今日の臨床サポート

亜急性甲状腺炎

著者: 西川光重 神甲会 隈病院

監修: 平田結喜緒 公益財団法人 兵庫県予防医学協会 健康ライフプラザ

著者校正/監修レビュー済:2021/02/10
参考ガイドライン:
  1. 日本甲状腺学会亜急性甲状腺炎(急性期)の診断ガイドライン
  1. 米国甲状腺学会(ATA):甲状腺中毒症の診断と治療ガイドライン2016(2016 American Thyroid Association Guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis)
患者向け説明資料

概要・推奨   

  1. 疼痛などの症状を有する亜急性甲状腺炎患者は、禁忌がなければステロイド薬で治療する。症状の軽い場合は非ステロイド抗炎症薬(NSAIDs)で治療しても良い。中等~高度の甲状腺中毒症症状のある患者にはβ遮断薬を併用する(推奨度2)
  1. 日本人亜急性甲状腺炎には副腎皮質ステロイド薬(プレドニゾロン(プレドニン) 初期量 15mg)が奏効する(推奨度2)。
  1. ステロイド群とNSAIDs群を比較すると、疾患持続期間はステロイド群が短いが、甲状腺機能低下症期間、FT4頂値、TSH最高値には差がない
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
西川光重 : 特に申告事項無し[2021年]
監修:平田結喜緒 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、本文と概要・推奨等の変更を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 亜急性甲状腺炎は、有痛性甲状腺腫と、甲状腺濾胞の破壊による一過性甲状腺中毒症を特徴とする疾患である。
  1. 急性期には痛みや発熱が強い疾患であるが、基本的には、数カ月で治癒する疾患である。通常、甲状腺中毒症期から一過性の甲状腺機能低下症期を経過して、数カ月で甲状腺機能は自然に改善するが、まれに永続性の甲状腺機能低下症を来すことがある。
 
  1. トルコでの亜急性甲状腺炎患者に関する臨床的報告(O)(参考文献:[1]
  1. 1987年から2001年の176例の患者を後ろ向きに検討した。平均年齢34.0歳。痛みは女性の97%、男性の100%にみられた。46%に高熱があり、赤沈は平均43mm/時であった。Tg抗体は20%、TPO抗体は4%で陽性であった。再発率は女性で約14%、男性で約11%にみられ、NSAIDs治療群とステロイド治療群で差はなかった。
  1. 追記:トルコ、特にAegean地方は甲状腺疾患の多いところとされている。この地の中心的病院であるEge大学病院1施設での亜急性甲状腺炎患者の特徴を検討した。
 
  1. 日本での多数の亜急性甲状腺炎患者の治療前臨床像に関する報告(O)(参考文献:[2]
  1. 亜急性甲状腺炎の治療前臨床的特徴を1施設での852人の患者を対象に後方視的に検討した。患者は40~50歳の女性に多く、発症に夏から秋に多い有意の季節変動がみられた。平均13.6カ年周期での再発が1.6%にみられた。28%で38℃以上の発熱があり、典型的甲状腺機能亢進症症状は60%以上にみられた。治療前、甲状腺中毒症、炎症所見、肝障害は発症1週間以内にピークがあった。甲状腺エコーでは、片葉の痛みを訴える患者の半数に甲状腺両葉の低エコー域が認められた。両側低エコー域の頻度は発症2カ月後に上昇する傾向にあった。
  1. 追記:多数の日本人亜急性甲状腺炎患者の臨床像を報告した。亜急性甲状腺炎の甲状腺機能異常と炎症は発症1週間でピークとなると考えられる。
 
  1. ミネソタのコミュニティでの亜急性甲状腺炎患者に関する報告(O)(参考文献:[3]
  1. 1960年から1997年の160人を研究した。亜急性甲状腺炎発症率は4.9人/10万人/年であった。痛みは96%にみられ、6~21年後に4%が再発。ステロイドは36%に投与された。早期の甲状腺機能低下症はステロイドあり(29%)なし(37%)両方でみられた。最終経過観察で、甲状腺機能低下症はステロイドあり(25%)はステロイドなし(10%)より有意に多かった(全体の甲状腺機能低下症比率は15%)。初期一過性甲状腺機能低下症はよくみられたが、永続性低下症はあまりなく、28年経過観察で15%のみがT4服用中であった。ステロイドで症状の改善はみられるが、早期・晩期の甲状腺機能低下症は防げない。
  1. 追記:ミネソタ州オルムステッド郡(2000年の国勢調査で人口12万人余)でのコミュニティ研究である。
病歴・診察のポイント  
  1. 急性上気道炎などの感染症の前駆症状をしばしば認める。その後、前頚部、側頚部から耳部にかけての痛みを訴える。

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文献 

著者: N Erdem, M Erdogan, M Ozbek, M Karadeniz, S Cetinkalp, A Gokhan Ozgen, F Saygili, C Yilmaz, M Tuzun, T Kabalak
雑誌名: J Endocrinol Invest. 2007 Jul-Aug;30(7):546-50.
Abstract/Text BACKGROUND: Turkey is an endemic area for thyroid diseases. The Aegean region is well documented for increased prevalence of thyroid disorders. In this study we investigated the demographic and clinical features of subacute thyroiditis (SAT) patients who had been diagnosed and treated in Ege University.
METHODS: The hospital files of patients admitted to the endocrinology clinic of Ege University between January 1987 and December 2001 were retrospectively evaluated. Patients who had been diagnosed as having any thyroid disorder were determined.
RESULTS: 176 fulfilled diagnostic criteria for SAT. The majority of patients with SAT were diagnosed as having subacute granulomatous thyroiditis (169/176) (134 females, 35 males, mean age 34.0+/-17.8 yr); 69% of the patients were between 30-50 yr of age. Thyroid pain was present in 97.1% of female patients, and in 100% of male patients. High fever was evident in 78 patients (46.2%). Mean erythrocyte sedimentation rate (ESR) was 43.42+/-39.68 mm/h. Anti-thyroglobulin antibody was positive in 20%, and anti-thyroid peroxydase antibody was positive in 4% of patients. Among patients who were treated with non-steroidal anti-inflammatory drugs (NSAD) 10 female patients (10.6%), and 3 male patients (12%) developed recurrence of the disease. Among patients who were treated with prednisolone 7 female patients (17.5%), and one male patient (10%) developed recurrence. There was no significant difference regarding the recurrence rates between patients who were treated with NSAD and patients who were treated with prednisolone.
CONCLUSION: With the exception of ESR, demographic, clinical, laboratory, and imaging findings and prognoses of our patients were comparable to the previous reports.

PMID 17848836  J Endocrinol Invest. 2007 Jul-Aug;30(7):546-50.
著者: Eijun Nishihara, Hidemi Ohye, Nobuyuki Amino, Kazuna Takata, Takeshi Arishima, Takumi Kudo, Mitsuru Ito, Sumihisa Kubota, Shuji Fukata, Akira Miyauchi
雑誌名: Intern Med. 2008;47(8):725-9. Epub 2008 Apr 16.
Abstract/Text OBJECTIVE: Subacute thyroiditis (SAT) is a transient inflammatory disease of the thyroid. We evaluated the clinical characteristics based on laboratory and imaging studies in patients with SAT before treatment.
PATIENTS: We reviewed the medical records of 852 patients (107 men and 745 women) with SAT who visited our thyroid clinic at Kuma Hospital from 1996 through 2004.
RESULTS: SAT developed most often in female patients aged 40 to 50 years, with significant seasonal clusters during summer to early autumn. While the rates of any virus infections and diseases did not differ from those in the general population, recurrent episodes of SAT at intervals of 13.6+/-5.6 years accounted for 1.6% of all cases. At the onset of SAT, 28.2% of patients had temperatures greater than 38 degrees C and typical symptoms associated with thyrotoxicosis developed in more than 60% of patients. Before treatment, most of the abnormal laboratory findings associated with thyrotoxicosis, inflammation, and liver dysfunction reached peak levels within 1 week after onset. Ultrasound examination showed that half of the patients with unilateral thyroid pain presented with bilateral hypoechogenic area in the thyroid and the rate of bilateral hypoechogenic area tended to increase 2 months after onset.
CONCLUSION: Laboratory studies of thyroid dysfunction and inflammation related to SAT presented peak levels within 1 week after onset.

PMID 18421188  Intern Med. 2008;47(8):725-9. Epub 2008 Apr 16.
著者: Vahab Fatourechi, Jaroslaw P Aniszewski, Guiti Z Eghbali Fatourechi, Elizabeth J Atkinson, Steven J Jacobsen
雑誌名: J Clin Endocrinol Metab. 2003 May;88(5):2100-5. doi: 10.1210/jc.2002-021799.
Abstract/Text Subacute thyroiditis (SAT), or granulomatous thyroiditis, is an inflammatory thyroid condition associated with pain and systemic symptoms. Few community studies are available. We studied the 160 patients with SAT in Olmsted County, Minnesota, seen between January 1, 1960, and December 30, 1997. Subjects were identified through the medical diagnostic index of the Rochester Epidemiology Project. The overall age- and sex-adjusted incidence from 1960 through 1997 was 4.9 cases per 100,000/yr. In the most recent 28-yr period (1970-1997), 94 patients were identified. In this group, pain was the presenting symptom in 96%. SAT recurred in 4% of the patients 6-21 yr after the initial episode. Corticosteroid therapy was given to 36%. Early-onset hypothyroidism occurred both in patients receiving corticosteroid therapy (29%) and in those not receiving corticosteroid therapy (37%). At latest follow-up, significantly more patients who had received corticosteroid therapy had a diagnosis of hypothyroidism than the group without corticosteroid therapy (25% vs. 10%, P < 0.05; overall rate of hypothyroidism, 15%). Early transient hypothyroidism is common in SAT. Permanent hypothyroidism is less common, and only 15% of the patients are receiving T(4) therapy after 28 yr of follow-up. Symptomatic relief is achieved with corticosteroid therapy, but such therapy does not prevent early- and late-onset thyroid dysfunction.

PMID 12727961  J Clin Endocrinol Metab. 2003 May;88(5):2100-5. doi: 10・・・
著者: Sumihisa Kubota, Eijun Nishihara, Takumi Kudo, Mitsuru Ito, Nobuyuki Amino, Akira Miyauchi
雑誌名: Thyroid. 2013 Mar;23(3):269-72. doi: 10.1089/thy.2012.0459.
Abstract/Text BACKGROUND: Oral glucocorticoids are administered in moderate and severe cases of subacute thyroiditis (SAT), providing dramatic relief from pain and fever. However, there have been no reports regarding the optimal dose of prednisolone (PSL) for treatment of SAT. In this study, we used 15 mg/day of PSL as the initial dosage and tapered it by 5 mg every 2 weeks. We assessed the effectiveness of this treatment protocol.
METHODS: We examined 384 consecutive and untreated patients with SAT who visited our thyroid clinic between February 2005 and December 2008. We excluded patients who did not fit our protocol, and the final number of subjects was 219. When patients complained of pain in their neck or C-reactive protein (CRP) was still high, physicians were able to extend the tapering of the dose of PSL or increase it at 2-week intervals. The endpoint of the study was the duration of the PSL medication. We also compared the severity of thyrotoxicosis and rate of hypothyroidism after SAT between the short medication group (patients who recovered within 6 weeks) and long medication group (patients who recovered in 12 weeks or more).
RESULTS: The number of patients whose thyroiditis improved within 6 weeks and did not recur was 113 (51.6%), and 61 (27.9%) improved within 7 to 8 weeks and did not have a recurrence. The longest duration was 40 weeks. Seven patients (3.2%) needed increases in the dosage of PSL. Thyroid hormone (free thyroxine and free triiodothyronine) levels measured at the initial visit in the short medication group were significantly higher than those in the long medication group (p<0.05). Serum CRP, male-to-female ratio, body weight, and age showed no differences between the two groups. There were no differences in the rate of hypothyroidism after SAT between the two groups (p=0.0632).
CONCLUSIONS: The treatment protocol that we employed had 15 mg/day of PSL as the initial dosage for the treatment of SAT, with tapering by 5 mg every 2 weeks, and was effective and safe for Japanese patients. However, 20% of patients with SAT needed longer than 8 weeks to recover from the inflammation.

PMID 23227861  Thyroid. 2013 Mar;23(3):269-72. doi: 10.1089/thy.2012.0・・・
著者: Douglas S Ross, Henry B Burch, David S Cooper, M Carol Greenlee, Peter Laurberg, Ana Luiza Maia, Scott A Rivkees, Mary Samuels, Julie Ann Sosa, Marius N Stan, Martin A Walter
雑誌名: Thyroid. 2016 Oct;26(10):1343-1421. doi: 10.1089/thy.2016.0229.
Abstract/Text BACKGROUND: Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition.
METHODS: The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group.
RESULTS: Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded.
CONCLUSIONS: One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

PMID 27521067  Thyroid. 2016 Oct;26(10):1343-1421. doi: 10.1089/thy.20・・・
著者: C A Benbassat, D Olchovsky, G Tsvetov, I Shimon
雑誌名: J Endocrinol Invest. 2007 Sep;30(8):631-5. doi: 10.1007/BF03347442.
Abstract/Text OBJECTIVE: To identify predictive factors of clinical outcome of subacute thyroiditis.
DESIGN: Retrospective case series of 56 consecutive patients treated in 3 outpatient clinics between 1999 and 2005. Medical records were reviewed for demographic data, seasonal disease distribution, laboratory and clinical course, treatment, and short-term outcome.
MAIN OUTCOME: Mean age was 48.6+/-12 yr; 70% were females. Twenty-five percent had antithyroid antibodies and 9% had recurrent disease. Differences in occurrence by season were not significant (p=0.28). Ultrasound, performed in 35 patients, revealed thyroid nodules in 25 (median size, 17 mm). Ten patients received no treatment, and 43 received either non-steroidal anti-inflammatory drugs (NSAID) (no.=25) or glucocorticoids (no.=18); data for 3 patients were missing. Median disease duration was 77 days; mean peak free T4 (FT4) level was 43.7+/-25.3 pmol/l. A hypothyroid phase was documented in 31 patients, and remained permanent in 6. Peak FT4 level, but not erythrocyte sedimentation rate or clinical score, was positively correlated with the highest TSH level and with disease duration. Untreated patients had less severe clinical disease than treated patients, but a similar outcome. Patients given glucocorticoids had a shorter overall disease duration (p=0.03), with no differences in duration of hyperthyroidism, peak FT4 or highest TSH levels, compared with patients given NSAID.
CONCLUSION: Subacute thyroiditis follows an unpredictable clinical course that is hardly affected by its clinical features or treatment.

PMID 17923793  J Endocrinol Invest. 2007 Sep;30(8):631-5. doi: 10.1007・・・

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