SUBACUTE THYROIDITIS by SELWYN TAYLOR, M.CH., F.R.C.S

Postgrad Med J: first published as 10.1136/pgmj.33.381.327 on 1 July 1957. Downloaded from 327 SUBACUTE THYROIDITIS By SELWYN TAYLOR, M.CH., F.R.C.S. Surgeon, King's College Hospital, Belgrave Hospitalfor Children, and Hammersmith Hospital; Lecturer in Surgery, Postgraduate Medical School of London The term ' thyroiditis ' implies inflammation of to become much more common in that particular the thyroid gland, but by long usage it has come clinic. I had never seen an example before I950, to be used for a number of conditions in which but saw six in the next three years and pro- infection or trauma play apparently no part. Sub- gressively more each year since then. The con- acute thyroiditis is the title given to a condition dition is much commoner in women than men in which was first clearly described by de Quervain the ratio of about six to one. It has not yet been in I904 and which has been rediscovered, or re- reported in a child and is commonest in the fourth described, on a number of occasions since then, and fifth decades, although I have seen it in a with the result that it now has a multiplicity of student teacher of twenty-one. In our own series different names: granulomatous thyroiditis, giant- there was a history of a pre-existing goitre in 50 cell thyroiditis, pseudotuberculous thyroiditis, per cent. of the patients. The incidence, compared creeping thyroiditis, struma granulomatosa, acute with that of Hashimoto's thyroiditis and Riedel's non-infectious thyroiditis, acute non-suppurative thyroiditis, varies widely in different clinics, but thyroiditis and de Quervain's thyroiditis. For those our own figures are most closely in agreement with who prefer eponymous nomenclature, the term those of Lindsay in San Francisco, who finds 'de Quervain's thyroiditis' offers a satisfactory Hashimoto's disease about io times as common as description of the disease. In recent years there de Quervain's and de Quervain's about io times copyright. have been some good reviews of the subject and as common as Riedel's. the reader is referred to Crile (1948), Hazard (I955), Lindsay (1952 and 1954) and Taylor Clinical Picture (I955). The onset is typically acute, the patient com- The article which de Quervain published in I904 plaining of a sore throat, malaise, fever and a described a condition which he called non-purulent tender or even exquisitely painful thyroid gland, thyroiditis and this distinctly separated from other the pain radiating up towards the ears. The patient thyroid conditions what we here describe as sub- often sweats profusely at night and complains of acute thyroiditis. His article, which was beautifully weakness and lassitude. However, few patients http://pmj.bmj.com/ illustrated with photomicrographs, gave a clear require or wish to be admitted to hospital and they description of the condition which was only recog- may be able to carry on with their work, though nized, and even then under a variety of names, on feeling extremely weak while so doing. some 60 occasions in the next 30 years. In I936 The tenderness may start in one lobe of the Professor de Quervain, together with Dr. Gior- gland, but almost invariably spreads to the other danengo, of Turin, wrote a further account of the side until the whole of the thyroid is involved. The condition, fresh In is then and on adding eight examples. I948 thyroid gland moderately enlarged on October 3, 2021 by guest. Protected Crile again drew attention to the condition and palpation has a distinctive rubbery feel. It is firm emphasized that this was the same as pseudo- as in Hashimoto's thyroiditis, but the edges are tuberculous thyroiditis; it is probably more to this not so well defined, nor does the gland feel so surgeon than to anyone else that we owe the mobile in the neck. This, of course, is in keeping universal interest in this condition today. with the finding of many adhesions of the capsule to the surrounding tissues which tether the gland Incidence to the strap muscles. With the passage of time one It would be a truism to say that subacute of two things happens to the gland: either it thyroiditis occurs most commonly where it is most returns to a normal size and normal consistence commonly recognized, but, in fact, it is only where or fibrosis is so intense that the gland feels hard. clinicians are constantly thinking about the con- In the latter case the surface has the bosselated dition that it is diagnosed. Again, rather as in feel which is 6s typical of Hashimoto's disease, bird-nesting, it is the discovery of the first example and this irregularity, combined with hardness and which leads to the finding of many more; once fibrosis, makes the differentiation from cancer a the condition has been properly recognized it seems difficult one. Postgrad Med J: first published as 10.1136/pgmj.33.381.327 on 1 July 1957. Downloaded from 328 POSTGRADUATE MEDICAL JOURNAL July 1957 The progress of the disease is almost always to Laboratory Findings spontaneous resolution and this usually occurs Just as the clinical findings are so much more between three to six months after the onset. One important than the laboratory findings in Graves' patient under my care complained of symptoms disease, so in subacute thyroiditis too much for a little over a year, but this appears to be reliance should not be placed on special investiga- unusual. tions. However, they may provide valuable sup- portive evidence where the diagnosis remains in Differential Diagnosis doubt, but they also require considerable skill The early stages of de Quervain's disease, with in their interpretation, since they change with the fever, sweating and a painful swollen neck, may progress of the disease, which may extend from well be mistaken for signs of thyroiditis due to three to I2 months. acute bacterial inflammation. Whereas in acute The white cell count remains unaffected and the thyroiditis the causative organism is almost always relative proportions of lymphocytes and poly- discovered, the white cell count is raised and there morphonuclear leucocytes are unchanged. This is is a relative increase of polymorphonuclear leuko- in contrast with the changes seen in bacterial cytes; none of these is found in subacute thy- thyroiditis. The erythrocyte sedimentation rate roiditis. One confusing point, however, is that is raised and may be as high as 50 mm. Westergren both these conditions are often preceded by acute in the first weeks of the disease. No organisms infection in the upper respiratory tract and or viruses have so far been isolated from the especially a sore throat or tonsillitis. thyroid tissue or blood of these patients, but this The commonest condition which is mistaken for does not exclude their presence and, indeed, many subacute thyroiditis is haemorrhage into a nodule workers have felt very strongly that a virus was of a simple nodular goitre. When there is a solitary responsible. nodule almost filling one lobe of the gland and In the early weeks of the disease it is usual to there is haemorrhage into this, it is often very find that the radioactive iodine uptake in the neck difficult to be certain of the right diagnosis. The is zero and, since this is not seen in any other patient has a painful swollen neck and the pain thyroid condition, it is one of the strongest pointscopyright. may radiate up to the ears, occasionally the tem- in favour of the diagnosis. As the months go by perature is elevated and certainly such patients the radioactive iodine uptake returns and after a almost always complain of malaise and fatigue. One year it is usual for it to be once more normal. important point of differentiation is that the ery- On the other hand, the level of protein-bound throcyte sedimentation rate (E.S.R.) is almost in- iodine in the serum may be high in the first weeks variably elevated in subacute thyroiditis. The of the disease (Lindsay, 1954), but subsequently other important differentiating test between the is lower than normal and does not return to the two conditions is that the radioactive iodine test usually accepted level of approximately 4 vg. per for uptake in the gland is nil in the early stages of cent. until after a year or 8 months has elapsed. http://pmj.bmj.com/ subacute thyroiditis, whereas there is always a fair A most useful ancillary method in coming to a uptake in simple nodular goitre. diagnosis in this disease is the employment of The most serious condition which may be con- needle biopsy. Many types of instrument have fused with subacute thyroiditis is carcinoma of the been used, but one of the simplest, which can be thyroidgland, especially the slow-growingpapillary carried ready sterilized in an ordinary clinical bag, form seen in young adults. Crile and Fisher (I953) is the Vim-Silverman split needle (Crile and described two patients in whom a needle biopsy Hazard, 1951; Taylor, 1955). The patient is asked had been done to confirm the diagnosis of subacute to lie on a couch and the neck is hyperextended by on October 3, 2021 by guest. Protected thyroiditis. When the tissue was examined it was means of a pillow. The skin is prepared with an found to contain carcinoma and the patients were antiseptic and then with a hypodermic needle a then treated by thyroidectomy. Finally, Hashi- tiny weal is raised using 2 per cent. Lignocaine. moto's thyroiditis may be mistaken for that of A tenotomy knife or spear-pointed scalpel is then de Quervain.

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