Hashimoto's thyroiditis

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Classification according to ICD-10
E06.3 Hashimoto's thyroiditis
Hashitoxicosis (transitory)
Lymphocytic thyroiditis
Struma lymphomatosa (Hashimoto)
ICD-10 online (WHO version 2019)

The Hashimoto's thyroiditis ( synonyms : Hashimoto's thyroiditis , struma lymphomatosa Hashimoto , (chronic) lymphocytic thyroiditis , Ord's thyroiditis , Hashimoto's disease ) is an autoimmune disease leading to a chronic inflammation of the thyroid gland leads. In this disease, thyroid tissue is destroyed by T lymphocytes as a result of a misdirected immune process . In addition, antibodies against thyroid- specific antigens can be detected. In the long run, the disease leads to hypothyroidism, although phases of hyperfunction may appear at the beginning - due to the destruction of the thyroid tissue. The course of the disease is easy in the majority of patients, but moderate and severe courses are also known. The symptoms are varied and - especially at the beginning of the disease - difficult to classify. Hashimoto's thyroiditis is currently not curable and is not treated causally. If the thyroid can no longer produce sufficient thyroid hormones due to the chronic inflammation, the hypofunction must be treated with substitution . The substitution takes place by daily oral intake of the thyroid hormones.

The disease was named after the Japanese doctor Hakaru Hashimoto (1881-1934), who was the first to describe it in 1912. The character as an autoimmune disease was recognized by Deborah Doniach and Ivan Roitt .

General

Hakaru Hashimoto was named after him around 1912 when he first described Hashimoto's thyroiditis

There are two known forms of progression:

Since the symptoms, diagnosis, therapy and prognosis of the two forms do not differ significantly and both forms can merge, they are now usually summarized under the term Hashimoto's thyroiditis. For both of these (the atrophic form as hypertrophic form is much more common) comes down to time to hypothyroidism , which at the beginning of the disease - even phases of the - due to the destruction of the thyroid tissue overactive able to show (so-called "leak hyperthyroidism. ", In extreme cases hashitoxicosis). The disease is considered incurable, but very treatable.

Hashimoto's thyroiditis belongs to the group of polyendocrine autoimmune diseases and therefore occurs more frequently with other conditions such as Addison's disease , type I diabetes mellitus , celiac disease , vitiligo and hypoparathyroidism .

Epidemiology

Hashimoto's thyroiditis is one of the most common autoimmune diseases in humans and the most common cause of primary hypothyroidism. A US survey found elevated antibodies in 10% of the test persons in a population sample, subclinical hypothyroidism in 4.3% and clinically manifest hypothyroidism in 0.3%. A recent study found 10% clinical and subclinical hypothyroidism. According to textbooks, the incidence of hypothyroidism, which is often associated with Hashimoto's thyroiditis, is 1–2% in Western Europe; However, subclinical courses are more common and range from 6–8%. Women fall ill more often than men (ratio 2: 1 to 5: 1). There are familial clusters, i. i.e. only the predisposition for Hashimoto is inherited. Observations show that Hashimoto's thyroiditis can arise in connection with hormonal changes ( puberty , childbirth , menopause ) and stressful situations.

causes

The exact factors that can lead to the onset of Hashimoto's thyroiditis have not yet been sufficiently clarified. In addition to familial (genetic) stress, serious viral diseases (such as Pfeiffer glandular fever , shingles ), dysfunction of the adrenal cortex , microchimerism and environmental influences are also up for debate . Hashimoto's thyroiditis is more than randomly found in polycystic ovary syndrome . The importance of excessive iodine intake for the onset of the disease is currently being debated . It can be considered relatively certain that, like Graves' disease , it can be triggered by very high doses of iodine (excess iodine) (e.g. by contrast media containing iodine ). Possible dangers that arise from iodination of food (as a result of feed iodination in livestock and salt iodization) are discussed (cf. iodine deficiency , iodine intolerance ).

Symptoms and course of the disease

Symptoms

Due to the possible initial hyperthyroidism (overactive thyroid gland), the following symptoms may occur for a certain time:

  • nervousness
  • irritability
  • restlessness
  • Trembling of hands
  • sleep disorders
  • sweat
  • Palpitations and racing heart
  • Cardiac arrhythmias
  • moist, warm skin
  • Cravings and thirst
  • Weight loss despite a good appetite
  • In women, there are also disorders in the menstrual cycle (irregular or heavy bleeding, no menstruation )

In the long term, the onset of hypothyroidism (underactive thyroid) with the following symptoms follows:

  • low body temperature
  • increased sensitivity to cold
  • Edema (swelling due to water retention, especially on the eyelids, face, extremities, myxedema )
  • lump in throat
  • Feeling of strangulation (even only in phases)
  • frequent throat clearing and coughing
  • hoarse or husky voice (vocal cord edema)
  • depressed mood
  • Lack of motivation
  • Listlessness
  • Muscle weakness
  • Muscle hardening
  • dry and cracked skin and associated itching
  • dry mucous membranes
  • brittle hair and nails
  • Hair loss
  • rapid and severe (almost uncontrollable) weight gain
  • nausea
  • Indigestion
  • Stunted growth
  • Enlargement of the heart
  • slow heartbeat
  • decreased libido
  • altered menstrual cycle
  • Eye disease ( endocrine orbitopathy )
  • Joint pain
  • Concentration and memory disorders
  • fatigue

Course of disease

The course of the disease is easy in the majority of patients, but moderate and severe courses are also known. The symptoms are varied and - especially at the beginning of the disease - difficult to classify. The multitude and variability of symptoms as well as the insidious course make diagnosis difficult.

Symptoms of hypofunction can occur even with subclinical (still considered euthyroid ) value constellations because the individual range of values ​​is usually much smaller than the inter-individual reference value spectrum based on statistical evaluations. Even subclinical value constellations can therefore lead to a reduction in quality of life.

In extremely rare cases, Hashimoto's encephalopathy is associated with the disease with neurological symptoms such as epileptic seizures or psychiatric symptoms such as hallucinations.

diagnosis

Sonographic findings in Hashimoto's thyroiditis with typical hypoechoic disease
Lymphoid infiltrates with formation of secondary follicles, histology, HE staining

The following are diagnostically relevant:

  • Thyroid peroxidase antibodies (antibodies against thyroid peroxidase = thyroid peroxidase) (TPO-AK), also called microsomal antibodies (MAK)
  • Antibodies against thyroglobulin (Tg-AK or TAK)

In the vast majority of cases, the TPO antibodies are increased (with or without an increase in the Tg-AK). In a far smaller proportion of the cases, only the Tg antibodies are increased (more). In very rare cases, Hashimoto's thyroiditis is present without the aforementioned antibodies being detectable. The diagnosis is then based on other criteria (goiter without any other explanation or lymphocytic infiltration in the thyroid puncture).

The following hormone values ​​are relevant to assess the metabolic status of the thyroid gland:

A thyroid diagnosis that relies solely on the TSH value is usually not significant enough to detect Hashimoto's Thyreoidis, because even a normwertiger TSH levels or normwertige free T3 and T4 levels are no exclusion criteria for Hashimoto's thyroiditis.

A sonogram of the thyroid gland is also very important for the diagnosis . Typically, the thyroid gland appears inhomogeneous and hypoechoic on ultrasound, which indicates ongoing destruction. In addition, the increased blood flow recognizable in the Doppler sonogram can be an indication of inflammation. The size of the thyroid can also be assessed on the sonogram. Since the hypertrophic form of Hashimoto's thyroiditis can be accompanied by a goiter , sizes over approx. 18 ml (women) or approx. 25 ml (men) total volume are to be regarded as conspicuous. Small thyroid glands with a size of less than 6 ml (women) or 8 ml (men), on the other hand, are typical of the atrophic form (Ord-Thyroiditis), whereby it must be noted that these sizes vary greatly - depending on the author - and are the subject of the Discussion are. In Germany, the so-called atrophic form with shrinking thyroid gland is far more common than the hypertrophic form with goiter formation (goiter).

Particularly at the beginning of the disease, it can be difficult to differentiate between Hashimoto's thyroiditis and Graves’s disease (an autoimmune disease that leads to the overproduction of thyroid hormones), as Hashimoto's can also have initial overactive attacks and TPO-Ak and Tg-Ak are positive for Graves’s disease can. If necessary, a thyroid scintigraphy can bring clarity, since it shows an increased uptake of the radiopharmaceutical in Graves' disease , but a decreased uptake in Hashimoto's thyroiditis.

The histological (tissue-microscopic) examination of thyroid tissue obtained by means of a fine-needle aspiration provides final certainty . In Hashimoto's thyroiditis, among other criteria, one recognizes above all a dense infiltrate of lymphocytes and also lymph follicles (see figure), which are an expression of the inflammatory processes.

Diagnostic criteria

Different systems of criteria have been developed for the diagnosis of Hashimoto's thyroiditis, but their content is similar.

According to the criteria of the Japan Thyroid Association, the following decision is made:

class criteria
Clinical signs (A) Enlarged thyroid gland (goiter) with no other explanatory cause (e.g. iodine deficiency, Graves disease or thyroid autonomy)
Laboratory results (B) positive MAK or TPO antibodies
positive Tg antibodies
lymphocytic infiltration in the puncture cytological examination
  • Definitive diagnosis: A + at least one criterion from B fulfilled
  • Suspected diagnosis 1: hypothyroidism with no other explainable cause
  • Suspected diagnosis 2: Antibodies without thyroid dysfunction or goiter
  • Possible diagnosis: hypoechogenic and / or inhomogeneous structure in thyroid ultrasound

treatment

Hashimoto's thyroiditis as an autoimmune process is currently not curable and is not treated causally. If the thyroid can no longer produce sufficient thyroid hormones due to the chronic inflammation, the hypofunction must be treated by (creeping) substitution (→ main article hypothyroidism ).

The substitution takes place by daily oral intake of the thyroid hormones. Because of the high physiological hormone levels in the early morning hours, it is recommended to take the tablet in the morning about 30 minutes before the first meal. There are various options available for this: taking thyroxine (T4, levothyroxine) alone if the conversion of T4 to T3 in the body is not impaired, or a combination of T4 and T3 either as a combination preparation with a fixed T4 / T3 ratio or with freely dosed individual preparations.

The TSH value and possibly also the hormone levels fT3 and fT4 must be checked regularly, as changes can occur in the course of the disease that require a dose adjustment. In addition, the thyroid should be checked sonographically at regular intervals (every 6 to 12 months).

The successful hiring often takes several months to 2 years. The longer a hypofunction has lasted and the more severe it is, the more time it takes to achieve a satisfactory hormonal status and well-being. Since fluctuations or relapses can also be part of the clinical picture, a lot of patience is sometimes required when adjusting the dose.

Substitution therapy is usually required for life. With a good attitude, the patient is usually symptom-free and life expectancy is not reduced. If the course is severe, the symptoms may persist despite hormone therapy.

The addition of selenium is not yet generally recognized as effective. However, there are several studies that suggest that supplementing this trace element has a positive effect on the immune process.

Medical malpractice

Iodine in tablet form, on the other hand, should not be taken in addition in Hashimoto's thyroiditis, as excess iodine can promote inflammation of the thyroid gland. The amounts of iodine contained in food are considered harmless.

literature

  • Petra-Maria Schumm-Draeger: Thyroid diagnosis and therapy. Update 2005 . In: Bayerisches Ärzteblatt . No. 4 . Bavarian State Medical Association, Munich 2005, p. 236–243 ( bayerisches-aerzteblatt.de [PDF; accessed on June 6, 2016]).
  • Terry F. Davies: Ord-Hashimoto's disease. Renaming a common disorder again . In: Thyroid. Official journal of the American Thyroid Association . tape 13 , no. 4 , April 2003, p. 317 , doi : 10.1089 / 105072503321669776 , PMID 12820593 .

Individual evidence

  1. ↑ Hakaru Hashimoto: To the knowledge of the lymphomatous changes in the thyroid gland (goiter lymphomatosa) . In: German Society for Surgery (Ed.): Archive for clinical surgery . tape 97 . Springer, Berlin January 1912, p. 219-248 .
  2. ↑ William Miller Ord: On myxœdema, a term proposed to be applied to an essential condition in the “cretinoid” affection occasionally observed in middle-aged women . In: Royal Medical and Chirurgical Society of London (Ed.): Medico-Chirurgical Transactions . tape 61 . Longmann, London 1878, p. 57-78.5 , PMC 2150242 (free full text).
  3. ↑ Joseph G. Hollowell, Norman W. Staehling, W. Dana Flanders, W. Harry Hannon, Elaine W. Gunter, Carole A. Spencer, Lewis E. Braverman: Serum TSH, T (4), and thyroid antibodies in the United States population (1988 to 1994). National Health and Nutrition Examination Survey (NHANES III) . In: The Journal of Clinical Endocrinology & Metabolism . tape 87 , no. 2 . Endocrine Society, Chevy Chase (Md.) March 2002, pp. 489-499 , doi : 10.1210 / jcem.87.2.8182 , PMID 11836274 .
  4. ↑ P. Valeix, C. Dos Santos, K. Castetbon, S. Bertrais, C. Cousty, S. Hercberg: Thyroid hormone levels and thyroid dysfunction of French adults participating in the SU.VI.MAX study . In: Annales d'endocrinologie . tape 65 , no. 6 . Elsevier Masson, Amsterdam / Jena December 2004, p. 477-486 , PMID 15731735 (French: Statut thyroïdien et fréquences des dysthyroïdies chez les adultes inclus dans l'étude SU.VI.MAX en 1994-1995 .).
  5. ↑ Meinhard Classen, Volker Diehl, Kurt Kochsiek, Wolfgang E. Berdel (eds.): Internal medicine . 5th edition. Urban & Fischer, Munich / Jena 2004, ISBN 3-437-42830-6 .
  6. ↑ Christoph Keck (Ed.): Fertility treatment in gynecological practice . Thieme, Stuttgart / New York (NY) 2014, ISBN 978-3-13-171671-2 , pp. 171 .
  7. ^ Japan Thyroid Association: Guidelines for the Diagnosis of Chronic Thyroiditis
  8. ^ R. Gärtner, BC Gasnier: Selenium in the treatment of autoimmune thyroiditis . In: BioFactors . tape 19 , no. 3–4 , 2003, pp. 165-170 , PMID 14757967 .
  9. ↑ LH Duntas, E. Mantzou, DA Koutras: Effects of a six month treatment with selenomethionine in patients with autoimmune thyroiditis . In: European Journal of Endocrinology . tape 148 , no. 4 , April 2003, p. 389-393 , PMID 12656658 .
  10. ↑ Konstantinos A. Toulis, Athanasios D. Anastasilakis, Thrasivoulos G. Tzellos, Dimitrios G. Goulis, Dimitrios Kouvelas: Selenium supplementation in the treatment of Hashimoto's thyroiditis. A systematic review and a meta-analysis . In: Thyroid. Official journal of the American Thyroid Association . tape 20 , no. 10 , October 2010, p. 1163-1173 , doi : 10.1089 / thy.2009.0351 , PMID 20883174 (review).
  11. ↑ R. Gärtner, PC Scriba: Why avoid iodine with Hashimoto's thyroiditis? In: BDI aktuell . No. 2 , 2004, p. 24 ( online [PDF; accessed March 4, 2015]).