Journal of Endocrinological Investigation

https://doi.org/10.1007/s40618-023-02286-y

ORIGINAL ARTICLE

Are sonographic characteristics of Hashimoto’s thyroiditis related

with immunologic parameters? A cross‑sectional study
K. Kenarlı1 · A. B. Bahçecioğlu2 · Ö. B. Aksu2 · S. Güllü2

Received: 9 August 2023 / Accepted: 14 December 2023

© The Author(s), under exclusive licence to Italian Society of Endocrinology (SIE) 2024

Abstract
Background The clinical, laboratory, and imaging characteristics of Hashimoto’s thyroiditis are widely recognized. However,
there is a dearth of information concerning the relationship between these aspects. The primary objective of this study was
to investigate the correlation between sonographic features and immunologic parameters in individuals with Hashimoto’s
thyroiditis.
Methods This cross-sectional study enrolled a cohort of 100 consecutive patients diagnosed with Hashimoto’s thyroidi-
tis. Ultrasonography was performed to classify thyroid gland characteristics, including parenchymal heterogeneity (mild/
moderate-to-high), extent of fibrosis (none-to-mild/moderate-to-high), and volume (atrophic/non-atrophic). As for immu-
nologic parameters, thyroid autoantibodies (TOA; anti-TPO and anti-Tg), along with IG (immunoglobulin) G4 levels and
lymphocyte subsets, were assessed.
Results Of the 100 patients evaluated, 88 were female (88%) and 12 were male (12%). IgG4/IgG ratio and weekly levo-
thyroxine (LT4) dose were significantly higher in the group with moderate-to-high heterogeneity than the group with mild
parenchymal heterogeneity (p = 0.043 and p < 0.001, respectively). Compared to the group with none-to-mild fibrosis, the
anti-TPO, IgG4, IgG4/IgG ratio and LT4 dose were significantly higher in the moderate-to-high fibrosis group. Anti-TPO
and IgG levels were significantly lower in the atrophic thyroid group compared to the non-atrophic thyroid group. Although
not reaching statistical significance, the proportion of plasma cells in the moderate/high fibrosis group was higher than in
the non-fibrosis/mild fibrosis group. There was a moderate positive correlation between fibrosis with Anti-TPO, and a low
positive correlation between anti-Tg, IgG4 levels with IgG4/IgG ratio.
Conclusion TOA, Ig G4 levels and severity of hypothyroidism were associated with ultrasonographic features such as
parenchymal heterogeneity and fibrosis in Hashimoto’s thyroiditis.

Keywords Hashimoto’s thyroiditis · Autoimmune thyroiditis · Thyroid diseases

Introduction

Hashimoto’s thyroiditis (HT) is the most common type of

* A. B. Bahçecioğlu chronic thyroiditis characterized by high serum thyroid anti-
[email protected] bodies and the presence of goiter. It is the most common
K. Kenarlı cause of goiter and hypothyroidism in populations without
[email protected] iodine deficiency [1–3]. Approximately, one in ten patients
Ö. B. Aksu with chronic autoimmune hypothyroidism has an atrophic
[email protected] thyroid gland, which may represent the last stage of thy-
S. Güllü roid insufficiency in Hashimoto’s thyroiditis. High serum
[email protected] thyroid peroxidase antibody (anti-TPO) concentrations are
encountered in 9 out of 10 HT cases, and high serum thy-
1
Department of Internal Medicine, Ankara University School roglobulin antibody (anti-Tg) concentrations are encountered
of Medicine, Ankara, Turkey
in 2–5 cases [4]. Besides volume changes, classical ultra-
2
Department of Endocrinology and Metabolism, Ankara sonographic findings of HT are heterogeneous sonographic
University School of Medicine, Ankara, Turkey

Vol.:(0123456789)
 Journal of Endocrinological Investigation

pattern, hypoechoic areas, fibrous septa, and pseudonodules immunological parameters in HT and examine whether the
[5]. Although the clinical features, autoimmune pathogenetic possible clinical, biochemical and immunologic differences
mechanisms and ultrasonographic changes of HT are well could aid characterization of disease or identification of
characterized, the data about the correlation between them subgroups.
are limited.
The relationship between thyroid ultrasonography (USG)
findings with autoantibody levels and thyroid functions in Materials and methods
HT has been known for a long time. Firstly, Sostre et al.
examined HT by dividing it into four different subgroups In this study, 100 consecutive patients with HT who applied
according to its sonographic features and it was shown that to the Endocrinology and Metabolism Outpatient Clinic of
parenchymal heterogeneity is associated with high autoan- Ankara University Faculty of Medicine, Department of
tibody levels and high frequency of hypothyroidism [6]. In Internal Diseases, between October 2019 and February
the following years, studies supporting these findings were 2020, were included. The study was approved by the Ethics
published by different authors. In addition, histopathology Committee of Ankara University (Project No: 19-1297-18)
studies have shown that HT is not a homogeneous disease and performed according to the ethical standards of the Dec-
and has different histological subtypes. Among these sub- laration of Helsinki as revised in 2013.
types, the most widely known subgroup is the ‘fibrous vari- Inclusion criteria were: being older than 18 years old,
ant of Hashimoto’s thyroiditis’ (HTFV) which accounts for having received a diagnosis of HT, and accepting to partici-
approximately 10% of HT cases [7]. Recently, Immuno- pate in the study. Exclusion criteria were: being diagnosed
globulin (Ig) G4-related thyroiditis (IgG4 RT) was defined with any form of immune deficiency, having undergone thy-
as a new variant of HT in a patient group with an excess roid surgery, receiving any medications that may alter serum
of IgG4-positive plasma cells in histopathological analysis. Ig levels (such as intravenous Ig), and having a medical his-
A significant histological similarity between IgG4 RT and tory of illness that may affect IgG4 levels (atopic dermatitis,
HTFV has been reported, and it has been stated that there pemphigus, asthma, Castleman disease).
may be common points between these two diseases. A lym- Patients’ demographic characteristics and the weekly
phoplasmacytic infiltration rich in IgG4-positive plasma dose of levothyroxine (LT4) prescribed were recorded. Thy-
cells, dense fibrosis, and pronounced follicular cell degen- roid-stimulating hormone (TSH), free triiodothyronine (fT3)
eration have been shown pathologically in IgG4 RT [8]. In free thyroxin (fT4), anti-TPO, anti-Tg, total IgG, and IgG4
subsequent clinical studies, cases of IgG4-related disease levels were measured by all patients included in the study.
(IgG4-RD) were found to demonstrate some clinical differ- Simultaneously, CD45, CD14, CD19, CD38 and CD138 lev-
ences, such as male gender predominance, low mean age, els were examined via flow-cytometry as markers of plasma
increased autoantibody level, shorter disease duration and cells and B cells.
more diffuse low echogenicity in ultrasonography [9, 10].
With these studies, evaluation of the relationship between Ultrasonographic evaluation and determination
IgG4 level and thyroiditis pathogenesis has become a popu- of study groups
lar research topic. Whether IgG4 RT is a distinct disease or
whether it represents a phase of the thyroiditis disease spec- Thyroid ultrasonography was performed in all cases and
trum remains as a controversial topic and further research images were recorded with the ESAOTE MyLab Twice
is needed [11]. ultrasound device. These recorded images were blindly
Hashimoto thyroiditis is characterized by chronic inflam- evaluated by two different experienced endocrinologists for
matory cell infiltrates which includes predominantly thyroid- parenchyma heterogeneity and fibrosis. The cases in which
specific B and T cells [12]. It is considered a T helper type no consensus was reached between the two clinicians were
1(Th1)-mediated disease. A Japanese study published in re-evaluated and a consensus was achieved. Parenchyma
2009 showed that increased peripheral Th1/Th2 ratio was echogenicity was evaluated according to the surrounding
associated with HT severity [13]. There are also studies neck muscle tissues and divided into two groups as “mild
showing that plasma cells are also involved in this autoim- heterogeneous” and “moderate-to-high heterogeneous”.
mune process [14]. However, there are not enough studies While evaluating fibrosis, a distinction was made according
questioning the relationship between inflammatory cell sub- to density of fibrotic septa in an axial view. While patients
types and USG findings in HT. with no fibrosis (with no fibrotic septa or signs of fibrosis)
The aim of this study is to examine the relationship and mild fibrosis (with 1–2 fibrotic septa) were included
between thyroid US findings and clinical, biochemical and in one group (no/mild fibrosis group), those with moderate
Journal of Endocrinological Investigation

fibrosis (with 3–10 fibrotic septa) and high fibrosis (> 10

fibrotic septa) were included in the other group (moderate/
high fibrosis group). Patients were also divided into two
groups as “atrophic” and “non-atrophic” with respect to a
4-ml limit according to thyroid volume. Ultrasonographic
axial section screenshot of different subgroups are shown
in Figs. 1, 2.

Determination of IgG and IgG4 levels

The blood sample taken from the patients was centrifuged

at 4000 rpm for 3 min and plasma was separated. Total IgG
and IgG4 levels were measured from these plasma sam-
ples in biochemistry laboratory using the Beckman Coulter
IMMAGE 800 branded device and The Binding Site SPA-
Plus IgG Kit (NK004.S) via the nephelometric method.
Reference range for total IgG was 7.51–15.60 g/L, and
0.04–0.86 g/L for IgG4).

Evaluation of flow cytometry data Fig. 2  Ultrasonographic axial section screenshot of different sub-
groups. A Mild parenchyma heterogeneity, no fibrosis. B Moderate/
high parenchyma heterogeneity, no fibrosis. C Mild parenchyma het-
Fresh blood samples taken into tubes with Ethylenediami-
erogeneity, mild fibrosis. D Moderate/high parenchyma heterogeneity,
netetraacetic Acid (EDTA) were evaluated in hematology mild fibrosis
laboratory via a Beckman Coulter Navios (3 lasers, 10
colors) brand flow cytometry device. Immunophenotyp-
ing was performed with Beckman Coulter branded CD45 CD38 (APC-Alexa Flour 750, CE-IVD) and CD138 (APC)
(Chrome Orange, CE-IVD), CD19 (ECD CE), CD14 (PE), antibodies.
Initially, CD45 positivity was utilized to isolate lympho-
cytes and plasma cells. Subsequently, CD38-positive and
CD14-negative cells were singled out to exclude monocytes.
Within the CD45-positive cell population, CD19-positive cells
were recognized as B lymphocytes. Among these B lympho-
cytes, CD38/CD138-positive cells were specifically identified
as plasma cells. Cell ratios were then calculated based on these
findings.

Statistical analysis

All analyses were performed on SPSS v21 (SPSS Inc., Chi-

cago, IL, USA). For the normality check, the Shapiro–Wilk
test was used. Data are given as mean ± standard deviation
or median (minimum–maximum) for continuous variables
according to normality of distribution, and as frequency
(percentage) for categorical variables. Normally distributed
variables were analyzed with the independent samples t-test.
Non-normally distributed variables were analyzed with the
Mann–Whitney U test. Categorical variable distributions were
evaluated using Chi-square tests or Fisher’s exact tests, con-
tinuous variables were compared using Spearman Correlation
Fig. 1  Ultrasonographic axial section screenshot of different sub- Coefficient Analyses. Two-tailed p-values of less than 0.05
groups. A Mild parenchyma heterogeneity, moderate fibrosis. B
were considered statistically significant.
Moderate/high parenchyma heterogeneity, moderate fibrosis. C Mild
parenchyma heterogeneity, high fibrosis. D Moderate/high paren-
chyma heterogeneity, high fibrosis
 Journal of Endocrinological Investigation

Results evident (p = 0.043 and p < 0.001, respectively). No statisti-

cally significant differences were observed between these
Characteristics of the study group groups in relation to other variables (p > 0.05 for all).
The patients were divided into two groups according to
Of the 100 patients evaluated in the study, 88 were female the fibrosis of the thyroid gland as low fibrosis (n = 51) and
(88%) and 12 were male (12%). The mean age upon inclu- high fibrosis (n = 49). Summary of individuals’ characteris-
sion in the study was 44.97 ± 12.62 years, whereas the tics with regard to fibrosis are shown in Table 2. Compared
mean age at the time of diagnosis was 28.94 ± 6.57 years. to the group with no/mild fibrosis, the levels of anti-TPO
Overall, mean TSH level was 3.13 ± 2.90 μIU/mL, mean (Fig. 4), IgG4, IgG4/IgG ratio and weekly LT4 dose were
fT4 level was 11.80 ± 2.67 pmol/L and mean fT3 level was significantly higher in the moderate/high fibrosis group
5.00 ± 0.75 pmol/L. The mean IgG4 level in the study popu- (p < 0.001, p = 0.029, p = 0.025 and p = 0.020, respectively).
lation was 41 ± 34 mg/dL. Only one patient had an IgG4 There was no statistically significant difference between
level above 135 mg/dL, and none of the patients had other these groups in terms of other variables (p > 0.05 for all).
organ involvement findings suggestive of IgG4 RD. The patients were divided into atrophic (n = 20) and non-
atrophic (n = 80) groups according to thyroid volume. Sum-
mary of these groups’ characteristics are shown in Table 3.
Comparison of US characteristics with clinic Compared to the non-atrophic thyroid group, the anti-TPO
and immunologic parameters and IgG levels were significantly lower in the atrophic thy-
roid group (p = 0.001 and p = 0.021, respectively).
Upon classification based on heterogeneity, the mild hetero- According to the flow cytometry results, there was no
geneity category comprised 56 patients, while the moderate- statistically significant difference between the parenchymal
to-high heterogeneity category encompassed 44 patients. A heterogeneity, fibrosis, and atrophy groups in terms of B
summary of individual characteristics concerning parenchy- lymphocyte ratio (p = 0.787, p = 0.866, p = 0.924, respec-
mal heterogeneity is provided in Table 1. In comparison to tively), parenchymal heterogeneity and atrophy groups in
the mild parenchymal heterogeneity group, the moderate-to- terms of plasma cell ratio (p = 0.112, p = 0.803, respec-
high heterogeneity group demonstrated significantly elevated tively) (Table 1). However, the ratio of plasma cells tended
IgG4/IgG ratio (as illustrated in Fig. 3) and a higher weekly to be higher in the moderate-to-severe fibrosis group than
levothyroxine (LT4) dosage, with statistical significance

Table 1  Summary of Parenchymal heterogeneity p

individuals characteristics
with regard to parenchymal Mild (n = 56) Moderate to high (n = 44)
heterogeneity of thyroid
Age (years) 45.0 (20.0–76.0) 47.0 (20.0–71.0) 0.077
Age at diagnosis (years) 28.09 ± 6.76 30.02 ± 6.23 0.145
Gender
Male 4 (7.1%) 8 (18.2%) 0.091
Female 52 (92.9%) 36 (81.8%)
TSH (μIU/mL) 2.92 ± 2.20 3.40 ± 3.61 0.721
sT4 (pmol/L) 11.55 ± 1.98 12.12 ± 3.36 0.326
sT3 (pmol/L) 4.95 ± 0.69 5.06 ± 0.81 0.472
Anti-TPO (IU/mL) 130.1 (0.9–1026.0) 206.9 (1.0–1026.0) 0.154
Anti-Tg (IU/mL) 7.2 (0.9–2419.0) 16.5 (0.9–2503.0) 0.178
IgG (g/L) 14.01 ± 3.20 12.99 ± 2.43 0.085
IgG4 (g/L) 0.36 ± 0.31 0.48 ± 0.38 0.142
IgG4/IgG 2.09 (0.35–8.72) 2.74 (0.41–9.82) 0.043
Plasma cell ratio (%) 0.63 (0.05–10.09) 0.93 (0.04–8.06) 0.112
B lymphocyte ratio (%) 12.95 (4.80–32.50) 12.27 (6.04–39.62) 0.787
Weekly LT4 dose (mcq) 400.0 (175.0–875.0) 625.0 (175.0–1050.0) < 0.001

Data are given as mean ± standard deviation or median (minimum–maximum) for continuous variables
according to normality of distribution and as frequency (percentage) for categorical variables
Ig immunglobulin, LT4 levothyroxine, sT3 free triiodothyronine, sT4 free thyroxin, tg thyroglobulin, TPO
thyroid peroxidase, TSH thyroid-stimulating hormone
Journal of Endocrinological Investigation

Fig. 3  IgG4/IgG ratio with

regard to parenchymal heteroge-
neity and fibrosis

Table 2  Summary of Fibrosis p

individuals characteristics with
regard to fibrosis of thyroid No/mild (n = 51) Moderate/high (n = 49)
gland
Age (years) 45.0 (20.0–76.0) 46.0 (20.0–71.0) 0.571
Age at diagnosis (years) 28.82 ± 6.96 2.06 ± 6.21 0.858
Gender
Male 5 (9.8%) 7 (14.3%) 0.491
Female 46 (90.2%) 42 (85.7%)
TSH (μIU/mL) 2.86 ± 2.52 3.41 ± 3.25 0.705
sT4 (pmol/L) 11.34 ± 2.12 12.28 ± 3.10 0.081
sT3 (pmol/L) 4.97 ± 0.67 5.03 ± 0.82 0.677
Anti-TPO (IU/mL) 103.2 (0.3–1026.0) 253.0 (3.4–1026.0) < 0.001
Anti-Tg (IU/mL) 6.5 (0.9–2419.0) 19.8 (0.9–2503.0) 0.105
IgG (g/L) 13.40 ± 2.58 13.74 ± 3.25 0.564
IgG4 (g/L) 0.36 ± 0.35 0.47 ± 0.34 0.029
IgG4/IgG 1.69 (0.35–8.80) 2.70 (0.44–9.82) 0.025
Plasma cell ratio (%) 0.52 (0.04–10.09) 0.98 (0.14–8.06) 0.056
B lymphocyte ratio (%) 12.68 (6.05–32.50) 12.40 (4.80–39.62) 0.866
WeeklyLT4 dose (mcq) 450.0 (175.0–875.0) 525.0 (175.0–1050.0) 0.020

Data are given as mean ± standard deviation or median (minimum–maximum) for continuous variables
according to normality of distribution and as frequency (percentage) for categorical variables
Ig immunglobulin, LT4 levothyroxine, sT3 free triiodothyronine, sT4 free thyroxin, tg thyroglobulin, TPO
thyroid peroxidase, TSH thyroid-stimulating hormone

in the mild fibrosis group (respectively, 0.52% and 0.98%, r = 0.416, respectively). There was a low positive correlation
p = 0.056) (Table 1). between TSH and thyroid volume (p = 0.025, r = 0.225). We
observed a low positive correlation between IgG4/IgG lev-
Correlation analyses els and parenchymal heterogeneity and fibrosis (p = 0.042,
r = 0.204, p = 0.029, r = 0.218, respectively) (Table 4).
Correlation analyses between US characteristics with clinic
and immunologic parameters are presented in Table 4. A mod-
erate positive correlation was found between anti-TPO with
fibrosis and thyroid volume (p < 0.01, r = 0.393, p < 0.01,
 Journal of Endocrinological Investigation

Fig. 4  Anti-TPO level with

regard to fibrosis and atrophy

Table 3  Summary of Atrophy p

individuals characteristics with
regard to atrophy Yes (n = 20) No (n = 80)

Age (years) 49.5 (33.0–71.0) 45.0 (20.0–76.0) 0.075

Age at diagnosis (years) 28.50 ± 6.61 30.70 ± 6.27 0.182
Gender
Male 2 (10.0%) 10 (12.5%) 1.000
Female 18 (80.0%) 70 (87.5%)
TSH (μIU/mL) 2.59 ± 3.98 3.27 ± 2.58 0.352
sT4 (pmol/L) 12.80 ± 2.81 11.56 ± 2.60 0.061
sT3 (pmol/L) 5.10 ± 0.45 4.98 ± 0.80 0.496
Anti-TPO (IU/mL) 74.7 (0.4–493.7) 251.3 (0.3–1026.0) 0.001
Anti-Tg (IU/mL) 9.8 (0.9–2378.5) 8.5 (0.9–2503.0) 0.848
IgG (g/L) 12.22 ± 2.34 13.90 ± 2.97 0.021
IgG4 (g/L) 0.40 ± 0.37 0.42 ± 0.34 0.548
IgG4/IgG 2.06 (0.46–8.80) 2.37 (0.35–9.80) 0.997
Plasma cell ratio (%) 0.91 (0.04–7.72) 0.74 (0.05–10.09) 0.803
B lymphocyte ratio (%) 12.22 (6.04–39.62) 12.54 (4.80–27.95) 0.924
Weekly LT4 dose (mcq) 450.0 (175.0–1050.0) 537.5 (175.0–875.0) 0.621

Data are given as mean ± standard deviation or median (minimum–maximum) for continuous variables
according to normality of distribution and as frequency (percentage) for categorical variables
Ig immunoglobulin, LT4 levothyroxine, sT3 free triiodothyronine, sT4 free thyroxin, tg thyroglobulin, TPO
thyroid peroxidase, TSH thyroid-stimulating hormone

Discussion RT), juvenile form, hashitoxicosis variant, painless (or

silent, or subacute lymphocytic) thyroiditis [28]. Among
This is the first study to show the correlation of plasma these, the ones known to have a pathogenetic relationship
IgG4/IgG level with ultrasonographic parenchymal hetero- with IgG4 are HTFV and IgG4 RT [15]. Although the
geneity in HT. An association between fibrosis in thyroid clinicopathological features that distinguish these variants
ultrasonography and an increase in IgG4/IgG ratio is found from each other have been defined, their ultrasonographic
in our study. distinguishing features are not clearly known. There is
Variants of primary HT are classic form, fibrous (or limited literature data on the USG characteristics of HT
fibrosing) variant (HTFV), IgG4-related variant (IgG4 variants, showing that IgG4-related HT is characterized by
marked parenchymal hypoechogenicity, while non-IgG4
Journal of Endocrinological Investigation

Table 4  Correlation analysis of dependent variables with individual A case series reported by Jin et al. from Korea showed
characteristics that serum IgG4 measurements would aid in the diagnosis
Parenchymal Fibrosis Thyroid volume of patients suspected of having IgG4 RT [20]. A recent
heterogeneity review by Rotondi et al. specifically focused upon IgG4-
related thyroid autoimmune disease suggests that it seems
Age (years) r 0.168 0.063 − 0.209
more appropriate to use the term thyroid disease with
p 0.095 0.532 0.037
an elevation of IgG4 instead of IgG4 RT. However, this
Age at diagnosis r 0.153 0.012 − 0.181
(years) review emphasized that the presence of elevated IgG4 lev-
p 0.128 0.902 0.071
els in patients with thyroid disease is characterized by dis-
TSH (μIU/mL) r − 0.036 0.019 0.225
tinct clinical features, such as a more pronounced presence
p 0.723 0.853 0.025
of fibrosis [15]. In our study, while only one patient had
sT4 (pmol/L) r 0.132 0.243 − 0.318
an IgG4 level above 135 mg/dL, we observed a correla-
p 0.191 0.015 0.001
tion between serum IgG4/IgG levels and ultrasonographic
sT3 (pmol/L) r 0.072 0.144 − 0.020
heterogeneity and fibrosis. Even if the serum IgG4 level
p 0.475 0.153 0.846
falls within the normal range according to the IgG4 RD
Anti-TPO (IU/mL) r 0.143 0.393 0.416
diagnostic criteria, it is believed that the serum IgG4/IgG
p 0.155 0.000 0.000
ratio is associated with the Hashimoto’s thyroiditis subtype
Anti-Tg (IU/mL) r 0.135 0.200 0.003
and its severity. In accordance with the outcomes of our
p 0.179 0.046 0.977
study and previous studies, we believe that an increase in
IgG (g/L) r − 0.157 0.008 0.182
IgG4/IgG ratio is associated with thyroid fibrosis. There-
p 0.119 0.937 0.070
fore, both the serum IgG4 levels and the IgG4/IgG ratio
IgG4 (g/L) r 0.148 0.206 0.041
may be useful when investigating HT variants.
p 0.143 0.040 0.686
No significant difference was observed between anti-
IgG4/IgG r 0.204 0.218 0.003
TPO level and parenchymal echogenicity in our study. The
p 0.042 0.029 0.979
typical sonographic finding in HT is the presence of diffuse
B lymphocyte ratio r −0.027 0.063 − 0.025
(%) hypoechogenicity and heterogeneity in most and hypoechoic
p 0.788 0.532 0.804
r 0.354 0.270 − 0.060
pseudonodular multifocal lesions in some patients [21, 22].
Weekly LT4 dose
(mcq) Greater thyroid heterogeneity and severity of lymphocytic
p 0.000 0.007 0.555
infiltration were associated with higher levels of anti-TPO
Ig immunoglobulin, LT4 levothyroxine, sT3 free triiodothyronine, sT4 [23, 24]. Since we could not show any association between
free thyroxin, tg thyroglobulin, TPO thyroid peroxidase, TSH thyroid- anti-TPO level and parenchymal echogenicity, this may be
stimulating hormone
due to the small sample size in our study.
A moderately positive correlation between anti-TPO level
thyroiditis is characterized by diffuse, coarse echogenicity and fibrosis was found in our study. The anti-TPO level was
[9, 10]. In a histopathological study conducted by Desh- particularly higher in our fibrotic cases of HT. Anti-TPO
pande et al., it was noted that the IgG4/IgG ratio and IgG antibody is present in over 80% of patients with HT and it
levels were higher in the fibrotic variant of the HT [16]. has been suggested that TPO antibodies are cytotoxic against
In a separate study by Zhang et al., a positive correlation thyroid cells and can inhibit TPO enzyme activity [25–27].
was established between the extent of fibrosis in cases of The fact that these autoantibodies are polyclonal indicates
IgG4-related disease (IgG4-RD) and the IgG4/IgG ratio in that they increase secondary to thyroid damage by T cells.
immunohistochemical analysis [5, 17]. Likewise, Li et al. Early studies supported the hypothesis that TPO antibodies
reported that IgG4 thyroiditis exhibited a higher grade play a pathogenic role in the development of autoimmune
of stromal fibrosis, lymphoplasmacytic infiltration, and thyroiditis [28]. Although there is no study demonstrating
follicular cell degeneration compared to non-IgG4 thy- a significant relationship between anti-TPO level and HT
roiditis. They also recommended measurement of serum severity, a relationship between active disease and anti-TPO
IgG4 concentration as a useful method for distinguishing level has been shown [29, 30]. Under current hypotheses,
IgG4 thyroiditis from non-IgG4 thyroiditis [9]. Although we believe that the higher anti-TPO level in fibrotic cases
there is no clear evidence with the current literature data might have been caused by the cytotoxic effect of anti-TPO
that circulating IgG4 levels reflect the presence of IgG4 on thyroid cells, and fibrosis may have developed as a result
in histopathological evaluation [18, 19] publications with of elevated anti-TPO.
similar results are accumulating that serum IgG4 levels Based on our study findings, we observed higher levels of
will help in the diagnosis of IgG4 RT and can be used as anti-TPO in the non-atrophic group compared to the atrophic
an indirect indicator of the level of parenchymal fibrosis. group. This observed relationship aligns with similar findings
 Journal of Endocrinological Investigation

reported in numerous prior studies within the literature. different ultrasonographic findings and different immuno-
Numerous investigations encompassing both pediatric and logical features. It should be kept in mind that increased
adult cohorts have consistently demonstrated a positive link serum IgG4/IgG ratio, especially with advanced parenchy-
between thyroid size and thyroid autoantibodies. Specifically, mal heterogeneity and signs of advanced fibrosis, may be
these studies indicate that thyroid antibody levels rise in indi- associated with the IgG4-RD.
viduals with goiter and enlarged thyroid glands [31–34]. It is
Acknowledgements This study was presented at the 42nd Turkish Con-
plausible to hypothesize that the fluctuations in anti-TPO levels gress of Endocrinology and Metabolic Diseases as an oral presentation.
may play a role in the pathogenesis, serving as an indicator of
the response to dispersed thyroid peroxidase (TPO) enzymes Author contributions KK: design of the work, collecting data, analysis
due to thyrocyte damage. As the gland atrophies and TPO dis- and interpretation of data, and article writing. ABB: collecting data,
conception and design of the work, writing and revising the article.
persion ceases, the antibody titer might consequently decrease. ÖBA: writing and revising the article. SG: conception and design of
In essence, our findings present two potential interpretations the work, analysis, and interpretation of data, and revising the article.
for debate: whether anti-TPO acts as a causative factor or as an
outcome, contingent upon the presence or absence of scattered Funding This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
TPO enzymes as a result of thyroid gland atrophy.
According to the flow cytometry results obtained from Data availability The data are available on request from the authors.
the peripheral serum samples of the patients, there was no
statistically significant difference between the subgroups in Declarations
plasma cell and B cell ratios. However, the ratio of plasma
Conflict of interest None of the authors have any potential conflicts of
cells in the moderate/high fibrosis group was higher than interest associated with this research.
the no/mild fibrosis group (0.98–0.52%), although it was not
statistically significant. In previous studies, IgG4+ plasma Ethical approval Ethical approval has been obtained from the ethical
cell dominance was shown in the pathology of patients with committee for human studies of Ankara University (Project Number:
19-1297-18).
IgG4-associated thyroiditis [11]. Pusztaszeri et al. also
showed the association of fibrosis and IgG4+ plasma cell Informed consent Written informed consent was obtained from all the
increase in thyroiditis cases [35]. Another study published patients before inclusion.
in 2020 showed that the presence of IgG4-positive plasma
cells histologically correlated with the degree of thyroiditis.
[14]. Our findings support the idea that the plasma cell could
be to responsible for fibrosis. References
An important limitation is that we did not examine the
thyroid characteristics of healthy controls in our study. 1. Jacobson DL, Gange SJ, Rose NR, Graham NM (1997) Epide-
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