Subacute Thyroiditis (de Quervain Thyroiditis)

How to Cite This Chapter: Brito JP, Lewiński A, Płaczkiewicz-Jankowska E. Subacute Thyroiditis (de Quervain Thyroiditis). McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. Accessed August 07, 2020.
Last Updated: June 21, 2019
Last Reviewed: June 21, 2019
Chapter Information

Definition, Etiology, Pathogenesis Top

Subacute thyroiditis (de Quervain thyroiditis, granulocytic thyroiditis, granulomatous thyroiditis, giant cell thyroiditis) is probably of viral origin and follows a 4-phase course. There is a strong correlation of subacute thyroiditis with the presence of certain human leukocyte antigens (HLAs). The disease is usually preceded (2-8 weeks earlier) by an upper respiratory tract infection.

Clinical Features and Natural History Top

The disease can be divided into 4 distinct phases (Table 5.6-3). Initially the dominant features are painful swelling of the thyroid gland and fever; pain is referred to the ears, mandibular angle, and upper chest. Thyrotoxicosis (lasting 3-8 weeks) results from destruction of the glandular parenchyma and release of thyroid hormones; usually it is not associated with prominent clinical features but it may be accompanied by malaise and muscle pain. The pain and fever subside spontaneously and hormone levels normalize after 8 to 16 weeks. Phase 3 (hypothyroidism) is not always present. Permanent hypothyroidism is extremely rare and recovery is almost always complete (phase 4). A rapidly growing nodule, requiring cytologic assessment to exclude malignancy, may actually be an inflammatory infiltrate in the course of subacute thyroiditis. In ~2% of patients the disease may recur after a long remission (up to 20 years).

Diagnosis Top

Diagnostic Tests

1. Laboratory tests:

1) Extremely elevated erythrocyte sedimentation rate (ESR) (accompanied by exquisite tenderness of the thyroid gland).

2) Thyroid-stimulating hormone (TSH) and thyroid hormones: Table 5.6-3.

3) Antithyroid antibodies (present only in 10%-20% of patients; thyroglobulin [Tg] antibodies are more frequent than thyroperoxidase [TPO] antibodies).

2. Imaging studies: Thyroid ultrasonography reveals diffuse or focal hypoechogenicity of the thyroid gland. Radionuclide thyroid imaging shows a very low iodine uptake (in the early phase of the disease).

3. Cytology: The dominant cells are neutrophils, giant cells (characteristic polynuclear macrophages), and epithelioid cells (mononuclear macrophages).

Diagnostic Criteria

The key diagnostic criteria are a painful or tender goiter, elevated ESR, transient thyrotoxicosis, and significantly decreased iodine uptake.

Differential Diagnosis

Other rare types of granulomatous thyroiditis: tuberculous thyroiditis, fungal thyroiditis (Aspergillus, Candida, Cryptococcus); Pneumocystis jiroveci thyroiditis in immunodeficient patients. If pain is not a dominant feature, differential diagnosis should include silent thyroiditis (markedly elevated ESR and association with a prior viral infection suggest de Quervain thyroiditis).

Treatment Top

The hyperthyroid phase requires no antithyroid treatment (propranolol may be used in patients with bothersome symptoms of hyperthyroidism). Administer acetylsalicylic acid 2 to 4 g/d or nonsteroidal anti-inflammatory drugs to control pain and inflammation; if pain is severe, consider prednisone 40 to 60 mg/d for the first week, then taper the dose down to discontinue treatment in ≤4 weeks. In the hypothyroid phase consider levothyroxine (L-T4) replacement therapy (to prevent exacerbation of the disease); note that hypothyroidism is transient and therapy should not be continued indefinitely. There is no indication for surgery, as the disease is self-limiting and does not cause permanent thyroid damage.


Table 5.6-3. Clinical phases of subacute thyroiditis (de Quervain thyroiditis)

Hormone levels

Iodine uptake

Clinical features

Phase 1

↑ FT4, ↑ FT3, ↓ TSH



Phase 2




Phase 3

↓ FT4, ↓ FT3, ↑ TSH



Phase 4




↑, increase; ↓, decrease; FT3, free triiodothyronine; FT4, free thyroxine; TSH, thyroid-stimulating hormone.

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