PANCE Blueprint Endocrinology (7%)


Patient will present as → a 37-year-old female with a 2-week history of a painful mass in her neck after having a sore throat and fever for 3 days. The patient reports the mass has slowly been enlarging over that time span and has become more painful to the touch. She also reports feeling hot, even when her coworkers feel cold, and reports loose stools over the past week. The patient’s vital signs are T 98.6F, BP 140/90, Pulse 110 bpm, and SpO2 100%. On exam, you note a diffusely enlarged thyroid that is painful to the touch. Thyroid stimulating hormone (TSH) is decreased, T4/T3 is elevated, and radioactive iodine uptake and scan at 24 hours reveals an uptake of 3% (normal 8-25%).

Subacute thyroiditis is the most common cause of thyroid pain and has a greater incidence in women.

  • The etiology is often post-infectious and viral in origin, usually following symptoms such as fever, myalgia, and pharyngitis.
  • Early in the course of the disease, the patient may be hyperthyroid as follicular cells are damaged and release large amounts of T3/T4.
    • This is often followed by a period of hypothyroidism as T3/T4 is depleted, and eventually euthyroidism within 6-12 months.
  • ↑ ESR (granulomatous) also called de Quervain’s thyroiditis.

Hashimoto's thyroiditis may present similarly to subacute thyroiditis, but the presence of neck tenderness and a recent viral illness should make you think subacute thyroiditis.

Postpartum thyroiditis:

  • 1-2 months of hyperthyroidism after delivery

Infectious bacterial thyroiditis is often due to the hematogenous spread of staph or strep

  • Fever, pain, redness, fluctuant mass
  • ↑ WBC

Lab values depend on cause of thyroiditis and may be euthyroid

  • Other possibilities include ↑ ESR (granulomatous), increased WBC count (infectious), no thyroid antibodies, TFTs (if abnormal) are usually hyperthyroid at presentation- ↓ TSH, ↑ T4 and ↑ T3

Ultrasound and radioactive iodine scanning have little value in this setting and are not warranted. If performed radioactive iodine (RAI) scan will reveal diminished uptake. 

If there is PAIN think:

  • Painful subacute - De Quervain's (granulomatous) usually post viral
  • Infectious - bacterial mainly - strep or staph most common
  • Radiation
  • Trauma

If there is NO PAIN think

  • Postpartum - 1-2 months of hyperthyroidism after delivery
  • Drug-induced - the most common cause of drug-induced thyroiditis is Lithium or Amiodarone
  • Chronic Lymphocytic (Hashimoto thyroiditis)
  • Fibrous

No anti-thyroid medications are necessary but may consider supplemental thyroid hormone if hypothyroid state

  • Patients will usually have return to euthyroid state within 12-18 months without treatment
  • Stop offending drugs *lithium *Amiodarone will usually return to euthyroid state once the meds are stopped
  • Aspirin for pain and inflammation in subacute thyroiditis
  • Antibiotics if bacterial etiology and ↑ WBC, drainage if abscess present
  • Postpartum thyroiditis: Completely resolves, give propranolol for cardiac symptoms
  • Some patients (5-20%) may develop permanent hypothyroidism
Question 1
A 29 year old woman presents to the clinic for the second time. You previously diagnosed her with a viral URI. She states that she began to improve, but her sore throat moved to the front of her neck and she began having palpitations. She now feels tired all the time and is constipated. Physical examination is normal except for mild, diffuse tenderness of the thyroid. What is the most likely diagnosis for this patient?
Grave's disease
Hashimoto thyroiditis
subacute thyroiditis
papillary thyroid carcinoma
Question 1 Explanation: 
Subacute thyroiditis is often preceded by a viral illness a few weeks earlier. There is often anterior neck tenderness due to the inflamed thyroid gland.
Question 2
In the previous scenario thyroid function testing confirms a current hypothyroid state. What is the most appropriate course of action?
perform a radioactive iodine scan
thyroid replacement therapy with close follow-up of thyroid function
no treatment; this will resolve on its own
assure the patient that her thyroid function will normalize in a few weeks
perform a thyroid ultrasound
Question 2 Explanation: 
The patient should be started on thyroid replacement therapy to correct her current hypothyroidism. Her TSH level should be monitored because most patients will become euthyroid during a period of weeks to months and will no longer need replacement. A subset of patients will remain hypothyroid. Ultrasound and radioactive iodine scanning have little value in this setting.
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Hypothyroidism (Prev Lesson)
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