Introduction
Hashimoto’s thyroiditis (HT) is a chronic inflammatory autoimmune disorder associated with producing antithyroid antibodies.1,2 It is the most common cause of hypothyroidism in iodine-sufficient regions.3,4 It is often underdiagnosed in its early stages due to the nonspecific nature of symptoms.5,6 The disease has a strong autoimmune origin, with a high prevalence of antithyroid peroxidase (TPO) and antithyroglobulin (TG) antibodies.3,7
The previous studies have reported that the thyroid autoimmune disease is prevalent in women compared to men,8,9 non-alcoholic liver disease is prevalent among males compared to females with subclinical hypothyroidism.10 This highlights that the thyroid autoimmune conditions are most common in females while fatty liver associated disorders are commonly reported in males. However, the HT is prevalent in females,11 our case was a male middle aged. The unique features include that the case had presented typical subclinical symptoms with difficulty diagnosing the case.
In Arab communities, vitamin D deficiency is common due to several factors including limited exposure sun, dietary insufficiency, and cultural clothing practices.12 Recent studies have shown a significant link between vitamin D deficiency and occurrence of autoimmune thyroiditis, indicating that vitamin D plays a role in controlling immune system and thyroid function.9,13 In our case, the coincidence of vitamin D deficiency may have contributed to the occurrence of autoimmune thyroiditis.
As presented in recent systematic review investigated the local symptoms of HT, highlighted the gap in research on the HT, and indicated the early symptoms reported were thyroid discomfort, dysphagia, neck pain and throat discomfort.14 These reviews highlight the importance of early detection of the condition before further deterioration to late stages. In the light of previous knowledge, we presented this case study of HT in an attempt to define the clinical features and any potent association of with other autoimmune conditions.
Case Description
A middle-aged male with a positive family history of undiagnosed autoimmune conditions was presented in this case study. The case complains of overweight, fatty liver, high lipid profile and allergy for unknown reasons for three years. Antihistamine and anti-lipid medications were prescribed for previous year with no significant improvement.
Recently he presented with low back pain, persistent fatigue, gastrointestinal disturbances, chronic allergic symptoms (sinusitis, itching), anxiety and cognitive fog.
As shown in Table 1 the case of HT with subclinical hypothyroidism was diagnosed by positive anti-TPO and thyroid ultrasound associated with vitamin D deficiency and mild systemic inflammation (elevated CRP, ESR), and positive h. pylori, additionally with coexisting ANA positivity (AC-4/5 pattern) indicating possible poly autoimmunity.Table 1Laboratory Investigations of the Case of HTTestResultReference RangeTSH, Serum8.89 μIU/mL0.55–4.78Free T40.75 ng/dL0.54–1.24Free T33.53 pg/mL2.3–4.2Anti-TPO Antibodies273 IU/mL<35Anti-TG Antibodies34 IU/mL<40ANA (AC-4,5, Speckled)1:80 (weak positive)<1:80Vitamin D15.02 ng/mLDeficiency <20CRP4.9 mg/LUp to 5ESR20 mm/hrUp to 15Thyroid ultrasoundThyroiditis with slight enlargementNormalStool for h. pyloriPositive (29 ng/mL)Negative <20
The thyroid ultrasound was conducted for this case to confirm the diagnosis and to be the baseline for frequent follow up. As shown in Figure 1, the case has thyroiditis with slight enlargement. It also indicates that the case is active and the deterioration of thyroid function has been detected.Figure 1Thyroid ultrasound for as case of HT.
It shows a case of thyroiditis with slight enlargement.
Management and Follow-Up
The patient was then started on a gluten-free, anti-inflammatory, elimination diet specific for autoimmune and histamine intolerance. He also was advised to start levothyroxine 50 microgram tablets as early morning. The monitoring of the thyroid function should be done every 6–8 weeks to measure the progress of the condition.
Initially the treatment was to address H. pylori infection with gastroenterologist consultation with a combination of metronidazole, tetracycline hydrochloride, bismuth subcitrate potassium and Xanprazan 20mg. The treating doctor also prescribed a vitamin D supplementation (50,000 IU weekly for 8 weeks), selenium 200 microgram daily for three months in addition to other supplements including zinc, vitamin b complex and ferrus sulphate.
Discussion
In this case, there were markedly elevation of anti‑TPO level (273 IU/mL), and TSH (8.89 μIU/mL), and associated with borderline anti‑Tg (34 IU/mL), is criteria for diagnosis of a case of HT. In more than 90% of patients exhibit anti‑TPO positivity in case of autoimmune thyroiditis.15 The pattern of elevated TSH (8.89 μIU/mL) with low‑normal Free T4 suggests a stage of subclinical hypothyroidism, consistent with typical characteristics in Hashimoto’s conditions.
Despite normal Free T3 (3.53 pg/mL), immunoassay testing of free hormones can overestimate levels, particularly at lower concentrations. This highlights the significance of using TSH level as the most sensitive screening tool and monitoring for Hashimoto’s cases and indicates that tissue-level thyroid activity may already be inadequate. The diagnosis of HT was usually done by high level of TSH and Anti-TPO in addition to alteration in thyroid using thyroid ultrasound.3
The vitamin D level of our patient of 15 ng/mL (deficient) aligns with previous findings linking vitamin D deficiency to HT.9,12,13,16 A systematic review on the association between vitamin D deficiency and HT had indicated that vitamin D deficiency could increase the risk of developing of HT.13 In addition to the association, vitamin D deficiency was found in other autoimmune conditions.16 Although autoimmunity is significantly linked with deficiency of vitamin D,16 a systematic review of randomized controlled trials have yielded that vitamin D supplementation is not significantly associated with improvement in thyroid hormones and TSH levels.17
In the Arab communities, specifically in Saudi Arabia, United Arab Emirates and Yemen, several studies have been conducted, they reported a high prevalence of vitamin D deficiency,18–21 which may play an essential role in the development of autoimmune diseases, including HT. Vitamin D also linked to autoimmune thyroiditis, influencing the thyroid and autoimmune functions.8,13,16,22,23 A previous review has reported that patients with HT have significantly lower levels of vitamin D compared to people with normal vitamin D levels, highlighting its role in developing HT.24–26
Levothyroxine therapy may decrease anti‑TPO antibody titers in long-term, although the restoration is complete in only a minority of patients. With the modest level of antibody while still in early-stage hypothyroidism, it seems appropriate to keep an eye on such and expect a gradual decline with treatment. Previous studies have shown that autoantibodies declines with levothyroxine long term treatment,27 and with selenium supplementation.28 This underscores the role of thyroid hormones and nutritional supplementations are essential for treating autoimmune thyroiditis.
The findings reported in this case were consistent with literature and represent the importance of early detection and appropriate management of autoimmune conditions. Generalizability may be less as this case was a male whereas HT is prevalent among females, another limitation was that this case was observed for short period of time, a need for follow up report to assess the long-term effect of early interventions with vitamin D, zinc, and selenium supplements with levothyroxine in minimizing thyroid antibodies.
Conclusion
This case of male HT illustrates the diagnostic difficulty in detecting TH from other conditions of hypothyroidism in men and underscores the importance of a routine comprehensive metabolic and hormonal assessment of middle age population. The improvement in subclinical symptoms and laboratory investigations after starting vitamin D supplementation with thyroid hormone replacement further highlights the relationship between vitamin D deficiency and thyroid autoimmune diseases. The case highlights that males could also have a risk of developing HT.