- Clinical Manifestations:
- The clinical manifestations:
- May be preceded by an upper respiratory tract infection, or a prodromal phase of:
- General malaise
- Generalized myalgia
- Pharyngitis
- Low-grade fevers
- Pain or swelling in the thyroid region develops later:
- Accompanied by higher fevers
- Up to 50% of patients have symptoms of thyrotoxicosis
- Pain may be moderate or severe
- Rarely symptoms are entirely lacking
- Similarly:
- Tenderness may be moderate or severe (or even exquisite):
- Or conversely, may rarely be lacking
- Tenderness may be moderate or severe (or even exquisite):
- One of the lobes may be involved initially and later spread to the opposite lobe:
- “Creeping thyroiditis”
- Both lobes may be involved from the outset
- The systemic reaction:
- May be minimal or severe
- Fevers may reach 40°C
- May be minimal or severe
- Rarely, subacute thyroiditis may present as:
- A non-tender solitary nodule:
- In these cases, the diagnosis has been made after fine-needle aspiration biopsy:
- Atypical presentations are often misdiagnosed as papillary cancer
- In these cases, the diagnosis has been made after fine-needle aspiration biopsy:
- A non-tender solitary nodule:
- Patients can generally localize the pain to the thyroid region over one or both lobes
- They may refer to their symptoms as a “sore throat,”:
- But upon specific questioning it becomes apparent that pain is in the neck, not within the pharynx.
- Typically, pain radiates from the thyroid region:
- Up to the angle of the jaw or to the ear on the affected side(s).
- The pain may also radiate to the anterior chest or may be centered over the thyroid only
- Moving the head, swallowing, or coughing may aggravate pain
- Although an occasional patient may have no systemic symptoms, most complain of:
- Myalgia
- Fatigue
- Fevers
- Malaise:
- Can be extreme and can be associated with arthralgias
- May be preceded by an upper respiratory tract infection, or a prodromal phase of:
- The clinical manifestations:
- On physical exam:
- Most patients appear uncomfortable and flushed on inspection:
- With variable elevations in temperature
- Palpation usually reveals:
- An exquisitely tender, hard, ill-defined nodular thyroid:
- The tender region may encompass an entire lobe and mild tenderness may be present in the contralateral lobe
- An exquisitely tender, hard, ill-defined nodular thyroid:
- The overlying skin is occasionally warm and erythematous
- Cervical lymphadenopathy is rarely present
- Although the majority of patients are only mildly to moderately ill:
- Subacute thyroiditis may have a dramatic presentation:
- With marked fever (greater than 40°C)
- Severe thyrotoxicosis
- Obstructive symptoms:
- Resulting from pronounced thyroid inflammation and edema
- Subacute thyroiditis may have a dramatic presentation:
- During the active / painful phase of subacute thyroiditis:
- The erythrocyte sedimentation rate is:
- Markedly elevated:
- In fact, a normal erythrocyte sedimentation rate essentially rules out subacute thyroiditis as a tenable diagnosis
- Markedly elevated:
- The white blood count is normal to mildly increased
- There is often a normochromic, normocytic anemia
- During the inflammatory phase there are increases in:
- Serum ferritin
- Soluble intercellular adhesion molecule-1
- Selectin
- Interleukin-6 levels
- C-reactive protein
- Alkaline phosphatase and other hepatic enzymes may be elevated in the early phase:
- It has been suggested that subacute thyroiditis may actually represent a multi-system disease also affecting the thyroid
- In the thyrotoxic phase:
- The serum T4 concentration is disproportionately elevated relative to the serum T3 concentration:
- Reflecting the intra-thyroidal T4:T3 ratio
- In addition:
- The acute illness decreases the peripheral deiodination of T4 to T3:
- Resulting in lower serum T3 concentrations than expected.
- The acute illness decreases the peripheral deiodination of T4 to T3:
- Serum TSH concentrations are low to undetectable
- It is important to note in subacute thyroiditis:
- Antibodies directed against thyroglobulin and thyroid peroxidase:
- Are either absent or present in low titer:
- These develop several weeks after disease onset and tend to disappear thereafter
- Are either absent or present in low titer:
- Antibodies directed against thyroglobulin and thyroid peroxidase:
- The serum T4 concentration is disproportionately elevated relative to the serum T3 concentration:
- The erythrocyte sedimentation rate is:
- The radioactive iodine uptake:
- During the thyrotoxic phase is:
- Low:
- Most often less than 2% at 24 hours:
- As with the erythrocyte sedimentation rate:
- A normal radioactive iodine uptake essentially rules out subacute thyroiditis as a tenable diagnosis
- As with the erythrocyte sedimentation rate:
- Most often less than 2% at 24 hours:
- Low:
- Ultrasound:
- May show generalized, multiple, or single regions of hypoechogenicity
- During the thyrotoxic phase is:
- Most patients appear uncomfortable and flushed on inspection:
- Pathology:
- The primary events in the pathology of subacute thyroiditis are:
- Destruction of the follicular epithelium
- Loss of follicular integrity:
- However the histopathologic changes:
- Are distinct from those found with Hashimoto’s thyroiditis
- However the histopathologic changes:
- The lesions are:
- Patchy in distribution and are off:
- Varying stages of development
- With infiltration of mononuclear cells in affected regions
- Partial or complete loss of colloid
- Fragmentation and duplication of the basement membrane
- Histiocytes congregate around masses of colloid:
- Both within the follicles and in the interstitial tissues:
- Producing giant cells:
- Often these giant cells consist of:
- Masses of colloid surrounded by large numbers of individual histiocytes:
- So they more accurately should be termed pseudo-giant cells
- Masses of colloid surrounded by large numbers of individual histiocytes:
- Often these giant cells consist of:
- Producing giant cells:
- Both within the follicles and in the interstitial tissues:
- The term granulomatous thyroiditis:
- A synonym for subacute thyroiditis:
- Should likewise be changed to pseudo-granulomatous thyroiditis:
- However, true giant cells and granulomas do appear in this disease as well
- Should likewise be changed to pseudo-granulomatous thyroiditis:
- A synonym for subacute thyroiditis:
- During recovery:
- The inflammation recedes and there is a variable amount of fibrosis and fibrotic band formation
- In addition:
- Follicular regeneration occurs:
- Without caseation, hemorrhage, or calcification
- Follicular regeneration occurs:
- Recovery is generally complete:
- Only in the rare instance:
- Is there complete destruction of the thyroid parenchyma that leads to:
- Permanent hypothyroidism
- Is there complete destruction of the thyroid parenchyma that leads to:
- Only in the rare instance:
- Patchy in distribution and are off:
- The primary events in the pathology of subacute thyroiditis are:
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