[Music] thank you greetings everybody Welcome to our updated talk on thyroiditis now this is a really complicated topic and um I had a video that I made about 10 years ago on this topic and I was only about a year out of medical school when I made it so um to say the least I was a little inexperienced in teaching so that video is kind of a mess I Do cover a lot of things that was relevant at the time but there are updated and new approaches to these that is worth updating and also um I want to kind of point out the most important things because I've looked over some of the step two and step three study materials some of the review books and only a few of these are apparently Jermaine to step three and step two for that matter however it's useful to understand most of the fire identities because they are all fair game for the exam so I'm going to point out the most important ones and then from that point you can decide whether or not you have the brain space to consider the others okay if you haven't had the chance yet please consider subscribing to my patreon you can get there by clicking the link in the description of the video or on the I button on the upper right hand corner I very much appreciate all the contributions I can get to help offset the cost of these videos and I thank all those of you who have already donated and if you haven't definitely feel free to subscribe to my channel I try to get videos out every weekday um so you'll get alerts when I put new videos up okay so this is just an overview some important information to know as we go forward and we take a look at each of these individual thyroidities so thyroiditis is a heterogeneous group of inflammatory thyroid disorders that share some similar features but there's a lot of caveats so there is generally with thyroiditis an enlargement or a goiter of the thyroid gland and typically you can appreciate it on the physical exam but not always so you're not always going to get a Frank enlarged thyroid sometimes it might be enlarged but you don't really feel it sometimes it's not enlarged at all so in if you do have a patient with a goiter you always have to consider thyroiditis but you can have a patient with thyroiditis who does not have a goiter with thyroiditis because there is some degree of destruction of the thyroid gland there's going to be some thyroid hormone that gets poured out initially and that's going to cause a hyperthyroid stage but eventually because of that destruction because of that damage you will eventually go to a hypothyroid phase and many of these are self-limited they self-resolve so the thyroid heals itself and so what you generally see with these thyroiditities is a hyperthyroid phase then a euthyroid phase as you start to go down in thyroid hormone then a hypothyroid phase and then back to a euthyroid state as you have resolved so as I said this should always be part of your differential for hypothyroidism hyperthyroidism or goiter if you have significant enlargements of the thyroid gland or if you have fibrosis which we're going to see with one of these thyroiditis it can cause compressive symptoms and so that can manifest as dyspnea dysphagia or a change in voice physical exam will often reveal a goiter but as I said not always if you do appreciate nodules so not a confluently enlarged thyroid but little nodules on the thyroid then you absolutely positively have to rule out cancer so that's very important to know thyroiditis tends to be more common in women than in men there is only one thyroiditis that's equal in the Sexes and it'll make a lot of sense when we get to it why that is the most accurate test we're not going to go we're not going to I'm not going to bring this up with every thyroiditis the most accurate test for any thyroiditis is a biopsy an open biopsy but for most thyroid Indies we do not do that we don't need to do that we can diagnose it based on labs and based on clinical presentation now you should be familiar with the radioactive iodine uptake test commonly written as an acronym reiu this is very useful in diagnosing thyroiditis as well as some of the other um disorders of the thyroid that are not often classified as thyroiditis like Graves disease or Hashimoto's and this allows you to visualize the activity of the thyroid so this is normal here on the left and what you see here on the right is an enhanced uptake of iodine because the thyroid is overactive and so that is what we see in Graves disease now on Labs of course with Graves disease you're going to see a very high T3 and T4 lots of thyroid hormone the thyroid is being stimulated by those thyroid stimulating immune globulins which if you aren't familiar with that go back to the hyperthyroid section and you'll also of course have a low TSH and that's because of negative feedback now with hypothyroidism you're going to have the opposite you're going to have very low uptake and that is typically because the thyroid gland is damaged and it's not taking up iodine it's not making thyroid hormone um so in this case you're gonna have a low T3 and T4 and a very high TSH because of the lack of negative feedback okay so I went over this in the hyperthyroid section but there's toxic multinodular goiter and a toxic adenoma where you see nodules on the reiu scan and often you're able to appreciate this on physical exam thyroidity so we're going to talk about I have them in bold I will make passive reference to supperative thyroiditis as we get to the end but we're going to talk about these five okay so one of them Hashimoto's we're just going to briefly talk about because I talk about that in the hypothyroid section now our first one is Subacute thyroiditis often referred to as decarabane thyroiditis this is a granulomatous disease so it's giant cell mediated and it's likely in response to a virus so you get a viral infection and then you develop this so it can happen in anyone but it tends to happen more in women the key here is that this is a painful thyroiditis and there aren't many of them so they have pain around the neck the jaw the upper arms just mainly in the neck though and you'll feel the thyroid and it'll often be enlarged and firm and very important tender to palpation so if you have a patient coming in either with hypothyroid symptoms or hyperthyroid symptoms or just a painful goiter you need to think of sub-acute thyroiditis so the thyroid symptoms are unreliable early on but as the disease progresses they will go into first a hyperthyroid State then a euthyroid state then a hypothyroid state which one you catch it in depends on when the patient comes in okay now on Labs if you get a set rate it'll be elevated because this is inflammatory and the TSH level will help you determine what phase the disease is in okay so if you're you have a high TSH you are in a hypothyroid phase if you have a low TSH you're in a hyperthyroid phase and you can also get T3 and T4 if you want the differential here is Graves disease particularly when you're in the hyperthyroid State now Graves disease will always be hyperthyroid because you have thyroid stimulating antibodies or immune globulins however um with if you have the caravanes in the hyperthyroid phase it can be difficult to tell the two apart and so that's where it's helpful to get that radioactive iodine uptake scan another thing that will help you is that Graves is not painful they'll have enlarged thyroid but it doesn't hurt the diagnosis here is based on Labs however the raiu is going to help you and what's going to distinguish this from graves is that the reiu in De caravanes is going to be low uptake all right whereas with Graves it's going to be high uptake because we have an overactive thyroid you can treat this symptomatically because it is self-limited the treatment of choice for the pain is NSAIDs now why do we go with NSAIDs they used to say aspirin but now we've kind of learned that aspirin can displace thyroid hormone and so it can worsen a hyperthyroid state so we tend to go with NSAIDs if that doesn't work for the pain we can try prednisone it'll cut down on the inflammation now as usual if you have hyperthyroid symptoms if you have a a thyrotoxicosis you can treat the symptoms with Propranolol a beta blocker if it's just moderate symptoms if you have more severe symptoms then you will probably want to go with potassium iodide now if you have hypothyroid symptoms then you'll go with levothyroxine that's just replacing the thyroid hormone and what you'll do is you'll titrate them and monitor their TSH and you want to get that TSH to normal you're not monitoring the T4 you're monitoring the TSA once once the TSH gets into the normal range they're considered euthyroid as I said this is self-limited the raiu uptake test is not needed but it will definitely differentiate sub-acute thyroiditis from grapes okay Hashimoto's I just want to briefly uh cover this because I talk about it in the hypothyroid section but it is part of Hashimoto's disease this is also painless it's enlarged it is almost always going to present as a goiter and hypothyroid symptoms will tend to predominate you can get a brief period of hyperthyroidism but it's often subclinical so these patients tend to come in with hypothyroid symptoms the best initial test here is going to be to get a TSH and anytime you get a TSH you can always add on like a free T4 or even just a total T4 and a T3 the diagnosis can be corroborated by getting that anti-tpo or anti thyroglobulin however those antibodies can be present in other autoimmune thyroidities and the autoimmune thyroiditities are any of the painless ones okay so that helped now with Hashimoto's this is not self-limited this will persist forever so if you go a year two years three years down the road and they've been having hypothyroid symptoms that long you're almost certainly dealing with Hashimoto's it's the number one cause of hypothyroidism in iodine sufficient regions uh levothyroxine is obviously going to be the treatment to replace the thyroid hormone remember to follow the TSH and you should check these patients out for nodules because approximately eight percent of nodules in patients with Hashimoto's are malignant remember the next step to do that then is FNA and you're looking for cancerous cells redial thyroiditis is fairly unique because this is very densely fibrotic and it can invade surrounding structures so this fibrosis will extend to other cervical structures including the esophagus trachea and musculature and so we really need to get ahead of this because this can cause some serious damage this is also going to be a painless goiter and it typically presents with hypothyroidism now you can get compressive symptoms this is the one where you really get those compressive symptoms because this is fibrosing so you get the dyspnea and dysphagia and the tightness and the pressure and hoarseness and cough even okay so when you think of a fibrosing thyroiditis a really invasive impinging thyroiditis think redials thyroiditis the best first and most accurate test in this case is indeed a surgical biopsy and the reason is because most of these were going to have to remove the thyroid because it's fibrosing and it's impinging on other structures so we don't really monkey around with this so this is this is the only one where you're definitely going to biopsy this and remove the thyroid the initial therapy this is another unique one and this is new it's tamoxifen what the heck that's something we give for breast cancer why does it work in ridulth thyroiditis I have no gosh darn clue but we give tamoxifen you can give prednisone with it but tamoxifen is the drug of choice now if you have hypothyroid symptoms of course you can treat that with levothyroxine and get them euthyroid these patients may need surgery if there are compressive symptoms and often they will go on to need surgery but the prednisone will really help uh mitigate some of that that inflammation and fibrosis acute lymphocytic and postpartum thyroiditis are the exact same process the only difference is if acute lymphocytic thyroiditis happens within a year after birth after you give birth then it's considered postpartum and if you don't or if a man gets it it's acute lymphocytic but it's the exact same presentation so this results in a relatively small goiter it is also painless and it's also self-limited there are these distinct phases as we expect and so this is really really common about seven percent of women will develop this after delivery and some say it's even more now you could have a very mild case where you don't come in so that may account for the discrepancies in the estimates this 10 so one to two months after uh you start with this process usually after giving birth you'll have a hyperthyroid face that lasts one to two months and then you'll go euthyroid for a little bit and then six to eight months of hypothyroidism same disease process as I mentioned acute lymphocytic and postpartum are the same disease process uh this is again a small painless goiter and the best initial tests are thyroid function tests which of course include TSH uh T4 and T3 and then the raiu treatment is only needed in in these disorders if they go into thyrotoxicosis uh and so in that case the best initial therapy is symptomatic and it would be propranolol now drug-induced thyroiditis is of course induced by drugs and there are certain drugs that do this and so you want to look at your history and you want to know some of the more common drugs that do this the big one is amiodarone and lithium obviously amiodarone is given as an antiarismic it's used a little less commonly now lithium though is used all the time so you really want to associate this with amiodarone and particularly lithium so with patients who are on lithium we do check their thyroid function on a regular basis interferon Alpha is given a little less commonly it's given in some of the chronic hepatitis it's also given for various cancers including malignant melanoma and capacity sarcoma as well as hairy cell leukemia then there's il2 that's given in a recombinant form in a drug called aldesalukin and this is given for also for malignant melanoma and renal cell carcinoma and these are that's given when it's metastasized okay so let's just take a look at what we've got here we kind of went over all of these the only one I didn't bring up here is separative that's where you get an actual bacteria or even a fungal infection of the thyroid this will of course be painful uh it is separative commonly these patients are euthyroid so typically these patients will come in with neck pain and your you may or may not feel an enlarged thyroid the thyroid function tests are going to be normal and so this is difficult sometimes so you might get a white count so you got neck pain and you get and you have an elevated white count elevated sed rate you can diagnose separative thyroiditis a lot of times these patients will also have a fever they'll be sick and stuff and obviously the treatment here is going to be antibiotics we give them parentorally and it's very simple antibiotics penicillin or ampicillin and then we didn't really talk about Graves but I just want want to point out one very important thing the T3 to T4 ratio which I did talk about in the hyperthyroid section when I talked about Graves if the T3 to T4 ratio is more than 20 then you have Graves if you have hyperthyroidism and it's less than 15 then you have a thyroiditis likely that where you're in the hyperthyroid phase so all of this I went over you can pause this and print it out if you want I'll just quickly though bring up on the bottom here any hyperthyroidism you can treat with Propranolol to to help with the symptoms if it's very severe treat it with potassium iodide and prednisone and if you're dealing with hypothyroidism obviously treat it with levothyroxine so to recap thyroiditis is inflammation of the thyroid either due to autoimmune causes infections or it can be idiopathic the basic labs to start out with are the TSH T3 and T4 and the raiu scan the only big exception to this is riddell's thyroiditis some hints if you have pain then you're either dealing with decarabane Subacute or a separative thyroiditis an infection and the way you can differentiate this is that if you have a low raiu you have some destruction of the thyroid and so that's going to be a low uptake whereas if you have separative thyroiditis the thyroid is actually working pretty well so you'll have a normal raiu if you have a man with a painful thyroid you're probably dealing with supperative thyroiditis because that's the only one that's one to one the rest of them have a female predominance dysphagia dyspnea and hoarseness you're dealing with redels thyroiditis uh if you have a young woman with a history of autoimmune disorders or a family history of autoimmune disorders think of Hashimoto's because Hashimoto's is so common it's much more common than the other ones maybe with the exception of postpartum thyroiditis now the treatment as I mentioned hypothyroid symptoms are treated with levothyroxine follow up on the TSH hyperthyroid symptoms are treated with Propranolol if they're moderate symptoms if they're severe symptoms treated with potassium iodide and prednisone prednisone will be important there because it will cut down on the potential of worsening the hyperthyroidism sub-acute is painful you'll treat this with actually no aspirin that's Old Co treat this with NSAIDs or prednisone if that's not enough you can go on to opiates but that's typically not needed reduce thyroiditis causes compressive symptoms so confirm that with a biopsy that's true with tamoxifen and steroids so these are just some things that you'll want to know if you remember these things you'll get your questions right if the patient's hyperthyroid and a total T3 to T4 ratio of more than 20 that suggests Graves and if it's less than 15 that suggests the thyroiditis now remember this is a total T3 to T4 ratio not free so you got to make sure if you're going to do this ratio that you're ordering the total T3 and the total T4 and then find needle aspiration is reserved for cold nodules and uh suspected separative thyroiditis so if you get that reiu scan and you see something like this where you got a lot of uptake and a lot of uptake but then there's this little spot where there's no uptake that's a cold nodule and you're going to want to FNA that [Music] all right