*Subacute Thyroiditis (de Quervain Thyroiditis)

Chapter: Subacute Thyroiditis (de Quervain Thyroiditis)
McMaster Section Editor(s): Victor M. Montori, Juan P. Brito
Section Editor(s) in Interna Szczeklika: Barbara Jarząb, Ewa Płaczkiewicz-Jankowska
McMaster Author(s): Juan P. Brito
Author(s) in Interna Szczeklika: Andrzej Lewiński, Ewa Płaczkiewicz-Jankowska
Additional 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. 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 1). Initially, the dominant features are a 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 the destruction of the glandular parenchyma and release of thyroid hormones; usually, it is not associated with prominent clinical features, but may be accompanied by malaise and muscle pain. The pain and fever subside spontaneously, and the 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 cytology 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 1.

3) Antithyroid antibodies (present only in 10%-20% of patients; thyroglobulin antibodies are more frequent than thyroperoxidase 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 the 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 the pain is severe, consider prednisone 40 to 60 mg/d for the first week, then taper the dose down to discontinue the 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 the 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.

TablesTop

Table 1. Clinical phases of subacute thyroiditis (de Quervain thyroiditis)

Hormone levels

Iodine uptake

Clinical features

Phase 1

↑ FT4, ↑ FT3, ↓ TSH

Low

Thyrotoxicosis

Phase 2

Normal

Low

Euthyroidism

Phase 3

↓ FT4, ↓ FT3, ↑ TSH

High

Hypothyroidism

Phase 4

Normal

Normal

Euthyroidism

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

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