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De Quervain's Subacute Thyroiditis Presenting As a Postgrad Med J: First Published As 10.1136/Pgmj.74.876.602 on 1 October 1998

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De Quervain's Subacute Thyroiditis Presenting As a Postgrad Med J: First Published As 10.1136/Pgmj.74.876.602 on 1 October 1998 Postgrad MedJ3 1998;74:602-615 © The Fellowship of Postgraduate Medicine, 1998 Short reports De Quervain's subacute thyroiditis presenting as a Postgrad Med J: first published as 10.1136/pgmj.74.876.602 on 1 October 1998. Downloaded from painless solitary thyroid nodule T Bianda, C Schmid Summary tion, drug or iodine exposure, or pregnancy. We describe a 39-year-old woman pre- Her sister had Graves' disease. Physical exam- senting with a painless solitary thyroid ination showed a regular heart rate of 72 beats/ nodule, initially without signs suggesting min, a blood pressure of 120/85 mmHg, an thyroiditis. The serum level ofthyrotropin axilla temperature of 36.8°C, no tremor and was suppressed whereas those of thyrox- unremarkable reflexes. There were no signs of ine and triiodothyronine were normal. ophthalmopathy or dermopathy. We found a Fine needle aspiration cytology showed no painless nodule in the right lobe of the thyroid signs ofinflammation or malignancy. One gland with a diameter of 2x2 cm without lym- week later, the patient felt pain and phadenopathy. Serum thyrotropin (TSH) was tenderness on her neck, and erythrocyte low (< 0.05 mUll), free thyroxine (fT4) was 17 sedimentation rate and C-reactive protein pmol/l (normal range 8.5-19) and total tri- were markedly elevated. Thyroid scintig- iodothyronine (T3) was 2.6 nmol/l (0.9-2.8). raphy showed a suppressed thyroid TSH-receptor and antimicrosomal antibodies pertechnetate uptake. At that time, the could not be detected. Thyroid sonography diagnosis of subacute thyroiditis was confirmed the presence of an inhomogenous, made. Upon treatment with steroids the solid in patient's symptoms as well as the thyroid nodule the right lobe without cystic nodule resolved. This case illustrates that lesions. Needle aspiration cytology from the subacute thyroiditis de Quervain may nodule showed cell-rich material consisting of present as a solitary, painless nodule with clusters of thyrocytes without multinucleated suppressed thyrotropin and should there- giant cells. fore be considered in the differential diag- A few days later, the patient complained for nosis of such lesions. the first time about pain in the thyroid gland which radiated to both ears and was aggra- Keywords: thyroiditis de Quervain; thyroid nodule vated by turning the head. Physical examina- tion now showed a tender nodule in the left lobe ofthe thyroid (diameter 3x2 cm), whereas Subacute thyroiditis, also called de Quervain's the nodule in the right lobe was no longer pal- http://pmj.bmj.com/ thyroiditis, is the most common form of pable. At this time, the laboratory tests showed non-autoimmune thyroiditis, most probably of increased erythrocyte sedimentation rate viral aetiology. Patients usually have a history of (ESR; 80 mm/h), C-reactive protein (CRP; 68 antecedent upper respiratory infection and mg/l) and total T, (3.1 nmol/l), normal fT4 suffer from neck pain, thyroid tenderness and (17.4 pmol/l) and decreased TSH (< 0.05 systemic symptoms of inflammatory disease.1 mU/l). Thyroid scintigraphy with [99m]Tc- Whereas cases with typical signs of thyroiditis pertechnetate revealed no tracer uptake. Non- on October 1, 2021 by guest. Protected copyright. de Quervain may pose little difficulty, some- steroidal anti-inflammatory drugs were with- times the diagnosis may be less clear, particu- out convincing effects after treatment for larly when the presenting symptom is a several days but prednisone (50 mg/day) painless, solitary thyroid nodule. The diagnosis therapy resulted in a prompt resolution ofpain of this variant form of subacute thyroiditis can within 12 hours. cause considerable difficulty. We describe a During the following week, the patient com- patient initially showing a single, painless, thy- pletely recovered, and no thyroid nodule could roid nodule without the characteristic clinical be detected by palpation; ESR (18 mm/h) and features suggesting subacute thyroiditis. CRP (4 mg/l) returned to normal; serum T3 was 2.1 nmol/l, ff4 20.4 pmol/l and TSH < 0.05 mU/l. Five weeks later, the patient, then Division of Case report Endocrinology and receiving prednisone 20 mg/day, remained Diabetes, Department A 39-year-old woman visited our out-patient asymptomatic; ESR was 3 mm/h, CRP < 3 of Internal Medicine, endocrinology division with a recent-onset, mg/l, T3 1.2 nmol/l, fT4 10.7 pmol/l, and TSH University Hospital, painless, non-tender nodule in the right lobe of had risen to 5.57 mU/l. The patient presented CH-8091 Zurich, the thyroid gland. History revealed after a further 6 weeks in Switzerland that in the good health. She had T Bianda previous 2 months she had lost 3 kg weight and regained 1 kg of body weight, and neither pal- C Schmid intermittently experienced sweating and palpi- pation nor ultrasound showed a thyroid tations. There was no history of fever, malaise, nodule. ESR was 5 mm/h, fr4 1.2 pmol/l, and Accepted 23 April 1998 neck pain, antecedent upper respiratory infec- TSH 6.22 mU/l. De Quervain's subacute thyroiditis 603 Discussion Learning points Patients with de subacute Quervain's thyroidi- * neck pain radiating to the ears, thyroid tis with a neck radiat- Postgrad Med J: first published as 10.1136/pgmj.74.876.602 on 1 October 1998. Downloaded from may present typical pain tenderness, systemic symptoms including fever ing to the ears, jaws and throat, thyroid tender- and malaise, and mild signs of hyperthyroidism ness and systemic symptoms and signs of are characteristic features of subacute thyroiditis inflammatory disease, such as fever, malaise, * a detailed history and clinical course may assist fatigue and anorexia, with or without diagnosis in patients with an unusual thyrotoxicosis.2 Hyperthyroidism results from presentation of thyroid disease destruction of the with * subacute thyroiditis may present atypically with a thyroid parenchyma solitary, painless thyroid nodule and should be release of stored hormone. If there are considered in the differential diagnosis of such symptoms of thyrotoxicosis, they are mild and lesions transient,3 and may be followed by transient * steroid treatment leads to rapid resolution of hypothyroidism. On physical examination the nodular disease and inflammation patient often appears acutely ill at presentation and the thyroid is tender and diffusely enlarged. The most important laboratory test suggesting subacute thyroiditis is an increased ESR (usually greater than 50 mm/h). Although it is often overlooked and misdiagnosed as ule. These tests turned out to be non- pharyngitis,4 the diagnosis of thyroiditis de diagnostic; a toxic adenoma was suspected. Quervain can be readily considered when The clinical course and subsequent findings patients present with the typical clinical (neck pain, high ESR, low thyroid tracer uptake picture. Depending on the physician's attitude and good response to steroids) allowed us to and local availability, fine needle aspiration consider a diagnosis of subacute thyroiditis as a cytology, ultrasound or scintigraphy may sup- cause of the nodule. Despite the fact that suba- port the diagnosis, in addition to the clinical cute thyroiditis appeared as a focal condition in course. Early recognition and diagnosis are our patient, tissue damage was sufficient to necessary for appropriate management of cause hormone release, resulting in suppressed affected patients. TSH secretion and thyroid tracer uptake.8 The On the other hand, the disorder can present diagnosis of subacute thyroiditis de Quervain with puzzling findings5-7 and can escape early in this patient was delayed by the initial recognition. Our patient presented with a soli- presentation without pain and signs of inflam- tary, painless nodule but neither history nor the mation, although the first interview revealed initial clinical findings suggested an inflamma- clinical symptoms of thyrotoxicosis. tory disease. Therefore, the initial work-up In conclusion, this case illustrates that suba- included a laboratory check of thyroid func- cute thyroiditis should also be considered in tion, an ultrasound examination of the neck the differential diagnosis of a solitary, painless and fine needle aspiration cytology of the nod- thyroid nodule with suppressed TSH. 1 Lazarus JH. Silent thyroiditis and subacute thyroiditis. In: 5 Piazza I, Girardi A. Painless giant cell thyroiditis. Postgrad http://pmj.bmj.com/ Braverman LE, Utiger RD, eds. The thyroid. Philadelphia: MedJ 1989;65:580-1. Lippincott-Raven, 1996; pp 577-91. 6 Bartels PC, Boer RO. Subacute thyroiditis presenting as a 2 Greene JN. Subacute thyroiditis. Am J Med 1971;51:97- painless cold nodule. J Nucl Med 1987;28:1488-90. 108. 7 PA. Occult subacute with 3 Volpe R, Johnston MW, Huber N. Thyroid function in Stonebridge thyroiditis unusual subacute thyroiditis. J Clin Endocrinol Metab 1958;18:65- features. Lancet 1985;ii:727. 78. 8 Hamburger JI, Kadian G, Rossin HW. Subacute thyroiditis 4 Volpe R, Johnston MW. Subacute thyroiditis - a disease evolution depicted by serial '3'I-scintigrams. J Nucl Med commonly mistaken for pharyngitis. Can Med Assoc J 1957; 1965;6:560-5. 77:297-307. on October 1, 2021 by guest. Protected copyright..
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