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Pathogenesis of Hashimoto's thyroiditis (chronic autoimmune thyroiditis)

Author
Terry F Davies, MD, FRCP, FACE
Section Editor
Douglas S Ross, MD
Deputy Editor
Jean E Mulder, MD

INTRODUCTION

Hashimoto's thyroiditis (chronic autoimmune thyroiditis) is the most common cause of hypothyroidism in iodine-sufficient areas of the world. Thyroid failure is seen in up to 10 percent of the population and its prevalence increases with age [1]. It is characterized clinically by gradual thyroid failure, with or without goiter formation, due to autoimmune-mediated destruction of the thyroid gland involving apoptosis of thyroid epithelial cells. Nearly all patients have high serum concentrations of antibodies against one or more thyroid antigens; diffuse lymphocytic infiltration of the thyroid, which includes predominantly thyroid-specific B and T cells; and follicular destruction, which is the characteristic hallmark of thyroiditis.

The cause of Hashimoto's thyroiditis is thought to be a combination of genetic susceptibility and environmental factors. The familial association with Graves' disease and the fact that Graves' disease may sometimes evolve into Hashimoto's thyroiditis (and vice versa) indicate that the two disorders are closely related pathophysiologically, albeit not functionally [2,3]. The pathogenesis and precipitating factors for Hashimoto's thyroiditis are discussed here. The treatment of hypothyroidism and the pathogenesis of Graves' disease are reviewed elsewhere. (See "Treatment of hypothyroidism" and "Pathogenesis of Graves' disease".)

CLINICAL CHARACTERISTICS

The name Hashimoto's thyroiditis is derived from the 1912 pathology report by Hashimoto describing patients with goiter and intense lymphocytic infiltration of the thyroid as “struma lymphomatosa” (picture 1) [4]. Some clinicians reserve this term only for patients with hypothyroidism. However, many patients do not have hypothyroidism, and others have no goiter or even have an atrophic thyroid gland. These are considered manifestations of the same disease with differing clinical phenotypes. The presence of serum thyroid autoantibodies may be sufficient evidence for Hashimoto's disease. This logic is based upon the observation that thyroid antibodies correlate well with the presence of a lymphocytic infiltrate in the thyroid gland at autopsy examination of individuals with no history of thyroid failure [5].

Hence, the two extreme forms of the disorder are goitrous autoimmune thyroiditis and atrophic autoimmune thyroiditis, with the common pathologic feature being lymphocytic infiltration and the common serological feature being the presence of high serum concentrations of antibodies to thyroid peroxidase (TPO) and thyroglobulin (Tg). Given the pathogenetic and pathologic similarities, we use the term Hashimoto's thyroiditis for all forms of chronic autoimmune (lymphocytic) thyroiditis. Although the thyroid enlargement that can occur is usually asymptomatic, rare patients have thyroid pain and tenderness [6], particularly if there is rapid thyroid swelling, and such patients may even require surgical relief.

Hashimoto's thyroiditis is primarily a disease of women, with a sex ratio of approximately 7:1; it can also occur in children (see "Acquired hypothyroidism in childhood and adolescence"). Variant mild forms of Hashimoto's thyroiditis have been given names such as silent (or painless) thyroiditis and postpartum thyroiditis, both of which are transient but may be followed years later by thyroid failure. (See "Painless thyroiditis" and "Postpartum thyroiditis".)

                          

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Literature review current through: Nov 2016. | This topic last updated: Wed Mar 23 00:00:00 GMT 2016.
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