Hashimoto Thyroiditis

Paulina Paciej
Group 5
 In 1912 Hashimoto described four patients with a chronic disorder of
the thyroid, which he termed struma lymphomatosa. The thyroid glands
of these patients were characterized by diffuse lymphocytic infiltration,
fibrosis, parenchymal atrophy,
and an eosinophilic change in some
of the acinar cells.

Clinical and pathologic studies of this

disease have appeared frequently
since Hashimoto's original description.

Dr. Hakaru Hashimoto

The disease has been called Hashimoto's thyroiditis,
chronic thyroiditis, lymphocytic thyroiditis,
lymphadenoid goiter, and recently autoimmune
thyroiditis.
Classically, the disease occurs as a painless, diffuse
enlargement of the thyroid gland in a young or middle-
aged woman. It is often associated with
hypothyroidism. The disease was thought to be
uncommon for many years, and the diagnosis was
usually made by the surgeon at the time of operation
or by the pathologist after thyroidectomy. The
increasing use of the needle biopsy and serologic tests
for antibodies have led to much more frequent
recognition, and there is reason to believe that it may
be increasing in frequency. It is now one of the most
common thyroid disorders.
Hashimoto Thyroiditis
 General
◦ Most common cause of thyroid disease in children.
◦ Most common cause of acquired hypothyroidism.
◦ Autoimmune in origin and associated with Graves’ disease.

 Etiology
◦ HLA haplotypes are associated with goiter and thyroiditis (HLA-
DR4, HLA-DR5) and with atrophic variant (HLA-DR3).
◦ Thyroid antiperoxidase antibodies and Thyrotropin receptor-
blocking antibodies are commonly found.
◦ Antithyroglobulin antibodies occur, but are more common in adults.
Hashimoto Thyroiditis
 Clinical Manifestations
◦ Girls:Boys 6-7:1
◦ More common after age 6 with a peak during adolescence.
◦ Most common manifestations are goiter and growth retardation.
 Most often, the thyroid is diffusely enlarged, firm, and nontender.
However, it may present as a multinodular goiter or a single nodule.
 With time, the goiter may not change, may become smaller, or may
disappear.
◦ May present with goiter alone, goiter and hypothyroidism, goiter
and euthyroid (asymptomatic), or with transient hyperthyroidism
followed by hypothyroidism.
 Patients with Hashimoto thyroiditis and subclinical hypothyroidism
may progress to overt hypothyroidism.
Hashimoto Thyroiditis
 Clinical Manifestations Continued
◦ Autosomal dominant inheritance of autoantibodies with
reduced penetrance in males
◦ 5-25% of siblings or parents of affected children may
develop autoimmune hypothyroidism
◦ Associated with other autoimmune disorders
◦ Clinical features include myxedematous skin, dry hair
and skin, cold intolerance, fatigue, bradycardia,
constipation, anemia, growth retardation with decreased
bone age, delayed tooth eruption, and possible slipped
capital femoral epiphysis.
Hashimoto Thyroiditis
 Laboratory
◦ Definitive diagnosis is by thyroid biopsy – however this
is rarely indicated
◦ Thyroid function tests are often normal
 TSH may be elevated
◦ Thyroid ultrasound shows scattered hypoechogenicity
◦ Thyroid peroxidase antibodies are common
◦ Antithyroglobulin test for thyroid antibodies is positive
50% of the time
◦ Radiograph of the left hand and wrist (bone age) may
show growth retardation
Hashimoto Thyroiditis
 Treatment
◦ Daily replacement of sodium-L-thyroxine (50-150mcg
daily)
◦ Behavioral problems may start after beginning therapy
because the child has more energy.
◦ The child’s appearance may change dramatically, and the
child may lose weight.
◦ Pubertal development and bone maturation should be
monitored closely to evaluate for too rapid of
progression.
◦ TSH should not be measured less than 6 weeks after
therapy is started.
Hashimoto Thyroiditis
 Prognosis

◦ Cognition – If hypothyroidism is acquired after age

3, there is not a risk of irreversible long-term
effects.
 Birth to age 3 is a critical period of brain
development.
◦ In most patients with chronic autoimmune
thyroiditis the hypothyroidism will be permanent.
Case 1

This case demonstrates how a 7-year-old male who

presented with a chief complaint of vomiting fecal
matter revealed a wide manifestation of clinical
symptoms of Hashimoto thyroiditis that remained
undiagnosed and untreated for a period of
approximately 3-4 years.
History of Present Illness
 Chief Complaint
◦ “Vomiting fecal matter”
 History of Present Illness
◦ 7 year-old-male who presented to the Emergency Center after
4-5 episodes of vomiting the previous night.
◦ The patient’s mother stated the vomitus looked and smelled
like fecal matter, and it did not contain any blood.
◦ The patient has a history of constipation since birth with a
stooling pattern of 1 bowel movement every three days (small,
pellet-like stools).
 Last stool was 3 days ago
◦ The patient also complained of vague abdominal pain,
nonspecific in nature.
Family History

 Family History:
◦ Mother with Graves disease, Thyroidectomy, Irritable
bowel syndrome
◦ Father with Bipolar Type II, Asthma, Gout, Arthritis
◦ Maternal Aunt with Hypothyroidism
◦ Maternal Grandmother with Hypothyroidism, Hepatitis
C, Emphysema
Review of Systems
 General
◦ “Fatigued” since age 4
◦ No weight gain since age 4
◦ Negative for fevers
 HEENT
◦ Negative for any recent sore
throat or congestion
◦ Negative for eye redness,
tearing, or discharge
 Cardiovascular
◦ Negative for history of heart
murmur or irregular heart
beat
 Respiratory
◦ Positive for cough
◦ Negative for labored
breathing or wheezing
 GI
◦ Positive for bad breath
◦ Positive for constipation,
vomiting, and abdominal
pain (see HPI)
 GU
◦ Negative for foul smelling
urine, hematuria or dysuria
Review of Systems Continued
 Musculoskeletal  Skin/Hair/Nails
◦ Positive for bilateral leg ◦ Positive for chronic dry skin
pain since age 4 on arms and legs
◦ Positive for muscle ◦ Positive for hair falling out
weakness since age 5 ◦ Positive for very dry hair
 Patient required  Psychiatric
assistance if he had to
walk greater than 50 ◦ Positive for possible
yards diagnosis of autism
 Patient would drag his  Endocrine
legs ◦ Positive for no growth since
 Neurological age 4
◦ Negative for seizures
Physical Examination

 General

◦ This is a very small, withdrawn 7 year old boy who

makes little to no eye contact and appears as if he
is 4 years old. There is an observed fecal odor in
the room.
 Vitals

◦ Age 7yr 4mo

◦ Temp 99.7 F (37,5C), Pulse 67, Respirations 20,
BP 111/69
◦ Weight 17.3 kg (<5%), Height 39.5 in (<<5%)
Hospital Course
 The patient was admitted to the pediatric floor where
he was given oral GoLYTELY and Milk of Molasses
enemas.
 The patient stooled without any problems.
 Endocrinology was consulted.
 The patient was started on Synthroid 88mcg daily.
 The patient was discharged the following morning with
prescriptions for Synthroid and Miralax.
 The patient followed up in the Endocrine clinic 6
weeks later. His activity and energy levels had
dramatically increased, and he was no longer requiring
assistance to walk.
 Case 2

Identical male twins with

Hashimoto's thyroiditis were
photographed at age 12. At age 8,
they had the same height and
appearance. During the intervening
4 years, small goiters developed
and the growth of the twin on the
right almost stopped. Biopsy
indicated Hashimoto's thyroiditis in
each twin's thyroid.
References
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77
 Braverman L, Utiger R. Werner & Ingbar’s: The Thyroid.
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 Web sites.