Chronic Lymphocytic Thyroiditis (Hashimoto thyroiditis)

The patient's clinical history is consistent with Chronic Lymphocytic Thyroiditis or Hashimoto’s thyroiditis (those are synonyms), with “subclinical” hypothyroidism. This is a common condition caused by the immune system mistaking the thyroid gland for a foreign body and therefore attacking it. While this sounds ominous, the only significant result is thyroid dysfunction which can be mild, as in this case, or profound. In this case, a legitimate attempt at replacing thyroid function with thyroid hormone in pills has resulted in multiple symptoms, some of which are suggestive of excessive thyroid hormone levels. However, the question of whether actual overdose has occurred cannot be answered with the data at hand, as a TSH level taken during the treatment with Eutirox 100 has not been provided. In any case I will answer the well formulated questions as precisely as possible.

1) What is the diagnosis on the basis of the examinations carried out? If it’s not possible to place a sure diagnosis, what diagnosis do you think is more probable?
Both the ultrasound description and the antibody tests and the thyroid dysfunction clearly indicate that the diagnosis is Hashimoto’s thyroiditis as detailed above.

2) Further necessary medical tests are advised? In the event of affirmative answer, which medical tests do you advise and why?
The diagnosis is well established and I do not think additional tests are necessary, especially if the symptoms observed during the treatment with Eutirox 100 have now resolved.

3) What therapy do you suggest? In particular, does a substitute for Eutirox exist in order to avoid aforesaid side effects when reaching the daily dosage of 100 mcg or higher? Speaking of this, which is your opinion on Novothyral and the possibility to use it in this patient's case?
In most cases of subclinical hypothyroidism, treatment with levothyroxine (for example Eutirox) alone is sufficient. Thyroid hormone therapy is a very benign treatment, in which the administered chemical compound is simply a “replacement” for a chemical that is natural to the body, not really a drug. Of course excessive doses can result in symptoms of hyperthyroidism, but most people tolerate the medication exceptionally well.
In this case, given the mildness of the hypothyroidism, a dose of 50 mcg daily should be sufficient to correct the abnormality, without causing overdose. However, should the patient not tolerate thyroxine at all (which would be unlikely), one could consider no treatment. Several studies have addressed the long term effect of subclinical hypothyroidism, when it is not treated. Some of these studies have suggested that some parameters of cardiovascular health such as lipid levels and signs of endothelial dysfunction may be altered in subclinical hypothyroidism. However results have been inconsistent. Moreover, there is no study suggesting increased cardiovascular mortality or increased risk for cardiovascular event (such as myocardial infarction and strokes). As a consequence, treatment of subclinical hypothyroidism is not considered mandatory. Novothyral contains the same active compound as Eutirox (thyroxine also known as T4) plus a more potent form of thyroid hormone (tri-iodothyronine aka T3). Since the patient had side effects from T4, the addition of T3 would only be expected to make her symptoms worse, so I do not recommend it.

4) The possible therapy with Eutirox or other drug is to be followed all life long? Speaking of this, do you think that the suspension of Levothyroxine 10 years ago can be responsible for the current worsening of the hypothyroidism clinical picture?
Hypothyroidism from Hashimoto’s thyroiditis tends to be irreversible, so, if it is decided that treatment is to be given, then yes, it is for life. I do not believe that stopping the medication 10 yrs ago had any influence on the current status of the patient.

5) Prognosis?
The prognosis of hypothyroidism is excellent as appropriate replacement with thyroid hormone is expected to result in normal life, both in terms of duration and quality. Similar prediction can be made if treatment is not selected and the thyroid dysfunction remains mild. However, in many cases of Hashimoto’s thyroiditis, subclinical (mild) hypothyroidism will progress with time to a more severe form of thyroid hormone deficiency (overt hypothyroidism), which will require treatment. This process is thought to be independent of whether thyroid hormone replacement is started early or not, but of course if the patient is already on thyroid hormone at the time when the thyroid becomes completely atrophied, then there will be no clinical consequences.
In terms of my recommendations for this patient, this is what I suggest:
a) Start treatment with Eutirox 50. If this is well tolerated and the TSH returns to normal, then the goals are achieved.
b) If Eutirox 50 is not tolerated, then one can consider half tablet per day (25 mcg), or no treatment, with the idea that if hypothyroidism becomes more severe, then the same steps will have to be tried again.
c) If Eutirox 50 is well tolerated, but TSH does not return to normal, then a dose of 75 mcg (one and one half 50 mcg tabletor one 75 mcg tablet, I do not know whether Eutirox comes in the 75 mcg strength) can be tried.