Clinical Course and Outcome

Aspirin was prescribed for the presumed diagnosis of subacute thyroiditis. However, symptoms progressed over the next day, requiring hospital admission for evaluation of fever to 104° F with drenching night sweats. The anterior neck pain worsened and still radiated to the left. Physical examination showed blood pressure 160/70 mm/Hg, heart rate 120 per minute, and temperature 101.7° F. Chest x-ray and blood and urine cultures were negative. Thyroidal RAIU was less than 1% (normal 5%-30%). (See Table 2 and Figures 1a, 1b, and 2 for additional laboratory and radiologic diagnostic evaluation.) The patient's temperature subsided to a normal range after 3 days, and she was discharged on aspirin with a diagnosis of subacute thyroiditis.

Ultrasound of the Thyroid (right lobe)
Note diffuse enlargement of thyroid with diffuse inhomogeneity consistent with thyroiditis. Right lobe 5.2 x 2.4 x 1.6 cm.

Ultrasound of the Thyroid (left lobe)
Note diffuse enlargement of thyroid with diffuse inhomogeneity consistent with thyroiditis. Left lobe 4.6 x 2.4 x 2.2 cm.

CT Scan of the Neck
Note diffuse enlargement of the thyroid gland extending from the mid thyroid cartilage to the thoracic inlet.

However, the high-grade fever recurred within a few days, and the patient was readmitted to the hospital. She now complained of an episode of left-sided monocular blindness for 20 minutes on the day prior to admission, with subsequent diplopia. The diplopia persisted at the time of admission to the hospital. She also complained of left-sided hearing loss, jaw pain, headaches, and an increase in the intensity of the neck pain. Physical examination revealed temperature of 104oF, scalp tenderness over the temporal artery, left facial muscle weakness, and left facial and thyroid tenderness. Again, a prominent and tender goiter was appreciated. Sixty milligrams of prednisone was prescribed daily by mouth, and within a few days the symptoms improved dramatically with complete defervescence.

What are additional differential diagnoses at this time?

  1. The symptoms of acute monocular blindness and diplopia, jaw claudication, and headaches are consistent with the diagnosis of giant cell arteritis. Scalp tenderness and fever are classic signs associated with this disorder, and normocytic, normochromic anemia and thrombocytosis are common findings. The criteria (3 of 5) established by the American College of Rheumatology for the diagnosis of giant cell arteritis are:

    • age greater than 50

    • new onset of a localized headache

    • tenderness or reduced pulse of the temporal artery

    • ESR greater than 50 mm/Hr

    • temporal artery biopsy showing a necrotizing arteritis with granuloma cells

    Rarely, other arteritides may involve the temporal artery.

View the correct answer.

What tests may aid in establishing the diagnosis?

  1. Although the described clinical symptoms are consistent with giant cell or temporal arteritis, the erythrocyte sedimentation rate (and/or C-reactive protein) is helpful as a non-specific marker of inflammation. It is usually markedly elevated (>100 mm/h). Biopsy of the temporal artery should be considered in most cases to confirm the diagnosis.

View the correct answer.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....