하시모토 갑상선염? TPO항체음성; 자가면역 갑상선염에서 관찰되는 두드러진 림프절

30대 여자 환자, 초진

갑상선 상담위해 내원

3년전 결절이 0.4 cm

기쿠치로 1년간? 증상... 조직학적 진단도 받았다고 하며...

당시 anti-Ro/ssA 항체는 양성이었으나 임상적 진단은 아니었다고 하며..

https://blog.naver.com/ejercicio/222224254870

갑상선 관련 항체중 anti-TG (thyroglobulin) 항체 양성, anti-TPO 항체는 음성의 결과를 보여주어 확인함

1년전 검진시 갑상선의 질이 안좋다? 라고 듣고 정기 평가를 권유받았다고 하며..

요즘 피곤한데 상기 배경을 고려 추적검사 위해 내원

초음파 모습은 실질의 불균질성이 관찰되니 갑상선 실질 질환이 의심되는데... 하시모토갑상선염 같은 자가면역 갑상선염

갑상선 아래쪽 림프절 이외에 갑상선의 중앙 높이까지 기관지를 따라 작은 림프절들이 관찰된다. paratracheal

왼쪽 갑상선 뒤쪽 식도의 외측으로, 처음엔 부갑상선인가 하였으니 뒤쪽 표면에 있는 낭종으로 보면 되겠다.

좌측 갑상선 아래쪽으로 림프절이 두드러진다. ~1.3 cm

우측도 마찬가지, 우측은 기관지를 따라 두번째 사진과 같이 림프절들이 여럿이 보인다.

초음파적으로 갑상선 실질질환의 모습이며 갑상선 기능 및 anti-TPO항체 혈액검사 확인 예정

두드러진 림프절의 모습도 자가면역갑상선 질환의 맥락으로 생각됨, 추적의 기간 설정

D323005HZ	Free T4 (ECLIA)	1.18	0.92-1.68 ng/dL	-
D325001HZ	TSH (ECLIA)	1.58	0.27-4.20 μIU/mL	-
D321204HZ	Anti Microsome (TPO) Ab	9.00 이하	≤ 34.00 IU/mL	-

There are many thyroid-related antibodies that target specific proteins within or around the thyroid follicular cells, including thyroid peroxidase (TPO), thyroid-stimulating hormone (TSH) receptor, Tg, and, rarely, carbonic anhydrase 2, megalin, triiodothyronine, thyroxine, sodium iodide symporter (NIS), and pendrin [7]. Thyroid-related antibodies are usually related to thyroid autoimmune diseases: TPO antibodies (TPOAb) and TgAb indicate Hashimoto’s thyroiditis (HT), and TSH receptor antibodies indicate Graves’ disease (GD).

Clinical implications of anti-thyroglobulin antibody measurement before surgery in thyroid cancer - PMC (nih.gov )

Most patients with Hashimoto’s thyroiditis have measurable antibodies in the blood, with ~90% of patients having positive TPO antibodies and ~50% of patients having positive thyroglobulin antibodies. TPO항체는 90%에서 양성, TG항체는 50%에서 양성 About 5 % of patients with a diagnosis of Hashimoto’s thyroiditis based on clinical grounds or by ultrasound appearance have no measurable thyroid antibodies. 5%정도는 모든 항체 음성이므로 임상적 모습이나 초음파 소견만으로 진단

Patients with Hashimoto’s thyroiditis and negative thyroid antibodies have a milder form of the disease

...

This lymphadenopathy is typically found in neck levels II–IV and VI.3 Paratracheal lymph nodes may be involved in Hashimoto’s thyroiditis.4 하시모토 갑상선염에서 림프절병이 특징적으로 II-IV, VI 구역에서 관찰되곤 한다. The lymphadenopathy locations reported correlate well with the lymphatic drainage of the thyroid gland, suggesting that lymphatic drainage is likely involved in the pathogenesis of lymphadenopathy in Hashimoto’s disease. Specifically, nodes in neck levels III, IV, V, and VI collect lymph from the thyroid gland.5

The affected lymph nodes in Hashimoto’s disease often demonstrate reactive lymphoid hyperplasia.3 Kikuchi-Fujimoto disease is a benign disease with a likely autoimmune etiology that has rarely been associated with Hashimoto’s disease. However, it was unlikely in our patient due to the absence of fever or tender cervical lymph nodes.6 Other causes of cervical lymphadenopathy such as infection (Epstein-Barr virus and Bartonella henselae) and malignancy also need to be ruled out. The clinical resolution of the cervical lymphadenopathy during follow-up in our patient was reassuring. In one study, 9 months of treatment with 100 μg of levothyroxine with 30 mg of prednisone tapered therapy significantly decreased cervical lymphadenopathy.7 The role of steroids in this setting remains to be clarified.

https://pmc.ncbi.nlm.nih.gov/articles/PMC6541063/#:~:text=This%20lymphadenopathy%20is%20typically%20found,levels%20II%E2%80%93IV%20and%20VI.&text=Paratracheal%20lymph%20nodes%20may%20be%20involved%20in%20Hashimoto's%20thyroiditis.&text=The%20lymphadenopathy%20locations%20reported%20correlate,lymph%20from%20the%20thyroid%20gland.&text=The%20affected%20lymph%20nodes%20in%20Hashimoto's%20disease%20often%20demonstrate%20reactive%20lymphoid%20hyperplasia.&text=Kikuchi%2DFujimoto%20disease%20is%20a,or%20tender%20cervical%20lymph%20nodes.&text=Other%20causes%20of%20cervical%20lymphadenopathy,therapy%20significantly%20decreased%20cervical%20lymphadenopathy.&text=The%20role%20of%20steroids%20in%20this%20setting%20remains%20to%20be%20clarified .

이건 갑상선염 환자에서 기쿠치가 겹친 상황; 발열과 함께 압통이 있는 촉지되는 목의 림프절

https://onlinelibrary.wiley.com/doi/10.1155/2012/267595#:~:text=Hashimoto's%20thyroiditis%20is%20an%20autoimmune,associated%20to%20other%20autoimmune%20conditions .

Cervical lymphadenopathy is common in patients with autoimmune thyroiditis and supposed to be pathognomic for the disease if found in the paratracheal compartment (Robbins level VI). 자가면역 갑상선염에서 경부 림프절병은 흔한데... 특히나 기관지 주변 (6번구획) 에서 발견되면 특징적이라고 여겨진다.

https://medwinpublishers.com/article-description.php?artId=678#:~:text=Abstract.%20Cervical%20lymphadenopathy%20is%20common%20in%20patients,cervical%20lymph%20node%20compartments%20in%20order%20to