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Thyroid disease is defined as a condition of malfunction of thyroid gland.
Thyroid Disease : Acute thyroiditisAcute thyroiditis is a condition of relatively high amount of iodine in the tissue caused by microbial inflammatory thyroiditis, pyrogenic thyroiditis and bacterial thyroiditis. Acute infectious thyroiditis is very rare, accounted for about 0.1-0.7% of all thyroiditis.
1. Fever and swelling and tenderness in the neck
Patient with thyrotoxicosis may be experience symptoms of fever due to neck inflammatory changes, pus and with anterior neck tender swelling and odynophagia(1).
2. Infectious hip arthritis, spondylitis and Roth’s spots
Acute right-sided suppurative thyroiditis may enhance infectious hip arthritis, spondylitis and Roth’s spots(2).
3. Chills, dysuria and recent painful neck swelling
Patients with acute suppurative thyroiditis secondary to Escherichia coli (E. coli) infection are more likely presented with fevers, chills, dysuria(3).
4. Firm, livid, hardly mobile cervical swelling
Patient with acute suppurative thyroiditis and right lobe thyroid abscess caused by Klebsiella spp are shown to present with firm, livid, hardly mobile cervical swelling, due tosoft-tissue swelling, thyroid lobe and swelling of the thyroid gland(4).
5. Impaired vocal cord mobility
Although it is rare, acute suppurative thyroiditis also induces symptoms of unilateral vocal cord paralysis (5).
6. Swollen, red, hot, and tender, and limited neck movement
Fever, swollen, red, hot, and tender, and neck movement limited due to left lobe of the thyroid gland also are considered as symptoms of acute thyroiditis (6).
7. Severe odynophagia and dysphagia, fever, chills, sore throat and right ear pain
Suppurative thyroiditis caused by Salmonella enteritidis in patients with diabetes mellitus type 2 may present with severe odynophagia and dysphagia associated with fever, chills, sore throat and right ear pain(6a).
8. Dysphonia, myalgia, swelling of the small joints of the hands, weight loss, and erythematous malar rash
Acute suppurative thyroiditis associated with juvenile systemic lupus erythematosus (JSLE) onset may present with a painful voluminous swelling in the anterior cervical region with fever, myalgia, swelling of the small joints of the hands, weight loss, and erythematous malar rash(6b).
B. Causes and Risk Factors
According to Georgetown University, the most common anaerobic bacteria are Gram-negative bacilli and Peptostreptococcus spp. agents, including Streptococcus anginosus(8)(9), piriform sinus fistula with thyrotoxicosis(10), etc.
Viruses have also shown to associate with subacute thyroiditis, and include measles, mumps, influenza, enterovirus Epstein-barr, adenovirus, echovirus, and St Louis encephalitis(7).
Other causes of acute thyroiditis also include cervical thymic cyst(11) fungi and parasites(12).
B.2. Risk Factors
1. Immunocompromised patients
People who have weakened immune system are at increased risk of bacterial, virus and fungal causes of cute infectious thyroiditis.
If you are elder, you are associated with increased risk of cute infectious thyroiditis.
3. Pre-existing thyroid diseases
Risk of acute thyroiditis increase for patient with hypothyroidism due to Hashimoto’s thyroiditis and mycobacterium avium intracellulare suppurative thyroiditis(13).
4. Congenital defect and infection
4.1. Complete congenital third branchial fistula
History of a small opening in the middle third of the anterior neck since birth, with recurrent surrounding swelling is associated to increased risk of infection of thyroid gland (14).
4.2. Fourth branchial arch anomalies
Fourth branchial arch anomalies represent <1% of all branchial anomalies may contribute to recurrent neck infections or suppurative thyroiditis(14a).
4.1. Persistent thyroglossal duct
Persistent thyroglossal duct infection may contribute to acute suppurative thyroiditis with abscess (15).
4.2. Piriform sinus fistula
Infected piriform sinus fistula with thyrotoxicosis is also associated to risk of acute suppurative thyroiditis(16).
C. Diseases associated to Acute thyroiditis
Patients with tonsillitis are shown to associate with the existence of suppurative thyroiditis complicated by thyrotoxicosis, in causation of trachea deviation and compressed large vessels; associated with internal jugular vein thrombosis, and sepsis(17).
2. Bacterial throat infection
Thyroid abscesses are rare complications of neck infections, but it can occur in patients with acute thyroiditis, with symptoms of increased neck pain and swelling(18).
3. Thyroid papillary carcinoma
Suppurative thyroiditis, thyroid cancer and chronic thyroiditis combination have been observed in elderly(19).
4. Esophageal carcinoma
Right-sided thyroid abscess with fistulous connection to the upper of two oesophageal carcinomas hasbeen found in patients with acute thyroiditis, may cause dysphagia, weight loss and a neck swelling(20).
5. Laryngologic problem
Acute pharyngitis or laryngitis associated with acute suppurative thyroiditis could be life threatening, according to the Klinika Otolaryngologii CMKP w Warszawie(20a).
6. Diabetes mellitus
Diabetes mellitus (DM) patients showed to be a precipitating factor for acquiring unusual infectious thyroiditis(20b).
According to the study by the Universidade do Estado do Rio de Janeiro, acute suppurative thyroiditis is a rare disorder, most often caused by Staphylococcus aureus or Streptococcus pneumoniae, inducing complication of pyriform sinus fistula in children, infection in the oropharynx or respiratory tract in adult. Delays diagnosis also showed to increase the risk of complications(21). Sacroileitis is also a frequently rare complication of brucellosis, endocarditis, thyroiditis and pyelonephritis are among the rare complications(21a).
1. Thyroid cancer
Patients with thyrotoxicosis presented with anterior neck tender swelling and odynophagia can be diagnosed as thyroid cancer due to the misleading computed tomography report, according to Fudan University(22).
2. Acute bacterial thyroiditis
Acute bacterial thyroiditis may be misdiagnosed if it is presented with absence of leucocytes and bacteria couple with initial borderline clinical and sonographic data(23).
3. Juvenile systemic lupus erythematosus
Although it is unusual, acute suppurative thyroiditis in at least one case is associated with juvenile systemic lupus erythematosus (JSLE) onset(24).
4. Hashimoto’s thyroiditis
Hashimoto’s thyroiditis has been misdiagnosed as thyroid abscess in cervical ultrasonograph
If you are experience certain symptoms of the above and your doctor suspects that you have developed acute thyroiditis, 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 ordered may include
1. Blood test
The aim of the test is to check for the elevation of white blood cell count, erythrocyte sedimentation(red blood cells/ hour) rate, abnormal thyroid hormone levels and alkaline phosphatase(measuring the amount of the enzyme transaminase(ALP) in the blood)26).
2. Needle aspiration
Needle aspiration of thyroid is a diagnostic procedure used to check for lumps or masses of thyroid gland. The procedure is safe, but in some cases, it can cause painful cervical swelling, fever, and chills due to infection, induced acute suppurative thyroiditis, according to Ankara University School of Medicine(27).
3. Ultrasound and oesophagography
The thyroid infection in children may induce abnormality of pyriform fossa sinus.
According to the Prince of Wales Hospital, ultrasound and oesophagography are helpful tools used to diagnose pyriform fossa sinus associated with suppurative thyroiditis(28).
4. CT scan
CT scan can be useful in identifying the location of the abscess, in unusual situations.
H.1. Diet to prevent Acute infectious thyroiditis
Sulforaphane (SFN), a natural constituent of cruciferous vegetables such as broccoli, Brussels sprouts, etc. is considered as one of most potent anti-oxidant and anti-inflammatory agent and probably a promising reagent for intervention of multiple sclerosis and other autoimmune diseases through its anti-oxidant activity and antagonizing autoimmune inflammation(29).
2. Fresh ginger
Several chemical constituents of Zingiber officinale Rosc. (Zingiberaceae) showed to inhibit reactive oxygen species (ROS), immune system response to the inflammation)(30).
Catechu, used as a food additive, astringent, tannin, and dye extracted from Acacia catechu
showed to exhibit a significantly strong anti inflammatory effect in vitro in study of rats, in concentration-depended manner(31).
20 g of soy protein with 160 mg of total isoflavones (64 mg genistein, 63 mg daidzein, and 34 mg glycitein) in 12 weeks enhanced serum adiponectin levels involved in regulating glucose levels as well as fatty acid breakdown, according to the study of 75 healthy postmenopausal women(32).
According to the study, curcumin (diferuloyl methane) was found effectively for treatment in patients with postoperative inflammation(33).
H.2. Phytochemicals and antioxidants to prevent Acute infectious thyroiditis
1. Alliin (S-allyl-L-cysteine-S-oxide)
Alliin (S-allyl-L-cysteine-S-oxide), an antimicrobial sulfur compound newly isolated from heated garlic extract, showed to exhibit its strong anti-yeast activity and rather weak antibacterial activity, similar to other antimicrobial compounds in garlic,(34).
2. Allyl sulfides
Antibacterial properties of Crushed garlic have been known for a long time for its anti bacterial activities including species of Escherichia, Salmonella, Staphylococcus, Streptococcus, Klebsiella, Proteus, Bacillus, and C!ostridium, according to “Allicin from fresh Garlic Nature’s Original Antimicrobial”, The Englishman’s Doctor (Harrington, 1609),
Triterpenoids, major chemical compound of several species showed a total antioxidant capacity of 42.94% as compared to ascorbic acid.
According to University of Milan, regular consumption of tomato drink, promoted DNA protection from oxidative stress, modulation of immune and inflammatory activity in young healthy volunteers(35).
Resveratrol, a natural polyphenol with antioxidant, anti-inflammatory, and anticancer properties may be effectively in induced expression of microRNAs for prevention of cancer(36).
I.1. In conventional medicine perspective
Drainage of the mass or lump and antibiotics and surgical resection
Administration of antibiotics has shown effectively for treatment of acute thyroiditis against the causative pathogen(s). Surgical drainage may be necessary in case of suppuration. In treatment of an acute thyroiditis in children, surgical removal of the fistula combined with partial thyroidectomy may decrease the recurrence rate but it should be delayed until the inflammatory process is resolved, according to Georgetown University(36).
I.2. In herbal medicine perspective
1. Aloe Vera
Aloe Vera also is popular used in treating infection and inflammation(38) through its antioxidant property(38) and as immune system enhancer in regulating the immunological parameters in cellular immune response and phagocytosis(39).
2. Black Walnut
Tannins extract of phenolic compounds from several herbal plants, including black walnut not only have exerted the relatively high level of anti bacterial activity (62.5 to 125 microg/ml) in fighting against Listeria monocytogenes(40) but also can fight the forming of free radical cause of DNA damage of irregular cells growth and enhance the immune system guarding our body from foreign invasion cause of inflammation and infection(41).
3.1. Immunomodulatory effect
Cinnamon is a popular herb used in traditional medicine to treat various disorders such as chronic gastric symptoms, arthritis, and the common cold through its immunomodulatory effect(42)
3.2. Antimicrobial Activities
Cinnamon oil-chitosan film promotes better antimicrobial activity than the clove bud oil-chitosan film(43).
3.3. Anti-inflammatory activity
Myristicin (1-allyl-5-methoxy-3,4-methylenedioxybenzene) is an active aromatic compound found in nutmeg, carrot, basil,cinnamon, and parsley showed significantly in inhibition of the production of calcium, nitric oxide (NO), etc. through its anti-inflammatory effect.(44).
Extracts of aged fresh garlic, aged over a prolonged period and its antioxidant effects showed the ability of AGE to protect against oxidant-induced disease, acute damage from aging, radiation and chemical exposure, and long-term toxic damage, etc.(45).
5.1. Thyroid function
Short-term dietary supplementation with kelp significantly increases both basal and poststimulation TSH(46).
Brown algae of the Laminariales (kelps) exhibits strong antioxidant effect through iodide accumulation and impact of atmospheric chemistry(47).
I.3.Treatments in traditional Chinese medicine perspective
1. Ba Jiao Hui Xiang
Ba Jiao Hui Xiang also known Chinese Star Anise is a spice used in traditional Chinese cooking and in TCM an antibiotic agent and to for treatment of hernia, chronic lower back pain, vomiting due to coldness in stomach, pain and coldness in stomach. etc. for thousand of years from a small evergreen tree, native in southwest China.
Extract from Bai Jiao hui xiang has showb to exert its antibacterial activity against 67 clinical drug-resistant isolates, including 27 Acinetobacter baumannii, 20 Pseudomonas aeruginosa, and 20 methicillin-resistant Staphylococcus aureus(48). Its essential oil has also exhibited strong inhibitory effect against fungi(49).
2. Black pepper and cardamom
Black pepper (Piper nigrum) and cardamom (Elettaria cardamomum) extracts significantly enhance the cytotoxic activity of natural killer cells by exerting immunomodulatory roles and antitumor activities50).
3. Radix et Rhizoma Rhei and Rhizoma Polygoni Cuspidati
Processed products of Radix et Rhizoma Rhei and Rhizoma Polygoni Cuspidati showed to scavenge superoxide radical (O2-.) generated through hypoxanthine-oxidase system and (.OH) generated through Fenton action(52).
3. Long Kui
Solanum nigrum fruit extract (SNFEt), in ethanol-induced toxicity in rats improved the antioxidant status by decreasing the levels of TBARS( a byproduct of lipid peroxidation) and altering the lipid profiles to near normal(53). The methanol and chloroform extracts of Solanum nigrum (SN) seeds also exhibited more than 50% inhibition of HCV at non toxic concentration(54).
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