A Case of IgG4 Hashimoto’s Thyroiditis Requiring Surgical Management

We report a case of IgG4 Hashimoto’s thyroiditis in a woman presenting with a painful neck and hypothyroidism. She was intolerant of first line therapy with steroids and required a total thyroidectomy for resolution of symptoms. Challenges exist surrounding the diagnosis and treatment of IgG-Related diseases (IgG-RD) of the thyroid gland. There are no current diagnostic criteria. Early diagnosis leads to proper treatment and relief of symptoms. Glucocorticoids remain the main therapeutic approach however, surgery may be required.

Case Description:

This is a 49-year old female who presented with a painful neck in the setting of newly diagnosed hypothyroidism. Laboratory results showed a TSH 76.050 uIU/mL (normal 0.3-5.8 uLu/mL), Free T4 0.53 ng/dL (normal 0.7-1.5 ng/dL). Thyroglobulin antibody greater than 2,200 IU/mL (normal 0.0-4.0 IU/mL) , Thyroid peroxidase antibodies was 908.9 IU/mL (normal 0.0-9.0 IU/mL) . Core needle biopsy was performed, which ruled out lymphoma and pathology was positive for crush lymphoid infiltrate and plasma cells, between dense collagen fibers and scant thyroid follicles. IgG4 staining was strongly positive. She was treated with NSAIDS as she failed a trial of glucocorticoids previously but due to persistent compressive symptoms she underwent a total thyroidectomy.

Discussion:

This case highlights the challenges surrounding the diagnosis and treatment of IgG-RD of the thyroid gland. No diagnostic criteria exists for the diagnosis of IgG4 related thyroiditis and early diagnosis is vital for proper treatment and relief of symptoms. As IgG4-related diseases often show good response to steroid therapy, presumably IgG4-related thyroiditis may as well. Glucocorticoids remain the main therapeutic approach, however surgery may be required. IgG4 Hashimoto’s thyroiditis is a rare presentation of thyroiditis and prompt recognition is necessary for proper treatment