Hashimoto Thyroiditis

Hashimoto's Thyroiditis, also referred to as chronic lymphocytic thyroiditis or autoimmune thyroiditis, is a condition in which one's immune system attacks its own thyroid gland.[1] Along with having an autoimmune basis, it appears to have a genetic disposition playing a factor in the etiology.[1] The destruction is ultimately caused by "the infiltration of the gland by lymphocytes and antithyroid antibodies.[2] "The disease process causes the T3 and T4 serum levels to decrease, which triggers the pituitary gland to increase TSH production.[1]The increased TSH levels causes the hyper-function of the thyroid leading to goiter formation.[2]Thyroid gland destruction can occur due to prolonged hyper-function leading to eventual hypothyroidism.[1]
There is evidence that there is a genetic factor in being diagnosed with Hashimoto Thyroiditis. The disease is associated with the gene "HLA-DR3, which is also present in other autoimmune conditions."][1]

Youtube video----https://www.youtube.com/watch?v=oINxr8_nR_Y [last accessed 03/20/2017][3]

Prevalence

Hashimoto's (chronic) Thyroiditis "is the is the most common cause of hypothyroidism in the United States.[1] It is primarily found in "middle-aged women” and leads to a genetic disposition. Affecting approximately women more than men at a 10:1 ratio.[1] However, Hashimoto’s thyroiditis can be diagnosed at any age , and may affect men and children.[4] The causative factor regarding the prevalence of antibodies is unknown, however there seems to be a familial correlation.[5]

Other Autoimmune Disease Associations

People with other autoimmune diseases are more likely to develop Hashimoto’s disease. The opposite is also true—people with Hashimoto’s disease are more likely to develop other autoimmune diseases. These diseases include

• Vitiligo, a condition in which some areas of the skin lose their natural color.

• Rheumatoid arthritis, a disease that causes pain, swelling, stiffness, and loss of function in the joints when the immune system attacks the membrane lining the joints.

• Addison’s Disease, in which the adrenal glands are damaged and cannot produce enough of certain critical hormones.

• Diabetes Mellitus type I, in which the pancreas is damaged and can no longer produce insulin, causing high blood glucose, also called blood sugar.

• Pernicious Anemia, a type of anemia caused by not having enough vitamin B12 in the body. In anemia, the number of red blood cells is less than normal, resulting in less oxygen carried to the body’s cells and extreme fatigue.

• Celiac Disease, a form of gastrointestinal gluten sensitivity, an autoimmune disorder in which people cannot tolerate gluten because it will damage the lining of the small intestine and prevent adsorption of nutrients. Gluten is a protein found in wheat, rye, and barley and in some products.

• Autoimmune Hepatitis, or nonviral liver inflammation, a disease in which the immune system attacks liver cells.[5]

Characteristics/Clinical Presentation

Hashimoto Thyroiditis does not present with any unique signs and symptoms.[1] “The condition progresses very slowly over many years, people with Hashimoto’s thyroiditis may not have any symptoms early on. Many of the signs and symptoms mimic general hypothyroid conditions. [2]

Signs and Symptoms:

• Painless thyroid enlargement

• Gland is sometimes easily palpable

• Fatigue and lethargy

• Cold intolerance

• Pale, dry skin

• Constipation

• Hoarseness

• Dysphagia

• Weight gain

• Myalgia and stiffness

• Proximal muscle weakness

• Excess or prolonged menstrual bleeding

• Increased PMS symptoms

• Depression

Without treatment the signs and symptoms increase in severity and include:

• Goiter: If the goiter is allowed to increase in size it can lead to "dysphagia and respiratory distress."

• Constipation

• Myxedema

As the disease progresses neurological involvement including:

• Difficulty learning

• Forgetfulness


Goiter.jpgGoiter2.png

Medications

Levothyroxine: "man-made form of T4 hormone." This medication "almost always"[6] needs to be taken for the rest of a person's life and in the same manner each day.[5] "Most people see a decrease in the size of the goiter and remain stable for years with treatment."[6] The generic name of the drug is Levothyroxine, but it also goes by the brand names of Levothroid, Levoxyl, Synthroid, Tirosint, and Unithroid and it can also be administered orally or by injection.


Levothyroxine.jpg


Populations

Appropriate studies have not assessed pediatric or geriatric specific medication problems warranting a decreased use of Levothyroxine. This drug is classified as a pregnancy category A; stating that studies have shown no increased risk of fetal abnormalities.

Drug Interactions

It is advised that individuals on Levothyroxine consult with their physician before taking the following medications due the potential for adverse effects:

• Amineptine

• Amitriptyline

• Amitriptylinoxide

• Amoxapine

• Clomipramine

• Desipramine

• Dibenzepin

• Doxepin

• Imipramine

• Ketamine

• Lofepramine

• Maprotiline

• Melitracen

• Mirtazapine

• Nortriptyline

• Opipramol

• Protriptyline

• Tianeptine

• Trimipramine


Side Effects include:[6]

• Chest pain or discomfort

• Decreased urine output

• Difficult or labored breathing

• Difficulty with swallowing

• Dilated neck veins

• Extreme fatigue

• Fainting

• Fast, slow, irregular, pounding, or racing heartbeat or pulse

• Fever

• Heat intolerance

• Hives or welts

• Increased blood pressure

• Increased pulse

• Irregular breathing

• Irritability

• Menstrual changes

• Nausea

• Pain or discomfort in the arms, jaw, back, or neck

• Shortness of breath

• Skin itching, rash, or redness

• Sweating

• Swelling of the eyes, face, lips, throat, or tongue

• Tightness in the chest

• Tremors

Diagnostic Tests/Lab Tests/Lab Values

Diagnosis of Hashimoto’s is based on a physical exam and medical history, the person’s signs and symptoms, and the results of blood tests. The blood tests are used to measure levels of thyroxine (T4) the main hormone emitted by the thyroid, and thyroid stimulating hormone (TSH) which is emitted by the pituitary gland.[7] T4 test Measures the actual amount of thyroid hormone circulating in the blood. In cases of hypothyroidism, T4 levels are lower than normal.[7]  TSH test The ultrasensitive TSH test is usually the first test performed. This test detects even tiny amounts of TSH in the blood and is the most accurate measure of thyroid activity available. Generally, a TSH reading above normal means a person has hypothyroidism.[7]

Antithyroid Antibody test

This test focuses attention on thyroid autoantibodies, or molecules produced by a person’s body that mistakenly attack the body’s own tissues. Two principal types of anti-thyroid antibodies are:

o anti-TG antibodies, which attack a protein in the thyroid called thyroglobulin

o anti-thyroperoxidase (TPO) antibodies, which attack an enzyme called thyroperoxidase in thyroid cells that helps convert T4 to T3. Presence of TPO autoantibodies in the blood indicates the body’s immune system has attacked tyroid tissue in the past.. Most people with Hashimoto’s disease have these antibodies, although people whose hypothyroidism is caused by other conditions do not.

Other diagnostic tests may include an ultrasound or a computerized tomography (CT) scan.[7]

Etiology/Causes

There are many factors that may play a role in acquiring Hashimoto’s disease, these factors include;
• Genes. Some people are more apt to Hashimoto's disease due to their genes. Researchers are continuing to work on finding the gene or genes that are involved
• Gender. Sex hormones are thought to take part in the cause. This may assist in explaining why Hashimoto's disease affects more women than men.
• Pregnancy. Pregnancy affects the thyroid. Some women have thyroid problems after having a baby, which usually go away. But about 20 percent of these women develop Hashimoto's disease in later years. This suggests that pregnancy might trigger thyroid disease in some women.
• Too much iodine and some drugs may bring about the onset of thyroid disease in people susceptible to acquiring it.
• Radiation exposure has been shown to trigger autoimmune thyroid disease. This includes radiation from the atomic bomb in Japan, the nuclear accident at Chernobyl, and radiation treatment of Hodgkin's disease.[8]


BupaHealth UK. How a thyroid gland can become underactive.

Available at: https://www.youtube.com/watch?v=qIn8AHHB1_o [last acessed 3/21/17][9]


Medical Management (current best evidence)

According to the NIH,” Treatment generally depends on whether the thyroid is damaged enough to cause hypothyroidism. Health care providers may choose to treat Hashimoto’s disease to reduce the size of the goiter, or choose not to treat and simply monitor their patients for disease progression.
Hashimoto’s disease, is treated with synthetic thyroxine. Health care providers prefer to use synthetic T4, such as Synthroid, rather than synthetic T3, because T4 stays in the body longer, ensuring a steady supply of thyroid hormone throughout the day
Health care providers routinely test the blood of patients taking synthetic thyroid hormone and adjust the dose as necessary, typically based on the result of the TSH test. Hypothyroidism can almost always be completely controlled with synthetic thyroxine, as long as the recommended dose is taken every day as instructed”[7]

Physical Therapy Management (current best evidence)

Physical therapy is not standard treatment for patients with this disorder. Physical therapists should know to screen for it.  Physical therapists also need to be aware of the disease because they may have a patient that has Hashimoto Thyroiditis as a co-morbidity.

A physical therapy screening for Hashimoto Thyroiditis should include:[10]

  • Subjective questioning
  • Upper and/or lower quarter clearing exam - depending on the patient's complaints
  • MMT - for the specific muscle(s)/area
  • ROM - for the specific muscle(s)/area
  • Special tests - for the specific joint/area
  • Palpation - thyroid and any other areas that are suspected as the cause of the symptoms
  • Any other measure that the physical therapist deems necessary for the patient's specific complaints


If the above screening does not indicate a musculoskeletal issue, the physical therapist should refer the patient to the appropriate health care provider.

Alternative/Holistic Management (current best evidence)

Supplements:

  • Selenium: Research has found that it aids in the regulation of T3 and T4 hormones.
  • Probiotics: Aid in the support of gastrointestinal health
  • Vitamin D
  • B vitamins: Are important for maintaining energy and metabolic function.[11]

Differential Diagnosis

Possible differential diagnoses:[12]

  • Euthyroid Sick Syndrome
  • Hypopituitarism (Panhypopituitarism)
  • Goiter
  • Polyglandular Autoimmune Syndrome, Type I
  • Goiter, Diffuse Toxic
  • Polyglandular Autoimmune Syndrome, Type II
  • Goiter, Lithium-Induced
  • Thyroid Lymphoma
  • Goiter, Nontoxic
  • Goiter, Toxic Nodular

Other possible issues include:[5]

  • Addison disease
  • Alopecia areata, totalis, and universalis
  • Autoimmune gastritis (pernicious anemia)
  • Chronic active hepatitis
  • Idiopathic hypoparathyroidism * Polymyalgia rheumatica and giant cell arteritis
  • Primary biliary cirrhosis
  • Primary ovarian or testicular failure * Rheumatoid arthritis * Sjögren syndrome * Systemic lupus erythematosus
  • Systemic sclerosis (scleroderma)
  • Type 1 diabetes mellitus
  • Vitiligo

Systemic Involvement

The patient may present with the symptoms listed above that mimic musculoskeletal pain.

Case Reports/ Case Studies

Hashimoto's Thyroiditis Case Study


A. M. McGregor, D. F. Roberts, and R. Hall. A study of triplets with Hashimoto's thyroiditis. Postgrad Med J. 1979 December; 55(650): 894–896. Click here for article.


A Shuper, T Leathem, A Pertzelan, B Eisenstein, and M Mimouni. Familial Hashimoto's thyroiditis with kidney impairment. Arch Dis Child. 1987 August; 62(8): 811–814. Click here for article.


Jan van Schaik,1 Olaf M. Dekkers,2 Eleonora P. M. van der Kleij-Corssmit,2 Johannes A. Romijn,2 Hans Morreau,3 and Cornelis J. H. van de Velde1*. Surgical Treatment for Unexplained Severe Pain of the Thyroid Gland: Report of Three Cases and Concise Review of the Literature. Case Report Med. 2011; 2011: 349756. Click here for article.


G. T. Ko, C. C. Chow, V. T. Yeung, H. Chan, and C. S. Cockram. Hashimoto's thyroiditis, Sjogren's syndrome and orbital lymphoma. Postgrad Med J. 1994 June; 70(824): 448–451. Click here for article.


P L Vold and P J Weiss. Rhabdomyolysis from tourniquet trauma in a patient with hypothyroidism. West J Med. 1995 March; 162(3): 270–271. Click here for article.

Resources

American Thyroid Association.  http://www.thyroid.org/

Recent Related Research (from Pubmed)

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Goodman CC, Fuller KS. Pathology: implications for the physical therapist. St. Louis, MO: Elsevier Saunders; 2015.
  2. 2.0 2.1 2.2 Goodman CC, Snyder TEK. Differential diagnosis for physical therapists screening for referral. St. Louis, MO: Saunders Elsevier; 2013.
  3. hardgrindcoffeeyo. YouTube [Internet]. YouTube. YouTube; 2014 [cited 2017Mar21]. Available from: https://www.youtube.com/watch?v=oINxr8_nR_
  4. http://www.thyroid.org/wp-content/uploads/patients/brochures/Hashimoto_Thyroiditis.pdf
  5. 5.0 5.1 5.2 5.3 Homepage [Internet]. American Thyroid Association. [cited 2017Mar21]. Available from: http://www.thyroid.org/
  6. 6.0 6.1 6.2 MedlinePlus - Health Information from the National Library of Medicine [Internet]. MedlinePlus Trusted Health Information for You. [cited 2017Mar21]. Available from: https://medlineplus.gov/
  7. 7.0 7.1 7.2 7.3 7.4 Hashimoto's Disease | NIDDK [Internet]. National Institutes of Health. U.S. Department of Health and Human Services; [cited 2017Mar21]. Available from: https://www.niddk.nih.gov/health-information/endocrine-diseases/hashimotos-disease
  8. ePublications [Internet]. Hashimoto's disease fact sheet. [cited 2017Mar21]. Available from: https://www.womenshealth.gov/publications/our-publications/fact-sheet/hashimoto-disease.html#d
  9. BH. How a Thyroid gland can become unactive [Internet]. How a Thyroid gland can become unactive. YouTube; 2013 [cited 2017Mar21]. Available from: http://www.youtube.com/watch?v=qIn8AHHB1_o
  10. Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis, Missouri: Saunders Elsevier; 2007.
  11. Hashimoto's thyroiditis [Internet]. Hashimoto's thyroiditis | Quick Answers: Physiotherapy | AccessPhysiotherapy | McGraw-Hill Medical. [cited 2017Mar21]. Available from: http://accessphysiotherapy.mhmedical.com/content.aspx?bookid=855§ionid=49734591
  12. Hashimoto's thyroiditis [Internet]. Hashimoto's thyroiditis | Quick Answers: Physiotherapy | AccessPhysiotherapy | McGraw-Hill Medical. [cited 2017Mar21]. Available from: http://accessphysiotherapy.mhmedical.com/content.aspx?bookid=855§ionid=49734591