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subacute granulomatous thyroiditis; De Quervain's thyroiditis; giant-cell thyroiditis

Subacute granulomatous thyroiditis, De Quervain's thyroiditis or giant-cell thyroiditis is a self-limited granulomatous inflammation of the thyroid gland. Etiology: 1) uncertain 2) circumstantial evidence suggests viral origin a) mumps b) measles c) influenza d) adenovirus e) coxsackievirus f) echovirus Epidemiology: 1) 80% in women 2nd to 5th decades of life 2) 65-70% association with HLA-B35 3) most common form of painful thyroid Pathology: 1) minimally to markedly enlarged 2) enlargement asymmetric or focal 3) may be slightly adherent to surrounding structures 4) acute inflammatory disruption of follicles with replacement by neutrophils early 5) later stages of disease a) multinucleated giant cells enclosing pools or fragments of colloid b) chronic inflammatory infiltrates c) fibrosis Clinical manifestations: 1) viral prodrome 2) 3 patterns of presentation a) acute systemic febrile reaction with increased ESR b) sudden painful thyroid enlargement with: 1] sore throat 2] neck pain 3] earache c) minimally painful enlargement of thyroid with transient hyperthyroidism 3) may be hypothyroid phase following initial thyrotoxicosis 4) recovery in 6-8 weeks Laboratory: 1) elevated serum T3 & serum T4 as a result of damage to thyroid follicles 2) suppressed serum TSH 3) low radioactive iodine uptake 4) elevated serum thyroglobulin 5) elevated erythrocyte sedimentation rate (ESR) a) generally > 50 mm/hr b) occasionally > 100 mm/hr c) normal value virtually excludes diagnosis 6) complete blood count (CBC) a) mild normocytic anemia b) normal or slightly increased WBC 7) serum IL-6 levels are increased Differential diagnosis: 1) hemorrhage into adenoma or carcinoma (nodule) 2) malignant neoplasm of thyroid a) fast growth with focal necrosis may mimic pyogenic infection b) hyperthyroidism may result from neoplasm by release of colloid-stored thyroxine 3) infectious thyroiditis 4) subacute lymphocytic thyroiditis 5) Graves disease 6) multinodular goiter - thyrotoxicosis after exposure to iodine containing contrast media [5] - goiter, thyroid nodules Management: 1) pharmacologic agents a) non-steroidal anti-inflammatory drugs (NSAIDs) b) prednisone 20-40 mg QD - severe cases not responding to other therapy - taper after 1 week with discontinuation in 2-4 weeks - restart if pain recurs c) propranolol 20-40 mg PO QID or atenolol for hyperthyroidism 2) follow-up a) generally duration of symptoms is 2-5 months b) 20% have recurrence c) permanent hypothyroidism in 5% d) continued observation necessary because thyroid abnormalities may persist

Related

radioactive iodine uptake (RAIU) test

General

thyroiditis

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 646-650
  2. Cotran et al Robbins Pathologic Basis of Disease, 5th ed. W.B. Saunders Co, Philadelphia, PA 1994 pg 1128-29
  3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 209
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 18. American College of Physicians, Philadelphia 1998, 2012, 2018.
  5. NEJM Knowledge+ Endocrinology