Author’s ambitions sometimes distort the truth, or once again about the disappearance of pseudonodules in subacute thyroiditis

A Case of Subacute Thyroiditis Associated with Primary HIV Infection

Subacute thyroiditis is also known as subacute granulomatous thyroiditis, giant cell thyroiditis, painful thyroiditis, and De Quervain's thyroiditis. Immature granulocytes (IG) and neutrophil-to-lymphocyte ratio (NLR) are new inflammatory markers that are easily detected in routine complete blood count (CBC) tests. The aim of this study was to investigate the role of IG and NLR as markers of treatment response in patients with subacute thyroiditis. The study included 41 patients with subacute thyroiditis treated and monitored in our outpatient clinic between April 2020 and April 2022. From a retrospective review of medical records, we recorded results of IG, NLR, thyroid-stimulating hormone (TSH), free thyroxine (fT4), free triiodothyronine (fT3), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) from blood tests obtained routinely before and after treatment. Overall, 31 (75.6%) patients were women and 10 (21.4%) were men. The median age was 41 years (range 22-68 years). The laboratory tests showed the following median (range) results: IG, 0.03 (0.01-0.08); NLR, 3.6 (1.2-5.2); TSH, 0.02 mIU/L (0.01-3.35 mIU/L); fT4, 2.3 ng/dL (1.0-7.0 ng/dL); fT3, 5.6 pmol/L (2.6-15.2 pmol/L); ESR, 49 mm/h (17.0-87 mm/h); and CRP, 73 mg/dL (3.0-188 mg/dL). Early diagnosis and treatment of subacute thyroiditis is fundamental. In the present study, the new inflammatory markers IG and NLR, measured routinely on CBC tests, decreased significantly after subacute thyroiditis treatment relative to pretreatment values. After treatment, the NLR change correlated with ESR and CRP changes, while the IG change correlated only with CRP change. These findings suggest that the markers IG and NLR may be used to evaluate treatment response in patients with subacute thyroiditis.

Reports on sonoelastography, which provide an objective estimation of tissue elasticity, are scarce in terms of thyroiditis. The aim of this study was to prospectively assess the applicability of sonoelastography in different types of thyroiditis. The study assessed and compared the thyroid tissue stiffness in patients with acute thyroiditis (AT), subacute thyroiditis (SAT), and chronic autoimmune thyroiditis (CAT) with healthy control subjects (CS), followed up for 10 weeks. The study group consisted of two patients with AT, 18 patients with SAT, 18 patients with CAT, and 40 CS matched for age and gender. Sonoelastography was performed at baseline, at a 4-week follow-up during treatment, and at 10 weeks following diagnosis and treatment initiation. Thyroid tissue stiffness was higher in SAT at baseline (214.26 ± 32.5 kPa) in comparison with values recorded at a 4-week follow-up (45.92 ± 17.4 kPa) and at 10 weeks following diagnosis and treatment initiation (21.65 ± 5.3 kPa, P < 0.0001). Baseline thyroid stiffness in SAT was higher than that found in CAT (36.15 ± 18.7 kPa, P < 0.0001) and CS (16.18 ± 5.4 kPa, P < 0.0001). In the remission of SAT, thyroid stiffness was lower than that found in CAT (P = 0.006), while it was higher than that in CS (P = 0.0008). No difference was observed between thyroid stiffness in SAT at 4-week follow-up and in CAT. Patients with CAT presented higher thyroid stiffness than CS (P < 0.0001), which was not influenced by L-thyroxine treatment. Thyroid stiffness in patients with AT was 216.6 and 241.9 kPa at baseline; after treatment, it decreased to 17.93 and 85.348 kPa respectively. Sonoelastography may assist in the diagnosis and treatment monitoring of AT, SAT and CAT, as well as in the differentiation of the various types of thyroiditis.

Subacute thyroiditis is thought to be virally induced in genetically predisposed individuals because a strong association has been suggested recently between HLA-B35 and patients in whom subacute thyroiditis has developed. Two identical twin brothers were seen at our clinic with the same symptoms and date of onset of hyperthyroidism and enlargement and tenderness of the thyroid, which gave us a unique opportunity to study the genetic predisposition and treatment of this thyroid disease. Diagnostic criteria for subacute thyroiditis were met in both twins, including hyperthyroxinemia, suppression of thyroidal 123I uptake, increased erythrocyte sedimentation rate, transient painful goiter, and absence of antimicrosomal antibodies. Twin B was treated with corticosteroids, and a nonsteroidal anti-inflammatory agent was prescribed for Twin A. The mode of treatment used did not make a difference in affecting the course of the disease. The erythrocyte sedimentation rate was normal after 2 months from onset of symptoms. Results of viral studies were inconclusive. The same HLA typing was found in each twin: A3, B18, B35, Cw4, DR2, DRw10, DQw1. Thus, each was heterozygous for HLA-B35. We reviewed the literature and found a strong association between HLA-B35 and subacute thyroiditis in various ethnic groups tested. Our experience with these identical twins provides additional evidence to suggest that HLA-35 and perhaps Cw4 confer genetic susceptibility in acquiring subacute painful thyroiditis in a possible dominant mode of inheritance.

The occurrence of subacute thyroiditis (SAT) after vaccines or after hyaluronic acid skin fillers is very rare and might be related to genetic susceptibility. We suggest that the co-administration of both products could potentially increase the possibility of development of SAT. A 58-year-old Caucasian healthy female initially presented with chills, myalgia, dysphagia, sore throat, dry cough, fatigue, and intermittent fever of 38.5°C orally after simultaneous injection of an influenza vaccine and a dermal filler containing hyaluronic acid. Ten days later the patient developed palpitations and neck pain radiating to the left jaw. She was diagnosed with SAT on day 16 after her first visit and responded promptly to etoricoxib treatment. The patient progressed clinically from hyperthyroidism to euthyroid state and eventually to hypothyroidism and further testing showed she had HLA B-35 haplotype. Physicians should be aware that SAT might be associated with the administration an influenza vaccine and this possible association might increase if the vaccine was co-administered with a dermal filler.

The term "thyroiditis" refers to several syndromes of differing etiology. Chronic or Hashimoto's thyroiditis (HT), an autoimmune disorder that is manifested by goiter and hypothyroidism, is by far the most common of these syndromes. Subacute thyroiditis (SAT) encompasses two distinct syndromes: subacute granulomatous thyroiditis (SAGT) and subacute lymphocytic thyroiditis (SLT). SAGT is viral in origin and usually presents with neck tenderness and hyperthyroid symptoms, while SLT, which is likely to be an autoimmune entity, results in goiter and transient hyperthyroidism. SLT is often seen in the postpartum period and is referred to as postpartum thyroiditis (PPT). Less common forms of thyroiditis include Riedel's struma, which is characterized by extensive fibrosis of the thyroid gland, and acute suppurative thyroiditis, which is a bacterial infection. Twenty patients with goiter were evaluated by thyroid scintigraphy. They were ultimately diagnosed as having either HT (14), SAGT (3), SLT (1), or PPT (2). Their scan findings were correlated with both clinical presentations as well as in vitro laboratory analysis.

To describe the sonographic characteristics of subacute granulomatous (De Quervain) thyroiditis. We retrospectively identified all patients at our institution during the last 11 years who had thyroid sonography with findings suggestive of subacute granulomatous thyroiditis. We then reviewed clinical data and laboratory results to establish the clinical diagnosis. A final diagnosis of subacute granulomatous thyroiditis was made on the basis of clinical symptoms, suppressed thyrotropin, an elevated erythrocyte sedimentation rate, and/or reduced or absent radionuclide uptake while hyperthyroid. Our study population consisted of 35 patients. Twenty-seven patients (79.4%) met clinical criteria for subacute thyroiditis. Symptoms included neck pain in 26 of 27 patients with subacute thyroiditis. The erythrocyte sedimentation rate ranged from 22 to 101 mm/h. In 21 cases (77.8%), sonography revealed focal, poorly defined, nonovoid areas of decreased echogenicity. Findings were bilateral in 16 patients and unilateral in 5. In the remaining 6, the gland or an entire lobe was diffusely heterogeneous. Color Doppler interrogation was performed in 20 patients. Flow was decreased to the sonographically abnormal areas in 19 (95%) and slightly increased in 1 patient. In all 9 patients who underwent radionuclide scanning, focal defects or large areas of decreased or absent uptake were found during the time of suppressed thyrotropin. Enlarged lymph nodes were noted in 16 patients (59.3%). The positive predictive value of sonography for diagnosing subacute granulomatous thyroiditis is 79.4%. The most common sonographic appearance is poorly defined regions of decreased echogenicity with decreased vascularity in the affected areas.

WITHIN the past decade and particularly within the past 5 years, an unusual form of hyperthyroidism has received increasing attention (1–22). The hyperthyroid manifestations are generally self limiting, although some cases relapse, are accompanied by chronic inflammatory changes within the thyroid parenchyma, and are marked by a very low 131I uptake. Despite the usually abrupt onset of symptoms and the diffuse lymphocytic infiltration, thyroidal pain and/or tenderness is completely absent. Because this syndrome overlaps many of the features of both lymphocytic thyroiditis and subacute thyroiditis, there has been much debate about how to categorize it or whether to consider it a new disease entity. Nomenclature used by the several groups describing it includes: painless thyroiditis (7, 11, 17, 20), silent thyroiditis (3, 9, 19, 22), occult subacute thyroiditis (1), painless subacute thyroiditis (10, 14), subacute nonsuppurative thyroiditis (2), atypical (“silent”) subacute thyroiditis (16), lymphocytic thy...

Common human leucocyte antigensassociated with the development of subacute thyroiditis and COVID-19

Diagnostic accuracy of thyroid/background ratio in distinguishing Graves' disease from subacute thyroiditis: A comparative study.

Vitamin D (VD) deficiency has become a global public health problem, and published studies have demonstrated that patients with subacute thyroiditis (SAT) have worse VD nutritional status and that VD supplementation may alleviate thyroid-related diseases by fighting against infections and mediating autoimmunity. This study explored the correlation between serum VD levels and the risk and extent of disease in patients with SAT. A case-control study. We included patients with SAT diagnosed at the First People's Hospital of Jining City between September 2021 and September 2023 and a healthy population during the same period. We collected clinical and laboratory data to determine differences in VD levels between the two populations and identify risk factors for the onset and extent of SAT. The 25(OH)D level of SAT patients was significantly lower than that of the healthy population (p < 0.05). Multifactorial logistic regression analysis showed that low 25(OH)D level, low body mass index (BMI), elevated leukocytes, and low lymphocyte count were independent risk factors for SAT. No significant difference was noted in VD levels between patients with mild SAT and those with moderately severe SAT (p > 0.05). Additionally, fever, thyroid tenderness, high BMI, and elevated free thyroxine (FT4) were independent risk factors for SAT severity; serum 25(OH)D levels were positively correlated with FT4/FT3 levels in SAT patients. VD levels are lower in patients with SAT than in healthy controls, and low VD levels increase SAT risk. Although VD levels are not related to SAT severity, adequate VD inhibits the conversion of FT4 to FT3, likely playing a protective role in SAT development.

Background: Hyperthyroidism, as well as systemic inflammation, are associated with a higher incidence and complications of cardiovascular disease. Both in Graves’ disease and subacute thyroiditis, patients are hyperthyroid. However, in Graves’ disease, there is an autoimmune process in the thyroid, and in subacute thyroiditis, hyperthyroidism is accompanied by systemic inflammation. It is not known if the rate of cardiovascular complications is higher in the course of Graves’ disease or subacute thyroiditis.. Methods: We performed a retrospective study of all hyperthyroid patients newly diagnosed with Graves’ disease or subacute thyroiditis between January 1st 2018 and December 31st 2021 at the Department of Nuclear Medicine, University Medical Centre Ljubljana. Cardiovascular complications in the period 3 months before or after diagnosis were registered. Values are expressed as mean (SD).. Results: The sample analysis included 1028 patients (247 with subacute thyroiditis, 781 with Graves’ disease). The two groups did not significantly differ by sex, age, and body mass index. A cardiovascular complication was registered in 78 patients; the incidence was significantly higher in Graves’ disease than in subacute thyroiditis (74 vs. 4, p&lt;0.001). Compared to patients with subacute thyroiditis, patients with Graves’ disease had significantly lower TSH: 0.010 (0.006) vs. 0.024 (0.044) mIU/L (p&lt;0.001), higher free T4: 44.1 (26.6) vs. 37.0 (14.7) pmol/L (p&lt;0.001), higher incidence of diabetes: 4.3 vs. 0.4% (p=0.001), arterial hypertension: 12.2 vs. 5.7% (p=0.004) and smoking: 26.7 vs. 8.7% (p&lt;0.001). In a logistic regression model, a significantly higher likelihood for cardiovascular complications was found in Graves’ disease vs. subacute thyroiditis (odds ratio 5.82, p=0.001), in patients with arterial hypertension (odds ratio 2.83, p=0.002), and in those with higher body mass index (odds ratio 0.92, p=0.043).. Conclusion: We report a higher incidence of cardiovascular complications in hyperthyroid patients with Graves’ disease in comparison to hyperthyroid patients with subacute thyroiditis. Patients with Graves’ disease were more severely hyperthyroid and had more adverse cardiovascular risk factors.

Background: This study aims to research the relationship of subacute thyroiditis with SARS-CoV-2. The prevailing risks of predisposition to certain diseases or organ dysfunctions even after surviving the disease are discussed more frequently each day. Aim: Could SARS-CoV-2 be considered as a triggering factor in patients diagnosed with subacute thyroiditis? Investigating the relationship between subacute thyroiditis and SARS-CoV-2. Methods: Thirty-three patients diagnosed with subacute thyroiditis between 01.11.2020 and 01.04.2020 were included in the study. Patients who tested positive for SARS-CoV-2 throughout the examinations performed at the time of the diagnosis for subacute thyroiditis and patients who were previously diagnosed with Covid-19, who tested positive for SARS-CoV-2, and subsequently diagnosed with subacute thyroiditis within 30 days have been included in the study. Clinical evaluation of the patient, thyroid hormone values, CRP values, sedimentation levels, and thyroid ultrasonography images were considered to diagnose subacute thyroiditis; patients whose results were compatible with subacute thyroiditis were diagnosed with subacute thyroiditis, and they were included in the study. Results: It was found that 5 (15%) of the 33 patients included in the study had Covid-19 disease before the diagnosis of subacute thyroiditis and were isolated for the SARS-CoV-2 virus. Conclusion: The SARS-CoV-2 virus can be considered a triggering factor for subacute thyroiditis. We believe that researching this relationship on a broader patient population will bring more clarity to the subject. Although encountered in only one of our cases, the Coronavirus vaccine and SAT relationship may shed light on future studies. Keywords: Subacute thyroiditis, SARS-CoV-2, COVID-19

This is a review of full-length articles strictly concerning subacute thyroiditis (SAT) in relation to the SARS-CoV-2 virus infection (SVI) and COVID-19 vaccine (COV) that were published between the 1st of March 2020 and the 21st of March 2022 in PubMed-indexed journals. A total of 161 cases were reported as follows: 81 cases of SAT–SVI (2 retrospective studies, 5 case series, and 29 case reports), 80 respective cases of SAT–COV (1 longitudinal study, 14 case series, 17 case reports; also, 1 prospective study included 12 patients, with 6 patients in each category). To our knowledge, this represents the largest cohort of reported cases until the present time. SAT–SVI was detected in adults aged between 18 and 85 years, mostly in middle-aged females. SAT–COVID-19 timing classifies SAT as viral (synchronous with infection, which is an original feature of SATs that usually follow a viral infection) and post-viral (during the recovery period or after infection, usually within 6 to 8 weeks, up to a maximum 24 weeks). The clinical spectrum has two patterns: either that accompanying a severe COVID-19 infection with multi-organ spreading (most frequent with lung involvement) or as an asymptomatic infection, with SAT being the single manifestation or the first presentation. Either way, SAT may remain unrecognized. Some data suggest that more intense neck pain, more frequent fever, and more frequent hypothyroidism at 3 months are identified when compared with non-SAT–SVI, but other authors have identified similar presentations and outcomes. Post-COVID-19 fatigue may be due to residual post-SAT hypothyroidism. The practical importance of SAT–SVI derives from the fact that thyroid hormone anomalies aggravate the general status of severe infections (particular concerns being tachycardia/arrhythmias, cardiac insufficiency, and ischemic events). If misdiagnosed, SAT results in unnecessary treatment with anti-thyroid drugs or even antibiotics for fever of unknown cause. Once recognized, SAT does not seem to require a particular approach when compared with non-COVID-19 cases, including the need for glucocorticoid therapy and the rate of permanent hypothyroidism. A complete resolution of thyroid hormone anomalies and inflammation is expected, except for cases with persistent hypothyroidism. SAT–COV follows within a few hours to a few weeks, with an average of 2 weeks (no particular pattern is related to the first or second vaccine dose). Pathogenesis includes molecular mimicry and immunoinflammatory anomalies, and some have suggested that this is part of ASIA syndrome (autoimmune/inflammatory syndrome induced by adjuvants). An alternative hypothesis to vaccine-related increased autoimmunity is vaccine-induced hyperviscosity; however, this is supported by incomplete evidence. From what we know so far concerning the risk factors, a prior episode of non-SVI–SAT is not associated with a higher risk of SAT–COV, nor is a previous history of coronavirus infection by itself. Post-vaccine SAT usually has a less severe presentation and a good outcome. Generally, the female sex is prone to developing any type of SAT. HLA susceptibility is probably related to both new types of SATs. The current low level of statistical evidence is expected to change in the future. Practitioners should be aware of SAT–COV, which does not restrict immunization protocols in any case.

This study sought to assess the utility of the inflammatory burden index (IBI) in differentiating subacute thyroiditis (SAT) from Graves' disease (GD) and to investigate its association with recovery time, hepatic function impairment, recurrence, and permanent hypothyroidism in patients with SAT. Clinical and laboratory data from 357 adult patients with SAT, 412 patients with GD, and 633 healthy controls were retrospectively analyzed. Determinants influencing recovery time, hepatic function impairment, recurrence, and permanent hypothyroidism in patients with SAT were systematically evaluated. The IBI in the SAT cohort was markedly higher than that observed in both patients with GD and healthy controls. Receiver operating characteristic curve analysis indicated that the optimal IBI cutoff value for distinguishing SAT from GD was 9.13, yielding a diagnostic sensitivity of 90.76%, a specificity of 88.35%, and an area under the curve (AUC) of 0.944 (95% confidence interval, 0.927 to 0.961). The AUC for IBI was markedly superior to those for erythrocyte sedimentation rate (ESR), C-reactive protein, systemic immune-inflammation index, and other complete blood count-derived indices. Among patients with painless SAT, the IBI was markedly elevated compared with that in thyroid-stimulating hormone receptor antibody (TRAb)-negative GD patients. Stepwise multiple logistic regression identified ESR, IBI, free thyroxine, and thyroid-stimulating hormone as independent predictive factors for SAT. IBI was not associated with recovery time in patients with SAT. However, higher IBI values were observed in patients requiring glucocorticoid therapy due to an insufficient response to non-steroidal anti-inflammatory drugs. Furthermore, no significant associations were identified between IBI and hepatic function impairment, recurrence, or permanent hypothyroidism in patients with SAT. IBI, as a simple and practical inflammatory biomarker, could potentially serve as a valuable diagnostic tool for differentiating SAT, particularly in diagnostically challenging cases. Moreover, it may have clinical relevance in guiding therapeutic decision- making for patients with SAT.