Subacute thyroiditis

Question 1

A 36 year old woman presents with a four day history of neck pain and swelling. She has a swollen painful thyroid. How would you assess and manage her?

Answer 1

Impression
Given 4 day history of swollen and painful thyroid, I am initially concerned about thyrotoxicosis (subacute thyroiditis). Importantly, I would want to screen for important complications including thyroid storm, as this has increased morbidity and mortality. Most commonly is granulomatous or lymphocytic, have triphasic disease process which can last weeks.

Differential causes of thyrotoxicosis to consider in this case include;

• De Quervain’s
• Autoimmune (Hashimoto’s)
• radiation
• post-partum
• suppurative
• rule out malignancy, Grave’s, other causes of neck lump, multinodular goitre

Consider other causes of painful neck lump - i.e. lymphadenitis (bacterial, viral).

Typically, thyroiditis is triggered by an infective event (bacterial, viral most common)

Determining the underlying cause in this situation is critical for appropriate ongoing management.

Question 2

Subacute thyroiditis - initial assessment

Answer 2

Initial assessment:
Given neck lump am concerned about implications for patients airway, and also would want to assess for evidence of thyroid storm in the acute setting. Would take A to E approach;
A - patent, maintaining, consider adjuncts
B - RR, SP02, resp exam
C - BP, HR - tachycardia, hypertension, diaphoresis
D
E
F

Question 3

Sub-acute thyroiditis - History

Answer 3

History

• sx: thyroid storm: hypertension, headache, tachycardia, fevers, vomiting, abdo pain, palpitations, preceding infective sx, other signs of hyperthyroidism including heat intolerance, weight loss, diarrhoea, swelling, psychological changes
• features of hypo: cold intolerance, slow speech, mood, constipation, weight gain
• REDFLAG: systemic features of malignancy
• HPI: recent infections
• PMHx: graves/hashimoto’s, other autoimmune, any recent radiation, pregnancy. (thyrogastric cluster)
• SNAP

Question 4

Sub-acute thyroiditis - Examination

Answer 4

Examination

• initial A to E assessment as above
• general inspection + vital signs; looking for features of hyper/hypothyroidism
• Thyroid examination: size, location, diffusely vs focally enlarged will help differentiate potential causes, lymph nodes for lymphadenitis, mass will rise with swallow but NOT with tongue extrusion (then thyroglossal duct cyst will rise)

Question 5

Sub-acute thyroiditis - Investigations

Answer 5

Investigations

• Bedside: vital signs, ECG
• Bloods: TFTs, CRP/ESR, Blood cultures if fevers, thyroid autoantibodies (anti-TSHR [Graves], anti- thyroid peroxidase and thyroglobulin antibodies [Hashimoto’s)
• Imaging: thyroid ultrasound, nuclear thyroid scan (radionuclide uptake scan)

Question 6

Sub-acute thyroiditis - Management

Answer 6

Management
Is largely supportive, treat symptoms of thyrotoxicosis and prevent complications

Pharmacological
- Propanolol (sympathetic symptoms)
- NSAIDs (anti-inflammatories)
- Potassium iodide
+/- Prednisone if significant inflammation
+/- Anti-thyroid if underlying cause is chronic (Carbimazole, Propothiouracil)
+/- levothyroxine for the hypothyroid phase of the disease process

Supportive

• analgesia
• patient education