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Questions and Answers

Which histologic feature differentiates subacute lymphocytic thyroiditis from Hashimoto thyroiditis?

  • Hürthle cell metaplasia
  • Germinal center formation (correct)
  • Lymphocytic infiltration
  • Extensive fibrosis

In granulomatous thyroiditis, multinucleate giant cells enclose pools of what substance?

  • Colloid (correct)
  • Fibronectin
  • Amyloid
  • Calcium

A patient presents with thyroid pain and transient hyperthyroidism. Which type of thyroiditis is the MOST likely diagnosis?

  • Subacute lymphocytic thyroiditis
  • Granulomatous thyroiditis (correct)
  • Hashimoto thyroiditis
  • Riedel thyroiditis

A woman develops painless hyperthyroidism two months after giving birth. Which condition is MOST likely?

<p>Postpartum thyroiditis (B)</p> Signup and view all the answers

Which of the following is a common long-term outcome of subacute lymphocytic thyroiditis?

<p>Progression to overt hypothyroidism (A)</p> Signup and view all the answers

Propylthiouracil (PTU) is used to manage hyperthyroidism because it inhibits thyroid hormone production. What additional mechanism contributes to its therapeutic effect?

<p>Inhibiting the peripheral conversion of T4 to T3 (B)</p> Signup and view all the answers

What feature is typically observed in granulomatous thyroiditis during microscopic examination?

<p>Multinucleated giant cells enclosing colloid pools (B)</p> Signup and view all the answers

A patient with a history of autoimmune disorders presents with painless goiter and transient hyperthyroidism. Which antibody is MOST likely to be elevated?

<p>Antithyroid peroxidase antibody (D)</p> Signup and view all the answers

In individuals with thyroid hyperfunction, high doses of iodide can rapidly decrease thyroid hormone release. What is the primary mechanism behind this effect?

<p>Blocking the proteolysis of thyroglobulin (D)</p> Signup and view all the answers

Calcitonin, secreted by the parafollicular cells of the thyroid gland, plays a role in calcium regulation. What is its primary action on bone tissue?

<p>Inhibits osteoclast activity, decreasing bone resorption (C)</p> Signup and view all the answers

Which of the following features is LEAST characteristic of subacute lymphocytic thyroiditis?

<p>Prominent fibrosis (D)</p> Signup and view all the answers

A patient with hyperthyroidism is being treated with propylthiouracil (PTU). What biochemical process is directly inhibited by PTU, leading to reduced thyroid hormone synthesis?

<p>The oxidation of iodide (D)</p> Signup and view all the answers

A patient presents with symptoms of hyperthyroidism. Which medication would directly block the synthesis of new thyroid hormones?

<p>Methimazole (C)</p> Signup and view all the answers

In a patient with Graves' disease (hyperthyroidism), which of the following mechanisms would be the MOST effective in immediately reducing the release of preformed thyroid hormones?

<p>Administration of a large dose of iodide to inhibit thyroglobulin proteolysis (D)</p> Signup and view all the answers

A researcher is studying the effects of a novel drug on thyroid hormone synthesis. The drug decreases the expression of genes regulated by thyroid hormone. At which point in the hypothalamus-pituitary-thyroid axis is this drug MOST likely acting?

<p>At the level of target tissues, interfering with thyroid hormone receptors (C)</p> Signup and view all the answers

What is the primary mechanism by which radioactive iodine helps to treat hyperthyroidism?

<p>Causing ablation of thyroid tissue over time (B)</p> Signup and view all the answers

Which of the following processes is NOT directly involved in thyroid hormone production within the thyroid gland?

<p>Peripheral conversion of T4 to T3 (A)</p> Signup and view all the answers

A patient with a thyroid disorder has elevated levels of both T3 and T4, but normal TSH levels. Which of the following could explain this?

<p>The patient has developed resistance to thyroid hormones at the target tissue level. (D)</p> Signup and view all the answers

A patient is diagnosed with autoimmune hypothyroidism. Which of the following is the most likely underlying cause?

<p>Hashimoto thyroiditis (C)</p> Signup and view all the answers

Following thyroid surgery, a patient experiences tingling in their fingers and muscle cramps. Lab results show hypocalcemia. Which of the following is the MOST likely explanation?

<p>Inadvertent removal or damage to the parathyroid glands. (C)</p> Signup and view all the answers

A patient has elevated levels of anti-thyroglobulin and antithyroid peroxidase antibodies but no symptoms. What condition is the MOST likely to develop?

<p>Hashimoto's thyroiditis (B)</p> Signup and view all the answers

A newborn is diagnosed with thyroid hypoplasia? Which of the following is the most likely cause?

<p>Germline mutations (A)</p> Signup and view all the answers

Which of the following mechanisms is NOT directly involved in thyroid cell death in Hashimoto's thyroiditis?

<p>Neutrophil extracellular traps (NETs) formation (A)</p> Signup and view all the answers

Which medication would be MOST effective in rapidly alleviating the symptoms of hyperthyroidism related to increased adrenergic tone?

<p>Propranolol (C)</p> Signup and view all the answers

Radioactive iodine is contraindicated with?

<p>Pregnant women. (B)</p> Signup and view all the answers

The development of Hashimoto's thyroiditis involves a breakdown in peripheral tolerance to thyroid autoantigens. What is the PRIMARY consequence of this breakdown?

<p>Autoimmune destruction of thyroid cells (D)</p> Signup and view all the answers

How do genetic factors such as polymorphisms in CTLA4, PTPN22, and IL2RA contribute to the pathogenesis of Hashimoto's thyroiditis?

<p>By disrupting the regulation of T-cell responses (D)</p> Signup and view all the answers

In Hashimoto's thyroiditis, what is the fate of the thyroid parenchyma as the disease progresses?

<p>It is replaced by lymphocytic infiltrates and fibrosis. (B)</p> Signup and view all the answers

If a patient is diagnosed with Hashimoto's thyroiditis and also has a family history of type 1 diabetes (T1D), which genetic factor might contribute to both conditions?

<p>Polymorphisms in CTLA4, PTPN22 or IL2RA (B)</p> Signup and view all the answers

Histological analysis of a thyroid biopsy from a patient with suspected Hashimoto's thyroiditis is performed. Which of the following findings would be MOST indicative of this condition?

<p>Dense lymphocytic infiltrate with germinal centers and Hürthle cells (C)</p> Signup and view all the answers

A researcher is investigating the cytokine profile within the thyroid gland of a patient with Hashimoto's thyroiditis. Which cytokine is MOST likely to be elevated, contributing to the inflammatory process?

<p>Interferon-γ (IFN-γ) (D)</p> Signup and view all the answers

Which of the following best describes the role of CD8+ cytotoxic T cells in the pathogenesis of Hashimoto's thyroiditis?

<p>They directly kill thyroid follicular cells, contributing to thyroid tissue destruction. (C)</p> Signup and view all the answers

A patient presents with a hard, fixed thyroid mass. This clinical presentation most closely mimics which condition?

<p>Thyroid carcinoma (C)</p> Signup and view all the answers

What is the typical duration of the initial hyperthyroid phase in transient thyroiditis if untreated?

<p>2 to 6 weeks (A)</p> Signup and view all the answers

Which antibody is most commonly associated with Graves disease, found in approximately 90% of patients?

<p>Thyroid-stimulating immunoglobulin (TSI) (B)</p> Signup and view all the answers

In contrast to hyperthyroidism caused by Graves disease, what happens to radioactive iodine uptake in transient thyroiditis?

<p>Radioactive iodine uptake is diminished (A)</p> Signup and view all the answers

Riedel thyroiditis is associated with fibrosis and tissue infiltration by plasma cells producing which immunoglobulin?

<p>IgG4 (C)</p> Signup and view all the answers

What is the typical age range in which transient thyroiditis most commonly occurs?

<p>40 to 50 years (B)</p> Signup and view all the answers

Which of the following genetic factors is associated with both Graves' disease and Hashimoto's thyroiditis?

<p>Polymorphisms in immune-function genes like CTLA4 (D)</p> Signup and view all the answers

What is the concordance rate of Graves disease in monozygotic twins compared to dizygotic twins?

<p>Monozygotic twins have a concordance rate of 30% to 40%, while dizygotic twins have less than 5% (A)</p> Signup and view all the answers

In the context of Hashimoto thyroiditis, what characterizes the initial phase of transient thyrotoxicosis (hashitoxicosis)?

<p>Elevated levels of free T4 and T3, diminished TSH, and decreased radioactive iodine uptake. (C)</p> Signup and view all the answers

Individuals with Hashimoto thyroiditis have an elevated risk for developing which of the following conditions?

<p>Both endocrine (e.g., type 1 diabetes) and non-endocrine (e.g., systemic lupus erythematosus) autoimmune diseases. (A)</p> Signup and view all the answers

How does the pathogenesis of Hashimoto thyroiditis differ from other autoimmune diseases, according to the presented model?

<p>Hashimoto thyroiditis is virus-initiated and not self-perpetuating, while other autoimmune diseases are. (C)</p> Signup and view all the answers

What macroscopic feature is typically observed in the thyroid gland affected by Hashimoto thyroiditis?

<p>A gland that is unilaterally or bilaterally enlarged and firm, with an intact capsule that may adhere to surrounding structures. (C)</p> Signup and view all the answers

Upon histological examination in the early stages of Hashimoto thyroiditis, what cellular characteristic is most likely to be observed?

<p>Scattered follicles disrupted and replaced by neutrophils forming microabscesses. (A)</p> Signup and view all the answers

Consider a patient presenting with symptoms suggestive of thyroid dysfunction following a bout of mumps. Which of the following findings would most strongly suggest the presence of Hashimoto thyroiditis triggered by the viral infection?

<p>Elevated T4 and T3 levels, decreased TSH, and decreased radioactive iodine update. (C)</p> Signup and view all the answers

A researcher is investigating the immune mechanisms underlying Hashimoto thyroiditis. If their hypothesis is correct that cytotoxic T-lymphocytes (CTLs) cause damage to thyroid follicle cells. Which of the following findings would provide the strongest support for this hypothesis?

<p>Elevated expression of MHC class I molecules on thyroid follicle cells alongside CTL infiltration. (D)</p> Signup and view all the answers

A patient with Hashimoto thyroiditis is found to have a firm, yellow-white area within their thyroid gland during a routine ultrasound. Histological examination reveals a monoclonal population of B-cells. This finding most strongly suggests the presence of which of the following complications?

<p>Extranodal marginal zone B-cell lymphoma. (D)</p> Signup and view all the answers

Flashcards

Propylthiouracil

Blocks thyroid hormone production by inhibiting iodide oxidation and T4 to T3 conversion.

Large doses of Iodide

Inhibits the proteolysis of thyroglobulin, blocking the RELEASE of thyroid hormones.

Parafollicular cells (C cells)

Synthesize and secrete calcitonin.

Calcitonin Function

Promotes calcium absorption by the skeletal system and inhibits bone resorption.

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Thyroid Hormone Secretion

Controlled by tropic hormones secreted by the hypothalamus and anterior pituitary.

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Hyperthyroidism

Excessive release of thyroid hormones.

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Thyroid Diseases

Conditions associated with excessive release of thyroid hormones

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C Cells

The thyroid gland follicles also contain a population of parafollicular cells, or C cells

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Increased Thyrocytes

Diffuse increase in thyroid cells.

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Organification of Iodine

Covalent binding of iodine to tyrosine residues in thyroglobulin.

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T3 and T4 Formation

Process of thyroid hormone creation from T3 and T4.

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β-blocker

Medication to control hyperthyroidism symptoms from increased adrenergic tone.

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Thionamide

Medication that blocks new thyroid hormone synthesis.

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Iodine Solution

Blocks the RELEASE of thyroid hormone.

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T4 to T3 Conversion Inhibitors

Inhibits peripheral conversion of T4 to T3.

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Hashimoto Thyroiditis

Autoimmune hypothyroidism, thyroid is typically enlarged.

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Peripheral Tolerance Breakdown

Failure of the body to recognize thyroid antigens as 'self'.

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Thyroid Autoimmune Destruction

Autoimmune destruction of thyroid cells by T cells, cytokines, or antibodies.

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CTLA4, PTPN22, IL2RA

Genes encoding regulators of T-cell responses.

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Autoimmune Disease Overlap

Conditions like Graves' disease and type 1 diabetes that share genetic links related to immune tolerance.

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Common Autoimmune Theme

Immune tolerance breakdown is a common underlying cause.

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Thyroid Cell Depletion

Gradual loss of thyroid cells due to immune attack.

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Lymphocytic Infiltration & Fibrosis

Lymphocytes invade and replace thyroid tissue, leading to scarring.

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Mechanisms of Thyroid Cell Death

CD8+ T cells, cytokines, and antibodies.

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Painless Thyroiditis

Subacute lymphocytic thyroiditis, an autoimmune condition, often presents with transient hyperthyroidism or painless goiter.

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Antibodies in Painless Thyroiditis

Antithyroid peroxidase antibodies are frequently found in patients with this condition.

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Histology of Painless Thyroiditis

Lymphocytic infiltration with germinal centers, follicle disruption, but without prominent fibrosis or Hürthle cells.

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Painless Thyroiditis Progression

A significant portion of cases progress to overt hypothyroidism within a decade.

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Granulomatous Thyroiditis

Also known as De Quervain thyroiditis, it features granulomatous inflammation.

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Granulomatous Thyroiditis Histology

Aggregates of lymphocytes, activated macrophages, plasma cells, multinucleate giant cells enclosing colloid.

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Symptoms of Granulomatous Thyroiditis

Variable gland enlargement and thyroid pain; the most common cause of thyroid pain.

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Effects of Granulomatous Thyroiditis

Inflammation of the thyroid and hyperthyroidism.

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Hashitoxicosis

A transient hyperthyroid phase in Hashimoto's thyroiditis due to follicle disruption and hormone release.

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Hashitoxicosis Hormone Levels

Elevated free T4 and T3, diminished TSH, and decreased radioactive iodine uptake during hashitoxicosis.

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Hypothyroid Hormone Levels

Falling T4 and T3 levels, accompanied by an increase in TSH.

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Hashimoto's Associated Autoimmune Diseases

Increased likelihood of developing type 1 diabetes, SLE and Sjögren syndrome.

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Hashimoto's Thyroid Gland Appearance

The gland may be unilaterally or bilaterally enlarged and firm

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Hashimoto's Cut Section Appearance

Firm and yellow-white areas contrasting with normal thyroid tissue.

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Hashimoto's Histologic Changes (Early)

Neutrophils replacing disrupted follicles forming microabscesses.

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Riedel Thyroiditis

A rare thyroid disorder with extensive fibrosis, potentially simulating thyroid carcinoma.

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Thyroid-Stimulating Immunoglobulin (TSI)

Antibody that binds to the TSH receptor, mimicking TSH and stimulating thyroid hormone release.

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Thyroiditis

Inflammation of the thyroid resulting in transient hyperthyroidism, often with diminished radioactive iodine uptake.

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Hyperthyroid Phase (Thyroiditis)

The phase following thyroiditis where thyroid hormone levels are high and TSH levels are low.

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Recovery Phase (Thyroiditis)

The period after the hyperthyroid phase in thyroiditis, where thyroid function returns to normal.

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TSH Receptor Blocking Antibodies

Antibodies that block the TSH receptor, leading to hypothyroidism in some Graves' disease patients.

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TSI Mechanism

Mimics TSH actions, stimulating adenyl cyclase.

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Graves Disease

A subtype of auto-immune thyroid disease that is associated with polymorphisms in immune-function genes.

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Study Notes

  • The thyroid gland has two lobes connected by a thin isthmus
  • The isthmus is usually located below and anterior to the larynx
  • Embryologically, it develops from an evagination of the pharyngeal epithelium
  • This evagination descends from the foramen cecum at the base of the tongue to the anterior neck
  • Ectopic thyroid tissue can be present at the base of the tongue (lingual thyroid) or other high neck sites due to this descent pattern
  • Thin fibrous septae divide the thyroid into lobules
  • Lobules consist of 20-40 follicles, lined by cuboidal to low columnar epithelium and filled with PAS-positive thyroglobulin

Role of TSH

  • TSH (thyrotropin) is released into circulation by thyrotrophs in the anterior pituitary in response to hypothalamic factors
  • Thyroid follicular epithelial cells activate their TSH receptor, associating with a G protein upon TSH binding
  • The G protein activation triggers downstream events, increasing intracellular cAMP levels
  • Increased cAMP stimulates thyroid growth, hormone synthesis, and release via cAMP-dependent protein kinases

Production of T3 and T4

  • Thyroglobulin is converted into thyroxine (T4) and smaller amounts of triiodothyronine (T3) by thyroid follicular epithelial cells
  • Released T4 and T3 enter systemic circulation and bind to plasma proteins like thyroxine-binding globulin and transthyretin reversibly
  • Serum unbound ("free") T3 and T4 concentrations are maintained within narrow limits by the binding proteins
  • Most free T4 gets deiodinated into T3 in the periphery
  • Nuclear thyroid hormone receptors in target cells bind to T3 with tenfold greater affinity and proportionately greater activity
  • A multiprotein hormone-receptor complex results from thyroid hormone binding to its nuclear receptor (TR)
  • Thyroid hormone response elements (TREs) near target genes are assembled by the hormone-receptor complex, increasing transcription

Effects of Thyroid Hormones

  • Thyroid hormone has diverse cellular effects
  • These include stimulating carbohydrate and lipid catabolism and protein synthesis in a wide range of cells
  • An increase in the basal metabolic rate is the net result of thyroid hormone production
  • Critical role in brain development in the fetus and neonate

Goitrogens

  • Chemical agents known as goitrogens can inhibit thyroid gland function
  • TSH levels increase, causing hyperplastic gland enlargement (goiter) due to suppressed T3 and T4 synthesis

Medication

  • Oxidation of iodide is inhibited and thyroid hormone production is blocked by the antithyroid agent propylthiouracil
  • Furthermore, propylthiouracil inhibits the peripheral deiodination of circulating T4 into T3, limiting thyroid hormone excess symptoms
  • The release of thyroid hormones is blocked by large iodide doses by inhibiting thyroglobulin proteolysis in individuals with thyroid hyperfunction
  • Thyroid hormone is synthesized and incorporated into colloid but not released into the blood

C cells

  • The thyroid gland follicles also have a population of parafollicular cells, or C cells
  • Calcitonin, a hormone that promotes calcium absorption by the skeletal system and inhibits bone resorption by osteoclasts is synthesized and secreted by C cells

Thyroid Diseases

  • Conditions such as hyperthyroidism (excess release of thyroid hormones), hypothyroidism (thyroid hormone deficiency), and mass lesions can affect the thyroid
  • Clinical consequences of disturbed thyroid function are considered first, followed by the disorders that generate those problems

Hyperthyroidism

  • Thyrotoxicosis is a hypermetabolic state caused by elevated circulating levels of free T3 and T4
  • Hyperthyroidism is often used to refer to thyrotoxicosis because it is frequently caused by hyperfunction of the thyroid gland

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