Advertisement

A young man with neck pain

Published:December 12, 2016DOI:https://doi.org/10.1016/j.ejim.2016.12.009

      1. Case description

      A 34-year old man had a two-month history of weight loss, palpitations, night sweating, low-grade fever, and neck pain. His past history was unremarkable, he took no medications including over-the-counter medications before the illness, had no known allergies, and did not drink alcohol or use illicit drugs. Physical examination revealed a tender goiter. Laboratory findings showed neutrophil leukocytes 12,161/mm3, C-reactive protein 36.8 mg/L (normal < 10), FT3 8.30 pg/mL (normal 2.3–4.2), FT4 4.37 ng/mL (normal 0.8–1.60), thyroglobulin 87.2 ng/mL (normal 1.3–31.8), and TSH < 0.008 uIU/mL (normal 0.30–4.50). Thyroid peroxidase antibodies and TSH-receptor antibodies were absent. A 24-h uptake of thyroid radioactive iodine (I13I) was done (Fig. 1).
      Fig. 1
      Fig. 1The 24-h I13I uptake is very low (<5%) compared to the normal range (Panel A). The thyroid is not recognized upon the neck scan (PanelB) compared to a normal subject (PanelC).

      2. What is the diagnosis?

      2.1 Discussion

      This patient had subacute painful thyroiditis. The 24-h I13I uptake was very low (<5%) and the gland could not be recognized with no isotope uptake in the thyroid. In the context of type B symptoms, the finding of elevated thyroid hormones, suppressed TSH, and undetectable I13I uptake suggests thyrotoxicosis caused by the discharge of preformed thyroid hormones due to the inflammatory destruction of the thyroid [
      • Pearce E.N.
      • Farwell A.P.
      • Braverman L.E.
      Thyroiditis.
      ]. The pattern of I13I uptake is different in hyperthyroidism, i.e. due to increased synthesis of thyroid hormones, as it would show diffusely increased uptake in Graves' disease, an asymmetrical and irregular normal or high uptake in toxic multinodular goiter, and a focal pattern in toxic adenoma, associated with suppressed uptake in the remaining thyroid tissue [
      • De Leo S.
      • Lee S.Y.
      • Braverman L.E.
      Hyperthyroidism.
      ].
      Subacute painful thyroiditis is the most common cause of thyroid pain accounting for up to 5% of all patients with thyroid disease [
      • Pearce E.N.
      • Farwell A.P.
      • Braverman L.E.
      Thyroiditis.
      ]. Patients have fever, myalgias, fatigue, and severe neck pain, swelling, or both. Up to 50% of them have a self-limited thyrotoxicosis followed by hypothyroidism as thyroid hormone stores are depleted [
      • Pearce E.N.
      • Farwell A.P.
      • Braverman L.E.
      Thyroiditis.
      ,
      • De Leo S.
      • Lee S.Y.
      • Braverman L.E.
      Hyperthyroidism.
      ]. Thyroid function returns to normal in most cases, however hypothyroidism is permanent in 5% of cases [
      • Pearce E.N.
      • Farwell A.P.
      • Braverman L.E.
      Thyroiditis.
      ]. Relapses of thyroiditis are rare [
      • Pearce E.N.
      • Farwell A.P.
      • Braverman L.E.
      Thyroiditis.
      ].
      Subacute painful thyroiditis frequently follows an upper respiratory tract infection with a peak incidence in summer that correlates with the peak incidence of enterovirus infection [
      • Martino E.
      • Buratti L.
      • Bartalena L.
      • et al.
      High prevalence of subacute thyroiditis during summer season in Italy.
      ]. This implicates a viral etiology even though a clear-cut evidence for it is lacking.
      Patients are given β-blockers during the thyrotoxic phase and non-steroid-anti-inflammatory drugs or salicylates to relieve pain and systemic symptoms. Glucocorticoids are helpful in more severe cases. Our patient quickly recovered with no treatment. Six months later, he remains euthyroid.

      References

        • Pearce E.N.
        • Farwell A.P.
        • Braverman L.E.
        Thyroiditis.
        N. Engl. J. Med. 2003; 348: 2646-2655
        • De Leo S.
        • Lee S.Y.
        • Braverman L.E.
        Hyperthyroidism.
        Lancet. 2016; 388: 906-918
        • Martino E.
        • Buratti L.
        • Bartalena L.
        • et al.
        High prevalence of subacute thyroiditis during summer season in Italy.
        J. Endocrinol. Investig. 1987; 10: 321-323