BACKGROUND: Autoimmune thyroid diseases have been shown to occur in association with connective tissue disorders. This study was undertaken to elucidate the prevalence of thyroid autoantibodies and thyroid dysfunction in Korean patients with rheumatoid arthritis (RA). METHODS: We have compared the prevalence of thyroid autoantibodies in 108 RA patients with 81 age-matched controls. Antimicrosomal antibody (AMA) and antithyroglobulin antibody (ATA) were measured by passive hemagglutinin assay. T3, T4, Free T4, and TSH were measured by chemiluminescence method. Rheumatoid factor was measured by nephelometry. Statistical analysis was performed by chi-square, Fisher's exact test, and Pearson correlation test. RESULTS: 1) The presence of AMA/ATA in patients with RA was significantly higher (28.7%/26.7% in 108 patients) than that of controls (11.1%/9.9% in 81 controls). The positive rates of AMA/ATA in female patients were also higher (28.9%/28.9% in 97 patients) than those of female controls (15.5%/12.1% in 58 controls). 2) Thirty three (17.6%) of 187 patients with RA had the abnormalities of thyroid function; 14 (7.5%) revealed subclinical hypothyroidism, 5 (2.7%) revealed biochemical primary hypothyroidism, 7 (3.7%) revealed sick euthyroid syndrome, and 7 (3.7%) revealed hyperthyroidism. CONCLUSION: These results suggest that autoimmune thyroiditis is highly associated with RA in Korean patients, showing the increased prevalence of thyroid autoantibodies and thyroid dysfunctions.
Arthritis, Rheumatoid* ; Autoantibodies* ; Connective Tissue ; Euthyroid Sick Syndromes ; Female ; Hemagglutinins ; Humans ; Hyperthyroidism ; Hypothyroidism ; Luminescence ; Nephelometry and Turbidimetry ; Prevalence ; Rheumatoid Factor ; Thyroid Diseases ; Thyroid Gland* ; Thyroiditis, Autoimmune

Autoimmune thyroid disease (AITD) includes hyperthyroid Graves disease, hypothyroid autoimmune thyroiditis, and subtle subclinical thyroid dysfunctions. AITD is caused by interactions between genetic and environmental predisposing factors and results in autoimmune deterioration. Data on polymorphisms in the AITD susceptibility genes, related environmental factors, and dysregulation of autoimmune processes have accumulated over time. Over the last decade, there has been progress in the clinical field of AITD with respect to the available diagnostic and therapeutic methods as well as clinical consensus. The updated clinical guidelines allow practitioners to identify the most reasonable and current approaches for proper management. In this review, we focus on recent advances in understanding the genetic and environmental pathogenic mechanisms underlying AITD and introduce the updated set of clinical guidelines for AITD management. We also discuss other aspects of the disease such as management of subclinical thyroid dysfunction, use of levothyroxine plus levotriiodothyronine in the treatment of autoimmune hypothyroidism, risk assessment of long-standing antithyroid drug therapy in recurrent Graves' hyperthyroidism, and future research needs.
Causality ; Consensus ; Drug Therapy ; Genes, rel ; Graves Disease ; Hashimoto Disease ; Hyperthyroidism ; Hypothyroidism ; Risk Assessment ; Thyroid Diseases* ; Thyroid Gland* ; Thyroiditis, Autoimmune ; Thyroxine

The most common cause of thyrotoxicosis is Graves' disease, followed by toxic adenoma, multiple nodular toxic goiter, and temporary thyroiditis. At initial presentation, however, it is often difficult to recognizinge subacute thyroiditis as a thyroid disease is often difficult. In many cases, subacute thyroiditis may be mistaken for certain upper respiratory infectious diseases, due to their similar clinical manifestations. Additionally, when subacute thyroiditis coexists with a thyroid nodule or is accompanied by severe thyrotoxicosis, it can be misdiagnosed as a thyroid tumor, toxic adenoma, or Graves' disease. Here we report the case of an autonomously functioning thyroid nodule combined with subacute thyroiditis, which was nearly misdiagnosed as toxic adenoma. This is the first reported case in Korea of a patient who had an autonomously functioning thyroid nodule combined with subacute thyroiditis, which was nearly misdiagnosed as toxic adenoma.
Adenoma ; Communicable Diseases ; Goiter ; Graves Disease ; Humans ; Korea ; Thyroid Diseases ; Thyroid Gland ; Thyroid Nodule ; Thyroiditis ; Thyroiditis, Subacute ; Thyrotoxicosis

Subacute thyroiditis is a self-limiting inflammation of the thyroid, presenting with painful thyroid swelling, thyrotoxicosis and low radioactive iodine uptake. The characteristic US findings for this disease are focal ill-defined hypoechoic areas in one lobe or diffuse hypoechoic areas in both lobes. Thyroid carcinomas should be included in the differential diagnosis for a lesion with focal hypoechoic areas and have been rarely reported to coexist with subacute thyroiditis. Takayasu's arteritis is an autoimmune disease that affects the aorta and its branches as well as pulmonary arteries. Subacute thyroiditis associated with Takayasu's arteritis is extremely rare, with only three cases being reported. We report here on the first case with the simultaneous diagnosis of subacute thyroiditis, papillary thyroid carcinoma and Takayasu's arteritis.
Aorta ; Autoimmune Diseases ; Carcinoma ; Diagnosis, Differential ; Inflammation ; Iodine ; Pulmonary Artery ; Takayasu Arteritis ; Thyroid Gland ; Thyroid Neoplasms ; Thyroiditis, Subacute ; Thyrotoxicosis

Autoimmune thyroid disease is characterized by the presence of autoantibodies against thyroid peroxidase (TPO), thyroglobulin (Tg), and the thyroid simulating hormone receptor (TSHR). The thyroid gland is a site of autoantibody secretion in autoimmune thyroid disease by the B cells infiltrated into the thyroid. Hashimoto's thyroiditis, a chronic autoimmune thyroid disease, characterized by the occurrence of high levels of serum thyroid antibodies for TPO and Tg and goiter, is the most common type of thyroiditis. A firm, diffuse, painless goiter is the most common initial finding in Hashimoto's thyroiditis. Some patients have atrophic thyroid glands rather than goiter, which may represent the final stage of thyroid failure in Hashimoto's thyroiditis. Levothyroxine is the treatment of choice for Hashimoto's thyroiditis presenting overt hypothyroidism. Patients with Hashimoto's thyroiditis and a thyroid nodule should undergo fine-needle aspiration biopsy to rule out lymphoma and thyroid carcinoma. Graves' disease is the most common cause of spontaneous hyperthyroidism in patients younger than 40 years of age. Patients with Graves' disease reveal heterogeneous lymphocytic infiltration without follicular destruction and also show various clinical presentations.
Antibodies ; Autoantibodies ; B-Lymphocytes ; Biopsy, Fine-Needle ; Goiter ; Graves Disease ; Hashimoto Disease ; Humans ; Hyperthyroidism ; Hypothyroidism ; Iodide Peroxidase ; Lymphoma ; Thyroglobulin ; Thyroid Diseases ; Thyroid Gland ; Thyroid Neoplasms ; Thyroid Nodule ; Thyroiditis ; Thyroxine

Acute suppurative thryroiditis is a rare disease because the thyroid gland is resistant to infection. Thyroid function tests are usually normal in acute suppurative thryroiditis. We care for a patient with acute suppurative thryroiditis and associated thyrotoxicosis. A 73-year-old diabetic woman presented with pain over the thyroid gland and an elevated serum thyroid hormone level and decreased radioiodine uptake, as occurs in subacute thyroiditis. A neck computed tomography showed an abscess in the right lobe of the thyroid gland. A neutrophilic infiltration was shown in a fine needle aspiration biopsy, and Gram negative Burkholderia gladioli grew from the aspirate culture. Antibiotic treatment ameliorated the symptoms of infection, followed by normalization of thyroid function.
Abscess ; Aged ; Biopsy ; Biopsy, Fine-Needle ; Burkholderia gladioli ; Female ; Humans ; Neck ; Neutrophils ; Rare Diseases ; Thyroid Function Tests ; Thyroid Gland ; Thyroiditis, Subacute ; Thyroiditis, Suppurative ; Thyrotoxicosis

With the generalized use of highly sensitive thyroid stimulating hormone (TSH) and free thyroid hormone assays, most thyroid function tests (TFTs) are straightforward to interpret and confirm the clinical impressions of thyroid diseases. However, in some patients, TFT results can be perplexing because the clinical picture is not compatible with the tests or because TSH and free T4 are discordant with each other. Optimizing the interpretation of TFTs requires a complete knowledge of thyroid hormone homeostasis, an understanding of the range of tests available to the clinician, and the ability to interpret biochemical abnormalities in the context of the patient's clinical thyroid status. The common etiologic factors causing puzzling TFT results include intercurrent illness (sick euthyroid syndrome), drugs, alteration in normal physiology (pregnancy), hypothalamic-pituitary diseases, rare genetic disorders, and assay interference. Sick euthyroid syndrome is the most common cause of TFT abnormalities encountered in the hospital. In hypothalamic-pituitary diseases, TSH levels are unreliable. Therefore, it is not uncommon to see marginally high TSH levels in central hypothyroidism. Drugs may be the culprit of TFT abnormalities through various mechanisms. Patients with inappropriate TSH levels need a differential diagnosis between TSH-secreting pituitary adenoma and resistance to thyroid hormone. Sellar magnetic resonance imaging, serum α-subunit levels, serum sex hormone-binding globulin levels, a thyrotropin-releasing hormone stimulation test, trial of somatostatin analogues, and TR-β sequencing are helpful for the diagnosis, but it may be challenging. TFTs should be interpreted based on the clinical context of the patient, not just the numbers and reference ranges of the tests, to avoid various pitfalls of TFTs and unnecessary costly evaluations and therapies.
Diagnosis ; Diagnosis, Differential ; Diagnostic Errors ; Euthyroid Sick Syndromes ; Homeostasis ; Humans ; Hyperthyroidism ; Hypothyroidism ; Magnetic Resonance Imaging ; Physiology ; Pituitary Neoplasms ; Rare Diseases ; Reference Values ; Sex Hormone-Binding Globulin ; Somatostatin ; Thyroid Diseases ; Thyroid Function Tests ; Thyroid Gland ; Thyrotropin ; Thyrotropin-Releasing Hormone

Aspects of autoimmune thyroid disease updated in this review include: immunoglobulin G4 (IgG4)-related thyroid disease (Riedel's thyroiditis, fibrosing variant of Hashimoto's thyroiditis, IgG4-related Hashimoto's thyroiditis, and Graves' disease with elevated IgG4 levels); recent epidemiological studies from China and Denmark indicating that excess iodine increases the incidence of Hashimoto's thyroiditis and hypothyroidism; immunomodulatory agents (ipilimumab, pembrolizumab, nivolumab) activate immune response by inhibiting T-cell surface receptors which down-regulate immune response, i.e., cytotoxic T-lymphocyte antigen 4 and programmed cell death protein 1 pathways; alemtuzumab is a humanised monoclonal antibody to CD52 which causes immune depletion and thyroid autoimmune disease especially Graves' hyperthyroidism; small molecule ligand (SML) agonists which activate receptors, SML neutral antagonists, which inhibit receptor activation by agonists, and SML inverse agonists which inhibit receptor activation by agonists and inhibit constitutive agonist independent signaling have been identified. SML antagonism of thyroid-stimulating hormone-receptor stimulatory antibody could treat Graves' hyperthyroidism and Graves' ophthalmopathy; and thyroxine treatment of subclinical hypothyroidism can produce iatrogenic subclinical hyperthyroidism with the risk of atrial fibrillation and osteoporosis. The increased risk of harm from subclinical hyperthyroidism may be stronger than the potential benefit from treatment of subclinical hypothyroidism.
Atrial Fibrillation ; Autoimmune Diseases ; Cell Death ; China ; CTLA-4 Antigen ; Denmark ; Epidemiologic Studies ; Graves Disease ; Hashimoto Disease ; Hyperthyroidism ; Hypothyroidism ; Immunoglobulin G ; Immunoglobulins ; Immunomodulation ; Incidence ; Iodine ; Osteoporosis ; T-Lymphocytes ; Thyroid Diseases* ; Thyroid Gland* ; Thyroiditis ; Thyroxine

One of the rare diseases for differential diagnosis of subacute thyroiditis is metastases within the thyroid gland. We report here on a 72-year-old-woman with painful goiter and signs of hyperthyroidism. Her serum concentration of thyroid hormone was in the upper limit of normal, and the uptake of radioactive iodine by the thyroid was completely depressed. Although subacute thyroiditis was suspected, an additional work up that included a chest CT scan was done for the combined cough and chronic weakness. The result was lung cancer with metastatic involvement of the thyroid and multiple lymph nodes. She refused further anti-cancer therapy and died 5 months after the diagnosis. For the differential diagnosis of such a rare case, careful examination is important even in patients with the typical symptoms and laboratory findings of subacute thyroiditis.
Adenocarcinoma ; Cough ; Diagnosis, Differential ; Goiter ; Humans ; Hyperthyroidism ; Iodine ; Lung ; Lung Neoplasms ; Lymph Nodes ; Neoplasm Metastasis ; Rare Diseases ; Thorax ; Thyroid Gland ; Thyroiditis, Subacute

BACKGROUND AND OBJECTIVES: The aim of this retrospective study was to evaluate the significance of sonographically detected thyroid calcifications in the diagnosis of thyroid cancer. SUBJECTS AND METHOD: Two hundred ninety-one patients with thyroid disease, including 75 with thyroid cancer and 54 with calcified thyroid nodule, were reviewed during the period of January 2001 to May 2003. Each patient underwent preoperative high resolution sonography to evaluate the thyroid gland for the presence of calcifications. RESULTS: The highest incidence of calcification was found in thyroid cancer (36%), followed by multinodular goiter (20%), follicular adenoma (13%), and single nodular goiter (3%). The incidence of cancer was significantly higher in calcified nodules (50%) than in noncalcified nodules in the entire group (20%) (p<0.001), with a relative risk of 3.9. In the group of solitary thyroid nodules, the incidence of cancer in the calcified nodules (56%) was higher than that in the nodules without calcification (21%) (p=0.002). In the group of multiple thyroid nodules, the incidence of cancer in the calcified nodules (47%) was higher than that in the nodules without calcification (19%) (p=0.001). The relative risk in presence of calcification was 4.6 in the solitary nodules and 3.7 in the multiple nodules. Compared with multiple noncalcified thyroid nodules, the solitary calcified nodules demonstrated a relative risk of 5.2. In patients younger and older than 40 years, the relative risk in the presence of calcification was about the same, around 4. CONCLUSION: The detection of thyroid calcifications by sonography is diagnostically valuable. The presence of calcifications should raise the suspicion of malignancy.
Adenoma ; Diagnosis ; Goiter ; Goiter, Nodular ; Humans ; Incidence ; Retrospective Studies ; Thyroid Diseases ; Thyroid Gland* ; Thyroid Neoplasms ; Thyroid Nodule* ; Ultrasonography