Subacute Thyroiditis (de Quervain) Presenting as a Painless "Cold" Nodule
Piet C. Bartels and Robbert O. Boer St. Franciscas Hospital, Department of Nuclear Medicine, The Netherlands
A 49-yr-old woman presented with a solid, painless, nontender nodule in the left thyroid lobe. Thyroid scintigraphy revealed a solitary "cold" area in the left lobe and a slightly decreased 24-hr radioactive iodine thyroid uptake (9%). Although there were no specific clinical or biochemical signs suggesting thyroiditis needle aspiration cytology showed the presence of a subacute thyroiditis. Approximately 1 mo later the entire thyroid gland was affected leading to a completely suppressed thyroid radioiodine uptake and elevated serum thyroid hormone concentrations. This case illustrates that in the early phase of the disease, subacute thyroiditis may present as a solitary, painless, "cold" nodule and should be considered in the differential diagnosis of such lesions.
J NucÃMed 28:1488-1490,1987
X,ypical clinical symptoms and features of subacute nodule and euthyroid function without the character thyroiditis vary widely during the course of illness. In istic clinical features suggesting thyroiditis. the early stage, characteristic clinical symptoms are local pain, extreme tenderness of the gland and pain CASE REPORT frequently radiating to the ears and increasing during swallowing. Otherwise symptoms may be totally absent ("silent thyroiditis"). The gland is typically two to three A 49-yr-old clinically euthyroid woman visited our outpa tient internal medicine department in December 1984. Some times normal size and often asymmetrically enlarged months earlier, she had developed complaints of sore throat, (7). Involved parts of the gland are firm and usually pain in the anterior part of the neck, fatigue, and general extremely tender. In some cases only nodules appear. weakness after an influenza-like illness. Previously she had In ~10% of the subjects with subacute thyroiditis only been seen by an otolaryngologist, who found a painless, non- one nodule is present (2). Regional involvement of the tender nodule in the left lobe of the thyroid gland. This finding gland may change very quickly. Despite the fact that was confirmed by our own examination. We found a focal, subacute thyroiditis may appear as a focal or migrating swelling in the left lobe of the thyroid gland with a diameter of ~2 cm. The nodule was not painful on examination. condition (3,4), scintigraphy usually reveals a uniform Initially, no signs of hyperthyroidism were present and thyroid depression of activity. In cases in which the disease is hormone levels in serum were normal. Thyroid scintigraphy restricted only to a circumscribed part of the gland, the with Na'23I revealed homogeneous accumulation of radio- concomitant thyrotoxicosis will lead to suppressed pi nuclide except a solitary "cold" nodule partly involving the tuitary-thyroid function. Thyrotoxicosis results from mid-left lateral lobe (Fig. 1A). There was no thyroid enlarge leakage of thyroid hormone from the affected part of ment. The 24-hr radioactive iodine thyroid uptake was 9%. the gland. The remainder of the thyroid is then sup Needle aspiration from the nodule in the left lobe showed pressed. The 24-hr radioactive iodine thyroid uptake is findings characteristic and conclusive for subacute thyroiditis decreased or undetectable during the acute phase of the de Quervain (Cell-rich material consisting of loosely coherent disease in which thyroid hormone levels in serum are clusters of thyrocytes, some multinucleated giant cells and high. We describe a serial scintigraphically documented histocytes. Macrophages and lymphocytes were rarely ob history of a subject initially showing a single "cold" served). One month later, she had more specific complaints of thyroiditis combined with thyrotoxicosis (anterior neck pain, general weakness, reduced heat tolerance, agitation, and Received May 5, 1986; revision accepted Apr. 17, 1987. weight loss) supported by typical laboratory findings [elevated For reprints contact: Robbert O. Boer, St. Franciscus Hospital, values for ESR, Tj. T4, and FTI, alkaline phosphatase activity Dept. of NucÃ.Medicine, Boerhaavelaan 25,4708 AE Roosendaal, was 160 U/l. (normal range 20-110 U/l)]. An extremely The Netherlands.
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FIGURE 1 Scintigrams in various stages of subacute thyroiditis in this case report. A: December 19th 1984: Cold nodule in the center of the left lateral lobe. B: January 23rd 1985: No demonstrable thyroid uptake. C: June 27th 1985: Normal distribution of iodine in the thyroid gland. tender nodule in the right thyroid lobe was now present and may become low in the third phase with a compensatory the nodule previously found in the left lobe was barely pal increased secretion of TSH. However, normalization of pable. Scintigraphy (Fig. IB) showed no thyroid I2il uptake. Thy biochemical parameters is not seen before the thyroid gland is sufficiently recovered (last phase). roid specific antibodies (hemagglutination technique) against If a single nodule is found in an euthyroid subject colloid were positive and against cytoplasm slightly positive. without typical clinical symptom and/or biochemical Five months later, the patient was entirely free of symptoms and thyroid palpation was normal. All laboratory results were evidence of thyroiditis, the cause of such an unilateral within the normal range. Thyroid Scintigraphy (Fig. 1C) swelling should be further elucidated. Increased alkaline showed even distribution of radionuclide in both lobes. Mid- phosphatase activity in serum is present in ~50% of lateral in the left lobe only a small region with decreased subjects with subacute thyroiditis (14). Since alkaline concentration of activity was observed. The 24 radioiodine phosphatase is routinely measured in many laborato uptake was 36%. Based on the findings in course of time ries, it may serve as a diagnostic clue for the physician. combined with the clinical presentation, the diagnosis "sub- acute thyroiditis de Quervain" could be established. A close chronological association between the rise and fall in serum alkaline phosphatase level and serum thyroxine has been demonstrated (13). However, in our DISCUSSION patient the alkaline phosphatase was normal in the initial stage of the subacute thyroiditis. In a thyroid clinic, one is frequently confronted as in this case with The findings of moderately elevated serum thyroxine the differential diagnosis of whether a "cold" nodule is concentration, a tender enlarged thyroid, and a low radioiodine thyroid uptake are characteristic of sub- malignant or benign. In most cases it is possible to differentiate a benign from a malignant lesion in a acute thyroiditis. Unfortunately, the disorder does not "cold" nodule by examination of a needle aspiration always present in the classic way and that is why sub- acute thyroiditis may escape recognition (3,6,7). The biopsy. In the presented patient we preferred to exclude initial stage of subacute thyroiditis may be confused the diagnosis of thyroid carcinoma early; microscopic with pharyngitis (5) and other infections of the upper interpretation of the aspirate demonstrated the classic respiratory tract (5,6). In about one-third of all cases of picture of subacute thyroiditis (12). subacute thyroiditis differential diagnosis is not clear because only a less specific symptom is manifest, e.g., painless goiter, palpable nodules, thyrotoxicosis, atrial ACKNOWLEDGMENTS fibrillation, or fever of unknown origin may form the The authors thank Dr. E.P. Krenning, Dijkzigt Hospital, clinical picture (9). Rotterdam for critically reading the manuscript and Vera Volpe (10) classified the course of subacute thyroid Meeus for providing excellent secretarial assistance. itis in four stages. The first stage includes a thyrotoxic phase with a low radioactive iodine thyroid uptake. Mild thyrotoxicosis may result from release of stored REFERENCES hormone from affected thyroid tissue. 1. Levine SN. Current concepts of thyroiditis. Arch In After a brief second euthyroid phase, the serum T4 tern M ed 1983; 143:1952-1956.
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