Beginning of July 2019. The patient presents.

Woman, '30s, in December 2018 spontaneous birth. Primipara.
TSH-reflex controls during pregnancy: 1.9 µU/ml first trimester; 2.1 second trimester; 2.5 µU/ml third trimester (TSH n.v. 0.25-4.40 µU/ml); anti-thyreoglobulin antibody and anti-thyeoperoxidase antibody titre measurement: not performed. Thyroid ultrasound: not performed.

June 2019: the patient feels neck tension, fatigue, widespread muscular pain. TSH 60.9 µU/ml (n.v. 0.25-4.40); free T3 2.2 pg / ml (n.v. 2.0-4.4); free T4 3.85 ng/ml (n.v. 9.0-17.0); antiTPO 119 IU/ml (n.v.<34); anti-Tg 136 IU/ml (n.v.<34); TrAb 0.1 IU/L (n.v. woman, negative: <0.4, doubtful: 0.5 - 1.1; positive: ≥ 1.2). CPK 843 IU L (n.v woman: 30 - 150 IU / L); Aldolase 243 IU / L (n.v. woman 1,3 - 8,2 U / l. Conclusions: severe postpartum hypothyroidism and rhabdomyolysis.

Thyroid ultrasound: gland in place, of increased volume, diffusely hypoechoic and inhomogeneous echostructure, vascular flows strongly increased with "hell thyroid" type pattern. Elastosonography: rigid gland. Absent nodular lesions. Conclusion: postpartum autoimmune thyroiditis, with glandular hypertrophy and hypervascularization. This last feature is unusual for the classic chronic autoimmune thyroiditis with Hashimoto's so-called hypothyroidism. It is likely that the marked and sudden increase in post-partum TSH has sustained the hypertrophy of the thyroid gland parenchyma and the observed vascular hyper-flow.

Therapy: L-thyroxine 75 µg / day 1 tab in the morning on an empty stomach.

Ultrasound images. 1 July 2019. Postpartum autoimmune chronic thyroiditis with "thyroid inferno"

19 August 2019. After 6 weeks of thyroxine therapy 75 µg/day

Clear improvement in subjectivity. Muscle pains disappeared, fatigue disappeared and tension in the neck. TSH 1.30 µU ml (v.n. 0.25-4.40); free T3 4.2 pg / ml (n.v. 2.0-4.4); free T4 15.85 ng/ml (n.v. 9.0-17.0). CPK 143 IU/L (n.v. woman: 30 - 150 IU/L); Aldolase 4.3 IU/L (n.v. woman: 1.3 - 8.2 U/L).

Thyroid ultrasound: gland in place, reduced volume compared to the previous survey, confirmed the diffusely hypoechoic and inhomogeneous echostructure, vascular flows returned to normal. Elastosonography: rigid gland. After normalization of TSH levels, thanks to treatment with thyroxine and to the favorable spontaneous course, any ultrasound, biohumoral and clinical alteration has disappeared.

Therapy: l-thyroxine continues 75 µg / day. TSH-reflex control 60 days apart.

Ultrasound images. 20 August 2019.

Postpartum autoimmune chronic thyroiditis with "thyroid inferno", treated with L-thyroxine

Dr. Roberto Valcavi

Endocrinologia - Malattie della Tiroide

P. IVA 02641010356

Centro Palmer Srl

Via Fratelli Cervi, 75/b

42124 Reggio Emilia RE, Italy


Roberto Valcavi
Centro Palmer


+39 0522 792400

+39 0522 307856

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