Subacute De Quervain's Thyroiditis Research Articles

Subacute thyroiditis: clinical significance of diffuse 18-fluorodeoxyglucose uptake. Case report

Background. Subacute thyroiditis is a rare inflammatory thyroid disease presumably associated with viral infection, including COVID-19. It accounts for about 5% of all thyroid diseases.
 Materials and methods. A clinical case of de Quervain's subacute thyroiditis in a patient with diffuse hypermetabolic 18-fluorodeoxyglucose uptake by the thyroid gland is presented.
 Results. A 61-year-old patient with no history of thyroid disorders 3 weeks after COVID-19 experienced fever in the evenings (37.839.8C). He had moderate pain in the thyroid gland with radiation to the jaw, severe weakness, hand tremors, shivers, 12 kg weight loss, and sweating. These symptoms lasted for 3 weeks. Physical examination showed an enlarged thyroid gland, dense and extremely tender, especially its left lobe. Ultrasound showed an enlarged thyroid gland with a heterogeneous structure and large hypoechoic areas in both lobes up to 47 mm with fuzzy contour. Color Doppler imaging revealed reduced blood flow. Combined positron-emission and X-ray computed tomography with 18-fluorodeoxyglucose showed an increased diffuse uptake of the radiopharmaceutical in the thyroid gland and enlargement of its lobes, SUVmax 10.55. Blood thyroid-stimulating hormone is low, free triiodothyronine and thyroxine are high, and ferritin concentration is markedly increased, consistent with thyrotoxicosis. A fine-needle aspiration biopsy was performed. Cytology confirmed de Quervain's subacute thyroiditis. Glucocorticoids and nonsteroidal anti-inflammatory drugs were administered. Four weeks after the treatment, the clinical manifestations resolved. The patient was assessed in 6 months. Ultrasound showed a thyroid gland of regular size with smooth contours; color Doppler mapping revealed normal blood flow. Thyroid-stimulating hormone, triiodothyronine, and thyroxine were within reference ranges.
 Conclusion. The SARS-CoV-2 virus can be regarded as the cause of subacute thyroiditis. Combined positron-emission and X-ray computed tomography with 18-fluorodeoxyglucose showed diffuse intensive radiopharmaceutical uptake in the thyroid gland. Cytology is the basis for differential diagnostics. Glucocorticoids and nonsteroidal anti-inflammatory drugs are the first-choice agents.

ПОДОСТРЫЙ ТИРЕОИДИТ, АССОЦИИРОВАННЫЙ С COVID-19

Purpose. The clinical cases of subacute thyroiditis that occurred in patients with COVID-19 demonstrate the difficulties of interpreting clinical and laboratory signs. The importance of multiparametric ultrasound examination in the diagnosis of this pathology is shown. Materials and methods. Two cases of subacute thyroiditis caused by a coronavirus infec-tion are presented. We studied the medical histories and examination data of patients. The clinic of de Quervain's subacute thyroiditis was atypical, since it was leveled by multiple organ changes and clinical manifestations of COVID-19. The results of clinical examination, results of ultrasound exam-ination of the thyroid, sonoelastography, multispiral computed tomography of lungs and laboratory tests were studied. Conclusion. Subacute thyroiditis is one of the variants of manifestation and complication of coronavirus infection. The clinical picture of subacute thyroiditis associated with COVID-19 may have an atypical course due to simultaneous lesions of many organs and systems. The disease may have a blurred picture due to the use of drugs used in the treatment of coronavirus infection. The main method of diagnosis of subacute thyroiditis associated with COVID-19 is ultrasound, which allows to establish structural changes in the thyroid gland, reflecting the nature and localization of the inflammatory process. The severity of changes in the thyroid gland in COVID-associated de Quervain thyroiditis does not correlate with clinical and laboratory data. © 2021 Russian Electronic Journal of Radiology. All rights reserved.

Subacute de Quervain's thyroiditis: clinical and pathomorphological features of patients operated on thyroid gland.

Background. An annual increase in the number of patients with endocrine pathology is observed in Ukraine. SubacutedeQuervain's thyroiditis is a rare inflammatory disease of thyroid gland of viral etiology which on average occurs in 3 - 6% of cases among all thyroid pathology. Objective – to study clinical and pathomorphological features of Subacute de Quervain's thyroiditis of patients operated on thyroid gland in the last ten years. Меthods. Analysis of archival data results of pathohistological reports on the patients operated on thyroid gland in Lviv Regional Clinical Hospital in 2006-2015 and medical histories with diagnosed cases of Subacute de Quervain's thyroiditis was conducted. In ten years’ time 5587 cases of patients operated on thyroid gland pathology have been revealed, among them 17 cases of Subacute de Quervain's thyroiditis which is 0,3% from all thyroid diseases. There were only women among the patients and their average age was 56. Results. While studying the medical histories it was revealed that the most frequent women’s complaints were the following: feeling of a foreign body in the neck area, discomfort when swallowing, bulging on the front of the neck, dyspnea, general weakness. Subacute de Quervain's thyroiditis was not diagnosed clinically in any case, and in one third of the cases there was a suspicion of malignant thyroid tumor. Pathoanatomical diagnosis in half of the cases was combined and often Subacute de Quervain's thyroiditis was combined with a multi-nodule colloid goiter. Conclusion. Subacute de Quervain's thyroiditis is a rare pathology of thyroid gland without sufficiently characteristic pathognomonic signs that makes clinical diagnostics rather difficult. Thoroughly collected anamnesis and conducting of appropriate laboratory tests including ultrasonic diagnostics of thyroid gland help to diagnose Subacute de Quervain's thyroiditis.

OPERATIONS AS procatarxis RECURRENCE THYROIDITIS Subacute de Quervain

This article provides an interesting case from practice of surgery on the thyroid was the cause of subacute thyroiditis de Quervain. The author proposes a new method for treating this disease with the help of low-intensity laser radiation

Tiroidite di De Quervain: concetti attuali e nostra casistica

Summary Introduction De Quervain's subacute thyroiditis is a self-limiting granulomatous inflammatory disorder, which is thought to be virally induced in genetically predisposed individuals. It is characterized by thyroid pain and thyrotoxicosis, as well as by systemic symptoms like fever, hepatic cytolysis, and an elevated erythrocyte sedimentation rate. It is often mistaken for an upper respiratory tract infection. Materials and methods The authors review recent advances in the understanding of the pathogenesis and pathophysiology of De Quervain's subacute thyroiditis; risk factors for complications, with emphasis on relapses and end-stage hypothyroidism; differential diagnosis and the exclusion of other subtypes of thyroiditis; and current treatment options. Four cases of De Quervain's thyroiditis are then analyzed and compared with cases in the literature. Discussion In three of the patients, onset occurred in June and was probably related to a small, seasonal epidemic cluster. These cases were quite different from the fourth one, which occurred in October, suggesting that two distinct viruses might be involved. One of the patients presented a very rare complication, vocal-cord paralysis, which responded well to glucocorticoid therapy. Another presented with an even rarer post-partum form of painful thyroiditis.

Fever of unknown origin (FUO): de Quervain's subacute thyroiditis with highly elevated ferritin levels mimicking temporal arteritis (TA)

Fever of unknown origin (FUO) refers to prolonged fevers of ≥101°F and that persists for >3 weeks that remain undiagnosed after an intensive in-hospital/outpatient workup. The most common FUO categories of are infectious, neoplastic, rheumatic/inflammatory, and miscellaneous causes. Malignancies have supplanted infectious diseases as the most common cause of FUOs in the adult population. Rheumatic/inflammatory causes of FUO are relatively less common than previously because of the introduction over the years of sophisticated diagnostic tests for most rheumatic diseases. The rheumatic/inflammatory disorders that remain important causes of FUO today are those that cannot be readily diagnosed by readily available/noninvasive tests, for example, adult Still's disease and temporal arteritis (TA). In older patients with FUO, TA can be a difficult diagnosis when the characteristic findings (ie, scalp tenderness, jaw claudication) are not present. Patients with TA presenting as FUO often have only headaches that may be accompanied by bilateral jaw discomfort. Endocrine causes of FUOs are rare. The most common endocrine disorder rarely presenting as an FUO is de Quervain's subacute thyroiditis. As in TA, subacute thyroiditis may present with headache and pain at the angle of the jaw. Both TA and subacute thyroiditis may be accompanied by fatigue, weight loss, and night sweats. We present a case of 55-year-old woman who presented with an FUO with clinical and laboratory findings suggesting TA. However, the absence of thrombocytosis and a normal alkaline phosphatase argued against the diagnosis of TA. Also against the diagnosis of TA was weight loss without loss of appetite and a slightly increased pulse. After nonspecific laboratory test results suggested that TA was not the cause of her FUO, additional tests were ordered. Thyroid function test results suggested the possibility of de Quervain's subacute thyroiditis as the cause of her FUO. To the best of our knowledge, this is the first case of de Quervain's subacute thyroiditis presenting as an FUO with elevated ferritin levels.

Long-term outcome of thyroid function after amiodarone-induced thyrotoxicosis, as compared to subacute thyroiditis

Two main forms of amiodarone- induced thyrotoxicosis (AIT) exist: type 1 AIT is a condition of true hyperthyroidism developing in patients with pre-existing thyroid disorders, and usually requires thyroid ablative treatment. On the other hand, type 2 AIT is a form of destructive thyroiditis occurring in normal thyroids, the management of which usually consists in glucocorticoid treatment. To assess the long-term outcome of thyroid function in a prospective study of type 2 AIT patients, as compared to patients with De Quervain's subacute thyroiditis (SAT). Sixty consecutive patients with type 2 AIT were evaluated during oral glucocorticoid treatment (oral prednisone 30 mg/day, gradually tapered and withdrawn over a 3-month period) and followed for 38+/-4 months (range 6-72) thereafter. Sixty consecutive patients with SAT, referred to our Institutes during the same period and treated with the same therapeutic schedule, served as controls. Type 2 AIT patients were older (p<0.0001) and showed a larger male preponderance (M:F 3.6:1 vs 0.5:1, p<0.0001) than SAT patients. Mean serum free T4 (FT4) and free T3 (FT3) concentrations at diagnosis were increased in both conditions, but higher in type 2 AIT than in SAT (FT4 47.6+/-18.8 and 29.6+/-8.3 pmol/l, respectively, p<0.0001; FT3 15.4+/-7.0 and 11.2+/-3.0 pmol/l, respectively, p<0.001). Correction of thyrotoxicosis was obtained in all patients in both groups, but restoration of euthyroidism occurred earlier in SAT than in type 2 AIT (p=0.006). Ten type 2 AIT patients (17%) and 3 SAT patients (5%, p<0.03) became permanently hypothyroid after glucocorticoid withdrawal and required levothyroxine replacement. A relevant proportion of type 2 AIT patients develop permanent hypothyroidism after correction of thyrotoxicosis. Thus, periodic surveillance of thyroid status is required after type 2 AIT.

De Quervain’s Subacute Thyroiditis - Colour Doppler Sonography Findings

De Quervain's subacute nonsuppurative thyroiditis has been well characterised clinically: there usually is pain in the region of the thyroid due to local pressure. Typically, the patient feels generally ill with fever. Signs of inflammation (raised ESR and CRP) are measurable laboratory parameters. Occasionally, there is transient hyperthyroidism followed by hypothyroidism. Little data is available on the vascularisation of the thyroid in this clinical entity. Twenty-one patients with confirmed De Quervain's subacute thyroiditis were investigated and the findings were analysed retrospectively (clinical features, sonography, cytology in some cases). Ultrasound devices (Siemens Elegra and Acuson Sequoia) with 7 and 12 MHz ultrasound transducers and modern technology (harmonic imaging, panorama imaging and sensitive colour Doppler units with standardised instrument settings) were used. The structures of the thyroid was found to be inhomogeneous. The hypoechoic to nonechoic areas corresponded to the inflamed areas. An alteration in the morphology and topographic distribution was observed in the course of the illness. Normal or slightly increased vascularisation in the echogenically "healthy" regions of the thyroid were found in colour Doppler sonography. The peak systolic velocity (PSV) in the afferent arteries (superior and inferior thyroid arteries) was in the normal range (< 40 cm/s). The hypoechoic/nonechoic map-like areas showed a reduction or complete absence of blood flow. De Quervain's subacute thyroiditis can be conclusively diagnosed by sonography in more than 90 % of cases based on the history, typical clinical features and clinical test parameters indicating signs of inflammation. Colour Doppler sonography can be useful in differential diagnosis of unclear cases.

The serum triiodothyronine to thyroxine (T3/T4) ratio in various thyroid disorders and after Levothyroxine replacement therapy

In order to examine the significance of differences in the triiodothyronine/thyroxine (T3/T4) ratio in the achievement of euthyroidism and in different thyroidal diseases, we studied 1050 subjects: 233 were euthyroid (Eu), 239 hypothyroid (Hypo) with initial TSH levels >15 mU/L, 273 hypothyroid on substitution therapy with L-thyroxine alone and TSH values of 0.35-3.5 mU/L, (hypoRx), 236 hyperthyroid (hyper) and 69 in the acute phase of subacute thyroiditis De Quervain's (DQ). The ratio of T3/T4 was calculated using the conventional values. The values of T3/T4 ratio in the various categories were: Eu= 15.89, Hypo= 24.12, hyper= 19.57, hypoRx= 13.42, DQ= 15.16. The T3/T4 ratio was lower in the hypoRx group than in the EU group (P <0.001), although neither TSH values nor T3 values showed any differences between these two groups, whereas T4 levels were significantly higher in the hypoRx group (Eu= 7.99+/-1.46, hypoRx = 9.11+/-1.58, P< 0.001). The T3/T4 ratio in the DQ group was comparable to that of the Eu group, but significantly lower than the hyper group (P=0.95 between Eu and DQ, P<0.001 between DQ and hyper). These findings indicate that in hypothyroid patients, L-T4-replacement that is sufficient to maintain a normal serum TSH is accompanied by a serum T4 that is higher than in normal individuals and may not result in an appropriately normal serum T3 concentration. In Thyrotoxicosis, a ratio of total T3/T4 >18.9 suggests Graves' disease or toxic multinodular goiter whereas T3/T4 <16 suggests thyroiditis (subacute or silent).

Trombosis venosa cerebral asociada a tiroiditis subaguda de De Quervain en una paciente con la mutación G20210A del gen de la protrombina

Recently, thyrotoxicosis has been described as a risk factor for cerebral venous thrombosis (CVT) in some reported cases. We present a case of CVT associated to a subacute De Quervain's thyroiditis in a young female who was an heterozygous carrier for the G20210A mutation of the prothrombin gene. A 42-year-old female with irrelevant past medical history developed a thrombosis of the superior sagital and right transverse sinus in the initial phase of a subacute thyroiditis. Diagnosis was made by thyroid radioactive iodine uptake, and cerebral computerized tomography scan, magnetic resonance imaging, and magnetic resonance angiography. Treatment with aspirin and corticosteroids was started until thyroid function was normalized. When CVT diagnosis was made, the patient was treated with anticoagulation. Two months later, magnetic resonance imaging showed resolution of the CVT. The patient was diagnosed as an heterozygous carrier for the G20210A mutation of the prothrombin gene by genetic studies. Subacute thyroiditis might act as a risk factor for CVT, increasing the thrombotic risk in the presence of other acquired or hereditary prothrombotic factors, such as the G20210A mutation of the prothrombin gene in our patient.

ABC of thyroid diseases and their treatment

Thyroid diseases are caused by a disturbance of thyroid hormone secretion, inflammations or tumors of the thyroid or combinations thereof. Most important causes for hyperthyroidism are Graves' disease and toxic nodular goiters (including toxic adenomas). Hypothyroidism is often caused by Hashimoto's chronic thyroiditis and can occur in patients after thyroidectomy. Chronic hashimoto's thyroiditis and subacute de Quervain's thyroiditis are the thyroid inflammations most frequently seen. Graves' disease and Hashimoto's thyroiditis are autoimmune thyroid diseases. Thyroid tumors encompass benign solitary nodules, diffuse and nodular goiters, papillary, follicular, medullary and anaplastic carcinomas.

Monitoring of treatment in thyroid diseases

The effectiveness of antithyroid drug treatment of Graves' hyperthyroidism is documented by measuring initially free T4 and free T3 and later free T4, free T3 and TSH. An elevated titer of the Graves'-specific thyroid stimulating antibodies is not usually rechecked before the end of the antithyroid drug therapy. Thyroxine treatment of primary hypothyroidism is controlled by TSH measurements. In patients in whom TSH levels might be affected by drugs or nonthyroid diseases, free T4 is measured in addition to TSH. The assessment of the treatment of Hashimoto's chronic thyroiditis consists of the control of the therapy of its associated hypothyroidism. In subacute thyroiditis de Quervain control of the effectiveness of the analgesic therapy is most important. To check the effect of thyroid hormone treatment given with the intent to reduce goiter size, serial sonographies are of great value. In the follow-up of patients with thyroid carcinomas, measurements of thyroglobulin (for papillary and follicular thyroid cancers) and of calcitonin (for medullary thyroid cancers) in the serum as well as thyroid scans and other imaging procedures play an important role.

De Quervain's subacute thyroiditis presenting as a painless solitary thyroid nodule.

We describe a 39-year-old woman presenting with a painless solitary thyroid nodule, initially without signs suggesting thyroiditis. The serum level of thyrotropin was suppressed whereas those of thyroxine and triiodothyronine...

Ultrasound appearances in de Quervain's subacute thyroiditis with long-term follow-up.

In order to determine whether permanent echo abnormalities are produced by subacute thyroiditis, ultrasound examination of the thyroid was performed repeatedly after a mean interval of 23 months in 17 subjects (8 women and 9 men) aged 31-52 (mean 41) years, suffering from subacute thyroiditis. The diagnosis was based on typical clinical symptoms, and cytological confirmation was obtained in all subjects but one. In the primary phase the ultrasonic finding was in all cases abnormal, showing either diffuse or focal hypoechogenicity and enlargement of thyroid lobes. At follow-up, a homogenous echo structure was found in 15 patients. Nodularity was detected in only two subjects. It is concluded that permanent focal echo abnormalities are generally not produced by subacute thyroiditis. Consequently, thyroid nodules in subjects with a history of SAT should not be ignored.

Is silent thyroiditis an autoimmune disease?

The entity of silent (painless) thyroiditis has been recognized over the past decade as a clinical syndrome manifested by transient hyperthyroidism associated with a marked depression of the thyroidal radioactive iodine uptake, often followed by a transient period of hypothyroidism, but most patients ultimately recover to normal. 1 The similarity of the thyroid dysfunction and the evolution during the course of the disease in silent thyroiditis to the picture seen in de Quervain's subacute thyroiditis brought with it the possibility that silent thyroiditis might share a similar cause with de Quervain's thyroiditis, namely, a possible viral infection. 1-4 However, a number of elements argue against that possibility. See also p 1974. First, the histologic appearance of the thyroid gland in this condition shows lymphocytic infiltration reminiscent of Hashimoto's thyroiditis. It is not identical with typical Hashimoto's thyroiditis, however, since there are few lymphoid follicles, few or no Hurthle cells are

Evaluation of a radioreceptor assay for TSH receptor autoantibodies.

A commercial radioreceptor assay for TSH receptor autoantibodies (TRAb), based on solubilized porcine receptor and purified radio-iodinated bovine TSH, was tested in 264 subjects with a variety of thyroid disorders. The sensitivity of the assay for the detection of hyperthyroid Graves' disease was 91%. The assay specificity for Graves' disease was 95%. With the exception of one patient with Hashimoto's disease and one patient with de Quervain's subacute thyroiditis no subjects other than Graves' patients had detectable TRAb. Thus purely blocking TSH receptor autoantibodies were not detected with the assay. One female with thyroxine-treated idiopathic primary hypothyroidism who had given birth to two children with transiently elevated TSH, was found to have a circulating TSH-binding substance that resulted in an abnormally negative TRAb value, and highly discrepant results when TSH was measured with a double antibody TSH radioimmunoassay and an immunoradiometric assay. The TSH-binding substance was precipitated like a protein, but was not IgG. Similar findings have not previously been reported.

SUBACUTE THYROIDITIS DE QUERVAIN: A DISEASE ASSOCIATED WITH A HLA-B ANTIGEN

ABSTRACT Twenty-four caucasian patients with subacute thyroiditis de Quervain were HLA-A, B, C and D typed to evaluate a possible association between the major histocompatibility system and this disease. A highly increased frequency of HLA-Bw35 could be demonstrated (71 per cent, P = 2 × 10−10, relative risk 16.2) together with a concomitant increase of Cw4 (54 per cent, P = 7.9 × 10−5, relative risk 5.7), while the HLA-D antigen Dwl was only moderately and insignificantly increased. Accordingly, this disorder is more strongly associated with HLA-B than HLA-D segregant series in contrast to most other HLA associated diseases. The HLA association proves that the susceptibility to develop subacute thyroiditis de Quervain is genetically influenced, and suggests that HLA-typing may be of value in the diagnosis.

DELAYED ADJUSTMENT OF THE PITUITARY RESPONSE TO VARIATIONS IN CIRCULATING THYROID HORMONES IN A CASE OF SUBACUTE THYROIDITIS

In a case of subacute de Quervain thyroiditis characterized by a period of pronounced hypermetabolism followed by hypometabolism, levels of T4, T3 and the TSH response to TRH were repeatedly measured. As expected, the response to TRH was absent or low during the hypermetabolic phase, high during the hypometabolic phase and returned to normal with recovery. However, at the beginning and at the end of the hypometabolic phase, while circulating levels of T3 and T4 both lay in the subnormal range, two periods of inadequate response to TRH could be demonstrated. During the first period, the response to TRH was zero or very small; during the second period, stimulation by TRH was exaggerated. The response to TRH thus depends not only on the level of circulating thyroid hormones but on other factors such as the previous state of pituitary stimulation or inhibition.

Isolation and some serological and epidemiological data on the viruses recovered from patients with subacute thyroiditis de Quervain.

Virological and serological methods were used in examination of 28 patients suffering from subacute thyroiditis de Quervain. Attempts to isolate a presumed viral agent from 8 patients were performed by inoculation of serum, urine, and aspiration biopsies of thyroid glands taken at different stages of the illness, into tissue cultures of different types of human and animal cells. Recovery of a cytopathic viral agent on cells of a rabbit lung continuous line was successful in 5 cases. Serological cross reactions exist between the isolated viruses and patient serum but not with serum of healthy people. Cases with the acquired illness and positive antibodies against the isolated viruses who had been in close and prolonged contact with patients suffering from subacute thyroiditis de Quervain were also investigated.

Ultrastructure of the thyroid in De Quervain's subacute granulomatous thyroiditis.

An electron microscope study of excised thyroid fragments from a case of De Quervain's subacute thyroiditis is reported. Deposit of material along the basement membrane making the latter apparently thickened, cytoplasmic alterations and stratification of thyroid cells seem to be induced by the thyroiditis process itself. The characteristic giant cells are syncytia resulting from fusion of inflammatory cells. The pathology is specific of a granuloma and is strikingly different from that of the other thyroidites.