plasma cells, Xu Tel cells.
The disease may coexist with other autoimmune diseases, such as pernicious anemia, systemic lupus erythematosus, rheumatoid arthritis, atrophic gastritis, etc. It may also coexist with hyperthyroidism (Hashimoto-hyperthyroidism), nodular goiter, and thyroid cancer, and a thyroid biopsy or surgical exploration may be performed if necessary to determine the diagnosis.
VIII. Treatment
1.Thyroid hormone preparation When thyroid function is normal or low, thyroid preparation can be used with good effect. You can take 80-160mg of thyroid tablets or 0.2-0.4mg of L-thyroxine daily, depending on the function of the thyroid gland, the degree of goiter, the age of the patient and the cardiovascular system. Generally, after 2-4 weeks of medication, the symptoms will improve and the thyroid gland will shrink, then the dose can be reduced appropriately and maintained for 1-2 years or even longer.
2.Anti-thyroid drugs If there is hyperthyroidism, anti-thyroid drugs can be applied appropriately, but the dose should not be too high, and thyroid function should be monitored, and the dose should be adjusted or stopped in time. In addition, according to the degree of hyperthyroidism, appropriate amount of thyroid tablets can be added to improve the enlarged thyroid gland and pressure symptoms.
Adrenocorticotropic hormone can be considered in patients with obvious enlargement of the thyroid gland, significant pressure symptoms and rapid progress of the disease, in order to obtain better results in a short period of time. 30mg of prednisone can be used daily and can be reduced after the effect is obtained.
If treatment is ineffective, the diagnosis should be reviewed, except for thyroid adenoma or lymphoma, and if necessary, surgical treatment may be used.
IX. Heredity
Hashimoto’s thyroiditis is a type of autoimmune disease. Hashimoto’s thyroiditis has a genetic predisposition, but is not necessarily inherited. As long as the condition of Hashimoto’s thyroiditis is well controlled during pregnancy, it is generally possible to avoid passing on Hashimoto’s thyroiditis to the next generation. Even if Hashimoto’s thyroiditis is inherited, if it is detected in time, the child can be treated promptly.
X. How to prevent
Hashimoto’s thyroiditis is an autoimmune disease and there are no special preventive measures. However, paying attention to dietary habits to properly balance iodine intake and avoiding foods that can cause goiter can play a role in prevention. The following is a detailed introduction by our experts.
The prevention of Hashimoto’s thyroiditis requires the following in terms of diet.
The diet focuses on high-fiber foods including green leafy vegetables, coarse grains, and many fruits. The actual fact is that you can find a lot of people who are not able to get a good deal on a lot of things. For patients with Hashimoto’s thyroiditis combined with hyperthyroidism, the intake of seafood such as kelp and seaweed should be temporarily limited to reduce the iodine content in the food. In contrast, patients with Hashimoto’s thyroiditis combined with hypothyroidism, such as those with chronic lymphocytic thyroiditis, should increase the amount of iodine in their diet and increase the concentration of iodine in their blood to prepare sufficient raw materials for the synthesis of thyroid hormones.
Some data show that Hashimoto’s disease has complex clinical manifestations, many comorbidities and a low preoperative diagnosis rate, so it should be taken seriously to avoid misdiagnosis. Surgical treatment of Hashimoto’s disease is desirable, but its indications should be strictly mastered, the surgical protocol should be individualized, enough thyroid tissue should be preserved intraoperatively as much as possible, and thyroxine replacement therapy should be taken for a long time after surgery to achieve good therapeutic and preventive effects.
XI. Three stages of Hashimoto’s disease
Early stage, hyperthyroidism stage
When the degree is mild, the patient has only mild hyperthyroid symptoms, such as good appetite, easy tiredness, mild insomnia, boredom and impatience. In severe cases, there are obvious symptoms of hyperthyroidism, and the patient can get good results with a little medication for hyperthyroidism, but it is also easy to develop drug-related hypothyroidism. In some cases, the inflammation is reduced and the patient “cures itself” without treatment. This stage is characterized by good efficacy and high recurrence rate.
Middle stage, coexistence of hyperthyroidism and hypothyroidism
After repeated destruction of the thyroid tissue, the number of cells with normal function gradually decreases, and hypothyroidism appears at a certain level. Another characteristic of this period is that the patient may have hyperthyroidism symptoms, but the laboratory tests may be slightly high or normal.
Late stage, hypothyroidism
The amount of thyroxine secreted decreases even more, and the clinical manifestation of hypothyroidism is already present. In patients with Hashimoto’s thyroiditis, although the laboratory indicators are normal after thyroxine supplementation, many people feel uncomfortable at times and sometimes feel symptoms of hyperthyroidism. It is important to note that some patients also develop hyperthyroidism and hyperthyroidism due to the aggravation of the infection, which is referred to as “hypothyroidism to hyperthyroidism” in some publications. Clinically, each episode of hyperthyroidism in a patient with Hashimoto’s thyroiditis is indicative of a further worsening of hypothyroidism.
It is not that there are no specific sensations early in the development of Hashimoto’s thyroiditis, but these sensations are not taken seriously by the patient and are not seen by the doctor. Although some patients with Hashimoto’s thyroiditis have indicators and symptoms of hyperthyroidism in the early or early-middle stages, surgery or isotope therapy should never be administered, as this can cause the patient to become more severely hypothyroid extremely quickly. Hashimoto’s thyroiditis has symptoms of hyperthyroidism in the early stages and hypothyroidism in the late stages, and is diagnosed as “Hashimoto’s disease with hyperthyroidism” or “Choban’s disease with hypothyroidism”.
The actual fact is that you will be able to get a lot more than just a few of these.
Twelve, Chinese medicine treatment
Treatment options
Hashimoto’s thyroiditis requires lifelong thyroid hormone replacement therapy to reduce thyroid hypertrophy and treat hypothyroidism, which is occasionally transient. The average T4 dose of replacement therapy is 75 to 150 μg/d.
1. Wind-heat offending surface type
Main symptoms: vicious chills and fever, heavy fever and light cold, headache and body pain, swelling and pain in the throat, strong pain in the neck, unfavorable rotation, burning pain in the gall, painful when touched, radiating to the child, occiput and jaw, dry mouth and throat, thirst for cold drinks, cough with little phlegm and sticky, sweating and weakness, red tongue, thin yellow coating, floating pulse.
Treatment: Drain wind and relieve symptoms, clear heat and detoxify, and relieve pain in the throat.
2. Liver stagnation and fire type
Main symptoms: Burning and painful gall, irritability, obstruction of the pharynx, thirst, hyperphagia, fine trembling of the hands, insomnia and dreaminess, weakness and spontaneous sweating, in women, premenstrual breast distension, irregular bowel movements, red tongue, thin yellow fur, string pulse and number.
Treatment: Relieve liver depression, clear liver fire.
3. Yin deficiency and Yang hyperactivity type
Main symptoms: painful gall swelling, dry mouth and throat, irritable heat in the heart, dizziness, insomnia, palpitations, spontaneous sweating and night sweating, hoarseness, red tongue with little moss or yellow moss, and thin pulse.
Treatment: Nourish Yin and submerge Yang.
4.Phlegm and blood stasis intertwined type
Main symptoms: Gall is hard and swollen, painful when pressed, throat discomfort, chest tightness and dullness, or coughing up phlegm, dark tongue, or petechiae, white fur, sunken and astringent pulse.
Treatment: Promote blood circulation and eliminate blood stasis, resolve phlegm and disperse the knots.
5. Spleen and kidney Yang deficiency type
Main symptoms: Gall swelling, light complexion, cold fear, cold limbs, fatigue, loose stools, weak limbs, decreased libido, impotence in men, decreased menstruation or amenorrhea in women, pale and fat tongue, white smooth coating, sunken and thin pulse.
Treatment: Warming the spleen and kidneys, promoting water retention and eliminating swelling.
6. Qi and blood deficiency type
Main symptoms: Gall swelling, light complexion, fatigue, weakness, easy to catch cold, dullness and loose stools, shortness of breath and lazy speech, dry mouth and throat, dizziness, soreness and weakness of the waist, insomnia and dreaminess, pale tongue with thin coating and sunken pulse.
Treatment: Benefit Qi and nourish Blood
XIII. Types of Hashimoto’s thyroiditis
The five types of Hashimoto’s thyroiditis
(1) Pseudohyperthyroidism: A few patients may have clinical manifestations of hyperthyroidism, such as palpitations, excessive sweating, and hypersensitivity, but there is no evidence of hyperthyroidism in thyroid function tests, and TGAb and TMAb are positive. Such patients do not need anti-thyroid medication and their symptoms may disappear on their own.
(2) Hashimoto hyperthyroidism: Patients with hyperthyroidism, some cases may also have infiltrative proptosis, mucinous edema, etc.. Typical hyperthyroidism may be present. The titer of circulating antibodies is high. The hyperthyroid state may persist for several years in these patients and often requires antithyroid medication, but the dose should not be too high and attention should be paid to the occurrence of pharmacologic hypothyroidism. Surgical resection or radionuclide therapy are not suitable and may lead to permanent hypothyroidism.
(3) Proptosis: Infiltrative proptosis can occur in this disease, and its thyroid function can be normal, hyper or hypothyroid. There is lymphocytic infiltration and edema in the retro-orbital muscles. Serum TGAb and TMAb are positive.
(4) Subacute thyroiditis type: A few patients have an acute onset with fever, rapid enlargement of the thyroid gland with local pain and tenderness, accelerated sedimentation, but normal or increased iodine uptake, and limited high titers of thyroid antibodies.
(5) Adolescent type: Hashimoto’s thyroiditis accounts for about 40% of adolescent goiters with small thyroid glands, normal thyroid function, and low thyroid antibody titers, making clinical diagnosis more difficult. Some patients have a rapidly enlarging goiter, called the juvenile hyperplasia type. Some patients may be combined with hypothyroidism.