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The Subacute Thyroiditis, Since Its First Description by De Quervain (1904), Has Been Reported Under Many Synonyms

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The Subacute Thyroiditis, Since Its First Description by De Quervain (1904), Has Been Reported Under Many Synonyms Endocrinol. Japon. 1964, 11 (2), 119～138 STUDIES ON SUBACUTE THYROIDITIS SHOZO SAITO Department of Radiology, School of Medicine, Gunma University, Maebashi The subacute thyroiditis, since its first description by de Quervain (1904), has been reported under many synonyms. Terms given with reference to the histo- logic features of this disease include "pseudotuberculous thyroiditis", "granulo- matous thyroiditis", "gaint-cell thyroiditis", "de Quervain's thyroiditis", "struma granulomatosa" or "struma fibrosa, giant cell variant". The clinical findings have given rise to such names as" acute and subacute nonsuppurative thyroiditis", "acute noninfectious thyroiditis"and"subacute thyroiditis" . In recent writings, the disease is most commonly referred to as subacute thyroiditis. Later, de Quervain and Giordanengo (1936) collected reports of 54 cases of the disease, appearing in the literature since de Quervain's original description, and clearly distinguished it from other forms of thyroiditis. Several years ago, the disease had been considered relatively rare, but with recent advance in endocrinology, more attentions have been drawn by it, and more reports published on it. For the past six years, the author has treated 51 cases of subacute thyroiditis, and obtained findings of interest, which are outlined in this paper. METHODS OF EXAMINATION The disease was confirmed by Silverman's needle biopsy (Crile and Rumsey, 1950; Crile and Hazard, 1951) of the thyroid in 36 of them, and the others were diagnosed by typical clinical symptoms, characteristic results of thyroidal function test and accelerated red cell sedimentation rate and its clinical course. Thyroid function test Basal metabolic rate (BMR) was examined by Knipping's method (normal range•}15%), and serum protein-bound iodine (PBI) by modification of Barker's method (Barker and Humphrey, 1950). The latter in normal 50 subject ranged between 3.0 and 7.5r/dl. I131 thyroidal uptake (24- hrs. value) in healthy 50 subjects ranged 10.0 to 45.5%. Thyroid-stimulating hormone (TSH) tests were performed in the following way: 250 units of TSH (MSE-Pretiron, Schering A. G., Berlin) was intramuscularly injected at one time, and after 24 hrs., PBI and I131 uptake were determined, which were respectively compared with those before the injection. In the averages for 5 normal controls, PBI rose from 4.8•}1.9r/dl to 6.8•}2.8ƒÁ/dl, and I131 uptake from 21.0•} 9.6% to 37.8•}17.1%. Serum cholesterol level was measured by modification of Bloor's method (Bloor, 1922). Received for publication February 28, 1964. 120 SAITO Vol.11, No.2 Measurement of serum iron and unsaturated iron binding capacity (UIBC) The values were determined by method of Landers and Zak (1958). (normal range, serum iron 120•}32r/dl; UIBC 225•}56r/dl). Electrophoretic analysis of serum proteins Blood was drawn from the patients, in the fasting state, and the serum proteins were frac- tionated by modification of Tiselius electrophoretic method, the standard method of the Japanese Society of Electrophoresis, using HT-B type apparatus. Liver function test Tests were performed for serum protein level, Meulengracht's icterus index, Hijmans van den Bergh's bilirubin qualitative reaction, Takada Jezler reaction, cobalt reaction, Gros reaction, Kunkel zinc sulphate test, cadmium reaction, cephalin cholesterol flocculation test (CCF), thymol turbidity test (TTT), thymol flocculation test (TFT), and bromsulphalein test (BSP%/45min.). Blood sugar tolerance test 1) Sakaguchi's sugar tolerance test: To the patients 270g of boiled rice and 2 eggs were given, and thereafter the test was performed every 20mins. for 3 hrs. The blood sugar in 10 normal subjects rose to a peak, averaging about 45% above the fasting level, within 40 to 60mins., and not exceeded 170mg/dl. And fall to the fasting level occurred about the end of 1 to 2 hrs. 2) Intravenous glucose tolerance test: Forty cc of 20%glucose was intravenously injected in 2 mins., and then every 10mins., blood sample was taken to determine glucose level. Time required to return to the initial level was always within 50mins., for 10 healthy controls. The possibility of abnormality in the glucose tolerance curve due to abnormalities of absorption from the intestine was obviated by intravenously injecting glucose (Cantarow and Trumper, 1955). 3) Insulin tolerance test: The purpose of the insulin tolerance test was to determine (1) the sensitivity of the organism to insulin, and (2) its responsiveness to insulininduced hypoglycemia. The blood sugar falls to about 45% of the fasting level 20 to 30mins. after intravenous injection of 2 units of insulin. And for convenience' sake, the so-called insulin sensitivity index (ISI) was computed from descending blood sugar curve (Kuzuya and Yagawa, 1952). The values for 20 healthy controls ranged 1.6 to 3.6. 4) Epinephrine tolerance test: The increase in blood sugar which follows administration of epinephrine has been utilized as an index of the quantity and availability of glycogen in the liver. After intramuscular injection of 0.01 cc per kg of a 1:1,000 solution of epinephrine hy- drochloride in 10 normal subjects, blood sugar concentration normally rose 30 to 45mg/dl in 40 to 60mins., returning to the resting level in 100 to 120mins. These blood sugar tests were executed at the time of empty stomach, and bleeding was made from the ear lobule, and the determination by Hagedorn-Jensen's method. Thorn's test The test was performed principally by injecting ACTH, and the results of the same test with epinephrine were also referred to (Thorn, 1951). Urinary excretion of 17-ketosteroid(17KS) The level was determined by Drekter's method (Drekter et al., 1952). Purification of human thyroglobulin Thyroglobulin was extracted from cadavers without thyroid disease, and prepared by the ammonium sulfate salting-out technic of Derrien et al.(1948 and 1949). Precipitation test By Oudin's serum agar technic (Oudin, 1952). June 1964 STUDIES ON SUBACUTE THYROIDITIS 121 Skin test Intracutaneously, 0.1 cc of 0.02% purified human thyroglobulin solution was injected, and 24 hrs. later the diameter of redness on the skin was measured. Data for 10 normal subjects are listed in Table 5. The diameters over 20mm and 20mm were defined positive. Serum xerogel-figure The procedures reported by Shichijo (1942) were followed. The figure represents one of serum colloid reactions. Electric skin resistance test One of thyroid function tests, which makes use of difference in electric resistance in different sites of the skin (Shichijo et al., 1958) RESULTS Age and sex Out of the 51 cases of subacute thyroiditis, 4 were males, and the other 47 were females. Thus women outnumbered men by 12 to 1. Forty six cases (90.2 %) were between 30 and 50 years of age. The youngest was 19 years, the oldest 62 years, and cases in the thirties numbered 21 (41.2%), the forties 19 (37.3 %), and the fifties 6 (11.8%) (Fig. 1). In 7 of the 51 cases, the disease developed in the season of epidemic influ- enza, and so gargling material and homogenized thyroid from 5 of these 7 were cultured in the chick embryo. And influenza virus was detected from gargling of 2, but could not from the thyroid. Clinical symptoms in acute phase The complaints by the 51 cases are listed in Table 1. As local symptoms, thyroid swelling was observed in all cases (100%). The gland was somewhat ir- regular in shape, and firm in all cases. It was painful and tender to touch (96.1 %). Involvement was usually bilateral (80%), sometimes unilateral (20%). The pain radiated to the back of the neck, ears, jaws and shoulders (92.2%). In the majority, sore throat, cough and sputum were complained, and so before the treatment, they were misdiagnosed as having upper respiratory infection, and given large doses of sulfonamides and antibiotics without apparent effect on the course of the disease. Besides, hoarseness and dysphagia were observed. Local redness and fluctuation could not be demonstrated in any of the 51 cases. As to systemic symptoms, 46 of the 51 cases (90.2%) had fever, varying from low 37.0•Ž to spiking temperature course with peaks as high as 40.2•Ž. Much the same 44 cases (86.3%) had fatigability, 42 (82.4%) weakness, 41 (80.4%) headache, 37 (72.5%) palpitation, and 32 (62.7%) weight loss of over 2 kg, and 31 (60.8%) finger tremor. Moreover, excessive perspiration, anorexia, nervousness, salivation。 epiphora and arthralgia were also complained. Further, menstrual abnormality was observed in 27 of 38 female cases—oligo and hypomenorrhea in 27. And in the other cases, the menstruation was normal (Fig. 2). Laboratory data in acute phase (Table 2). 122 SAI TO Vol.11, No.2 Fig.1. Age Table1. Clinical symptoms in acute phase(51 cases) June 1964 STU DIES ON SUBA CUTE THYRO IDITIS 123 Cases Acute phase Recovery phase Hypo-and Normal Hyper-and Normal oligomenorrhea polymenorrhea Fig. 2. Change in menstruation Table 2. Main laboratory finding in acute phase 124 SAI TO Vol.11, No.2 Thyroid function test In all the 51 cases, BMR ranged -1.6 to +62.1%(Mean•}Standard Devi- ation+20.7•}13.2%),and the normal range of •} 15% was found in 17 cases (33.3%). PBI ranged 3.8 to 16.8ƒÁ/dl (Mean, 6.9•}2.4ƒÁ/dl), the normal range 3.0 to 7.5ridr was observed in 41 cases(80.4%), and higher value of above 7.6ƒÁ/dl in 10(19.6%). I131 uptake ranged 0.2 to 10.8%(Mean 2.9•}2.8%), and low normal range was given by 2(3.9%), and extremely low values below 3% by 35 (68.6%). Results of examinations of 10 cases at 1 to 2 weeks after the onset, BMR + 15.4•`+32.8%(Mean+25.3%), PBI 6.1-16.8 ridl(Mean 10.2ƒÁ/dl), I131 uptake 0.2•`5.1%(Mean 1.2%).
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