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Updated: Dec 9 2021

Subacute Thyroiditis

  • Snapshot
    • A 40-year-old man presents to his primary care physician for palpitations. He had previously presented to the emergency room for similar reasons, when his EKG was found to be tachycardic but otherwise regular rhythm. He was sent home after intravenous hydration at that time. He reports that ever since an upper respiratory infection a few months ago, he has lost weight, felt fatigued, and experienced intermittent palpitations. He has no significant medical history. He also reports having increasing jaw and anterior neck pain. On physical exam, his thyroid is very tender to palpation. No goiter was palpated. His T3 and T4 levels come back elevated, and his physician prescribes him 2 medications for this disease with reassurance that symptoms usually resolve over time.
  • Introduction
    • Clinical definition
      • a granulomatous autoimmune disease of the thyroid that causes hyperthyroidism that may be followed by a hypothyroid phase
        • also known as de Quervain or granulomatous thyroiditis
    • Associated conditions
      • medical conditions and comorbidities
  • Epidemiology
    • Demographics
      • women > men
      • adults
    • Risk factors
      • viral infections
      • human leukocyte antigen-B35
      • family history
    • Pathogenesis
      • Mechanism
        • transient inflammation of the thyroid gland causes release of ↑ T3 and T4
        • results from injury of thyroid follicles
  • Presentation
    • Symptoms
      • anterior neck and jaw pain
        • de Quervain causes pain
      • flu-like prodrome
        • fever, malaise, and fatigue
      • 3 phases
        • hyperthyroid phase
          • nervousness, tachycardia, and palpitations
          • sweating
          • resting tremor
          • hyperactive reflexes
        • hypothyroid phase
          • increased relaxation of deep tendon reflexes
        • euthyroid phase
  • Studies
    • Diagnostic testing
      • studies
        • T3/T4
          • ↑ during hyperthyroid phase
          • ↓ during hypothyroid phase
        • thyroid stimulating hormone (TSH)
          • ↓ during hyperthyroid phase
          • ↑ during hypothyroid phase
        • ↓ radioactive iodine uptake
          • i.e., gold standard for diagnosis
        • ↑ inflammatory markers C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
      • biopsy
        • rarely needed but will show granulomatous inflammation
  • Differential
    • Postpartum thyroidits
      • distinguishing factor
        • thyroiditis after childbirth
        • painless thyroid
    • Silent thyroiditis
      • distinguishing factor
        • painless thyroid
        • hyperthyroidism followed by transient hypothyroidism
    • Riedel thyroiditis
      • distinguishing factor
        • hard and painless thyroid
  • Treatment
    • Management approach
      • because this disease is self-limited, management of symptoms is the mainstay treatment
    • First-line
      • nonsteroidal anti-inflammatory drugs (NSAIDs)
        • indication
          • mild symptoms
      • beta-blockers
        • indication
          • given with anti-inflammatory agents
    • Second-line
      • corticosteroids
        • indication
          • symptoms of thyrotoxicosis
          • refractory to NSAIDs
  • Complications
    • Recurrence
    • Permanent hypothyroidism
  • Prognosis
    • Patients will generally return to normal thyroid function within a year
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