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Musculoskeletal/Small parts » Thyroid, Parathyroid, Salivary Glands
Diffuse thyroiditis
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Presentation A 25 year old femae presents with a one week history of a tender midline swelling of the neck. She also had complaints of palpitations and fine tremors of the hand. Laboratory features revealed increased levels of T3 and T4 and decreased TSH level.
 
 
 
Caption: Transverse sonogram of the neck.
Description: Transverse sonogram reveals a heterogeneous and coarse echotexture of the enlarged thyroid gland.
 
 
 
Caption: Sagittal view of right lobe of thyroid.
Description: Sagittal view of the enlarged right thyroid reveals a coarse and heterogeneous echotexture. No focal mass is identified.
 
 
 
Caption: Sagittal view of the left lobe of thyroid.
Description: Sagittal view of the enlarged left thyroid also reveals a coarse and heterogeneous echotexture. No focal mass is identified.
 
 
 
Caption: Color Doppler study of the right lobe of thyroid.
Description: Color Doppler view showing increased vascularity of the right lobe.
 
 
 
Caption: Color Doppler view of left thyroid gland.
Description: Color Doppler view showing increased vascularity in the left lobe of the thyroid gland.
 
Differential Diagnosis Diffuse thyroiditis
 
Final Diagnosis Diffuse thyroiditis
 
Discussion Thyroiditis is the most common group of inflammatory disorders affecting the thyroid gland and is encountered very often in clinical practice. Thyroiditis can be painful or painless. The suggested classification of thyroiditis is acute, subacute and chronic. Acute thyroiditis usually has a bacterial etiology and can be very painful. Subacute thyroiditis usually presents with a transient hyperthyroidism followed by hypothyroidism and they encompass two distinct varieties. The lymphocytic kind, which is silent [has an unknown pathogenesis or is autoimmune] or the granulomatous kind, which is painful [and typically has a viral etiology]. The chronic lymphocytic type of thyroiditis is Hashimotos and it is known to have an autoimmune basis. Graves' disease and Hashimotos thyroiditis are the most commonly encountered thyroid disorders.

A diffuse or multifocal decrease in echogenicity demonstrated on ultrasound is the hallmark of many types of thyroiditis. This decrease in echogenicity may be due to an increase in the intrathyroidal blood flow, increased cellularity of the thyroid follicles with decreased colloid production and or lymphocytic infiltration. On color and power Doppler studies, increased blood flow is noted throughout the gland. This constellation of findings of reduced echogenicity of the gland with an increased vascularity is highly suggestive of a diffuse thyroiditis. In addition, the gland is often heterogeneous.

Return of the normal thyroid echogenicity and blood flow is noted on resolution of the disease.  However heterogeneity may persist if the chronic thyroiditis ensues [fibrosis may set in within the gland, resulting in a coarsened echotexture].

Radioactive iodine uptake testing can aid in identifying the various etiologies of hyperthyroidism and also help in patient selection for I-131 treatment.

 
Case References 1.Arslan H, et al. Power Doppler sonography in the diagnosis of Graves' disease. Eur J Ultrasound. 2000 May 11(2): 117-22.
2.Vitti P, et al. Thyroid blood flow evaluation by color-flow Doppler sonography distinguishes Graves' disease from Hashimoto's thyroiditis.J Endoc Invest. 1995 Dec 18(11): 857-61.
3.Vitti P, et al. Thyroiditis: clinical aspects and diagnostic imaging. Rays. 1999 Apr-Jun; 24(2): 301-14.
4.Singer PA. Thyroiditis. Acute, subacute, and chronic. Med Clin North Am. 1991 Jan; 75(1): 61-77.
5.Niedziela M, et al. Thyroid echogeneity as a useful tool for the differential diagnosis of hyperthyroidism in the course of Graves disease and Hashimoto thyroiditis. Endokrynol Diabet 2000; 6(2): 143-50.
6.Aydin O et al. Cytological correlation in patients who have a pre-diagnosis of thyroiditis ultrasonographically. Endocrine Research. 29(1):97-106, 2003 Feb.
7.Hamburger JI. The various presentations of thyroiditis.Ann Intern Med. 1986 Feb; 104(2): 219-24
 
Follow Up No histopathology was available, however a follow up ultrasound demonstrated a normal sized thyroid gland with homogeneous echotexture, concurring that the patient had an episode of subacute viral thyroiditis.
 
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