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Friday, 29 November 2013

Thyroid Disease : Silent thyroiditis – The Misdiagnosis and diagnosis

Thyroid disease is defined as a condition of malfunction of thyroid. Hyperthyroidism is a condition in which the thyroid gland is over active and produces too much thyroid hormones. Hypothyroidism is a condition in which the thyroid gland is under active and produces very little thyroid hormones. Thyroid cancer is defined as condition in which the cells in the thyroid gland have become cancerous.
Silent thyroiditis
Silent thyroiditis is the inflammation of the thyroid gland. Patients with silent thyroiditis are experience back and forth between hypothyroidism and hyperthyroidism. The disease classically present with a triphasic course: a brief period of thyrotoxicosis due to release of preformed thyroid hormone that lasts for 1 to 3 months, followed by a more prolonged hypothyroid phase lasting up to 6 months, and eventual return to a euthyroid state. However, the types and degree of thyroid dysfunction are variable in these disorders, and individual patients may present with mild or more severe cases of thyrotoxicosis alone, hypothyroidism alone, or both types of thyroid dysfunction(a).
D. Misdiagnosis and diagnosis
D.1. Misdiagnosis
There is a report of silent thyroiditis misdiagoesd as Malignant lymphoma of the thyroid.
It was difficult to make differential diagnosis of this case from malignant lymphoma of the thyroid clinically and cytologically when immune rebound phenomena with invasion of lymphocyte and appearance of lymph follicle were the strongest. There is a report of a case of a 30-year-old female with postpartum silent thyroiditis misapprehended as malignant lymphoma of the thyroid(36).
D.2. Diagnosis
After recording the past and present history and completing a physical exam, including assessing symptoms and complaints commonly seen including enlarged thyroid gland, heart rate, shaking hand etc. The tests which your doctor orders may include
1. Radioactive iodine uptake test, or RAIU test
In the study to investigate the effects of iodine restriction on the RAIU value, and the necessity of iodine restriction in differentiating between Graves’ disease (GD) and silent thyroiditis (ST) of 415 patients, 277 of whom were patients with GD who had undergone iodine restriction before RAIU [GD(+)], 66 were patients with GD who did not undergo iodine restriction [GD(-)], 61 were patients with ST who had undergone iodine restriction [ST(+)], and the remaining 11 were patients with ST who did not undergo iodine restriction [ST(-)], indicated that high diagnostic value of the RAIU test was confirmed, but not affected by the presence of iodine restriction in the differentiation between GD and ST, therefore, iodine restriction before the RAIU test was unnecessary(37).
2. Blood test for blood levels of the thyroid hormones T3 and T4
The aim of the test is to the level of free T4 and thyroid stimulating hormone (TSH) levels. Circulating analytes used in the exploration of thyroid function are TSH and free thyroid hormones (FT4 and FT3). TSH is used as first line analysis in diagnosis because a normal value excludes almost always a thyroid dysfunction(38).
3. Thyroid scintigraphy
Thyroid scintigraphy with 99mTc allows establishing the functional characteristics of thyroid nodules (warm or cold) and to precise the origin of a thyrotoxicosis (autonomous toxic nodule vs Graves-Basedow, sub acute or silent thyroiditis(39).
4. Thyroid biopsy
In the study of usefulness of thyroid needle biopsy in the differential diagnosis of thyroid disorders revealing unusual thyroid function, in 601 cases of chronic thyroiditis. indicated that group A, the majority of the cases showed a latent or overt hypothyroidism and in histologic group B, hyperthyroid, euthyroid and latent hypothyroid cases were found in nearly equal frequency, respectively. In histologic group C, most cases were in euthyroid and in histologic group D, most cases showed a hyperthyroidism. In the silent thyroiditis and postpartum thyroiditis, known to show a characteristic clinical and laboratory finding, the histologic features of thyroid gland were as follows: the observed characteristic histologic changes in both diseases were an extensive follicular destruction associated with chronic diffuse thyroiditis(40).
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Sources
(a) http://www.ncbi.nlm.nih.gov/pubmed/22443972
(36) http://www.ncbi.nlm.nih.gov/pubmed/8341248
(37) http://www.ncbi.nlm.nih.gov/pubmed/15307943
(38) http://www.ncbi.nlm.nih.gov/pubmed/23091928
(39) http://www.ncbi.nlm.nih.gov/pubmed/23091928
(40) http://www.ncbi.nlm.nih.gov/pubmed/1942566