Introduction: Thalassemia is a hemoglobin synthesis disorder associated with chronic anemia and transfusion-related iron overload, which predisposes patients to multiple endocrine complications. Iron deposition in the pituitary and gonads may result in growth hormone deficiency (GHD) and hypogonadism. Empty sella syndrome (ESS), characterized by herniation of the subarachnoid space into the sella turcica, may also contribute to hypopituitarism. The coexistence of thalassemia-related endocrinopathies, ESS, and autoimmune thyroid disease is rare and presents significant diagnostic complexity. Case: A 27-year-old female with transfusion-dependent thalassemia on deferiprone presented with secondary amenorrhea and short stature. Her height was 145 cm (below the target range of 140.5–157.5 cm), body mass index 17.3 kg/m², and Tanner stage M3P1. Laboratory evaluation revealed elevated thyroidstimulating hormone (10.92 mIU/L) with low-normal free thyroxine 4 (11.4 pmol/L), consistent with primary hypothyroidism. Thyroid ultrasound demonstrated features of chronic thyroiditis, and anti-thyroid peroxidase antibodies (8.18 IU/mL) supported a diagnosis of Hashimoto’s thyroiditis. Insulin-like growth factor-1 was markedly reduced (68 ng/mL), indicating GHD. Morning cortisol was within normal range (14.5 µg/dL). Gonadotropins were inappropriately low-normal (folliclestimulating hormone 7.42 mIU/mL, luteinizing hormone 11.41 mIU/mL) with low estradiol (26.49 pg/mL), suggesting hypogonadotropic hypogonadism. Skeletal survey showed thalassemia-related bone changes, including trabecular coarsening and metaphyseal widening, with a predicted adult height of 142.7 cm. Pituitary magnetic resonance imaging revealed an empty sella. Conclusion Thalassemia must be recognized not only as a primary hematologic condition but also as a complex multisystem disorder with profound endocrine implications. Furthermore, the co-occurrence of these conditions with rare manifestations such as ESS and Hashimoto’s thyroiditis underscores the diagnostic complexity faced by clinicians. Therefore, early detection and rigorous, regular endocrine screening are essential to optimize management strategies and improve the long-term quality of life for patients with thalassemia.
Empty Sella Syndrome ; Growth Hormone ; Thalassemia ; Thyroiditis

Introduction: Painful Hashimoto's thyroiditis is a rare and atypical form of autoimmune thyroid disease characterized by thyroid pain and tenderness. It can closely resemble subacute thyroiditis and must be distinguished from other causes of thyroid pain, including hemorrhage into a cyst and thyroid abscess. This distinction is particularly important in pregnancy, where radionuclide imaging is not recommended. Case: A 27-year-old pregnant female (G4P3) at 24 weeks’ gestation, with Southeast Asian ovalocytosis and dietcontrolled gestational diabetes, was diagnosed with primary hypothyroidism at 14 weeks following evaluation of a painless goiter. Initial tests showed markedly elevated thyroid-stimulating hormone (>150 mIU/L), low free thyroxine (3.5 pmol/L), and positive anti-thyroid peroxidase antibodies (319 IU/mL), consistent with Hashimoto's thyroiditis. Levothyroxine therapy achieved biochemical euthyroidism. At 24 weeks, she developed acute right-sided anterior neck pain radiating to the ear, with dysphagia, odynophagia, and fever. Examination revealed a tender thyroid without lymphadenopathy. Ultrasound demonstrated diffuse enlargement with bilateral ill-defined hypoechoic avascular areas. Inflammatory markers showed markedly elevated C-reactive protein (184 mg/L) with a normal erythrocyte sedimentation rate (16 mm/h), while thyroid function remained within target range. Imaging and clinical findings made abscess and hemorrhage unlikely. The presence of pre-existing autoimmune thyroid disease, antibody positivity, and hypothyroidism before symptom onset supported painful Hashimoto's thyroiditis over subacute thyroiditis. This case highlights that normal thyroid function tests do not necessarily indicate disease remission, as inflammatory activity may persist independently of hormone levels. Conclusion Painful Hashimoto's thyroiditis should be considered in pregnant patients with known autoimmune thyroid disease presenting with acute thyroid pain despite normal thyroid function. Diagnosis requires integration of clinical, biochemical, and imaging findings to guide appropriate management.
Female ; Pregnancy ; Thyroiditis, Subacute

Introduction: Hashimoto's thyroiditis is a common autoimmune thyroid disease; however, pulmonary involvement is a rare manifestation. Lymphocytic interstitial pneumonitis is commonly associated with autoimmune diseases, but its association with Hashimoto's thyroiditis remains poorly understood. Case: A 63-year-old male with prior diagnosis of Hashimoto's thyroiditis presented with recurrent massive pleural effusion and progressive dyspnea. He also experienced fatigue, cold intolerance, and constipation. Physical examination revealed facial puffiness, diffuse goiter, and dry skin. Thyroid function tests performed 6 months before admission confirmed overt hypothyroidism (thyroidstimulating hormone [TSH] 80.30 µIU/mL, free thyroxine 4 [FT4] 0.46 ng/dL). One month prior to admission, laboratory findings showed subclinical hypothyroidism (TSH 9.09 µIU/mL, FT4 1.42 ng/dL). Despite levothyroxine treatment TSH levels remained elevated at 21.8 µIU/mL during admission. Anti-thyroid peroxidase antibodies were positive (13.95 IU/mL). Repeated thoracentesis revealed exudative pleural effusion with lymphocytic predominance and no evidence of malignancy in cytological examination. Infectious etiologies and malignancy were ruled out. Thyroid ultrasonography demonstrated diffuse hypoechoic enlargement of the thyroid gland. Chest radiography showed massive unilateral pleural effusion, while thoracic computed tomography revealed ground-glass opacities with a reticulogranular pattern and interlobular septal thickening, accompanied by multiple thin-walled cysts, highly suggestive of lymphocytic interstitial pneumonitis. Thyroid immunohistochemical analysis was performed (CD 20, CD 3, CD 10, CD 138, Ki 67, BCL 2, BCL 6, Thyroglobulin, MUM 1, Cyclin D1), consistent with lymphocytic thyroiditis. Significant clinical and laboratory improvement was achieved after combined treatment with levothyroxine and corticosteroid. Conclusion This case underscores the importance of considering autoimmune-related lymphocytic interstitial pneumonitis in patients with Hashimoto's thyroiditis who present with unexplained recurrent pleural effusion after exclusion of more common etiologies, such as infection and malignancy. Early recognition may lead to favorable improvement.
Lung Diseases, Interstitial ; Pleural Effusion ; Thyroiditis

Introduction: Steroid-responsive encephalopathy associated with thyroiditis (STREAT) is a rare clinical entity. Clinical presentations of STREAT can range from a strokelike presentation to psychiatric symptoms. STREAT is diagnosed based on four major criteria which include altered cognitive function, new or worsening psychiatric symptoms, elevated antithyroid antibodies, and exclusion of infectious, toxic, metabolic, or neoplastic causes. Corticosteroids are the cornerstone of treatment, with reported excellent response in neurocognitive symptoms resolution. Case: This was a case of a 48-year-old male with Graves’s disease who underwent radioiodine therapy 4 months earlier and was started on levothyroxine 100 mcg 2 weeks prior to presentation. He presented with 4 days of behavioral symptoms, irritable mood with auditory and visual hallucinations. There was no history of fever, headache, limb weakness, or seizure. On general appearance, the patient was agitated, talking incoherently, and disorientated with normal vitals. There was no delayed relaxation of the reflex. The examination of the cranial nerve, motor, sensory, and cerebellar system was normal. A lumbar puncture showed normal opening pressure with a high protein CSF content of 1,596 mg/L. The thyroid-stimulating hormone (TSH) was elevated at 72.7 uIU/mL and T4 at 9.56 pmol/L. Serum antithyroid peroxidase was elevated at 877.42 IU/mL, and antiTSH receptor antibody at 21.30 IU/L. CSF oligonal band, serum aquaporin-4, and viral screening were negative; noncontrasted computed tomography brain revealed normal findings. Based on the clinical history and examination, a diagnosis of STREAT was made at the emergency department. The patient was initiated on hydrocortisone 100 mg three times a day. Within 24–48 hours of steroid therapy, marked improvement and subsequent resolution of the mental status and behavioral symptoms were seen. Conclusion Hashimoto’s thyroiditis can rarely lead to STREAT, a condition with diverse neurological manifestations, where early recognition and prompt corticosteroid therapy are essential for favorable outcomes.
Brain Diseases ; Thyroiditis ; Steroids

Introduction: Primary thyroid lymphoma (PTL) is a rare malignancy representing 1–5% of all thyroid cancers, most frequently arising on a background of chronic autoimmune thyroiditis. Case: We report a 73-year-old Malay male who initially presented with large goiter, symptomatic bradycardia, and subsequently developed severe primary hypothyroidism (thyroid-stimulating hormone 231 mIU/L, anti-thyroid peroxidase 643 IU/mL), consistent with Hashimoto’s thyroiditis. During his clinical course, he also sustained a non-ST elevation Myocardial Infarction which was attributed to demand-supply mismatch of hypothyroidism. Computed tomography scan of the neck revealed a large multinodular goiter with retrosternal extension, tracheal compression, and extensive nodal lymphadenopathy. Initial Fine needle biopsy was non-diagnostic, but a repeat biopsy was performed due to rapidly enlarging goiter within weeks with suspicious nodules seen on bedside thyroid ultrasound. Ultrasound-guided core biopsy confirmed Diffuse Large B-cell Lymphoma (DLBCL), non-germinal centre B-cell (non-GCB) subtype. Despite initiation of levothyroxine and corticosteroid therapy, the patient deteriorated with remarkable rapidity over the ensuing weeks, culminating in a 15 × 10 cm compressive neck mass, Type 1 respiratory failure, hypercalcemia, complete dysphagia, and concurrent pneumonia. He was then transferred to hematology tertiary centre for commencement of his chemotherapy. Conclusion This case of PTL presenting in the background of Hashimoto’s thyroiditis emphasizes the role of early tissue diagnosis in patients with rapidly enlarging goiter. Identification of PTL is critical because management shifts from surgical intervention to systemic chemotherapy.
Thyroiditis

Introduction: Autoimmune thyroid disease can follow a triphasic course: thyrotoxicosis, a transient euthyroid period, and eventual hypothyroidism, and may coexist with myelodysplastic syndrome (MDS) in the context of immune dysregulation. Case: We describe a 35-year-old male with MDS (multilineage dysplasia) receiving cyclosporine who initially presented with painless thyrotoxicosis, with suppressed thyroidstimulating hormone (TSH) and elevated free thyroxine (FT4). During this hyperthyroid phase, thyrotropin receptor antibody (TRAb) was positive. Over time, his thyroid status fluctuated, progressing to overt hypothyroidism, and he had poor adherence to thyroid medications. On admission, he had prominent hypothyroid features (fatigue, cold intolerance, slowed movement, periorbital puffiness) with severe biochemical hypothyroidism (TSH 49.5 µIU/mL; FT4 0.419 ng/dL). Anti-thyroid peroxidase (anti-TPO) antibodies 12.62 IU/mL (negative <5.61 IU/mL; positive ≥5.61 IU/mL) showed an autoimmune response to the thyroid. Thyroid ultrasound showed heterogeneous, hyperechoic with some hypoechoic parts, and no significant increase in thyroid vascularity was observed, supporting autoimmune thyroiditis representation. His hematologic profile remained consistent with MDS, with chronic macrocytic anemia and thrombocytopenia. Conclusion This case highlights a dynamic autoimmune thyroiditis phenotype progressing from a hyperthyroid phase with TRAb positivity to higher anti-TPO overt hypothyroidism in a patient with MDS. In individuals with MDS and changing thyroid function tests, clinicians should keep autoimmune thyroiditis variants in mind and use thyroid antibodies together with ultrasound to secure the diagnosis when the clinical pattern is typical.
Myelodysplastic Syndromes ; Thyroiditis, Autoimmune ; Hypothyroidism ; Thyrotoxicosis

Introduction: Subacute thyroiditis (SAT) and acute suppurative thyroiditis (AST) are two distinct inflammatory conditions but share many overlapping clinical and biochemical features, which may pose a diagnostic challenge. We report a case of SAT mimicking AST. Case: A 39-year-old female presented with a 3-week history of painful neck swelling and symptoms of thyrotoxicosis, including palpitations, heat intolerance, and diaphoresis. She had no family history of thyroid disease. On examination, she was febrile and had a smooth and tender goiter. Her blood tests showed leukocytosis with elevated erythrocyte sedimentation rate and C-reactive protein. Her thyroid function test (TFT) showed thyroid-stimulating hormone of 0.023 mIU/L and free thyroxine 4 of 32.15 pmol/L. An urgent ultrasound revealed a large, ill-defined heterogeneously hypoechoic lesion predominantly at the left lobe of the thyroid gland with mild intralesional vascularity. These were reported as features of thyroiditis with infective or early suppurative changes. Fine needle aspiration (FNA) of the lesion was attempted by the radiologist but was unsuccessful. She was treated with intravenous antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs), but symptoms persisted. Repeated ultrasound and computed tomography scans about 1 week later confirmed an enlarged thyroid gland with no obvious lesion or collection within the gland. The diagnosis was revised to SAT, and prednisolone 15 mg OD was started. This resulted in rapid improvement in her symptoms and inflammatory markers. Four weeks later, she remained asymptomatic, and prednisolone was gradually tapered off. Serial TFT monitoring showed a classic triphasic pattern with an initial hyperthyroid phase, followed by hypothyroidism before returning to euthyroidism. Conclusion SAT can present with a focal lesion on the ultrasound during the early stage of the disease, making it difficult to distinguish from a thyroid abscess due to overlapping features. Good clinical judgement guided by FNA and appropriate follow-up imaging may be helpful in differentiating between the two conditions.
Thyroiditis, Subacute ; Thyroiditis, Suppurative

This study aims to explore the effects of Buzhong Yiqi Decoction(BYD) on the cyclic guanosine monophosphate-adenosine monophosphate synthase(cGAS)-stimulator of interferon genes(STING) signaling pathway in the mouse model of autoimmune thyroiditis(AIT) and the mechanism of BYD in alleviating the immune injury. Forty-eight NOD.H-2~(h4) mice were assigned into normal, model, low-, medium-, and high-dose BYD, and selenium yeast tablets groups(n=8). Mice of 8 weeks old were treated with 0.05% sodium iodide solution for 8 weeks for the modeling of AIT and then administrated with corresponding drugs by gavage for 8 weeks before sampling. High performance liquid chromatography was employed to measure the astragaloside Ⅳ content in BYD. Hematoxylin-eosin staining was employed to observe the pathological changes in the mouse thyroid tissue. Enzyme-linked immunosorbent assay was employed to measure the serum levels of thyroid peroxidase antibody(TPO-Ab), thyroglobulin antibody(TgAb), and interferon-γ(IFN-γ). Flow cytometry was employed to detect the distribution of T cell subsets in the spleen. The immunohistochemical method was used to detect the expression of cGAS, STING, TANK-binding kinase 1(TBK1), and interferon regulatory factor 3(IRF3). Real-time PCR and Western blot were employed to determine the mRNA and protein levels, respectively, of markers related to the cGAS-STING signaling pathway in the thyroid tissue. The results showed that the content of astragaloside Ⅳ in BYD was(7.06±0.08) mg·mL~(-1). Compared with the normal group, the model group showed disrupted structures of thyroid follicular epithelial cells, massive infiltration of lymphocytes, and elevated levels of TgAb and TPO-Ab. Compared with the model group, the four treatment groups showed intact epithelial cells, reduced lymphocyte infiltration, and lowered levels of TgAb and TPO-Ab. Compared with the normal group, the model group showed increases in the proportions of Th1 and Th17 cells, a decrease in the proportion of Th2 cells, and an increase in the IFN-γ level. Compared with the model group, the four treatment groups presented decreased proportions of Th1 and Th17 cells and lowered levels of IFN-γ, and the medium-dose BYD group showed an increase in the proportion of Th2 cells. Compared with the normal group, the modeling up-regulated the mRNA levels of cGAS, STING, TBK1, and IRF3 and the protein levels of cGAS, p-STING, p-TBK1, and p-IRF3. Compared with the model group, the four treatment groups showed reduced levels of cGAS, STING, TBK1, and IRF3-positive products, down-regulated mRNA levels of cGAS, STING, and TBK1, and down-regulated protein levels of cGAS and p-STING. The high-dose BYD group showed down-regulations in the mRNA level of IRF3 and the protein levels of p-TBK1 and p-IRF3. The above results indicate that BYD can repair the imbalance of T cell subsets, alleviate immune injury, and reduce thyroid lymphocyte infiltration in AIT mice by inhibiting the cGAS-STING signaling pathway.
Animals ; Drugs, Chinese Herbal/administration & dosage* ; Signal Transduction/drug effects* ; Thyroiditis, Autoimmune/metabolism* ; Mice ; Membrane Proteins/metabolism* ; Mice, Inbred NOD ; Humans ; Female ; Nucleotidyltransferases/metabolism* ; Male ; Disease Models, Animal

Acute suppurative thyroiditis is a rare and potentially fatal condition. We present a case of an 18-year-old Malay female who presented with one-week history of painful right sided neck swelling, fever and odynophagia. Neck CT confirms ruptured multiloculated abscess with posterosuperior extension into prevertebral space. Pus and tissue cultured Streptococcus anginosus and Eikenella corrodens with positive TB PCR. She responded well to ampicillin/sulbactam and anti-tuberculosis treatment with no evidence of residual collection from ultrasound.
Thyroiditis, Suppurative

Ultrasound (US) elastography has been introduced as a non-invasive technique for evaluating thyroid diseases. This paper presents a detailed description of the technical principles, peculiarities, and limitations of US elastography techniques, including strain elastography and shear-wave elastography. This review was conducted from a clinical perspective, and aimed to assess the usefulness of US elastography for thyroid diseases in specific clinical scenarios. Although its main focus is on thyroid nodules, the applications of US elastography for other thyroid diseases, such as diffuse thyroid diseases and thyroiditis, are also presented. Furthermore, unresolved questions and directions for future research are also discussed.
Elasticity Imaging Techniques ; Thyroid Diseases ; Thyroid Gland ; Thyroid Nodule ; Thyroiditis ; Ultrasonography