Diagnosis and Management of Painful Hashimoto Thyroiditis: A Case Review

Woman with throat sore is holding her aching throat – body pain concept
Researchers conducting a comprehensive literature review for painful Hashimoto thyroiditis identified only 70 cases of the rare condition.

Researchers conducting a comprehensive literature review for painful Hashimoto thyroiditis identified only 70 cases of the rare condition. Management was typically similar to that of subacute thyroiditis, but better results were seen with intrathyroidal glucocorticoid injection or total thyroidectomy, according to a review presented at the 89th Annual Meeting of the American Thyroid Association, held October 30 to November 3, 2019 in Chicago, Illinois.

The goal of the review was to characterize the demographics, clinical features, laboratory and imaging findings, and management of painful Hashimoto thyroiditis.

The researchers completed a comprehensive search in PubMed, Embase, Scopus, and Web of Science and included in the review 24 publications with a total of 70 cases (91.4% women; median age, 39 years [interquartile range 32.5-49.75]) of painful Hashimoto thyroiditis, published between 1951 and February 2019.

Approximately half of the patients (50.8%) had pre-existing thyroid disease, including Hashimoto thyroiditis, Graves disease, and seronegative goiter. Most patients had positive antithyroid peroxidase (83.3%) or antithyroglobulin (71.2%) antibodies. On imaging, the features were consistent with Hashimoto thyroiditis.

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At initial presentation, normal thyroid function tests were evident in 20 patients (28.1%), while hypothyroidism and hyperthyroidism were each documented in 25 individuals (35.9%). Over time, most cases evolved into hypothyroidism (55.3%), and the remainder were euthyroid (44.7%). Medical treatment was usually associated with reduction in thyroid size.

While in most patients treatment was concordant with the recommended options for subacute thyroiditis — including corticosteroids, levothyroxine, or nonsteroidal anti-inflammatory drugs — none provided sustainable pain resolution. The outcomes were better with low-dose oral prednisone (<25 mg/d) and intrathyroidal corticosteroid injection. Surgical intervention in the form of a total thyroidectomy provided pain resolution in all cases.

Overall, the diagnosis of painful Hashimoto thyroiditis was based on clinical evidence of Hashimoto thyroiditis accompanied by recurrent thyroid pain after medical therapy.

“Total thyroidectomy or intrathyroidal glucocorticoid injection should be considered if low dose oral prednisone fails to achieve pain control,” concluded the researchers.

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Peng C, Chang R, Pennant M, Huang H, Munir K. A review of painful Hashimoto’s thyroiditis: 70 cases in the past 70 years. Presented at: American Thyroid Association 2019 Annual Meeting; October 30-November 3, 2019; Chicago, IL. Poster 55.