Riedel Thyroiditis Clinical Presentation

  • Author: Chris K Guerin, MD, FACE; Chief Editor: George T Griffing, MD   more...
 
Updated: Feb 16, 2012
 

History and Physical Examination

Riedel thyroiditis (RT) is characterized by the replacement of normal thyroid parenchyma with dense fibrotic tissue and by the extension of this fibrosis to adjacent structures of the neck. Most patients are euthyroid, but hypothyroidism is noted in approximately 30% of cases. Rarely, hyperthyroidism can occur, but this is probably secondary to a coexisting condition.

Clinical features of RT closely resemble those of anaplastic carcinoma of the thyroid. Patients note a nonpainful, rapidly growing thyroid mass.

Patients typically present with a hard, fixed, painless goiter. The character of the thyroid gland is often described as stony or woody. The onset of the goiter may be sudden, but it is usually gradual.

Local compressive symptoms are frequent and can include the following:

  • Neck tightness or pressure
  • Dyspnea
  • Dysphagia
  • Hoarseness
  • Choking
  • Cough

Such symptoms are the result of the increasing thyroid mass or are due to the extension of the fibrotic process to adjacent neck structures (eg, strap muscles, trachea, esophagus, recurrent laryngeal nerve).

Hypoparathyroidism is rare and presumably reflects fibrotic involvement of the parathyroid glands. Recurrent laryngeal nerve paralysis is also uncommon, but it can be observed in extensive disease.[7]

Approximately one third of patients with RT have an associated extracervical manifestation of multifocal fibrosclerosis. These manifestations can include the following[6] :

  • Retroperitoneal fibrosis
  • Mediastinal fibrosis
  • Orbital pseudotumor
  • Pulmonary fibrosis
  • Sclerosing cholangitis
  • Lacrimal gland fibrosis
  • Fibrosing parotitis
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Contributor Information and Disclosures
Author

Chris K Guerin, MD, FACE  Director, Diabetes Education Services, Chief, Division of Endocrinology, Tri-City Medical Center; Assistant Clinical Professor of Medicine, University of California, San Diego School of Medicine

Chris K Guerin, MD, FACE is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Society of Hypertension, Endocrine Society, and National Lipid Association

Disclosure: Nothing to disclose.

Coauthor(s)

John Boone, MD  Consulting Staff, Department of Otolaryngology, Naval Hospital Oak Harbor

John Boone, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Stephanie L Lee, MD, PhD Associate Professor, Department of Medicine, Boston University School of Medicine; Director of Thyroid Health Center, Associate Chief, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center; Fellow, Association of Clinical Endocrinology

Stephanie L Lee, MD, PhD is a member of the following medical societies: American College of Endocrinology, American Thyroid Association, and Endocrine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Kent Wehmeier, MD Professor, Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, St Louis University School of Medicine

Kent Wehmeier, MD is a member of the following medical societies: American Society of Hypertension, Endocrine Society, and International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

References

  1. Riedel BM. Die chronische, zur Bildung eisenharter Tumoren fuhrende Entzundung der Schilddruse. Verh Dtsch Ges Chir. 1896;25:101-5.

  2. Schwaegerle SM, Bauer TW, Esselstyn CB Jr. Riedel's thyroiditis. Am J Clin Pathol. Dec 1988;90(6):715-22. [Medline].

  3. Fatourechi MM, Hay ID, McIver B, Sebo TJ, Fatourechi V. Invasive fibrous thyroiditis (riedel thyroiditis): the mayo clinic experience, 1976-2008. Thyroid. Jul 2011;21(7):765-72. [Medline].

  4. Divatia M, Kim SA, Ro JY. IgG4-related sclerosing disease, an emerging entity: a review of a multi-system disease. Yonsei Med J. Jan 2012;53(1):15-34. [Medline]. [Full Text].

  5. Dahlgren M, Khosroshahi A, Nielsen GP, Deshpande V, Stone JH. Riedel's thyroiditis and multifocal fibrosclerosis are part of the IgG4-related systemic disease spectrum. Arthritis Care Res (Hoboken). Sep 2010;62(9):1312-8. [Medline].

  6. Oguz KK, Kiratli H, Oguz O, et al. Multifocal fibrosclerosis: a new case report and review of the literature. Eur Radiol. May 2002;12(5):1134-8. [Medline].

  7. Hennessey JV. Clinical review: Riedel's thyroiditis: a clinical review. J Clin Endocrinol Metab. Oct 2011;96(10):3031-41. [Medline].

  8. Perimenis P, Marcelli S, Leteurtre E, et al. [Riedel's thyroiditis: current aspects]. Presse Med. Jun 2008;37(6 Pt 2):1015-21. [Medline].

  9. Li Y, Nishihara E, Kakudo K. Hashimoto's thyroiditis: old concepts and new insights. Curr Opin Rheumatol. Jan 2011;23(1):102-7. [Medline].

  10. Morselli-Labate AM, Pezzilli R. Usefulness of serum IgG4 in the diagnosis and follow up of autoimmune pancreatitis: A systematic literature review and meta-analysis. J Gastroenterol Hepatol. Jan 2009;24(1):15-36. [Medline].

  11. Khosroshahi A, Stone JR, Pratt DS, Deshpande V, Stone JH. Painless jaundice with serial multi-organ dysfunction. Lancet. Apr 25 2009;373(9673):1494. [Medline].

  12. Drieskens O, Blockmans D, Van den Bruel A, et al. Riedel's thyroiditis and retroperitoneal fibrosis in multifocal fibrosclerosis: positron emission tomographic findings. Clin Nucl Med. Jun 2002;27(6):413-5. [Medline].

  13. Kotilainen P, Airas L, Kojo T, et al. Positron emission tomography as an aid in the diagnosis and follow-up of Riedel's thyroiditis. Eur J Intern Med. 2004;15:186-9.

  14. Beahrs OH, McConahey WM, Woolner LB. Invasive fibrous thyroiditis (Riedel's struma). J Clin Endocrinol Metab. Feb 1957;17(2):201-20. [Medline].

  15. Lorenz K, Gimm O, Holzhausen HJ, et al. Riedel's thyroiditis: impact and strategy of a challenging surgery. Langenbecks Arch Surg. Jul 2007;392(4):405-12. [Medline].

  16. Lo JC, Loh KC, Rubin AL, et al. Riedel's thyroiditis presenting with hypothyroidism and hypoparathyroidism: dramatic response to glucocorticoid and thyroxine therapy. Clin Endocrinol (Oxf). Jun 1998;48(6):815-8. [Medline].

  17. Vaidya B, Harris PE, Barrett P, et al. Corticosteroid therapy in Riedel's thyroiditis. Postgrad Med J. Dec 1997;73(866):817-9. [Medline].

  18. Few J, Thompson NW, Angelos P, et al. Riedel's thyroiditis: treatment with tamoxifen. Surgery. Dec 1996;120(6):993-8; discussion 998-9. [Medline].

  19. De M, Jaap A, Dempster J. Tamoxifen therapy in steroid resistant Reidel's thyroiditis. Scott Med J. Apr 2001;46(2):56-7. [Medline].

  20. Jung YJ, Schaub CR, Rhoades R, et al. A case of Riedel's thyroiditis treated with tamoxifen: another successful outcome. Endocr Pract. 2004;10(6):483-6.

  21. Pritchyk K, Newkirk K, Garlich P, et al. Tamoxifen therapy for Riedel's thyroiditis. Laryngoscope. Oct 2004;114(10):1758-60. [Medline].

  22. Levy JM, Hasney CP, Friedlander PL, Kandil E, Occhipinti EA, Kahn MJ. Combined mycophenolate mofetil and prednisone therapy in tamoxifen- and prednisone-resistant Reidel's thyroiditis. Thyroid. Jan 2010;20(1):105-7. [Medline].

  23. Khosroshahi A, Stone JH. A clinical overview of IgG4-related systemic disease. Curr Opin Rheumatol. Jan 2011;23(1):57-66. [Medline].

 
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Gross pathology of Riedel thyroiditis. The cut edge is avascular, with a characteristic white color. Image courtesy of SL Lee.
Riedel thyroiditis. The atrophic thyroid follicles are surrounded by a dense, inflammatory infiltrate composed of lymphocytes, plasma cells, and eosinophils and accompanied by dense fibrosis. The wide bands of keloid-type collagen located between the individual follicles and surrounding clusters are a common feature of this condition.
Riedel thyroiditis. This vein shows infiltration of its wall by a heavy, inflammatory infiltrate.
Riedel thyroiditis. The inflammatory infiltrate and dense, pink bands of fibrosis can obliterate thyroid follicles. Image courtesy of SL Lee.
 
 
 
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