Treatment of Thyroiditis

1. Subacute (de Quervain's / Granulomatous) Thyroiditis

• NSAIDs or aspirin (e.g., aspirin 600 mg every 4-6 h) are first-line for mild-to-moderate pain. Add gastroprotective cover (PPI).
• Glucocorticoids (prednisone 15-40 mg/day, Goldman-Cecil uses 40-60 mg/day) if symptoms are severe or NSAIDs inadequate. Taper slowly over 6-8 weeks, guided by symptom improvement and falling ESR. Rapid taper risks relapse.
• Beta-blockers (e.g., atenolol 25-50 mg/day) for symptomatic thyrotoxicosis (palpitations, tachycardia). Antithyroid drugs (PTU, methimazole) have no role - hormone synthesis is not increased, only release.

• If prolonged or symptomatic: levothyroxine (LT4) 50-100 µg/day (low dose to allow TSH-mediated recovery). Most patients recover spontaneously within 6-9 months.
• Permanent hypothyroidism occurs in ~15% (more common with coincident thyroid autoimmunity).

2. Silent (Painless) / Postpartum Thyroiditis

• Usually mild and self-limited. Glucocorticoids are NOT indicated.
• If severe: short course of propranolol 20-40 mg TID/QID (or atenolol 25-50 mg/day).
• Antithyroid drugs again play no role.

• Levothyroxine if symptomatic or severe. Taper after 6-9 months to assess recovery.
• If pregnant or attempting conception: continue LT4 throughout pregnancy without tapering.

3. Drug-Induced Thyroiditis

• Treatment is the same as for silent thyroiditis - beta-blockers for symptomatic thyrotoxicosis, LT4 for prolonged hypothyroid phase.
• Routine monitoring of thyroid function tests is recommended throughout treatment.

4. Infectious (Acute/Suppurative) Thyroiditis

• Antibiotics guided initially by Gram stain, then by FNA culture results.
• Surgical drainage if an abscess has formed (localize by CT or ultrasound).
• Thyroid function is usually normal; monitor for rare thyrotoxicosis or hypothyroidism.
• Complications (septicemia, mediastinitis, tracheal obstruction) are prevented by prompt antibiotic use.

5. Hashimoto's (Chronic Autoimmune) Thyroiditis

• If hypothyroid: Levothyroxine replacement is the cornerstone. Target TSH within normal range (typical adult dose ~1.6 µg/kg/day, individualized). In subclinical hypothyroidism (TSH <10 mIU/L), treat if TPO Abs positive, symptoms present, or atherosclerotic vascular disease is present.
• If euthyroid: Monitor periodically; no treatment required.
• Thyroid replacement therapy increases cortisol clearance - always check ACTH status before starting LT4 in secondary hypothyroidism to avoid precipitating adrenal crisis.

6. Riedel's Thyroiditis

• Glucocorticoids - first-line for initial management.
• Tamoxifen - used as second-line therapy, with demonstrated efficacy.
• Surgery may be needed to relieve tracheal or esophageal compression (isthmusectomy).

Quick Reference Summary

Postpartum Thyroiditis (PPT)

Definition

Epidemiology & Risk Factors

• Occurs in 4-8% of postpartum women (some studies report up to 22% depending on screening methods and population)
• Among TPO antibody-positive women identified in the first trimester, 33-50% will develop PPT
• Higher risk in women with 60-70% TPO Ab positivity vs. <1% without TPO Abs
• Type 1 diabetes mellitus - PPT occurs in ~25%
• History of prior PPT - ~70% recurrence rate in subsequent pregnancies
• Associated HLA haplotypes: HLA-DR3, DR4, DR5
• Also increased in women with Graves disease, SLE, chronic viral hepatitis

Pathophysiology

• Phase 1 (1-4 months postpartum): Cytotoxic T cells and NK cells rise, exacerbating tissue injury in the thyroid (Hashimoto-like), causing the thyrotoxic phase
• Phase 2 (4-10 months postpartum): CD5+ B cells rise, can cause Graves disease relapse separately

Clinical Phases

Clinical Features

• Fatigue, insomnia, nervousness, palpitations, heat intolerance, anxiety, weight loss, irritability
• Painless goiter (nontender), no exophthalmos, no bruit
• TSH low/undetectable; free T4 elevated; T4:T3 ratio >20:1 (reflects stored hormone release)
• TPO antibodies positive; TRAb negative (key distinction from Graves)
• Radioactive iodine uptake: low to undetectable

• Fatigue, weight regain, depression, impaired concentration, paresthesia, dry skin
• Symptoms often missed as they overlap with normal postpartum complaints
• TSH may still be suppressed from the prior thyrotoxic phase - check FT4 as well
• TSH elevated when the hypothyroid phase is established

Differentiating PPT from Graves Disease

Treatment

Thyrotoxic Phase

• Usually mild and self-limiting - no specific treatment often needed
• Beta-blockers (propranolol 20-40 mg TID/QID, or metoprolol) for symptomatic palpitations, tachycardia, or tremor
• Antithyroid drugs (PTU, methimazole) are CONTRAINDICATED - the excess hormone is from destruction/release, not overproduction; ATDs will have no effect
• Glucocorticoids are NOT indicated (unlike subacute thyroiditis)
• Follow TFTs every 4-8 weeks to monitor for transition to hypothyroid phase

Hypothyroid Phase

• TSH ≥10 mIU/L with symptoms
• Overt hypothyroidism (low FT4)
• Patient is lactating
• Patient is attempting future conception or pregnant

• Full replacement dose (1.6 µg/kg/day) usually not needed; start low: 50-75 µg/day
• If not actively trying to conceive, taper at 12 months postpartum to assess whether hypothyroidism has resolved
• If pregnant or attempting conception: continue LT4 without tapering throughout pregnancy
• TSH/FT4 recheck every 4-8 weeks until stable

Prognosis & Long-term Follow-up

• 50-80% recover to euthyroidism by 1 year
• 20-70% ultimately develop permanent hypothyroidism (wide range due to study differences)
• Risk factors for permanent hypothyroidism:
  • Higher TPO antibody titers
  • Greater severity of initial hypothyroidism
  • Multiparity, older age
  • Thyroid hypoechogenicity on ultrasound

• Annual TSH in all women with a history of PPT (even if recovered)
• Women who are TPO antibody-positive: check TSH at 6-12 weeks gestation AND again at 6 months postpartum in future pregnancies
• Recurrence risk in subsequent pregnancies: ~70-80%

PPT and Postpartum Depression

• A statistically significant association exists (incidence rate ratio ~1.99 for first-onset psychiatric disorders in PPT vs. non-PPT)
• However, a prospective RCT of LT4 in TPO-positive women found no reduction in postpartum depression rates
• Causality is uncertain, but hypothyroidism is a partially treatable contributor to mood symptoms
• The ATA and Endocrine Society recommend screening for thyroid dysfunction in all patients with depression

Screening & Prevention

• Universal screening of all postpartum women is NOT recommended (insufficient evidence)
• Screen high-risk groups:
  • History of prior PPT
  • Known TPO antibody positivity
  • Type 1 diabetes
  • Personal or first-degree family history of autoimmune disease
  • New postpartum depression or anxiety
• Prevention: Selenium supplementation, LT4, and iodine have NOT been shown to reliably prevent PPT and are not recommended

• Thyrotoxic (1-4 months) - 25% of patients
• Hypothyroid (median onset 19 weeks) - 50% of patients
• Both/triphasic - 25% of patients

• Thyrotoxic phase: Beta-blockers if symptomatic; NO antithyroid drugs, NO glucocorticoids
• Hypothyroid phase: Levothyroxine 50-75 µg/day if TSH ≥10, symptomatic, lactating, or trying to conceive; taper at 12 months to check for recovery

• Incidence: 4-8% of postpartum women
• TPO antibodies positive in ~85%
• Recurs in ~70% of subsequent pregnancies
• 20-70% develop permanent hypothyroidism
• Annual TSH monitoring recommended long-term

Patient Details

• Name: Deepika Sharma | Age: 31 years, Female
• Sample drawn: 21/05/2026
• Lab: Agilus Diagnostics (formerly SRL), Indore

Results at a Glance

Trend Analysis (Serial Reports)

Interpretation

Pattern: Overt Thyrotoxicosis (suppressed TSH + elevated T3 and T4)

Key clinical context to consider:

• Is a 31-year-old woman
• Has had our prior discussion about postpartum thyroiditis
• Shows a pattern of thyroid dysfunction evolving since mid-2025

• TRAb / TSI antibodies (thyroid-stimulating immunoglobulin) - if positive, confirms Graves'
• TPO antibodies - if positive, supports Hashimoto's/PPT
• Thyroid ultrasound with Doppler - low flow favors PPT; high flow favors Graves'
• RAIU scan - low uptake = PPT; high uptake = Graves' (rarely needed)

• PPT thyrotoxicosis: treat only with beta-blockers; antithyroid drugs are contraindicated
• Graves' thyrotoxicosis: requires antithyroid drugs (carbimazole/PTU)

Recommended Next Steps

1. TRAb (TSH receptor antibody) - most important single test to distinguish Graves' vs PPT
2. TPO antibodies - supports autoimmune thyroiditis
3. Thyroid ultrasound with color Doppler - assess vascularity
4. Clinical history - date of last delivery, breastfeeding status, current symptoms (palpitations, weight loss, heat intolerance, tremor)

Immediate Clinical Concerns

• TSH of 0.005 for 3+ months is associated with risks of:
  • Atrial fibrillation
  • Bone loss (osteoporosis with prolonged exposure)
  • Cardiovascular strain
• This patient needs urgent endocrinology review, not self-referral (report shows "REF. DOCTOR: SELF")
• If symptomatic (palpitations, tremor, tachycardia): beta-blocker (propranolol 20-40 mg TID) is appropriate while awaiting further workup

⚠️ This report requires urgent clinical evaluation by an endocrinologist. The prolonged suppressed TSH over 3 months with elevated T3/T4 is not a self-resolving pattern and needs definitive diagnosis and treatment.