Kronik Tiroiditler
Özet
Kronik tiroitler, iyot eksikliği bulunmayan bölgelerde hipotiroidizmin gelişiminde rol oynayan en önemli patolojiler arasında yer almakta ve temel olarak kronik otoimmün tiroidit (Hashimoto tiroiditi) ile Riedel tiroiditi şeklinde sınıflandırılmaktadır. Tiroid bezinin ilerleyici fonksiyon kaybıyla karakterize olan Hashimoto tiroiditi, özellikle 30-50 yaş aralığındaki kadınlarda en sık görülen otoimmün tiroid patolojisidir. Hastalığın patofizyolojisinde lenfositik infiltrasyon, folikül yıkımı ve plazma hücrelerinin aktivasyonu yer almakta; tanı sürecinde yüksek antiTPO ve antiTg antikor düzeyleri ile ultrasonografide heterojenite izlenmektedir. Başlangıçtaki tirotoksik fazın (haşitoksikoz) ardından gelişen aşikar veya subklinik hipotiroidi tablosunda temel tedavi yaklaşımı hastanın durumuna ve kilosuna göre ayarlanan levotiroksin replasmanıdır. Diğer taraftan, oldukça nadir ve invaziv bir form olan Riedel tiroiditi, tiroid dokusunda yoğun fibrozis ve IgG4 pozitif plazma hücrelerinin varlığı ile karakterize IgG4 ilişkili bir hastalıktır. Çevre sinir, damar ve kas dokularına invazyon gösterebilen bu sert ve fikse kitle yapısı, sıklıkla malignite ile karışmakta; yutma güçlüğü, ses kısıklığı ve boyunda şiddetli baskı hissi gibi bası semptomlarına yol açmaktadır. Tanısında kalın iğne veya açık biyopsi gereken Riedel tiroiditinin medikal tedavisinde kortikosteroidler, tamoksifen ve raloksifen kullanılırken, ciddi mekanik bası semptomlarının giderilmesinde cerrahi olarak istmus rezeksiyonuna başvurulmaktadır.
Chronic thyroiditis primarily encompasses chronic autoimmune thyroiditis (Hashimoto's thyroiditis) and Riedel's thyroiditis, serving as the leading cause of hypothyroidism in iodine-sufficient populations. Hashimoto's thyroiditis is a progressive disease characterized by the gradual loss of thyroid function, most frequently observed in women aged between 30 and 50 years. Its underlying mechanism involves extensive lymphocytic infiltration, follicular destruction, and plasma cell involvement, which trigger the generation of antithyroid peroxidase (antiTPO) and antithyroglobulin (antiTg) antibodies. While it initially presents with a transient thyrotoxic phase known as hashitoxicosis, it eventually transitions into clinical hypothyroidism, necessitating individualized levothyroxine replacement therapy based on body weight and clinical status. In contrast, Riedel's thyroiditis is an extremely rare and invasive form characterized by predominant systemic fibrosis and IgG4-positive plasma cell infiltration. This condition forms a hard, fixed thyroid mass that extensively invades adjacent nerves, vessels, and muscles, closely mimicking malignancy and causing severe compressive symptoms such as dysphagia, hoarseness, and neck pressure. Diagnosis typically requires core needle or open biopsy, and management involves medical therapies including corticosteroids, tamoxifen, or mycophenolate mofetil, alongside surgical interventions like isthmus resection to alleviate mechanical compression.
Referanslar
Hallowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T4, and Thyroid Antibodies in the United States Population(1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). Journal of Clinical Endocrinology and Metabolism. 2002;82(2):489–499. doi: 10.1210/jcem.87.2.8182
HAY ID. Thyroiditis: A Clinical Update. Mayo Clinic Proceedings. 1985;60(12):836–843. doi: 10.1016/S0025-6196(12)64789-2
Karahatay S, Ayan A, Aydin U et al.The increased risk of globus pharyngeus in patients with chronic thyroiditis: A case control study. European Review for Medical and Pharmacological Sciences. 2015;19(24):4722–4727.
Türkiye Endokrinoloji ve Metabolizma Derneği. Ti̇roi̇d Hastalıkları Tanı ve Tedavi̇ Kılavuzu. 2020. 1–245 p.
Tamai H, Ohsako N, Takeno K, et al. Changes in thyroid function in euthyroid subjects with a family history of graves’ disease: A foliow-up study of 69 patients. Journal of Clinical Endocrinology and Metabolism.1980;51(5):1123–7. doi: 10.1210/jcem-51-5-1123
Kralem Z, Baron E, Kahana L, et al. Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper‐thyroidism and back to hypothyroidism. Clinical endocrinology (Oxford). 1992;36(2):211–214. doi: 10.1111/j.1365-2265.1992.tb00960.x.
Kahaly GJ, Diana T, Glang J, et al. press.endocrine.org/journal/jcem. Journal of Clinical Endocrinology and Metabolism. 1998;101(5): doi: 10.1210/jc.2016-1220
Hutchings PR, Cooke A, Dawe K, et al. A Thyroxine-containing Peptide Can Induce Murine Experimental Autoimmune Thyroiditis. Journal of Experimental Medicine. 1992;175:869–872. doi: 10.1084/jem.175.3.869
Bagchi N, Brown TR, Urdanivia E, et al. Induction of autoimmune thyroiditis in chickens by dietary iodine. Science (80- ). 1985;230(4723):325–327. doi: 10.1126/science.4048936
Lomas J, Anderson GM, Domnick-Pierre K, et al. The New England Journal of Medicine Copyright © 2010 Massachusetts Medical Society. 1989;321(19):1306–1311.
Allen EM, Appel MC, Braverman LE. The effect of iodide ingestion on the development of spontaneous lymphocytic thyroiditis in the diabetes-prone BB/W rat. Endocrinology. 1986;118(5):1977–1981. doi: 10.1210/endo-118-5-1977
Boukis MA, Koutras DA, Souvatzoglou A, et al. Endemic Goiter Journal of Clinical Endocrinology and Metabolism. 2015;57(4):859–862. doi: 10.1210/jcem-57-4-859
Kraiem Z, Cho BY, Sadeh O, et al. The IgG subclass distribution of TSH receptor blocking antibodies in primary hypothyroidism. Clinical endocrinology (Oxford). 1992;37(2):135–140. doi: 10.1111/j.1365-2265.1992.tb02297.x
Strieder TGA, Prummel MF, Tijssen JGP, et al. Risk factors for and prevalence of thyroid disorders in a cross-sectional study among healthy female relatives of patients with autoimmune thyroid disease. Clinical endocrinology (Oxford). 2003;59(3):396–401. doi: 10.1046/j.1365-2265.2003.01862.x
Menconi F, Monti MC, Greenberg DA, et al. Molecular amino acid signatures in the MHC class II peptide-binding pocket predispose to autoimmune thyroiditis in humans and in mice. Proceedings of the National Academy of Sciences of the United States of America. 2008;105(37):14034–14039. doi: 10.1073/pnas.0806584105
Tomer Y, Davies TF. Searching for the Autoimmune Thyroid Disease Susceptibility Genes: From Gene Mapping to Gene Function. Endocrine Reviews. 2003;24(5):694–717. doi: 10.1210/er.2002-0030.
Brix TH, Kyvik KO, Hegedüs L. A population-based study of chronic autoimmune hypothyroidism in Danish twins. Journal of Clinical Endocrinology and Metabolism. 2000;85(2):536–539. doi: 10.1210/jcem.85.2.6385
Arata N, Ando T, Unger P, et al. By-stander activation in autoimmune thyroiditis: Studies on experimental autoimmune thyroiditis in the GFP+ fluorescent mouse. Clinical Immunology. 2006;121(1):108–117. doi: 10.1016/j.clim.2006.03.011
Ban Y, Greenberg DA, Concepcion E, et al. Amino acid substitutions in the thyroglobulin gene are associated with susceptibility to human and murine autoimmune thyroid disease. Proceedings of the National Academy of Sciences of the United States of America. 2003;100(25):15119–15124. doi: 10.1073/pnas.2434175100
Villanueva R, Greenberg DA, Davies TF, et al. Sibling recurrence risk in autoimmune thyroid disease. Thyroid. 2003;13(8):761–764. doi: 10.1089/105072503768499653
Kimura H, Davies TF. Thyroid-specific T cells in the normal Wistar rat. Clinical Immunology and Immunopathology. 1991;58(2):195–206. doi: 10.1016/0090-1229(91)90136-x
Tomer Y, Barbesino G, Greenberg DA, et al. Mapping the major susceptibility loci for familial Graves’ and Hashimoto’s diseases: Evidence for genetic heterogeneity and gene interactions. Clinical Endocrinology and Metabolism. 1999;84(12):4656–4664. doi: 10.1210/jcem.84.12.6216
Walsh JP, Ward LC, Burke V, et al. Small changes in thyroxine dosage do not produce measurable changes in hypothyroid symptoms, well-being, or quality of life: Results of a double-blind, randomized clinical trial. Clinical Endocrinology and Metabolism. 2006;91(7):2624–2630. doi: 10.1210/jc.2006-0099
Heufelder AE, Wenzel BE, Gorman CA, et al. Detection, cellular localization, and modulation of heat shock proteins in cultured fibroblasts from patients with extrathyroidal manifestations of graves’ disease. Clinical Endocrinology and Metabolism. 1991;73(4):739–745. doi: 10.1210/jcem-73-4-739
Giordano C, Stassi G, Maria R De, et al. Potential Involvement of Fas and Its Ligand in the Pathogenesis of Hashimoto ’ s Thyroiditis FasL expression by activated lymphocytes. Science.1997;275(February):960–963. doi: 10.1126/science.275.5302.960
Neufeld DS, Platzer M, Dey TF. Reovirus induction of mhc class ii antigen in rat thyroid cells. Endocrinology. 1989;124(1):543–545. doi: 10.1210/endo-124-1-543
Jameson JL, Mandel SJ, Weetman AP. Hypothyroidism. Harrison’s Principles of Internal Medicine içinde. New York: Mc Graw Hill Education; 2018. p. 2698–703.
Heufelder AE, Bahn RS. Tissue Eosinophilia Riedel ’ s Invasive. Clinical Endocrinology and Metabolism 1996; Mar;81(3):977-984. doi: 10.1210/jcem.81.3.8772560
Hennessey J V. Riedel’s thyroiditis: A clinical review. J Clin Endocrinol Metab. 2011;96(10):3031–41.
Brent GA, Weetman A. Hypothyroidism and Thyroiditis. Williams Textbook of Endocrinology içinde. Canada:Elsevier;2020 p. 404-432.
Kumar N, Gupta R, Sayed S, et al. Difficulties in diagnosis of Riedel’s thyroiditis on aspiration cytology: A case report and brief review of the literature. Diagnostic Cytopathology. 2019;47(5):512–516. doi: 10.1002/dc.24130
Dilmaghani A, Sciences M, Street D. Accepted manuscript. 2020;1–7.
Erdoğan MF, Anıl C, Türkçapar N, et al. A case of Riedel’s thyroiditis with pleural and pericardial effusions. Endocrine. 2009;35(3):297–301. doi: 10.1007/s12020-009-9168-0
Chong Xi R, Hong Qiao W, Yan L. Severe trachea compression caused by Riedel’s thyroiditis: A case report and review of the literature. Annals of Medicine and Surgery. 2016;12(17):18–20. doi: 10.1016/j.amsu.2016.10.005
Slman R, Monpeyssen H, Desarnaud S, et al. Ultrasound, elastography, and fluorodeoxyglucose positron emission tomography/computed tomography imaging in riedel’s thyroiditis: Report of two cases. Thyroid. 2011;21(7):799–804. doi: 10.1089/thy.2010.0242
Drieskens O, Blockmans D, Van Den Bruel A, et al. Riedel’s thyroiditis and retroperitoneal fibrosis in multifocal fibrosclerosis positron emission tomographic findings. Clinical Nuclear Medicine. 2002;27(6):413–415. doi: 10.1097/00003072-200206000-00005
Kotilainen P, Airas L, Kojo T, et al. Positron emission tomography as an aid in the diagnosis and follow-up of Riedel’s thyroiditis. European Journal of Internal Medicine 2004;15(3):186–189. doi: 10.1016/j.ejim.2004.03.002
Sabbadin C, Mian C, Nacamulli D, et al. Association of primary aldosteronism with chronic thyroiditis. Endocrine. 2017;55(1):303–306. doi: 10.1007/s12020-016-0880-2
