Copyright© AE&M all rights reserved. thyroid follicles, and by proteolysis of the stored thy ofthestored follicles, andbyproteolysis thyroid ofthe tothedestruction secondary hormones thyroid thyrotropin, elevated rate of erythrocyte sedimenta elevated rateoferythrocyte thyrotropin, suppressed on clinicalsymptomsofhyperthyroidism, gland (4). the release of preformed T ofpreformed the release causedby becausesymptomsare with hyperthyroidism 178 (PT)radioiodine uptakeis (5). Inpainless thyroiditis orabsentradionuclide uptake tion, and/orreduced T ofnew which inhibittheproduction drugs, tithyroid onlyforsymptomaticpatients(3).An recommended with beta-blockers is treatment weeks) (2). Therefore, and it is self-limiting (lasting two to six perthyroidism, with other causes of hy usually mild, compared sis are Theclinicalmanifestations of thyrotoxico thyroiditis). orbe“silent” (painless (acute andsubacutethyroiditis) canmanifestasneckpain (1).Thyroiditis roglobulin D INTRODUCTION DOI: 10.1590/2359-3997000000104 on Aug/11/2015Accepted Received onJuly/28/2015 [email protected] –Porto90020-090 Alegre, RS, Brasil Professor Annes Dias,295 Misericórdia dePorto alegre Casade Irmandade daSanta deEndocrinologia Serviço Erika LauriniSouzaMeyer Correspondence to: 2 1 case report Porto Alegre, RS, Brasil. de Porto Alegre, UFCSPA, CasadeMisericórdia da Santa (UFCSPA), Porto Alegre, RS, Brasil Ciências daSaúdedePorto Alegre Alegre, Universidade Federal de Casa deMisericórdiaPorto Endocrinologia, IrmandadedaSanta Serviço deRadiologia, Irmandade Serviço Unidadede de Tireoide, Serviço 4 are not indicated in the management of patients are The diagnosis of subacute thyroiditis (SAT)The diagnosis of subacute thyroiditis is based inflammation, consequent deregulated release of inflammation, consequentderegulated ischaracterizedbythyroid thyroiditis estructive 3 and T and Rogério Friedrich Izquierdo Friedrich Rogério ultrasonography evaluation thyroid carcinoma: role ofinitial Painless thyroiditis associatedto Raisa Bressan ValentiniRaisa tion focus. thyroid noduleand/ornon-nodularhypoechoic (>1cm)orheterogeneous areaswithmicrocalcifica thyroid nodule.Further cytologicalexaminationisrecommendedincasespresentingwithsuspect ultrasound examforinitialevaluationofpainlessthyroiditis, particularly inpatientswithpalpable thyroid ultrasoundevaluationshouldbedelayeduntilclinicalrecovery. We recommendedathyroid sitory ultrasoundchanges thatobscurethecoexistenceofpapillarycarcinoma.Duetothis,initial carcinoma andlymphocytic infiltration. Subacutethyroiditis, regardless of type,mayproducetran with papillarythyroid carcinoma.Postsurgical pathologyevaluationshowedamulticentricpapillary Fine needleaspirationbiopsywasfromthisnodule;cytology taken assessedforcompatibility microcalcification focusintheheterogeneousthyroid parenquimaandcervicallymphadenopathy. thyroid noduleanultrasoundwas prescribedandtheimagesrevealedasuspiciousthyroid nodule, established byphysical examinationandlaboratoryfindings. Withthepresenceofapalpablepainless to theemergencyroomduehyperthyroidism symptomswas diagnosedwithpainlessthyroiditis was suspectedinaninitialultrasoundevaluation. first A30-yearoldfemalepatientwho was referred patient withsubacutelymphocyticthyroiditis (painlessthyroiditis) andpapillarythyroid cancerthat scribed intheliteraturearerelatedtoitsgranulomatousform(Quervain’s thyroiditis). We presenta Even thoughitisarareevent,mostassociationsofthyroid carcinomawithsubacutethyroiditis de ABSTRACT 4 from thedamaged from Arch EndocrinolMetab. 2016;60(2):178-82 1 , MussoideMacedo Bruno - - - - - 2 , Meyer Souza Erika Laurini limited to cases when a nodule is discovered bypal limited tocaseswhenanoduleisdiscovered and it is usually for the assessment of hyperthyroidism isnoviralprodrome. and there SAT,well asfrom patientsexperience nopain where Graves’ diseaseas from itisdifferent low; therefore, trasound changes maycompletelydisappear whenare cancer(10).These ul may suggestthyroid focal areas andmarkedhypoechoic,ill-defined carcinoma thyroid (9).Infact,findings inSAThypoechoic areas canmimic canexhibitfocal carcinomas nign nodulesandthyroid (8),whilebothbe disease andHashimotothyroiditis hypoechogenicityisalsofoundinGraves’ tion. Diffuse shouldallowdifferentia but theclinicalpresentation cancer, andsometypesofthyroid types ofthyroiditis and the ultrasound appearances may overlap with other notpathognomicforSATthese ultrasoundfindingsare (7).Though low flowoncolorDopplerintheseareas hypoechoecogenicity, ordiffuse borders andlackor gland,focalhypoechoiczoneswithindefinite thyroid enlargement of are especially granulomatousform, ofSAT,pation (6).Characteristicultrasoundfeatures Thyroid ultrasound (US) is not routinely indicated ultrasound(US)isnotroutinely Thyroid 1 ,

1 Arch Metab. Endocrinol 2016;60/2 ------and microcalcifications on left lobe (Figure 1).Micro onleftlobe(Figure and microcalcifications border x 1.0cmsizedsuspiciousnodule withirregular 2.0 x1.8cmisoechoicnoduleontherightlobeand1.2 ofa waspresence There with difusehypoechoicpattern. gland enlarged thyroid and demonstratedadiffusely 10-MHz transducer timelineararray out usingareal US was carried with beta-blockers. Thyroid improved 25). Medicaltherapywasinitiatedandthesymptoms denopathy was found in central neck (Figure 3). denopathy was foundincentralneck(Figure 2)wasdescribed.Suspect lympha in rightlobe(Figure area calcification focusinnon-nodular heterogeneous 440000/μL). Radioiodineuptake( countwas353000(150000- g/dL), andthrombocyte 6792 (1500-7000/μL),haemoglobin:14.6(11.4-16.4 phil: 11690(3600-11000/μL),absoluteneutrophil: 3.5(<5.0mg/L),neutro protein: mm/h), C-reactive sedimentationrate:5(0-20 35 UI/mL),erythrocyte 274(10- 230 (70-210ng/dL),anti-thyroperoxidase: T4:2.8(0.7-2.0ng/dL),T3: (0.4-4.5 μUI/mL),free <0.02(0.02-0.06μg/L), TSH:0.02 sitivity troponin (26 –140U/L),CK-MB:10(<24high-sen kinase (CK): 38 creatine showed sinus tachycardia, as follows: electrocardiogram examinations were ratory diameter of2cmwithoutlymphadenopathy. Herlabo gland with a nodule in the right lobe of the thyroid ofpainless gland.Presence ged andnon-tenderthyroid mopathy. enlar adiffusely Neckexaminationrevealed nosignsofophthalmopathyorder were ties. There oftheextremi oftremors waspresence 36.8°C. There of of120/85mmHg,andaxillatemperature pressure rateof120beats/min,ablood heart showed aregular disease.Physicalexamination ofthyroid family history norpregnancy. oriodineexposure infection, drug No ver, malaise,neckpain,antecedentupperrespiratory offe wasnohistory sweating andpalpitations.There experienced she hadlostfourkgandintermittently 2months thatintheprevious revealed dial pain.History andatypicalprecor becauseoftachycardia gency room A 30-year-old attheemer womanwasbeingtreated CASE REPORT during activephaseofdisease. cancerfirstsuspectedintheultrasoundevaluation roid thy andpapillary (painlessthyroiditis) cytic thyroiditis carcinoma. roid ultrasound findingsofPTanditsassociationwiththy mission in SAT takes place (7). Little is known about Arch Metab. Endocrinol 2016;60/2 Here, we present apatientwithsubacutelympho wepresent Here, 131 I) was1%(15------area (notconfirmed byhistologicalexamination). with microcalcificationsinperinodular area(arrows). B. Isoechoicnodular Figure 2. Transversal imageof rightlobe. (AandB)Heterogenousareas with irregularborderandmicrocalcifications(arrows). heterogeneous changesoflymphocyticthyroiditisandasuspiciousnodule Figure 1. Transversal imageofleftlobeshowsparenquimawith B A Thyroid cancerassociatedtopainlessthyroiditis 179

Copyright© AE&M all rights reserved. Copyright© AE&M all rights reserved. cytology and was compatible with papillary thyroid car thyroid cytology andwascompatiblewithpapillary amalign left noduleandcentrallymphnoderevealed 180 immunoglobulins, as well as by and thyroid-stimulating ophthalmopathy,thrill orbruit, myxedema, pretibial Graves’ diseasebythelackofathyroid from ferentiated isdif Painlessthyroiditis pain andtenderness. thyroid bytheabsenceof subacute granulomatousthyroiditis isdistinguishedfrom ves’ disease.Painlessthyroiditis andGra thyroiditis) ordeQuervain’s cute thyroiditis, suba (alsoknownasgiantcellthyroiditis, thyroiditis subacutegranulomatous from guish painlessthyroiditis todistin Itisimportant tion ratetypicallyisnormal. sedimenta of patients,buttheerythrocyte 80 percent found in antibodies (anti-TPO) are peroxidase thyroid autoimmunedisease(1).Elevatedlevelsof of thyroid ofthespectrum suggestingthatitispart thyroiditis, autoimmune of chronic a variantform It isconsidered ofallcaseshyperthyroidism. accounts foronepercent butitoccursintheabsenceof pregnancy.thyroiditis, It is clinicallyandpathologicallysimilartopostpartum (painless thyroiditis) Subacute lymphocyticthyroiditis DISCUSSION present. cancerwas thyroid nodesmetastasis ofpapillary Lymph sive lymphocyticinfiltration(Hashimoto’sthyroiditis). to 0.8cmofdiameter. ofexten waspresence There 0.2cm (four inrightlobeandoneisthmus)from lesions cm) ontheleftlobeandfivemicrocarcinoma (1.2 carcinoma thyroid tobeclassicalpapillary ported Postsurgical pathologyevaluationwasre performed. and centralnecklymphnode(levelVI)dissectionwere cinoma. Afterclinicalrecovery, atotalthyroidectomy Thyroid cancerassociatedtopainlessthyroiditis rounded lymphnodeswithmicrocalcifications(arrows). Figure 3. The fine needle aspiration biopsy taken from the The fineneedleaspirationbiopsytakenfrom Cervical level Cervical VI lymphadenopathy. Presence of enlarged and ------a loworabsentratherthanelevatedradioiodineupta thyroid carcinoma or thyroid lymphomaduetoitshy orthyroid carcinoma thyroid on therightlobewasfeltbypalpation. because anodule during theacutephaseofthyroiditis ultrasoundwasperformed case,thyroid In thispresent noduleoranabscessdue toinfection. into athyroid forexplanationssuchasacutehemorrhage to search anteriorneck paininorder ted forpatientspresenting However,­ commonlyreques ultrasoundmaybemore thyroiditis. the evaluationofpatientswithdestructive Nuclear medicineandultrasoundcanbothbeusedin lesions(16-18). diagnosisofthyroid the differential in beconsidered andshouldtherefore thyrotropin asasolitary,present palpablenodulewithsuppressed may thyroiditis dies havedemonstratedthatdestructive stu­ nodule.Previous withpalpablethyroid thyroiditis carcinoma. thecoexistenceofpapillary scure inultrasoundchangesthatob canresult thyroiditis cancer can be challenging because subacute of thyroid (12-15).Thediagnosis ofthyroiditis ulomatous form cancerisassociatedwithgran In moststudies,thyroid carcinomas. andthyroid istence ofsubacutethyroiditis (4). thyroiditis ortopostpartum pathological features withlymphocytic applied tosilent,painlessthyroiditis isnotusually “subacutethyroiditis” ke (11)Theterm in Hashimoto’s thyroiditis andGraves’sdisease(8). in Hashimoto’s thyroiditis isalsoseen hypoechoicpattern function (19).Adiffuse thyroid of normal graphic appearancewithrecovery echo toanormal dysfunction thatreverted thyroid focal, coincidingwitheach of theepisodestransient hypoechogenicity,may present ormulti eitherdiffuse thyroiditis andpostpartum nodule. Painlessthyroiditis associatedwithsuspiciousthyroid hypoechoic pattern adifuseheterogeneous (15). Ourpatientpresented ultrasound doneafterclinicalandlaboratorialrecovery thyroid focusfoundonlyatcontrol microcalcification nodule(0.9cm)with described amalignantthyroid (granulomatous thyroiditis) case of subacute thyroiditis out anunderlyingnodulardisease(13).Recently, a torule inorder tonormal valueshavereturned tory andlabora nation whenthesymptomshadresolved to get another ultrasonography exami recommended itwas lesion.Therefore, inflammatory volvement from nodularin is whatmadeitimpossibletodifferentiate hypoechoicchangeinthethyroid palpation. Diffuse on poechoic appearanceintheultrasoundandfirmness In fact, subacute thyroiditis canoccasionally mimic In fact,subacutethyroiditis atypical“silent”(painless) Our patientpresented on thecoex reported studieshaverarely Previous Arch Metab. Endocrinol 2016;60/2 ------with irregular borders and presence of microcalcifica and presence borders with irregular nodule wasfoundonleftsidebyultrasound,thatis, and ultrasound (Figure 2) was not confirmed inthehis 2) wasnotconfirmed and ultrasound (Figure nodule ontherightlobedescribedbypalpation thyroid (13).Interestingly, carcinoma thyroid of papillary the inraisingthesuspicion changes playsarole thyroiditis of the focusnotedinthebackground crocalcifications howmi reinforce Thesefindings calcification areas. micro heterogeneous diameter atthecorresponding 0.2 to 0.8 cm of lobe from mas on the right thyroid histological evaluationalsofoundfourmicrocarcino noduleonleftlobe,the inthyroid cancer discovered thyroid (13).Besidespapillary amination ofthyroiditis on the initial ultrasound ex carcinoma with papillary clues forthenodularinvolvement are in thethyroid focus withmicrocalcification areas that heterogeneous with some studies which have demonstrated agreement 2).Thisisin inthecontralaterallobe(Figure ular areas focus of microcalcification clues tocytologicalanalysis. important andare preserved malignancyare of thyroid theultrasound features tive phaseofpainlessthyroiditis thatevenintheac geneous (22).Thesedatareinforce orpoorlydefinedwhentheglandishetero be irregular likelyto more nodulemargins are except thatcancerous nodule is similar,trasound appearance of the cancerous cancer, andthyroid with Hashimotothyroiditis theul nodule.Amongpatients or vascularity of the cancerous andtype, calcificationpresence margins, halopresence, inthesize,echogenicity,cant difference composition, was nosignifi ative patients,demonstratedthatthere dase (TPO) antibody-positive to TPOantibody-neg However, studiescomparingcancersinthyroperoxi (21). withmarkedfolliculardestruction ic thyroiditis forinstance,chron thyroiditis; ofchronic be aform may indicate that silent thyroiditis histological features andthese thyroiditis have showntobeinfactchronic nodu­ thyroid asmalignant insubacutethyroiditis the mostfrequent vascularityas echogenicityandnointernal reduction ofpoordefinedmargin, centripetal that apresence diagnosisandithasbeenconsi­ for differential Some studieshavedemonstratedhelpfulUSindicators nodule. malignantthyroid of subacutethyroiditis and a considerableoverlapbetweentheultrasoundfeatures noma byhistology. Interestingly, itispossibletohave carci papillary 1)thatconfirmed tion focus(Figure Arch Metab. Endocrinol 2016;60/2 In our case, a suspicious heterogeneous thyroid thyroid In ourcase,asuspiciousheterogeneous An interestingly aspect of this case was the presence aspectofthiscasewasthe presence An interestingly les (20). Specimens of painless thyroiditis les (20).Specimensofpainlessthyroiditis in heterogeneous non-nod in heterogeneous dered dered ------concomitant thyroid cancer.concomitant thyroid tothesuspicionof ultrasound examinationwascrucial 3)through inthecentralneck(Figure crocalcification lymphadenopathywithmi cervical of round-shaped tients withthiscondition(27).Inourcaseadescription enlarged lymphnodesmaybedescribedin66%ofpa and frequent, extremely lymphadenopathiesare matory inflam quently complex(26).Insubacutethyroiditis, lymphadenopathycanbefre the diagnosisofcervical tuations, lossofhilumandperipheralvascularization, lignancy, punc such as cystic appearance, hyperechoic ofspecific characteristicsofma Even withthepresence cancer(15,24). of lymphnodeinvolvementbythyroid taneously duringthecourseofseveralmonths(23). spon canimprove the patientswithpainlessthyroiditis in observed follicular epithelialchangesofthethyroid, suchaslymphocytic infiltrationand cal abnormalities lymphocyticinfiltration(18).Infact,histologi diffuse duetofocalor noduleprobably with transientthyroid maymanifest tological evaluation. Painless thyroiditis 6. 5. 4. 3. 2. 1. REFERENCES was reported. relevant tothisarticle nopotentialconflictofinterest Disclosure: focus. microcalcification with areas non-nodular hypoechoic or heterogeneous noduleand/or withsuspectthyroid cases presenting in cytologicalexaminationisrecommended and further amongpatientswiththistypeofthyroiditis, carcinoma tention shouldbepaidtothecomplicationofpapillary at nodule. Therefore, patients withpalpablethyroid in particularly tial evaluationofpainlessthyroiditis,

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