Subacute Thyroiditis Research Articles

Long-term Thyroid Outcomes After COVID-19 Vaccination: A Cohort Study of 2,333,496 Patients from the TriNetX Network.

Reports on long-term thyroid dysfunction following COVID-19 vaccination are limited. Understanding the risk of subacute thyroiditis, hyperthyroidism, and hypothyroidism in vaccinated individuals is crucial for post-vaccination monitoring. This study evaluated the risk of thyroid dysfunction in COVID-19 vaccinated individuals compared to unvaccinated individuals using a large cohort. We conducted a retrospective cohort study from January 1, 2022, to December 31, 2023, using the TriNetX database, including 1,166,748 vaccinated and 1,166,748 unvaccinated individuals. Propensity score matching was used to balance baseline characteristics. The primary outcomes were new diagnoses of subacute thyroiditis, hyperthyroidism, and hypothyroidism. The risk of subacute thyroiditis remained unchanged (95% confidence intervals [CIs] included 1). A significant reduction in hyperthyroidism risk was observed from 3 to 9 months post-vaccination (hazard ratios [HRs]: 0.65-0.89, all 95% CIs below 1), but this trend was not significant at 12 months (HR: 0.99, 95% CI: 0.92-1.06). In contrast, the risk of hypothyroidism significantly increased from 6 to 12 months post-vaccination (HR: 1.14-1.30, all 95% CIs above 1). Among mRNA vaccine recipients, the risk of both hyperthyroidism and hypothyroidism was significantly elevated at 12 months (HR: 1.16-2.13). COVID-19 vaccination was associated with a reduced risk of hyperthyroidism and an increased risk of hypothyroidism, highlighting the need for ongoing thyroid function monitoring.

P-56 THE CASE OF SUBACUTE THYROIDITIS IN AN ELDERLY PATIENT MIMICKING MALIGNANCY

Abstract Introduction Subacute thyroiditis is a self-limiting inflammatory thyroid disease characterized by fever, neck pain, and thyroid dysfunction. It typically appears following an upper respiratory tract viral infection. Most cases of subacute thyroiditis are diagnosed through clinical and laboratory testing. The thyroid gland is large, painful, and tender during thyroid examination. Blood tests typically reveal elevated levels of free T4 and free T3, as well as a significantly increased sedimentation rate and C-reactive protein (CRP). Ultrasonographic findings of subacute thyroiditis are well defined. Clinical Case A 68-year-old male was consulted by the anesthesia department before the endoscopy and colonoscopy procedure planned to screen for malignancy. He was very worried and afraid because of the possibility of cancer and was psychologically negatively affected. He presented with night sweats and 10 kg of weight loss in the last 6 weeks. He had no history of previous disease. When a detailed history was taken, he stated that he had severe pain in his neck before his complaints started and that it went away on its own after a few weeks. On examination, he had no fever, a heart rate of 90 beats per minute, and a blood pressure of 120/80 mmHg. Neck examination showed no thyromegaly or lymphadenopathy. The general and systemic examination was unremarkable. Laboratory investigations showed hemoglobin 12.2 g/dL, WBC 8380 (x109/L), erythrocyte sedimentation rate (ESR) 78 mm/hour, CRP 50.1 mg/L, thyroid stimulating hormone 0.08 mIU/L (N = 0.55 – 4.78 mIU/L), free t4 1.4 ng/dL (N = 0.89 – 1.76 ng/dL), free t3 4.34 ng/L (N = 2.3 - 4.2 ng/L), and negative anti-thyroid peroxidase and thyroid stimulating immunglobulin. Thyroid ultrasonography was suggestive for subacute thyroiditis. He was given NSAIDS. Since his free T4 and T3 levels were normal at follow-up, endocrinological approval was given for the planned procedures. It was recommended to have a beta blocker ready during the procedure if needed. No findings in favor of cancer were detected in the detailed examinations, and the weight loss was attributed to subacute thyroiditis. Conclusion When elderly patients have complaints of weight loss or fatigue, it is important to exclude thyrotoxicosis and make a diagnosis by performing the necessary examinations. Subacute thyroiditis may not be severe; it is easy to diagnose with careful history-taking and simple laboratory examinations, and clinicians should keep it in mind in the differential diagnosis of weight loss.

The Importance of Laboratory Parameters in the Differential Diagnosis of Graves' Disease and Subacute Thyroiditis

Abstract Introduction Graves' disease and subacute thyroiditis (SAT) are two of the most common causes of thyrotoxicosis. free T3 to free T4 ratio (fT3/fT4), neutrophil to lymphocyte ratio (NLR) and mean platelet volume (MPV) have not been analysed in detail for diagnosis in previous studies. Materials and Methods A total of 141 patients with subacute thyroiditis, 133 with Graves' disease and 126 healthy volunteers were included in the study. Thyroid stimulating hormone (TSH), fT3, fT4, C-reactive protein (CRP), MPV, NLR, erythrocyte sedimentation rate (ESR) and TSH receptor antibody (TRAb) levels were recorded. The laboratory parameters were compared between the two groups. ROC analysis was performed to evaluate fT3/fT4 ratio, ft4/TSH ratio, NLR and MPV to aid diagnosis, as well as cut-off values, sensitivity and specificity. Results The fT3/fT4 ratio was significantly different between the subacute thyroiditis (SAT) and Graves' disease groups (2.45 ± 0.68 vs. 3.48 ± 1.8, p < 0.01). The MPV was lowest in the SAT group (8.83 ± 1.29). The NLR ratio was highest in the SAT group (2.84 ± 1.48 p < 0.01). The fT4/TSH ratio was highest in the Graves group (461.85 ± 536.2 p < 0.01).The AUC of ft3/ft4 ratio for estimating Graves' disease was 0.773, the specificity was 77.9%, the sensitivity was 66.2% (p < 0.01), and the cut-off value was 2.95. The AUC of the NLR ratio for the assessment of SAT was 0.742, the specificity was 80% and the sensitivity was 50% (p = 0.02). Conclusions The ratio of fT3 to fT4, fT4/TSH ratio, MPV and NLR differ significantly between SAT and Graves’ disease and can provide helpful information in the differential diagnosis.

Presentation and Surgical Outcomes of Primary Hyperparathyroidism After Radioactive Iodine Therapy.

Radioactive iodine (RAI) is a common treatment for various thyroid diseases. Previous studies have suggested susceptibility of parathyroid glands to the mutagenic effect of RAI and the development of primary hyperparathyroidism (PHPT). We tested the possible link between prior RAI treatment, disease presentation, and treatment outcomes. A retrospective analysis of 704 individuals who underwent parathyroidectomy for PHPT at a tertiary care center between the years 2015 and 2023 was performed. Preoperative and postoperative parameters, including demographic characteristics, biochemical markers, imaging data, and surgical and pathology findings were collected and analyzed to compare differences in patients who had previous RAI treatment and those who did not (non-RAI). Univariate statistical analyses were performed. Twenty-nine patients had a history of RAI treatment. Indications for RAI treatment included hyperthyroidism (n=18), papillary thyroid cancer (n=6), subacute thyroiditis (n=1), follicular cancer (n=1), and toxic goiter (n=1). Average latency time between RAI exposure and development of PHPT was 18.4ys. On comparison of the two groups, there was no difference in age, sex, race/ethnicity, day of surgery body mass index, preoperative parathyroid hormone, calcium, glomerular filtration rate, creatinine, vitamin D, or phosphate levels. There was also no difference in preoperative diagnosis of osteoporosis or nephrolithiasis. Postoperatively, there was no difference in parathyroid hormone, calcium, or creatinine levels, or in rate of cure. There was significantly higher chance of unilateral exploration in the operating room (75.9% RAI, 54.1% non-RAI, P=0.02) and increased rate of single-gland disease in the RAI group, although the latter finding was not statistically significant (79.3% RAI, 65.2% non-RAI, P=0.12). There was no difference in adenoma size as noted on the pathology report (greatest dimension 1.7cm RAI, 1.7cm non-RAI, P=0.28). Subgroup analysis of the RAI group based on reason for RAI treatment (cancer versus hyperthyroidism) showed no statistically significant differences in the examined demographic or clinical data. There does not seem to be a relationship between prior RAI treatment and the clinical presentation of PHPT. Additionally, differences in RAI dose do not appear to be associated with a change in clinical presentation. Our study revalidates that age and latency are inversely related, which is a previously shown finding. Clinicians may be reassured that patients with prior RAI history may not have differences in clinical characteristics, disease presentation, or treatment outcomes.

Subacute thyroiditis - Is it really linked to viral infection? Retrospective hospital patient registry study.

Subacute thyroiditis (SAT) is a painful inflammatory disorder of the thyroid gland, which - after a phase of thyrotoxicosis - leads to transient, or less frequently permanent hypothyroidism. Apart from a strong association with specific HLA alleles, the causes are uncertain. Viral disease has been hypothesised as a trigger, with Enteroviruses, namely Echoviruses and Coxsackieviruses, showing a seasonal distribution that coincides with the incidence of SAT. In the first year of the COVID-19 pandemic, strict hygiene measures led to a sharp decline in infections and thus offered the opportunity to test this hypothesis. We analysed national registry data of hospitalised patients from Germany during the years 2015 to 2022 (Federal statistical Office (Destatis), Wiesbaden, Germany) and surveillance data on infectious diseases from the same years (clinical-virology.net and RKI). Statistical analysis includes modelling of seasonality by month, polynomial autoregression and Granger causality to assess dependency of future SAT frequencies from past ones, and association of virus incidence to SAT frequency, respectively. Our study confirms previously described epidemiological findings with higher incidence in females and a seasonal peak in late summer coinciding with the seasonality of enteroviruses until 2019. In 2020, the pattern remained unchanged, except for the marked reduction of enteroviruses and other pathogens (except SARS-CoV-2) due to hygienic measures. Moreover, the SAT seasonality in the years 2021 and 2022 was apparently unaltered through the COVID-19 pandemic. Our study provides strong evidence that despite their seasonal pattern, Echoviruses and Coxsackieviruses are not the cause of SAT. Moreover, no other analysed virus (including Influenza A and B, Parainfluenza, Rhinovirus, Human Coronaviruses including SARS-CoV-2) showed any association.

Proteomics unveil candidate biomarkers and pathogenesis of subacute thyroiditis.

Subacute thyroiditis (SAT) is an inflammatory thyroid disease characterized by neck pain, tenderness, general symptoms, and thyroid dysfunction. Despite gaining new insights into the epidemiology, pathogenesis, and treatment of SAT in recent years, the exact pathogenesis and determinants of its clinical progression remain unclear. Here, we profiled thyroid in situ protein alterations in fine needle aspiration biopsy samples from SAT patients using proteomic analysis and uncovered 57 differentially abundant proteins. Gene Ontology and KEGG enrichment analyses identified that these proteins were enriched in processes involving infection, inflammatory response, and cell adhesion and junction, which likely contribute to the pathogenesis. Moreover, the top three high-abundance proteins (NNMT, FTL, and TYMP) were further validated in the plasma from a larger SAT cohort using an enzyme-linked immunosorbent assay. After adjusting for sex, Spearman correlation analysis showed that NNMT, FTL, and TYMP levels were positively correlated with FT3, FT4, T3, T4, Tg, and ESR and negatively correlated with TSH. Furthermore, binary logistic regression analyses revealed that NNMT, FTL, and TYMP were independent factors of SAT. We also conducted a receiver operating characteristic (ROC) curve analysis to assess the diagnostic accuracy of NNMT, FTL, and TYMP for SAT. The results revealed that each factor demonstrated an area under the curve (AUC) score above 0.8. Thus, these high-abundance proteins can potentially serve as biomarkers for SAT diagnosis and outcome prediction. Our findings provide valuable insights into SAT biomarkers, and shed light on the potential pathogenesis and therapeutic targets of SAT.

The Impact of COVID-19 Vaccination on Thyroid Disease in 7 Million Adult and 0.2 Million Adolescent Vaccine Recipients.

Emerging reports have raised concerns regarding the potential link between COVID-19 vaccination and thyroid dysfunction, specifically thyroiditis. This study aimed to investigate the potential association between COVID-19 vaccination and the prevalence of thyroid diseases using data from a Korean national cohort. This study included 7,579,210 adult and 241,063 adolescent vaccine recipients. A self-controlled case series design was applied to estimate the incidence rate ratio (IRR) of thyroid disease during the 55-day post-vaccination period (first and second dose) compared to the baseline period (non-exposure period) using conditional Poisson regression. In the adult population, IRRs for hyperthyroidism, hypothyroidism, subacute thyroiditis, and thyroid eye disease were 0.98 (95% CI 0.89-1.09), 0.91 (95% CI 0.84-0.98), 1.27 (95% CI 0.94-1.72), and 0.68 (95% CI 0.50-0.93) after the first vaccine dose and 0.96 (95% CI 0.87-1.06), 0.93 (95% CI 0.87-0.99), 1.32 (95% CI 0.96-1.80), and 1.06 (95% CI 0.81-1.38) after the second vaccine dose. While the risk of hyperthyroidism recurrence did not increase after vaccination, we observed an increased risk of hypothyroidism exacerbation. Subgroup analyses based on age, sex, and vaccine type revealed no significant differences in the incidence of thyroid diseases. In adolescents aged 12-17 years, no increase in the risk of thyroid disease was observed after vaccination. This extensive national self-controlled case series analysis found an increased risk of exacerbation of hypothyroidism following COVID-19 vaccination. However, no significant association was observed between COVID-19 vaccination and an increased risk of most other thyroid diseases. These findings contribute to increasing evidence supporting the safety of COVID-19 vaccination in relation to thyroid health.

A higher incidence of cardiovascular complications in hyperthyroid patients with Graves’ disease in comparison to hyperthyroid patients with subacute thyroiditis

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<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<0.001), higher free T4: 44.1 (26.6) vs. 37.0 (14.7) pmol/L (p<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<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.

Epidemiology and Gender Variation in Thyroid Malignancies: A Retrospective Study of a Tertiary Care Center

Abstract Background: Thyroid malignancies are among the most common endocrine cancers, ranking ninth in incidence. In Saudi Arabia, thyroid cancer rates have significantly increased in both genders. Despite the rising incidence, mortality rates have declined. The evolving epidemiology of thyroid malignancies in Saudi Arabia reflects changes in demographics, culture, and clinical practices. This study aims to update the epidemiological data and examine gender variations in thyroid malignancies. Materials and Methods: This retrospective study included cases admitted to an academic tertiary care center from January 2023 to June 2024. Data on demographic variables (gender, age, and nationality) and clinical diagnosis categories (ranging from nondiagnostic to malignant) were collected. Histopathological details of thyroid lesions were also recorded. Clinical, cytological, and histopathological data were as per the Bethesda system, and they were analyzed accordingly. Results: The average age of 300 patients in our study cohort was 45.56 years, with 81.3% of them being female. The majority of patients were Saudi nationals (87.7%). According to the Bethesda system, the most common findings for lesions were benign (category II), followed by malignant (category VI) and atypia of undetermined significance (AUS; category III). Histopathologically, 52.7% showed benign features, with hyperplastic thyroid lesions (20.7%) and follicular adenomas (14.3%) being the most common. The most common malignancy was papillary carcinoma (42.7%). Age-specific analysis revealed differences, with younger patients more likely to have follicular neoplasm/suspicious for follicular neoplasm (category IV) and older patients having a higher risk of malignancy. Other variables including colloid cyst, subacute granulomatous thyroiditis, follicular carcinoma, Hürthle cell type, and medullary carcinoma were not statistically associated with any age group. Conclusion: Our findings are consistent with global trends indicating a significant increase in thyroid cancers, particularly among women. In our cohort, female patients were diagnosed with thyroid cancer nearly four times more frequently than male patients, which is double the commonly reported gender gap. There were statistically significant differences between genders in age groups, malignancies, and histopathological findings, with hyperplastic thyroid lesions and papillary carcinoma being more common in women. We also observed age-related differences in thyroid findings, with younger patients having more follicular neoplasms and older patients having more AUS.

Tiroiditis subaguda post dengue en una mujer peruana: reporte de caso y revisión de la literatura

Expanded dengue syndrome are unusual conditions, such as subacute thyroiditis (SAT). We present the case of a 38-year-old woman who had dengue without alarm signs for a month, along with cervical pain and increased cervical volume, palpitations, tremor and dysphagia. Hormonal evaluation, ultrasound andthyroid scintigraphy were consistent with SAT. She received corticoids for two months, with remission afterfour months. SAT is characterized by neck pain, fever and symptoms of thyrotoxicosis. It is associated withviral infections and it comprises a phase of thyrotoxicosis followed by hypothyroidism. Diagnosis involves hormonal and biochemical tests, thyroid ultrasound with Doppler and scintigraphy. This condition is managed with non-steroidal anti-inflammatory drugs and corticosteroids, according to severity. SAT, an infrequent manifestation of dengue, requires a high degree of suspicion and appropriate management. A review of published cases of SAT due to dengue was carried out in the Scopus, PubMed and Web of Science databases, finding six reported cases, mostly in men.

Coexisting parathyroid adenoma, thyroid carcinoma, and tuberculosis of thyroid: a case report

BackgroundCoexisting parathyroid adenoma, thyroid carcinoma, and tuberculosis of thyroid is a very rare phenomenon. Primary thyroid tuberculosis is itself very rare despite high global prevalence of tuberculosis in developing countries. Majority of thyroid tuberculosis identified in postoperative histopathology or cytopathology. The coexistence of thyroid cancer with tuberculosis or parathyroid adenoma has been reported in the literature but not a single case of the three pathologies coexisting together has been found in the literature published. We are presenting a rare case of a constellation of synchronous parathyroid adenoma, thyroid carcinoma, and thyroid tuberculosis. This case report will provoke researchers to work on understanding the association of hypercalcemia or chronic inflammation leading to development of malignancy or parathyroid adenoma in the presence of hypothyroidism will give future perspective in managing such patients.Case presentationA Islam lady aged 45 years old, diagnosed with hypothyroidism, was evaluated for pregnancy loss and rapid weight gain from 13 years back and started on tablets of levothyroxine 25 µg once daily. She was doing well until the past 2 years; there after she noticed insidious onset of a swelling over anterior aspect of right side of the neck and bone pain in back and lower limbs. Patient underwent routine investigations and was found to have raised serum calcium (11.4 mg/dl) and parathyroid hormone (253 pg/ml). Anti-thyroid peroxidase (TPO) and anti-thyroglobulin (Tg) level were normal. Ultrasounds showed multiple nodules in both lobe of thyroid and left inferior parathyroid adenoma. The patient underwent total thyroidectomy with left inferior parathyroidectomy, and final histopathology showed features of subacute granulomatous thyroiditis along with hurthle cell change in right lobe of thyroid. The left lobe additionally showed necrotizing epitheloid cell granulomas, which on Zeihl–Neelson staining revealed presence of acid-fast bacilli. Sections from the isthmus show a focus of papillary thyroid microcarcinoma. The left inferior parathyroid gland sent as a frozen sample was found to be parathyroid adenoma. On 6-month follow-up, the patient was feeling much relief in bone pain and tolerating antitubercular drugs uneventfully.ConclusionCoexistence of parathyroid adenoma, nonmedullary thyroid carcinoma, and thyroid tuberculosis is extremely rare. Surgery is curative for hyper parathyroidism and thyroid carcinoma. Thyroid tuberculosis responds well to current antitubercular drugs. Its etiology needs to be explored more; the probable hypothesis is chronic inflammation due to latent tuberculosis might leads to development of thyroid carcinoma and parathyroid adenoma. Further studies need to be done for better understanding of underlying mechanism and better management options for such patients. To the best of our knowledge, similar cases have not been reported.

Association of COVID-19 with thyroid dysfunction and autoimmune thyroid disease: A retrospective cohort study

BackgroundSince the end of the COVID-19 pandemic, the potential roles of thyroid-inflammatory derangements in driving or being associated with the prognosis of COVID-19 remain controversial. We aimed to clarify the association between COVID-19 infection and thyroid dysfunction, and highlight the impacts of subsequent autoimmune thyroid disease (AITD) on the prognosis of COVID-19. MethodsThe retrospective, multicenter, cohort study enrolled 2,339 participants with COVID-19 from three hospitals located in the north, middle, and south regions of Shaan Xi Province, China, between December 2022 and July 2023. 464 non-COVID-19 patients within the same period were supplemented, divided into groups with and without AITD. At hospital admission (baseline), 3- and 6-month follow-ups, we presented a dynamic description and correlation analysis of thyroid-inflammatory-autoimmune derangements in patients with AITD. ResultsA total of 2,082 COVID-19 patients diagnosed with AITD and 257 cases without AITD were included in the study, and 464 non-COVID-19 patients were supplemented, dividing into 14 AITD and 450 non-AITD cases. We found that COVID-19 infection was closely associated with thyroid dysfunction (χ2 = 1518.129, p = 0.000). AITD patients with COVID-19 showed a higher prevalence of symptoms and comorbidities and longer hospital stays at baseline than non-AITD patients with COVID-19 (p = 0.000, p = 0.000, and p = 0.000). The baseline free triiodothyronine (FT3), free thyroxine, and radioactive iodine uptake at 24 h in AITD cases significantly decreased (p = 0.000, p = 0.000, and p = 0.000), while thyroid stimulating hormone, thyroglobulin, reverse triiodothyronine (rT3), and thyroid antibodies varying elevated from the baseline to the follow-up (baseline: p = 0.000, p = 0.000, p = 0.000, p = 0.000, p = 0.000, and p = 0.000; 3-month follow-up: p = 0.000, p = 0.000, p = 0.000, p = 0.000, p = 0.030, and p = 0.000). C-reactive protein, calcitonin, interleukin-6, -8, -10, and tumor necrosis factor-α rose significantly at baseline (p = 0.000, p = 0.000, p = 0.000, p = 0.000, p = 0.000, and p = 0.000) in AITD. Interferon-α and interferon-γ at baseline showed a significant decrease (p = 0.000 and p = 0.000), and remained at low levels after 6 months (p = 0.000 and p = 0.000). FT3 and rT3 were positively and negatively correlated with hospitalization, respectively (r = -0.208 and 0.231; p = 0.000 and p = 0.000). ROC curves showed that FT3 and rT3 had better robustness in predicting severe COVID-19 prognosis (AUC = 0.801 and 0.705). Ordered logistic regression revealed that ORs were 0.370, 0.048, and 0.021 for AITD [(subacute thyroiditis, Grave's disease, and Hashimoto's thyroiditis compared to non-thyroidal illness syndrome (NTIS)] with COVID-19 risk, indicating that NTIS was the predominant risk factor for the severity of COVID-19. ConclusionsA robust association has been identified, wherein COVID-19 infection is closely associated with thyroid dysfunction, and the subsequent AITD may aggravate the poor prognosis of COVID-19.

Difficulties in Diagnosing a Patient with Fever of Unknown Origin

Fever of unknown origin is a difficult syndrome for differential diagnosis. Absence of a key feature, variety of causes and the lack of single examination algorithm makes difficult further diagnosis. The presented clinical case describes a 53-year-old patient with a prolonged fever of more than 1.5 months, pain syndrome in the facial area. During outpatient monitoring, the cause was not clarified. At the inpatient stage, a comprehensive examination was conducted for all classes of causes. The revealed changes in the thyroid gland and thyrotoxicosis made it possible to diagnose subacute thyroiditis. According to the literature, subacute thyroiditis is one of the rare causes of fever of unknown origin. Prescription of glucocorticosteroid made it possible to achieve complete regression of clinical symptoms in 4 days. After 5 months, subclinical hypothyroidism was achieved. The nosological approach and multidisciplinary interaction contributed to the correct tactics and a favorable outcome of the disease.

6594 A Rare Case of Clomiphene Induced De Quervain’s Subacute Thyroiditis

Abstract Disclosure: A. Abdelhameed: None. M. Mortagy: None. A. Elsandouby: None. A. Ghaffar: None. Introduction: Clomiphene is a selective estrogen receptor modulator that stimulates LH release by inhibiting negative feedback on the hypothalamic-pituitary axis. De Quervain’s subacute granulomatous thyroiditis is usually caused by viral infections and less often is drug-induced. We present a case of possible subacute thyroiditis induced by clomiphene. To the best of ourknowledge, this association has not been reported before. Case presentation: A 35-year-old female with a past medical history of unexplained infertility presents to the general medicine clinic with severe neck pain for the last 5 days. Her neck pain started 2 days after the completion of the clomiphene course for induction of ovulation (50 mg daily for 5 days). She denied upper respiratory symptoms. She had an extremely tender thyroid with no palpable nodules. Throat was clear. She was clinically euthyroid with no rash or itching. TSH was 3.9 mIU/L (TSH was normal 6 months prior). ESR was 40 mm/hr. Thyroid ultrasound was unremarkable. She was treated with Ibuprofen for subacute thyroiditis. In the first 2 weeks, the patient complained of increased anxiety. In the next month, she had a missed menstrual cycle. Her pain and tenderness resolved after 50 days. Repeat TSH was 2.4 mIU/L. The patient was advised not to retake clomiphene. Discussion: This is a typical presentation of subacute thyroiditis as persistent thyroid pain and tenderness with elevated ESR. The patient didn’t have the classical symptoms of preceding viral infection. However, her symptoms began immediately after completion of clomiphene course suggesting a temporal relation. The patient didn’t have any history of thyroid problems. She had increased anxiety initially followed by a missed period which suggests clinical thyroid dysfunction.Clomiphene has been associated in the literature with an increased risk of thyroid cancer. Uncontrolled thyroid dysfunction is a contraindication for clomiphene use. This might suggest an interaction between clomiphene and thyroid homeostasis. Subacute thyroiditis could be caused by drugs (e.g., lithium and amiodarone). This suggests that other drugs could lead to subacute thyroiditis such as clomiphene in our case. Conclusion: Clinicians should be aware that clomiphene could be associated with thyroid disorders such as subacute thyroiditis. It is also important to note that thyroid dysfunction is a contraindication for clomiphene use. Presentation: 6/3/2024

7527 Subacute Thyroiditis in First Trimester of Pregnancy: Rare Cause of Thyrotoxicosis

Abstract Disclosure: K. Wilcher: None. A. Gupta: None. Background: Subacute thyroiditis (SAT) is extremely rare in pregnancy with only 8 prior cases reported in the literature. SAT can result in maternal and fetal complications. In this case report, we describe a case of subacute thyroiditis presenting in the first trimester of pregnancy. Case Presentation: A 38-year-old female with past medical history of stillbirth presented with thyrotoxicosis in gestational week 10 of her pregnancy. The patient has a history of stillbirth in gestational week 38 of her first pregnancy requiring cesarean section one year prior to presentation. She was in the process of getting in vitro fertilization (IVF) and had an egg retrieval. During the process, she started on thyroxine 50 mcg daily for blood thyroid-stimulating hormone (TSH) 3.77 mcIU/mL. She became pregnant without the help of IVF and stopped thyroxine. One month later, labs showed low TSH 0.022 mcIU/mL (reference range: 0.4-4.5 mcIU/mL) and high blood free thyroxine (FT4) 1.87 ng/dL (reference range: 0.7-1.8 ng/dL). Repeat labs two weeks later showed low blood TSH 0.012 mcIU/mL, high FT4 2.08 ng/dL, and high blood free triiodothyronine (FT3) 5.2 pg/mL (reference range: 2.3-4.2 pg/mL). She was referred to endocrinology for evaluation. She reported mild intermittent right sided neck pain since diagnosis of pregnancy. She denied any history of viral infection, cough, or fever. She reported symptoms of severe nausea, mild constipation, and mild anxiety. She denied diarrhea, tremors, changes in voice, palpitations, or weight loss. Her family history is significant for hypothyroidism in her father. Physical exam demonstrated a non-tender, symmetric thyroid without enlargement or nodules. Ultrasound showed heterogenous thyroid with an ill-defined heterogenous area in the right lobe appearing pseudo-nodule, and increased vascularity. At this time, the patient was diagnosed with mild gestational hyperthyroidism with a plan to monitor thyroid hormone levels. Repeat labs two weeks later showed low blood TSH 0.005 mcIU/mL, high FT4 2.35 ng/dL, and high FT3 6.4 pg/mL. TSH-receptor antibodies, thyroid stimulating immunoglobulin, and thyroid peroxidase antibodies were normal on testing. In gestational week 16, labs showed normal TSH 2.76 mcIU/mL, low FT4 0.56 ng/dL, and low FT3 2.1 pg/mL. At that time, she started on levothyroxine 75 mcg daily and was diagnosed with subacute thyroiditis. Follow up labs in gestational weeks 18, 20, and 24 showed improvement in TSH and FT4 on thyroid hormone supplementation. Conclusion: This case report discusses the findings of SAT in first trimester pregnancy. Currently, she is in gestational week 28 and still requiring thyroid hormone supplementation. SAT in pregnancy is very rare. This case report significantly contributes to the literature and current knowledge of the prevalence, presentation, and disease process of subacute thyroiditis in first trimester pregnancy. Presentation: 6/2/2024

5039 Chronic Painful Hashimoto's Thyroiditis

Abstract Disclosure: S. Ahmed: None. M. Vahidi Rad: None. S.A. Westphal: None. M.D. Whitaker: None. Introduction: Painful Hashimoto thyroiditis is a rare variant of Hashimoto thyroiditis that mostly affects women. Most cases are empirically treated as subacute thyroiditis with corticosteroids, levothyroxine, or nonsteroidal anti-inflammatory drugs. However, no medical treatment may provide sustained pain resolution, so optimal treatment remains unclear. We describe the case of a 40-year-old female with longstanding throbbing anterior neck discomfort that failed medical therapy and her symptoms completely resolved with total thyroidectomy. Case Report: A 40-year-old lady with anterior neck pain centered over the thyroid for more than 16 years, shortly after she delivered her last child. The pain is described as intense, it tends to wax and wane but there is a constant throbbing with occasional radiation to the angle of the jaw. Over the years the pain has gradually worsened and during its flares, the thyroid itself is very tender to the point where she experiences difficulty in swallowing and hoarseness of voice. Complicating the issue is her underlying diagnosis of fibromyalgia, as she tends to experience discomfort in many other areas of her body. However, the neck pain appears to be of a different character. No symptoms of hyper or hypothyroidism. The anterior neck pain has been difficult to alleviate, she has used chronic opioids for it which seems to have helped to some extent, in the past she was on prednisone for 1 month however this made no difference to it. On examination, the thyroid is tender and somewhat firm without lymphadenopathy. Thyroid levels have been consistently normal and the most recent of which was a TSH: 1.48, FT4: 1.4, FT3: 3.5 with negative TPO and thyroid stimulating antibodies. ESR and CRP were unremarkable. Thyroid ultrasound showed mildly heterogeneous parenchyma with no solid nodules or lymphadenopathy. Interestingly she had an elevated thyroid uptake in her scan dated April 1st 2022, 4 hour and 24-hour uptakes were abnormal at 23% and 49% respectively which can be seen with Hashimoto's. She underwent total thyroidectomy and her surgical pathology showed benign thyroid tissue with multiple foci of chronic lymphocytic thyroiditis and hyperplastic nodules. Her pain completely resolved after total thyroidectomy. Discussion: Painful Hashimoto thyroiditis is a rare diagnosis and optimal treatment remains unclear. The painful variant of Hashimoto's thyroiditis should be considered in the differential diagnosis of pain and tenderness of the thyroid which can be managed successfully by surgical treatment. Thyroidectomy not only can lead to alleviation of symptoms but also provides the definitive diagnosis. The risks of surgical intervention must be taken into consideration, especially because painful Hashimoto thyroiditis can be associated with a small fibrous gland; hence, the importance of access to highly skilled, experienced surgeons cannot be overemphasized. Presentation: 6/1/2024

7504 A Case of Methicillin Sensitive Staphylococcus Aureus Thyroiditis

Abstract Disclosure: K. Patel: None. P. Kachhadia: None. S. Khan: None. F. Akanbi: None. A. Abu Limon: None. S.A. Aldasouqi: None. Introduction: Acute suppurative thyroiditis refers to bacterial infection of the thyroid gland. It is rare as the thyroid gland is typically protected from infection due to isolation of the gland from neighboring structures as well as its rich blood supply and adequate lymphatic drainage. It shares characteristics with subacute and autoimmune thyroiditis which make for difficult diagnosis. Here we present a case of acute suppurative thyroiditis in the setting of methicillin sensitive staphylococcus aureus (MSSA) bacteremia. Case Presentation: We have a 45 year old gentleman with a history of polysubstance abuse who was admitted after a drug overdose. He was being treated for rhabdomyolysis and approximately ten days after admission he became febrile with Tmax 103.3 Farenheit with a sore throat and dysphagia. Workup showed leukocytosis, ESR 86 mm/h [0-15], CRP 45.5 mg/dL [0-1], blood cultures with MSSA, negative viral upper respiratory panel, throat culture, Syphilis and HIV testing. He had a positive Hepatitis C antibody without a detectable viral load. Echocardiogram ruled out vegetations. He was treated with cefazolin. CT neck was obtained and showed thyroid enlargement. Subsequent ultrasound showed heterogeneous echotexture and increased color flow and a left inferior pole nodule 2.3 x 2.1 x 2.0 cm. Thyroid labs showed TSH 0.16 [0.35 - 4.01 u[IU]/mL,] Free T4 3.91 ng/dL [0.61 - 1.37], TPO <0.3. The nodule was biopsied and endocrinology was consulted. On exam thyroid was nontender. He was started on beta blockers and thyroid labs were monitored. TSI and TRAB were negative. TSH, Free T4 and Free T3 improved to normal range. Nodule biopsy results showed benign follicular cells with abundant acute inflammation suggestive of an abscess. Metronidazole was added after biopsy results. Post antibiotic therapy, CRP improved to 1.7 mg/dL. Discussion/Conclusion: Incidence of acute suppurative thyroiditis has been published as occurring <1% of all thyroid diseases. One systematic review found 200 cases reported from January 2000 to January 2020. Prior case reports have described acute suppurative thyroiditis in adult patients with prior thyroid gland pathology or an immunocompromised state and some demonstrated a correlation with intravenous drug users. The most common culprits include Staphylococcus spp, Streptococcus spp, Salmonella spp, Escherichia spp. Management includes antimicrobial therapy and/or needle aspiration. Non-responders can undergo incision and drainage of abscess or thyroidectomy. Mortality was reported in about 8% of the reported 200 cases. In our patient, his history of drug use and Hepatitis C likely made him prone to infection. Although there was no description of pus during biopsy, pathology suggested acute inflammation. This along with elevated inflammatory markers led to the diagnosis. This case highlights an uncommon but potential cause of thyroiditis. Presentation: 6/3/2024

7008 Challenges in the Management of Thyroid Lymphoma - Case Report

Abstract Disclosure: F. Toloza Bonilla: None. P. Veeraraghavan: None. R. Lakhotia: None. M. Roschewski: None. N. Nilubol: None. S. Gubbi: None. J. Klubo-Gwiezdzinska: None. Introduction: Primary thyroid lymphoma is an extremely rare thyroid malignancy accounting for less than 5% thyroid malignancies. The management depends on the histological subtype and tumor staging, typically involving chemotherapy alone or combined with radiotherapy. Although, surgical intervention is generally not recommended, given the potential surgical risks and the absence of additional benefits compared to chemoradiation therapy, it is reserved to obtain tissue diagnosis and to treat compressive symptoms. Clinical Case: A 66-year-old Caucasian female presented with dysphagia to solid food and acute neck swelling for a few weeks. History was negative for fever, weight loss or nocturnal diaphoresis. The patient had a history of primary hypertension, pre-diabetes, and Hashimoto’s hypothyroidism. A neck computed tomography (CT) scan showed a thyromegaly (8.3 x 5.8 cm) and bilateral cervical lymphadenopathy. Thyroid ultrasound showed sub centimeter nodules in the right mid-gland and a heterogeneous and irregular left thyroid lobe. TSH was normal (0.87 mcIU/mL [0.27-4.2]). She was treated for suspected subacute thyroiditis with prednisone for two weeks, showing initial clinical improvement, but symptoms recurred after steroids were stopped. Subsequently, a CT neck and fludeoxyglucose F18 (FDG) positron emission tomography (PET) scan demonstrated FDG avid thyroid enlargement with local adenopathy and rightward tracheal deviation. Lymph node, FNA, core biopsies and molecular testing were consistent with stage IIE MYC/BCL6 rearranged diffuse large B-cell lymphoma as she had no bone marrow or central nervous system (CNS) involvement. The patient’s treatments included four cycles of etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab with ibrutinib added after the first cycle and intrathecal methotrexate with cycles 3-6, to reduce the risk of CNS involvement. A 6-month post-therapy follow-up showed complete response (CR) on imaging with symptoms resolution. Four months later, she experienced worsening symptoms, including dysphagia with solids and liquids, and hoarseness despite CR to therapy and stable CT imaging. Laryngoscopic evaluation noted left vocal cord paralysis and extrinsic compression of the tracheoesophageal groove. Patient opted for a left hemithyroidectomy, experiencing excellent symptom relief. Surgical pathology showed findings consistent with a necrotic tumor and residual areas of lymphocytic thyroiditis. No active DLBCL was appreciated. The patient remains in remission and continues to be symptoms-free 24 months post-thyroid lymphoma treatment. Conclusion: While thyroidectomy is not typically recommended as the initial treatment for primary thyroid lymphoma, it emerges as a potentially effective option to manage recurrent or persistent compression symptoms following the completion of medical therapy. Presentation: 6/3/2024

8105 Radiation-Induced Hyperthyroidism in the Context of Palliative Radiation Therapy

Abstract Disclosure: A. Randhawa: None. G. Palaguachi: None. J.G. Karam: None. Introduction: Palliative radiotherapy, designed to alleviate focal symptoms in advanced, incurable cancer, aims to enhance quality of life with minimal treatment burden. The thyroid gland's susceptibility to neck radiation is known, primarily leading to hypothyroidism. However, hyperthyroidism is a much less frequently reported adverse effect that is poorly understood. This case report highlights an unusual instance of radiation-induced hyperthyroidism. Case Presentation:The patient is a 53 years-old woman with history of Ewing’s sarcoma of the sacrum diagnosed in August 2022, treated initially with chemotherapy (cyclophosphamide, vincristine, etoposide and ifosfamide), but diagnosed with leptomeningeal metastasis and T12/L1 mass in October 2023 when she presented with lower extremities weakness and urinary incontinence. She underwent T12-L1 laminectomy, resection of tumor and fusion, and was started on palliative intent radiation therapy for the brain and C-spine. A month later, she was admitted for altered mental status and was found to be persistently tachycardic at 140 bpm. Thyroid function testing was sent and revealed hyperthyroidism with TSH of 0.07 mIU/L (0.39-4.08), Free T4 of 1.74 ng/dl (0.58-1.64), T4 of 10.7ug/ml (4.4-9.5), T3 of 0.54 ng/ml (0.72-1.35), with undetectable Thyroid Peroxidase Antibodies and Thyroid Stimulating Immunoglobulin level. Thyroid Ultrasound showed a small and homogenous thyroid gland with no discrete nodules. Radioactive Iodine uptake and scan was not obtained because of exposure to iodized contrast during hospital stay. The patient had no available baseline thyroid function tests. She had no recent fever or viral illness. Unfortunately, her clinical condition deteriorated rapidly, and she passed away on the seventh day of admission. Conclusion: While hypothyroidism is a well-established consequence of high-dose irradiation, the mechanisms behind the rarer radiation-induced hyperthyroidism remain unclear. Speculation includes the release of autoantigens from damaged thyroid glands, triggering an immune response and potentially leading to Graves' hyperthyroidism. However, our case more likely represents a hyperthyroid phase in the triphasic sequence of destructive subacute thyroiditis, given the absence of elevated thyroid antibodies, thyroid nodules, and other causes of thyroiditis. Increasing awareness of radiation-induced hyperthyroidism, unraveling its mechanisms, and refining diagnostic strategies such as obtaining baseline and monitoring thyroid function testing are crucial, particularly in the context of palliative therapy, where striking the delicate balance between efficacy and minimizing toxicity is paramount. Presentation: 6/3/2024

Thyroid Dysfunction and Alopecia Areata: A Genetic Prediction Causality Analysis Study.

Observational studies have suggested a correlation between alopecia areata (AA) and thyroid dysfunction (TD). However, the causal relationship between AA and TD remains uncertain. The purpose of this study is to investigate the causal relationship between these two conditions. Understanding the potential causal relationship between AA and TD is valuable for elucidating the pathogenesis of AA and for designing innovative methods to prevent and treat AA and its related complications. All data for this two-sample Mendelian randomization (MR) study were sourced from public databases. This study selected hypothyroidism, Hashimoto's thyroiditis, hyperthyroidism, subacute thyroiditis, and Graves' disease as exposure factors, with AA as the outcome variable. Data for hypothyroidism, Hashimoto's thyroiditis, hyperthyroidism, subacute thyroiditis, Graves' disease, and AA were obtained from related genome-wide association studies (GWAS). Various MR analysis methods such as inverse variance weighted (IVW), MR-Egger, and weighted median were utilized. Additionally, Cochrane's Q test was used to detect heterogeneity in MR results, and the MR-Egger intercept test and MR pleiotropy residual sum and outlier (MR-PRESSO) test were used to detect horizontal pleiotropy. A leave-one-out analysis was conducted to investigate the sensitivity of this association. We found statistically significant genetic predictions of AA with hypothyroidism, Hashimoto's thyroiditis, and subacute thyroiditis (IVW OR=1.4009815, 95% confidence interval [CI]: 1.1210399-1.750829; p=0.003030698, OR=1.396101, 95% CI: 1.030134-1.89208; p=0.03144273, OR=0.732702, 95% CI: 0.604812-0.887634; p=0.001483368). Furthermore, tests for pleiotropy showed no evidence of pleiotropy, enhancing the credibility of the study results. Finally, the leave-one-out test demonstrated the stability and robustness of this association. This study provides new evidence of a potential genetic link between thyroid issues and AA. By employing the two-sample MR method to eliminate confounding factors and reverse causation, unbiased results were obtained, confirming a causal relationship between hypothyroidism, Hashimoto's thyroiditis, subacute thyroiditis, and AA. This lays the foundation for further mechanistic studies and potential clinical applications. Future research should further explore the specific biological mechanisms between TD and the onset of AA.