A Literature Review of Painful Hashimoto Thyroiditis

70 Published Cases in the Past 70 Years

Carol Chiung-Hui Peng; Rachel Huai-En Chang; Majorie Pennant; Huei-Kai Huang; Kashif M. Munir


J Endo Soc. 2020;4(2) 

In This Article

Abstract and Introduction


Painful Hashimoto thyroiditis (pHT) is a rare diagnosis, and optimal treatment remains unclear. To better characterize pHT, PubMed, Embase, Scopus, and Web of Science indexes were searched for case reports or case series reporting pHT, published between 1951 and February 2019. Seventy cases reported in 24 publications were identified. Female predominance (91.4%) and a median age of 39.00 years (interquartile range, 32.50–49.75 years) were observed. Among reported cases, 50.8% had known thyroid disease (including Hashimoto thyroiditis, Graves disease, and seronegative goiters), 83.3% had positive antithyroid peroxidase antibodies, and 71.2% had antithyroglobulin antibodies. Most cases did not have preceding upper respiratory tract symptoms or leukocytosis. Ultrasound features were consistent with Hashimoto thyroiditis. Thyroid function at initial presentation was hypothyroid (35.9%), euthyroid (28.1%), or thyrotoxic (35.9%). Cases evolved into hypothyroidism (55.3%) and euthyroidism (44.7%), whereas none became hyperthyroid after medical treatment. Thyroid size usually decreased after medical treatment. Most cases were empirically treated as subacute thyroiditis with corticosteroids, levothyroxine, or nonsteroidal anti-inflammatory drugs. However, no therapy provided sustained pain resolution. In subgroup analysis, low-dose oral prednisone (<25 mg/d) and intrathyroidal corticosteroid injection showed more favorable outcomes. Total thyroidectomy yielded 100% sustained pain resolution. Diagnosis of pHT is based on clinical evidence of Hashimoto thyroiditis and recurrent thyroid pain after medical treatment. The reference standard of diagnosis is pathology. Total thyroidectomy or intrathyroidal glucocorticoid injection should be considered if low-dose oral prednisone fails to achieve pain control.


Painful Hashimoto thyroiditis (pHT) is a rare variant of Hashimoto thyroiditis (HT) that mostly affects women. It is also known as acute exacerbation of HT or painful autoimmune thyroiditis. Diagnosis of pHT is established when painful thyroid presents along with HT, which typically features an elevated serum level of thyroid antibodies (antithyroperoxidase [TPO] or antithyroglobulin [Tg]) and a firm, painless goiter.[1] According to an earlier hypothesis, capsular stretching, which results in the rapid enlargement of the thyroid and related pain, may be the cause of pHT.[2] However, this hypothesis could not be fully supported because various sizes of the thyroid gland were observed in the reported cases.[3] Patients with atrophic thyroid glands were still experiencing pain. The epidemiology and pathophysiology of pHT remain unclear given the limited data from the previous publications.

Among the differential diagnoses of pHT, subacute (or de Quervain) thyroiditis, a self-limited disease related to a postviral inflammatory process, is the most common etiology. Other causes include hemorrhagic cyst, suppurative thyroiditis, Riedel thyroiditis, infiltrative disease, trauma, or malignant tumor. The majority of patients were initially diagnosed with subacute thyroiditis. However, most patients had only temporary, partial pain relief or did not benefit from medical treatment, including the administration of corticosteroids and other analgesic medications. A significant number of reported patients experienced repeated relapses that eventually required thyroidectomy to relieve pain effectively.[3] However, the appropriate medical treatment for pHT remains unclear.

All the publications regarding pHT are either case reports or case series,[4–27] with 1 short review article[3] available to date. To the best of our knowledge, no statistical analysis for disease characteristics and treatment efficacy has been performed. Therefore, we conducted this first comprehensive review including a total of 24 articles and 70 patients from the literature that met our inclusion criteria. The reviewed publications were published between 1951 and early 2019. This study aimed to provide clinicians the basic demographics, features in clinical presentation, laboratory results, and imaging findings of pHT cases that have been reported in the past 70 years, along with treatment options.