What is the treatment for a patient with ultrasound (USG) findings suggestive of thyroiditis?

Treatment of Thyroiditis Based on Ultrasound Findings

The treatment approach for thyroiditis depends entirely on the specific type of thyroiditis identified and the patient's thyroid function status, not on the ultrasound findings alone—ultrasound confirms the diagnosis but thyroid function tests (TSH, free T4) and clinical presentation determine the therapeutic strategy. 1, 2

Initial Diagnostic Workup Required

Before initiating treatment, you must determine:

• Thyroid function status: Measure TSH and free T4 to identify whether the patient is in the thyrotoxic phase (low TSH, high T4), hypothyroid phase (high TSH, low T4), or euthyroid 1, 2
• Presence or absence of thyroid pain: This distinguishes painful thyroiditis (subacute granulomatous) from painless variants (Hashimoto's, postpartum, drug-induced) 1, 3
• Thyroid peroxidase (TPO) antibodies: Elevated in Hashimoto thyroiditis and predictive of permanent hypothyroidism risk 1, 4
• Clinical context: Recent pregnancy/delivery (postpartum thyroiditis), viral illness (subacute thyroiditis), or medication exposure (amiodarone, checkpoint inhibitors, lithium, interferon) 1, 2, 3

Treatment Algorithm by Thyroiditis Type

Hashimoto Thyroiditis (Chronic Autoimmune)

For overt hypothyroidism (elevated TSH with low free T4):

• Initiate lifelong levothyroxine therapy to normalize TSH and alleviate hypothyroid symptoms 1, 2
• This also reduces goiter size over time 2

For subclinical hypothyroidism (TSH 4-10 mIU/L with normal T4):

• Consider levothyroxine if symptomatic or if fertility is desired 2

For euthyroid presentation:

• Monitor thyroid function every 6-12 months as progression to hypothyroidism is common 1

Subacute Granulomatous Thyroiditis (Painful)

This follows a triphasic pattern requiring phase-specific management 1, 2:

Thyrotoxic phase (initial 2-8 weeks):

• Beta blockers (propranolol or atenolol) for adrenergic symptoms (palpitations, tremor, anxiety) 1, 2
• Do NOT use antithyroid drugs (methimazole/PTU)—the hyperthyroidism is from hormone release, not overproduction 2, 3

For thyroid pain management:

• First-line: NSAIDs (ibuprofen 1800 mg daily or high-dose aspirin) for mild-moderate pain 2, 4
• Second-line: Corticosteroids (methylprednisolone 48 mg daily or prednisone 40 mg daily) for severe pain or inadequate NSAID response 1, 4
  • Taper over 4-6 weeks to prevent recurrence 4
  • Critical caveat: Steroid therapy provides faster symptomatic relief (within 2 weeks) compared to NSAIDs (59.5% of NSAID patients require treatment escalation), but recurrence rates are higher with steroids (23% vs 10.5%) 4

Hypothyroid phase (weeks 8-20):

• Generally no treatment needed unless TSH >10 mIU/L or patient is symptomatic 1, 2
• If treated, levothyroxine is typically temporary (3-6 months) 1

Recovery phase:

• Spontaneous return to euthyroidism in most cases 2, 3
• Monitor for permanent hypothyroidism (occurs in 5-15% of cases, higher risk with positive TPO antibodies) 4

Postpartum Thyroiditis

Occurs within 12 months of delivery, miscarriage, or medical abortion 1, 2:

Thyrotoxic phase:

• Beta blockers only for symptomatic relief 2
• Avoid antithyroid drugs 2

Hypothyroid phase:

• Levothyroxine if TSH >10 mIU/L or if TSH 4-10 mIU/L with symptoms or fertility concerns 2
• Reassess at 6-12 months to determine if hypothyroidism is permanent or transient 1

Drug-Induced Thyroiditis

For checkpoint inhibitor-induced thyroiditis (anti-PD1/PD-L1):

• Thyrotoxic phase: Conservative management with beta blockers; this is self-limiting and leads to permanent hypothyroidism within 1-2 months 5
• Do NOT use high-dose steroids unless there is concurrent hypophysitis 5
• Monitor TSH every 2-3 weeks during the thyrotoxic phase 5
• Initiate levothyroxine when hypothyroidism develops (typically permanent, requiring lifelong replacement) 5

For amiodarone-induced thyroiditis:

• Management depends on type (destructive vs. iodine-induced hyperthyroidism) and requires endocrinology consultation 3

Critical Monitoring and Follow-Up

All patients with thyroiditis require:

• Serial thyroid function testing every 4-6 weeks during active disease, then every 3-6 months for the first year 1, 2
• Assessment for permanent hypothyroidism at 6-12 months, particularly in patients with positive TPO antibodies (risk factor for permanent dysfunction) 4
• Endocrinology referral for atypical presentations, treatment-refractory cases, or when permanent hypothyroidism develops 5

Common Pitfalls to Avoid

• Do not treat the thyrotoxic phase of destructive thyroiditis with antithyroid drugs—this worsens outcomes as the mechanism is hormone release, not synthesis 2, 3
• Do not assume all thyroiditis is self-limiting—22.8% of patients treated with NSAIDs alone develop permanent hypothyroidism, compared to 6.6% with steroid treatment 4
• Do not discontinue levothyroxine prematurely in postpartum or subacute thyroiditis—reassess thyroid function after 6-12 months before stopping therapy 1, 2
• In patients with both adrenal insufficiency and hypothyroidism (hypophysitis), always start steroids before thyroid hormone to avoid precipitating adrenal crisis 5