THYROIDITIS [thyreoiditis; lat. (glandula) of thyreoidea a thyroid gland + - itis] — an inflammation of a thyroid gland. The term «thyroiditis» combines several various but to an etiology and a pathogeny of diseases.
One of the most accepted classifications of T. the classification offered in 1980 by J. Heriman and made taking into account character of a course of process, distinctions in a wedge, a picture, etiol is. factors, morphology, etc. Division of T is the cornerstone of this classification. on acute, subacute and chronic.
The acute thyroiditis
the Acute thyroiditis meets seldom. In its etiology an essential role is played acute or chronic inf. diseases of upper respiratory tracts (quinsy, diphtheria), osteomyelitis, staphylococcal and streptococcal sepsis. Contagiums extend lymphogenous, more rare in the hematogenous way. More often one share of a thyroid gland is surprised, seldom process happens diffusion.
Histologically find leukocytic infiltration of a stroma of gland with impurity of macrophages and lymphocytes, hemorrhages, formation of the centers of a necrosis. In thyrocytes swelling of mitochondrions, destruction of cristas, change of a form and size of tanks of a cytoplasmic reticulum is noted.
Beginning acute purulent T. it is characterized by emergence of pain in a thyroid gland at first during the swallowing, and then the constant irradiating in ears. a neck, a mandible, is more rare in a shoulder. Pain amplifies during the swallowing, cough, turn of the head. The fever, fever with rises in body temperature to 39 — 40 °, tachycardia is noted. A little to calm neck pain, patients hold in a bed a semi-sitting position with the chin lowered on a breast. At an acute purulent inflammation of the goitrous changed gland — a strumitis decrease in body resistance of the patient leads to damage of fabric and cells to a phase of alteration more and volume, than at an inflammation of an intact thyroid gland, and the phase of proliferation — a reparative stage of an inflammation — differs in a long current. In a phase of alteration at such patients it can be noted tranzitorny thyrotoxicosis (see) as a result of receipt in a blood stream of a large amount of thyroid hormones from the destroyed follicles.
Duration acute T. from several days to several weeks. Inflammatory process if it does not undergo involution, leads to abscessing with possible spontaneous opening of abscess and formation of fistula. Among other complications coming, as a rule, at untimely treatment of T., are noted hypostasis of a throat and trachea, laryngitis (see), tracheitis (see), esophagitis (see). Acute purulent T. can be complicated by a septicaemia also (see. Sepsis ) and thrombophlebitis (see).
Diagnosis acute purulent T. put on the basis of characteristic a wedge, pictures, confirm with a research of the material received at a puncture of a thyroid gland and allocation of the activator. From a lab. researches at acute T. changes of indicators of a gemogramma are most informative (see): ROE is sharply accelerated, the leukocytosis reaches 30 000, in a blood count note shift to the left. Thyroid autoantibodies in blood at acute T., as a rule, are not defined, concentration proteinaceous and connected iodine (see) most often there is normal, as well as a capture gland 131 I. Most often it is necessary to differentiate acute T. with subacute T. In this case results of a biopsy and lack of effect of treatment by antibiotics matter at under acute T.
Treatment is carried out by antibiotics and sulfanamide drugs. At the created abscess an operative measure is necessary: opening of abscess or removal of all struck share of a thyroid gland.
The forecast at timely diagnosis of ii the correct treatment by favorable. In rare instances at extensive destruction of a parenchyma of a thyroid gland develops hypothyroidism (see).
Subacute thyroiditis (synonym: de Querven's thyroiditis, a granulematozny thyroiditis, a psevdogranulematozny thyroiditis, a pseudotuberculous thyroiditis, a giant-cell thyroiditis) occurs at 1 — 2% of the persons having diseases of a thyroid gland. Women at the age of 20 — 50 years are ill more often, it is rare children. Subacute T. almost never develops, as a rule, in a normal thyroid gland and — in in goitrous changed.
Etiology subacute T. finally it is not found out, however assume that the disease has the virus nature since usually it develops soon after viral infections — flu (see), measles (see), epidemic parotitis (see. Parotitis epidemic ), etc., and in blood of patients in the heat of a disease antibodies to the corresponding viruses can be defined.
During subacute T. depending on the content in blood of thyroid hormones allocate several stages. In the I stage subacute T. as a result of disturbance of integrity of membranes of thyrocytes and follicles of a thyroid gland and an exit of their contents in a stroma of gland in blood concentration increases thyroxine (see) — T4 and triiodothyronine (see) — T3, and also non-hormonal compounds of iodine that increases a difference between amount of the proteinaceous and connected iodine (see) and butanolekstragiruyemy iodine (see) and blocks capture of iodine a thyroid gland. Stroma of a thyroid gland of an infiltrirovan segmentoyaderny leukocytes, lymphocytes and fabric macrophages. Nek-ry patients in blood have anti-thyroid antibodies. In the II stage there is a decrease in intensity of destructive processes in a thyroid gland that leads to reduction of concentration of non-hormonal compounds of iodine in blood and to recovery of the mechanism of capture of iodine gland. In a stroma of gland scanty infiltration by macrophages and lymphocytes with impurity of plasmocytes and disappearance of neutrophils is noted. Masses streamed in a stroma from the destroyed follicles of a colloid is surrounded with histiocytes and colossal cells (see), similar to so-called cells of foreign bodys (fig. 1). Decrease in content in blood of thyroid hormones and sometimes tranzitorny hypothyroidism are characteristic of the III stage in connection with reduction of volume of the functioning ferruterous fabric. In this stage inflammatory process abates, the centers of regeneration of follicles come to light. In the IV stage — a stage of recovery — the increased capture of iodine is quite often noted by gland, edges before it was grown poor by it therefore this phenomenon has compensatory character. At the same time the maintenance of T3 and T4 in blood is reduced or is normal. At electron-but-microscopic examination of a thyroid gland at patients with a subacute thyroiditis of the III—IV stage note signs of increase in functional activity of thyrocytes, but the apical pseudopodiums containing drops of a colloid, no, and colossal cells of a mezenkhimny origin represent groups of histiocytes without signs of phagocytosis of particles of a colloid. At the end of a stage of recovery all indicators are normalized.
Wedge, picture subacute T. it is characterized by the acute beginning, emergence of pains, often intensive, in a thyroid gland, irradiating in ears, a mandible, a nape and a neck. Sometimes note pain during the swallowing and turn of the head. Overall health worsens, body temperature is increased (sometimes considerably). The thyroid gland is increased diffuzno or ochagovo (one its share increases more often), is dense to the touch, sharply painful at a palpation. Sometimes at the beginning one share (more often right) with the subsequent involvement in process of other share of gland is surprised. Skin over a thyroid gland hot to the touch. Regional limf, nodes are not increased. ROE is usually accelerated, sometimes to 60 — 90 mm/hour, the lymphocytosis can be observed, the leukocytic formula is usually not changed, the quantity of leukocytes are normal, in blood serum abundance of 7 globulins and fibrinogen is increased. Characteristic sign subacute T. decrease in capture zhelezoy131 is!. At the subsequent stages functional capacities and a condition of a thyroid gland are gradually normalized. Overall health is also returned to norm. Duration subacute T. from 1 month to I 1 2 — 2 years.
The diagnosis the wedge, pictures (the dense, painful thyroid gland which is not soldered to surrounding fabrics at intact regional limf, nodes), results establish on the basis of characteristic a lab. researches, and also anamnestic data (the postponed 6 — 8 weeks back a viral disease, etc.). Confirms the diagnosis blockade of capture with a thyroid gland 131 I.
The differential diagnosis is carried out with acute to purulent T. generally on character of a gemogramma (lack of a leukocytosis), with quinsy (see), at a cut there are no characteristic changes of a thyroid gland, with a diffusion toxic craw (see. Craw diffusion toxic ) and toxic adenoma of a thyroid gland. With tumors of a thyroid gland, to-rye also T can be followed by the expressed pain syndrome, subacute. differentiate on indicators of functional activity of gland, including on capture by it 131I, and also on lack of a spayaniye with the next tissues of a neck and local lymphadenitis (see). Diagnostically as the important test serves reaction to treatment by glucocorticoids, high doses to-rykh (to 60 mg of Prednisolonum a day) within 14 — 18 days lead to improvement of a condition of the patient with a subacute thyroiditis.
In differential diagnosis with specific T. at tuberculosis (see) and syphilis (see) an important role Mantoux tests play (see. Tuberculinodiagnosis ) and Wasserman (see. Wasserman reaction ), and also these biopsies (see).
Treatment subacute T. usually conservative, appoint generally predipzoly (an initial dose of 20 — 30 mg a day). Reduction of a dose of Prednisolonum often causes a recurrence of a disease therefore the gradual dose decline should be carried out under constant control of ROE and existence of a pain syndrome. It is necessary to reduce a dose of Prednisolonum in the absence of morbidity in a thyroid gland approximately by 5 m of each 7 — 10 days, however after all as the main indicator serves decrease in ROE. In mild cases it is possible to be limited to purpose of salicylates (acetilsalicylic to - you are 2 — 4 g and more in days) or indometacin, Brufenum, butadiene, pyramidon. Prescription of antibiotics and anti-thyroid means inefficiently.
Forecast favorable; as a rule, there occurs recovery. A recurrence and the persistent course of a disease can lead to a sclerosis of a thyroid gland and, as a result, to a hypothyroidism.
A chronic thyroiditis
To hron. T. carry lymphocytic (autoimmune) T., or Hashimoto's disease (see. Hashimoto disease ), fibrous and invasive T. and specific T.
Fibrous and invasive thyroiditis [synonym: Ridel's thyroiditis (the most usable synonym), Ridel's craw, a ligneous thyroiditis, a chronic invasive thyroiditis, a chronic fibrous thyroiditis] — a disease of not clear etiology, at Krom the parenchyma of a thyroid gland is replaced by fibrous fabric. It is for the first time described in 1896 by B. Ridel.
Fpbrozno-invazivny T. meets at persons more often 50 years are more senior, it is preferential at women. According to the data provided in 1957 Vulnerom (L. Century of Woolner), etc., it is revealed at 0,05% of the patients operated concerning diseases of a thyroid gland.
The thyroid gland is increased, dense and at the expressed process by a ring covers a trachea. Parenchymatous elements have an appearance of separate islands in the fibrous, sometimes hyalinized connecting fabric (fig. 2). Note total disappearance of lobation. Thyrocytes of the remained follicles are flattened. There is no colloid in a gleam of follicles or it is not enough. Focal lymphoid accumulations, sometimes with impurity of multinucleate colossal cells come to light.
Fibrosis at fibrous and invasive T. has aggressive character and it is characterized by extensive growths of fibrous fabric. The last extends out of limits of the capsule of a thyroid gland and affects the next muscles, nerves, vessels, is quite often combined with idiopathic fibrosis of other areas (retroperitoneal, mediastinal, etc.). At fibrous and invasive T. there is a shift and a prelum of a trachea, as a result to-rogo the expressed change of a voice develops. During the involvement in process of both recurrent guttural nerves paralysis of a throat can develop. Sometimes fibrosis extends to a mediastinum.
Patients complain of a prelum in a neck, difficulty of breath and swallowing. Skin over a thyroid gland is not changed and easily gathers in folds.
Complication fibrous and invasive T. there can be a hypothyroidism though the unimpaired sites of a parenchyma thyroid glands usually provide an euthyroid state. Fibrous and invasive T. it can be combined with fibrosis of parotid glands, language, retrobulbar and retroperitoneal fibrosis (Ormond's syndrome).
The diagnosis is made on the basis of specific by a wedge, pictures, existence dense craw (see), soldered to surrounding fabrics and slowly increasing in sizes. During the scanning of gland find the so-called cold centers. Thyroid autoantibodies define seldom and in low credits. The biopsy of a thyroid gland is diagnostically especially informative.
The differential diagnosis with an amyloidosis and cancer of a thyroid gland is based hl. obr. on results gistol. researches. From a nodal nontoxic craw fibrous and invasive T. the extraordinary density of a thyroid gland and its spayaniye with the next fabrics distinguishes; from Hashimoto's disease — a spayaniye of a craw with the next fabrics, absence in an organism expressed immunol. shifts, rare and late development of a hypothyroidism; from subacute T. — the course of a disease, lack of the specific changes of a picture of blood characteristic for subacute T., lack of a pain syndrome and a spayaniye of a craw with the next fabrics.
Treatment operational. Indications to operation are the big sizes of a craw, shift and a prelum of the next bodies. At diffusion defeat removal of a part of both shares and an extirpation of an isthmus of gland is recommended, at unilateral process — a resection of the corresponding share. Operational removal of parts of a thyroid gland, besides, detains fibrosis. Cases of the spontaneous termination of such process, and also its return development after a biopsy of gland are described. At the developed hypothyroidism replacement therapy tireoidnymp hormones is necessary.
The forecast in the presence of symptoms of a prelum depends on timeliness of operation since at considerable germination of fibrous fabric in the next bodies the postoperative period can proceed especially hard.
Specific thyroidites (tubercular, syphilitic, actinomycotic, etc.) meet extremely seldom and usually are local manifestations of general diseases.
Tubercular T. develops as a result of a hematogenous dpsse-mination. The thyroid gland has a dense consistence, sometimes with a chicken skin. In it the tubercular granulomas or larger caseous centers surrounded with specific granulyatsionny fabric are found. Increase regional limf, nodes is characteristic. Detection of primary center and positive reactions to tuberculine allow to make the correct diagnosis.
At syphilitic T. the thyroid gland is dense and slow-moving in connection with its union with surrounding fabrics. The diagnosis is confirmed positive serol. tests.
At actinomycosis (see) a thyroid gland it is condensed in the beginning, then characteristic fistulas and pus develop. Detection in pus of druses of actinomycetes allows to confirm the diagnosis.
Treatment of specific T. it is directed to a basic disease. The forecast depends on timely diagnosis and rational treatment.
See also Thyroid gland .
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I. D. Levitte, V. V. Talantov; V. A. Odinokova, M. E. Bronstein (stalemate. An.).