Case Presentation

A 52-year-old Latin American woman presented to the emergency room with the chief complaint of anterior and left neck pain. The patient first noticed the pain 6 weeks earlier, and initially sought dental care because the pain radiated to the left jaw. Despite a left molar extraction, several visits to the dentist, and a course of antibiotics, the pain was not relieved. The patient eventually presented to the emergency room after 2 days of intermittent fever to 100.0° F, fatigue, and worsening neck pain.

Review of systems revealed that over the past 4 weeks she had lost 10 pounds and experienced occasional palpitations. There was no history of recent travel or contact with ill people. Past medical and surgical history was unremarkable. Family history was negative for diabetes mellitus and thyroid and autoimmune disorders. Except for the course of the antibiotic taken 3 weeks previously, the patient reported that she had not taken any medications, alcohol, or illicit drugs.

Physical examination showed temperature 100.1° F, heart rate 104 per minute, blood pressure 132/70 mm/Hg, and respiratory rate 18 per minute. The patient was in severe distress from the pain. Exquisite anterior neck tenderness was elicited on light palpation over the thyroid gland. The gland was irregular in texture with a prominent left lobe. The patient's palms were moist with a fine tremor in the fingers, but there was no lid lag. The rest of the examination was normal, including deep tendon reflexes.

Laboratory investigation ( Table 1 ) disclosed the following values when the patient was seen in the emergency room and at a subsequent outpatient clinic visit 3 days later.

What is the differential diagnosis of the neck pain and tenderness in this patient?

  1. Although many of the described symptoms are nonspecific, the neck pain, tender goiter, and signs and symptoms of hyperthyroidism are consistent with thyroiditis.There are several classifications of thyroiditis that encompass a variety of disorders, many of which have several synonyms and eponyms. Typically, thyroiditis describes an inflammatory condition in which destruction of thyroid follicular cells leads to release of pre-formed thyroid hormones into the blood stream, resulting in hyperthyroid symptoms and a low thyroidal radioactive iodine uptake (RAIU).Disorders associated with thyroid pain are acute infectious thyroiditis and subacute thyroiditis. Acute infectious thyroiditis is a sudden and uncommon -- but very serious -- infection of the thyroid gland, typically localizing to 1 lobe. This may result from bacterial, parasitic, or fungal organism infection of the thyroid gland via hematogenous spread or through a fistulous connection with the pyriform sinus. Individuals with acute infectious thyroiditis typically do not have acute or chronic thyroid dysfunction. Treatment is urgent and targeted specifically at the infecting microorganism, which requires prompt microbiological identification and antibiotic treatment.Subacute thyroiditis, also known as giant cell thyroiditis, subacute granulomatous thyroiditis, DeQuervain's thyroiditis, or nonsuppurative thyroiditis, is thought to be caused by viral infection rather than an underlying autoimmune pathology, although there is an association with the HLA-B35 haplotype. Lymphocytes, macrophages, giant cells, granulomas, and disruption of thyroid follicles are seen on histological specimens. It is diagnosed more frequently in women, and is less common than Graves' disease as a cause of hyperthyroidism. The clinical manifestations typically include neck pain and tenderness, fatigue, fever, goiter, and symptoms of hyperthyroidism such as palpitations, tremors, or heat intolerance. Laboratory investigation usually reveals suppressed TSH, elevated T4 and T3, low thyroidal RAIU, and elevated erythrocyte sedimentation rate (sometimes above 100 mm/hr).The symptoms of hyperthyroidism are transient (2-6 weeks) and usually respond to beta-blockers; thionamides (PTU or methimazole) are ineffective because of the underlying pathology. Approximately one fourth of patients may experience transient hypothyroidism lasting 2-6 weeks. One in 10 patients will have permanent hypothyroidism that requires thyroid hormone replacement. Nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin can be used for treatment of the pain. Treatment with glucocorticoids (typically for 4-8 weeks) is reserved for patients with severe symptoms that are not controlled by standard NSAID therapy.Riedel's thyroiditis (fibrous thyroiditis), Hashimoto's (autoimmune or chronic lymphocytic) thyroiditis, silent thyroiditis (subacute lymphocytic or painless thyroiditis), infiltrative diseases (such as sarcoidosis), irradiation, and medications (amiodarone, interleukin 2, lithium, and interferon-alpha) may be associated with thyroid inflammation ("thyroiditis"). However, in these conditions, pain is usually absent. Postpartum thyroiditis may be a variant of subacute lymphocytic thyroiditis. Other causes of neck or thyroid pain include hemorrhage into a thyroid nodule. Rarely, Graves' disease or Hashimoto's thyroiditis may present with neck pain, perhaps due to rapid growth of the thyroid gland.

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What is the differential diagnosis of the suppressed TSH and elevated T4?

  1. The suppressed TSH and symptoms of thyrotoxicosis provide evidence for thyroiditis. Thyroiditis, exogenous thyroid hormone ingestion, iodine-induced hyperthyroidism, struma ovarii, and metastatic thyroid cancer with release of thyroid hormone are causes of thyrotoxicosis and low thyroidal RAIU. Graves' disease, toxic adenomas ("hot nodules"), toxic multinodular goiter, and TSH-secreting pituitary tumors are disorders associated with high RAIU.Most cases of subacute thyroiditis have ratios of T3/T4 less than 20, as shown in this case (127/13.8 = 9.2). This ratio usually is greater than 20 in cases of hyperthyroidism associated with high RAIU. Thyroid antibodies are typically not positive or elevated in cases of thyroiditis (with the exception of Hashimoto's thyroiditis), but may help differentiate the various forms of hyperthyroidism. Serum thyroglobulin is frequently elevated in cases of subacute thyroiditis.

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What are potential treatment options based on the differential diagnosis?

  1. NSAIDs or aspirin are sufficient to alleviate the pain in most cases. Glucocorticoids, such as prednisone 20-40 mg per day, are reserved for severe cases that do not respond to NSAIDs. One should question the diagnosis of subacute thyroiditis if the patient does not respond to steroids after a few days.

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