Subacute Thyroiditis / De Quervain’s Thyroiditis (Part 1)

• Subacute thyroiditis (like painless sporadic and postpartum thyroiditis):
  • Is a spontaneous remitting inflammatory disorder of the thyroid:
    • That may last for weeks to months.
  • This disorder has a number of eponyms, including:
    • De Quervain’s thyroiditis
    • Giant cell thyroiditis
    • Pseudo-granulomatous thyroiditis
    • Subacute painful thyroiditis
    • Subacute granulomatous thyroiditis
    • Acute simple thyroiditis
    • Noninfectious thyroiditis
    • Acute diffuse thyroiditis
    • Migratory “creeping” thyroiditis,
    • Pseudotuberculous thyroiditis
    • Viral thyroiditis
  • The first description of subacute thyroiditis was in:
    • 1895 by Mygind:
      • Who reported 18 cases of “thyroiditis akuta simplex
  • The pathology of subacute thyroiditis was first described:
    • In 1904 by Fritz De Quervain:
      • Whose name is associated with the disorder:
        • He showed giant cells and granulomatous-type changes in the thyroids of affected patients

• Subacute thyroiditis:
  • Is the most common cause of:
    • The painful thyroid:
      • May account for up to 5% of clinical thyroid abnormalities
• As with other thyroid disorders:
  • Women are more frequently affected than men:
    • 5 to 1
• The peak incidence is in the:
  • Fourth and fifth decades of life (20 to 60 years of age):
    • This disorder is rarely observed in children and the elderly.
• Although the term subacute thyroiditis connotes a temporal quality that could apply to any thyroidal inflammatory process of intermediate duration and severity:
  • It is actually referring specifically to the granulomatous appearance of the thyroid found on pathologic exam

• Pathogenesis:
  • Infectious Association:
    • Although there is no clear evidence for a specific etiology:
      • Indirect evidence suggests that subacute thyroiditis:
        • May be caused by a viral infection of the thyroid
    • The condition is often preceded by a:
      • Prodromal phase of:
        • Myalgia
        • General malaise
        • Low-grade fevers
        • Fatigue
        • Frequently by an upper respiratory tract infection
    • It has been reported most frequently in:
      • The temperate zone:
        • Only rarely from other parts of the world
    • It has been found to occur seasonally:
      • The highest incidence is in the summer months:
        • July through September:
          • Which coincide with the peak of enterovirus:
            • Echovirus infection
            • Coxsackie virus A and B infection
    • The incidence rate has been shown to vary directly with:
      • Viral epidemics:
        • Specifically mumps:
          • The incidence of subacute thyroiditis has been found to be higher during these viral epidemics
          • Interestingly:
            • Antibodies to the mumps virus have even been detected in individuals with subacute thyroiditis who do not have clinical evidence of mumps
        • Subacute thyroiditis has also been associated with:
          • Measles
          • Influenza
          • The common cold
          • Adenovirus
          • Infectious mononucleosis
          • Coxsackie virus
          • Myocarditis
          • Cat scratch fever
          • St. Louis encephalitis
          • Hepatitis A
          • The parvovirus B19 infection:
            • Antibodies to Coxsackie virus, adenovirus, influenza, and mumps have been detected:
              • In the convalescent phase of this disease
            • Coxsackie virus is most commonly associated with subacute thyroiditis:
              • Coxsackie virus antibody titers have been shown to directly follow the course of the thyroid disease
    • Certain non-viral infections, including:
      • Q fever and malaria:
        • Have been associated with a clinical syndrome similar to subacute thyroiditis.
    • A case of subacute thyroiditis occurring simultaneously with:
      • Giant cell arteritis has been reported.
    • Another case of subacute thyroiditis developed during:
      • Alfa-interferon treatment for hepatitis C
  • Autoimmune Association:
    • Unlike painless or postpartum thyroiditis:
      • There is no clear association between subacute thyroiditis and autoimmune thyroid disease
      • Serum thyroid peroxidase and thyroglobulin antibodies levels:
        • Are usually normal
      • When described:
        • The levels of thyroid peroxidase and thyroglobulin antibodies:
          • Correlated with the phase of transient hypothyroidism
      • Antibodies to an un-purified thyroid preparation can be detected:
        • For up to 4 years after a bout of subacute thyroiditis
      • Antibodies to the thyrotropin (TSH) receptor:
        • Have been rarely detected during the course of subacute thyroiditis
        • In most studies:
          • There was no correlation between the presence of :
            • Thyrotropin receptor binding inhibitory immunoglobulin (TBII) or of thyrotropin receptor stimulating immunoglobulin and the thyrotoxic phase of the thyroiditis:
              • On the other hand:
                • There has been some correlation between thyroid-blocking antibodies and the development of hypothyroidism
        • It is thought that the appearance of the TSH-receptor antibodies results from:
          • An immune response:
            • That occurs after there is damage to the thyrocytes:
              • Specifically membrane desquamation
      • Following recovery from the inflammatory process of subacute thyroiditis:
        • All immunologic phenomena disappear:
          • The transitory immunologic markers that are observed during the course of subacute thyroiditis:
            • Appear to occur in response to the release of antigenic material from the thyroid
  • Genetic Association:
    • There is an apparent genetic predisposition for subacute thyroiditis:
      • With HLA-Bw 35 reported in all ethnic groups:
        • The relative risk of HLA-Bw 35 in subacute thyroiditis:
          • Is high:
            • Ranging from 8 to 56
      • Additional evidence for genetic susceptibility is the:
        • Simultaneous development of subacute thyroiditis in identical twins heterozygous for the HLA-Bw 35 haplotypes
      • A weak association of subacute thyroiditis with:
        • HLA-DRw8 has been reported in Japanese patients

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