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Thyroid disease is defined as a condition of malfunction of thyroid gland.
Thyroid Disease : Silent thyroiditisSilent thyroiditis is the inflammation of the thyroid gland. Patients with silent thyroiditis are experience back and forth between hypothyroidism and hyperthyroidism. The disease classically present with a triphasic course: a brief period of hyperthyroidism due to release of preformed thyroid hormone that lasts for 1 to 3 months, followed by a more prolonged hypothyroid phase lasting up to 6 months, and eventually return to a euthyroid state. However, the types and degree of thyroid dysfunction, individual patients may present with mild or more severe cases of hyperthyroidism alone, hypothyroidism alone, or both types(a).
Symptoms are associated to the stage of the diseases and may include
1. Chronic fatigue
Chronic fatigue is associated to the presence of chronic lymphocytic thyroiditis, according to Bo Wikland and colleagues (March 24, p 956)1 report. Thyroxine, the primary medication may be used to relief the symptom(b).
In the phase of hyperthyroidism
2. Heat intolerance
Patient with silent thyroiditis may be experience the symptoms of heat intolerance, according to the Gifu Red Cross Hospital, Japan(c).
Hyperthyroidism is associated with unpleasant symptoms and hypertension due to increased adrenergic tone, according to the study by the Harran University Faculty of Medicine(d).
4. Tachycardia, fatigue, and weight loss, hyperactive reflexes, increased sweating, heat intolerance, tremor, nervousness, polydipsia, and increased appetite, anorexia, atrial fibrillation and goiter
Depending to the age, patients with Thyroid adenoma with the presence of hyperthyroidism may be experience certain above symptoms, according to the study by the Centre Hospitalier et Universitaire de Rouen(e).
In the phase of hypothyroidism
1. Weight gain and fatigue
Hyperthyroidism is associated to weight gain, especially in patients with co-existence of diabetes(1).
The comparable study of patients with thyroid carcinoma (DTC) and 138 with autoimmune hypothyroidism (AIH), also indicated a significantly higher levels of fatigue in hypothyroidism patients(1b). Statistics of study of 198 consecutive breast cancer patients receiving adjuvant chemotherapy, 22.2% of this patient population showed a significant and progressive weight gain of 6.7 lbs, and 94% of all patients reported fatigue, due to cytotoxic agents influence hypothyroidism in breast cancer patients(1a).
2. Vitiligo and alopecia areata
Vitiligo is associated with autoimmune endocrine disorders, especially withhypothyroidism(2). Primary hypothyroidism patients is at increased risk to develop vitiligo, depigmentation of parts of the skin and hair lost from some or all areas of the body, especially in the scalp(2a)
3. Chronic constipation(3a)
Hypothyroidism may induce the pathogenesis of constipation, according to the study by the University of California at Los Angele(3).
4. Hypothyroid women showed also significantly higher frequency of urticaria and puffiness of hands and feet, yellow ivory skin, coarse rough dry skin(4).
Patients with hypothyroidism have a higher occurrence of depressivesyndrome, these may be result of alterations in blood flow and glucose metabolism in the brain(5).
6. Mood and motor learning
Oral administration of usual dose l-T(4) (euthyroid arm) vs. higher dose l-T(4) (subclinical thyrotoxicosis arm) , showed to improve confusion, mood and motor learning in patients with hypothyroidism(6).
B. Causes and Risk factors
The cause of silent thyroiditis is unknown. The autoimmune thyroiditis processes progressively and slowly tinduce necrosis/apoptosis of thyroid cells, causing functional impairment of thyroid gland. Other forms of autoimmune thyroiditis includes postpartum thyroiditis and silent thyroiditis(11). Other researchers suggested that silent thyroiditis is an autoimmune disease characterized by lymphocytic(white blood cells) infiltration of the thyroid and by transient hyperthyroidism, followed occasionally by transient hypothyroidism and eventual recovery(12).
B.2. Risk factors
1. Gentic and environment factors
Genetic and/or environmental factors are important in the development of familial type of silent thyroiditis, according to the study by the Gifu Red Cross Hospital(14). Other study indicated that antecedent infection or exposure to antigen may cause the development of silent thyroiditis(15).
Patients with unilateral adrenalectomy for treatment of Cushing’s syndrome are associated to increased risk of silent thyroiditis(16).
3. Lithium therapy
While hypothyroidism secondary to treatments by lithium are well known, cases of hyperthyroidism are less common. Lithium carbonate treatment in a long period of time without any auto-immunity biological markers, associated with a very low thyroid tracer uptake on scintigraphy(17).
4. Alpha-interferon therapy
Alpha-interferon therapy treatment in patients with chronic active hepatitis C develops may induce silent thyroiditis(18). Other study report indicated the development of a episode of silent thyroiditis in a patient with chronic thyroiditis and papillary adenocarcinoma following alpha interferon treatment for hepatitis C(19).
5. Thyroid-stimulation-blocking antibodies (TSBAb)
Thyroid-stimulation-blocking antibodies (TSBAb) showed to induce thyrotoxic symptoms with hypokalemic periodic paralysis, a disorder that causes occasional episodes of muscle weakness and sometimes a lower than normal level of potassium in the blood(20).
Viral infection such as rubella could cause the development of silent thyroiditis with synptoms of heat intolerance(21).
If you are women, you are associated to increased risk of silent thyroiditis.
8. Low level of selenium
Se levels were significantly decreased in cases of sub-acute and silent thyroiditis. according to WOMED(22).
9. Postpartum period
Silent or painless thyroiditis is a frequent cause of transient hyperthyroidism characterized by the onset of symptoms patient with a normal to modestly enlarged and firm thyroid gland, particularly in the postpartum patient(22a).
10. Autoimmune type 1 diabetes mellitus
Patients with autoimmune type 1 diabetes mellitus have often, besides immune diabetes markers, also other organ-specific antibodies, particularly thyroid autoantibodies(22b).
11. Thyroid peroxidase autoantibodies
Thyroid peroxidase (TPO) is a key enzyme in the formation of thyroid hormones and a major autoantigen in autoimmune thyroid diseases, depending to the degree of lymphocytic infiltration in euthyroid subjects, with prevalence rate of 12-26%(22c).
1. Sudden unexpected death
Silent (painless) thyroiditis, especially, is easily overlooked at autopsy as there are no macroscopic changes and often no prior symptoms or history of thyroid disease pointing towards this condition.
Extensive lymphocytic infiltration of the thyroid parenchyma has found to cause‘unknown cause of death’ in some patients with silent (painless) thyroiditis. (23).
2. Oncocytic follicular nodules
Oncocytic follicular (OF) cells, arising in multinodular goiter and chronic lymphocytic thyroiditis (CLT) has beed used as a prominent component of fine needle aspiration (FNA) specimens from neoplasms (adenomas and carcinomas) and nodules(24).
3. Recurrent Silent thyroiditis (ST)
Silent thyroiditis (ST) recurred with a high incidence (65%, 35/54), according to the study by the Department of Endocrinology and Metabolism, Toranomon Hospital(25).
4. Hashimoto’s thyroiditis and lymphoid follicles
Patient with silent thyroiditis, during the thyrotoxic phase, and 15 specimens during the early or late recovery phase are susceptible to develop chronic thyroiditis and lymphoid follicles(26).
D. Diseases associated to Silent thyroiditis
Hyperprolactinemia may presents in patients with silent thyroiditis due to its influence in the active phase of some non organ-specific autoimmune diseases, including autoimmune thyroid diseases(29).
2. Graves’ disease
Graves’ disease, an autoimmune disease as a result of overproduction of thyroid hormones have associated to the presence of silent thyroiditis, according to the study by the Fourth Department of Internal Medicine, Saitama Medical School(30). The two diseases are closely linked because sequential development of GD followed by ST, or the reverse course of events(31).
3. Progressive systemic sclerosis (PSS)
Patients with progressive systemic sclerosis (PSS) with increased serum T3 and T4 and low 24-h thyroidal uptakeare more likle to be presence with silent thyroiditis(32).
4. Idiopathic thrombocytopenic purpura (I.T.P.)
Patients with diopathic thrombocytopenic purpura, a disorder of easy or excessive bruising and bleeding on the presence of symptoms of thyrotoxicosis. accompanied with the diagnosis of low uptake of radioactive iodine and technesium(chemical Tc) with may develop silent thyroiditis(33).
Thymoma often accompanies an autoimmune disease, is thought to be involved in the onset of silent thyroiditis(34).
6. Chronic adrenocortical insufficiency
chronic adrenocortical insufficiency (Addison’s disease), a autoimmune disorder is associated to the prevalence of silent thyrotoxic thyroiditis(35).
E. Misdiagnosis and diagnosis
Silent thyroiditis in some cases has misdiagoesd as malignant lymphoma of the thyroid. Clinically and cytologically, it is difficult to make a distinction of diagnosis if immune response phenomena with invasion of lymphocyte and appearance of lymph follicle are the strongest(36).
After recording the past and present history and completing a physical exam, including assessing symptoms and complaints commonly seen including enlarged thyroid gland, heart rate, shaking hand etc. The tests which your doctor orders may include
1. Radioactive iodine uptake test, or RAIU test
Radioactive iodine uptake (RAIU) test measures how much tracer the thyroid gland absorbs from the blood with radioactive tracer. In mast cases, patients with either Graves' diseases and silent thyroiditis are undergone iodine restriction before taking the test(37).
2. Blood test for blood levels of the thyroid hormones T3 and T4
The aim of the test is to the level of free T4 and thyroid stimulating hormone (TSH) levels to exclude thyroid dysfunction(38), if normal value of TSH is presented(38).
3. Thyroid scintigraphy
Thyroid scintigraphy, the test used to establish the functional characteristics of thyroid nodules (warm or cold) and to precise the origin of a thyrotoxicosis(hyperthroidism) of sub acute or silent thyroiditis(39).
4. Thyroid biopsy
In thyrroid biopsy, removed small sample of tissue from the thyroid gland is examined under a microscope for sign of unusual thyroid function(40).
F.1. Diet to prevent silent thyroiditis
Sulforaphane (SFN), a natural constituent of cruciferous vegetables such as broccoli, Brussels sprouts, etc., exhibits its anti inflammatory effect against LPS-induced inflammation in RAW 264.7 cells(41).
Anthocyanin-rich cherries, tested in the Zucker fatty rat model of obesity and metabolic syndrome, significantly attenuated the postprandial inflammatory response in a cross -over design of overweight adults consumed a high-carbohydrate, moderate-fat meal (HCFM) accompanied by either a strawberry or a placebo beverage(42).
Walnut consumption showed to increase levels of apolipoprotein A, a protein played an important role in lipid metabolism with anti-inflammatory effects in adipocytes(fat cells) and adipose(fat) tissue similar in other cell types(43)
1,2-vinyldithiin, a chemical ingredient from garlic inhibits differentiation and inflammation of human preadipocytes( precursor cells for the development of fat cells)(44).
F.2. Phytochemicals and antioxidants to prevent silent thyroiditis
Resveratrol (trans-3,4′,5-trihydroxystilbene), a natural polyphenol with antioxidant, anti-inflammatory, and anticancer properties, showed to induce the expression of a tumor-suppressor and anti-inflammatory microRNA(44).
Pterostilbene showed to inhibit inflammatory effects in patients with colon cancer through controlling cellular responses to cytokines(45).
Combination of CoQ10 and colorless carotenoids (phytoene and phytofluene, or to combinations of these antioxidants) treatment showed to enhance protection from inflammation and premature aging caused by sun exposure46).
Se levels were significantly decreased in cases of sub-acute and silent thyroiditis as well as in follicular and papillary thyroid carcinoma(48).
G.1. In conventional medicine perspective
Treatment of the disease is to relieve the symptoms and most of the patients show complete recovery and return of the thyroid gland to normal after 3 months as the disease rarely lead to permanent thyroid disease, although some loss of thyroid reserve may occur(49). Also, in some study thyroid suppression with thyroid hormone showed to be ineffective in preventing this disease(50).
G.2. In herbal medicine perspective
The below herbal medicine has been proven to be effective in treating inflammatory diseases
According to the study by the Shandong University, the resins of Commiphora species have emerged as a good source of the traditional medicines for the treatment of inflammation, arthritis, obesity, microbial infection, wound, pain, fractures, tumor and gastrointestinal diseases(54).
2. Desmodium gangeticum (L.) DC. and Desmodium adscendens (Sw.) DC.
Desmodium gangeticum is used as a tonic, febrifuge, digestive, anticatarrhal, antiemitic, in inflammatory conditions of chest and in various other inflammatory conditions in the Ayurvedic System of Medicine while Desmodium adscendens is widely used for the treatment of asthma in Ghana, Africa(55).
3. Senecio scandens
Senecio scandens is a medicinal plant with a climbing woody stem. Extracts and compounds isolated from Senecio scandens show a wide spectrum of pharmacological activities, including anti-inflammatory, antimicrobial and toxicological activities(56).
G.3. In traditional Chinese medicine perspective
The below TCM herbal medicine has been proven to be effective for treatment of inflammatory diseases
1. Deer antler
Deer antler base (Cervus, Lu Jiao Pan) has been recorded in the Chinese medical classics Shen Nong Ben Cao Jing 2000 years ago and has been extensively used in traditional Chinese medicine (TCM) to treat a variety of diseases including mammary hyperplasia, mastitis, uterine fibroids, malignant sores and children’s mumps. According to the study by the Dalian University of Technology, both in vitro and in vivo, deer antler base possess immunomodulatory, anti-cancer, anti-fatigue, anti-osteoporosis, anti-inflammatory, analgesic, anti-bacterial, anti-viral, anti-stress, anti-oxidant, etc.(51).
2. Brown seaweed Sargassum
According to the study by the Southern Cross University, Sargassum spp. showed to exhibit it anticancer, anti-inflammatory, antibacterial and antiviral activities in vivo and in vitro(52).
3. Callicarpa L. (Verbenaceae)
According to the study by the Second Military Medical University, isolates and crude extract containing Callicarpa species, exhibited anti-inflammatory, hemostatic, neuroprotective, anti-amnesic, antitubercular, antioxidant, antimicrobial, etc. effects in vitro and in vivo(53).
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(6) http://www.ncbi.nlm.nih.gov/pubmed/18285414(14) http://www.ncbi.nlm.nih.gov/pubmed/16284442.