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.
- 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
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)
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
papillary thyroid carcinoma
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