Subacute granulomatous thyroiditis
Subacute granulomatous (de Quervain) thyroiditis is a painful, tender destructive thyroiditis that follows a viral upper respiratory illness and produces a transient thyrotoxic phase, often followed by a hypothyroid phase, with a markedly elevated erythrocyte sedimentation rate. Treatment is symptomatic, an NSAID for mild pain or a glucocorticoid taper for moderate to severe pain, with a dramatic response within 24 to 48 hours, since thionamides and radioactive iodine have no role.
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What this article covers
- Overview
A postviral, painful destructive thyroiditis: subacute granulomatous thyroiditis (de Quervain thyroiditis) follows an upper respiratory tract infection and causes granulomatous inflammation with…
- Epidemiology
A recognized cause of painful thyroid disease: subacute granulomatous thyroiditis is the most common cause of a painful thyroid gland.
- Risk factors
Recent upper respiratory tract viral infection: the principal identified trigger, typically preceding thyroid symptoms by 2 to 8 weeks.
- Pathophysiology
Granulomatous inflammation with giant cells: distinguishes the histology from the lymphocytic-only infiltration of Hashimoto, painless, and postpartum thyroiditis.
- Clinical features
Painful, exquisitely tender goiter: the hallmark finding, often with pain radiating to the jaw or ears, and frequently migrating from one side of the gland to the other.
- Differential diagnosis
Painless (silent) thyroiditis: a non-tender goiter without fever or an elevated erythrocyte sedimentation rate, unlike the painful, systemically inflammatory presentation here.
- Diagnosis
The diagnosis is established clinically by a painful, tender goiter with a markedly elevated erythrocyte sedimentation rate following a viral illness, together with biochemical thyrotoxicosis and low…
- Management
First, treat mild to moderate pain with an NSAID: ibuprofen 600 mg PO three to four times daily, continued until pain resolves, typically 2 to 6 weeks.
- Complications
Transient hypothyroidism: common in the weeks following the thyrotoxic phase as hormone stores are depleted, usually resolving without permanent treatment.
- Prognosis
Excellent overall: most patients recover full thyroid function within weeks to a few months.
- Prevention
No specific primary prevention exists, since the trigger is a common viral upper respiratory infection.
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Related articles
- Hashimoto thyroiditis
Hashimoto thyroiditis is a chronic autoimmune process in which lymphocytic infiltration destroys the thyroid, and is the most common cause of hypothyroidism in iodine-sufficient regions such as the United States. Diagnosis rests on an elevated thyroid-stimulating hormone with a low or normal free thyroxine, and first-line treatment is lifelong levothyroxine replacement dosed to normalize thyroid-stimulating hormone.
- Painless thyroiditis
Painless (silent) thyroiditis is a self-limited destructive thyroiditis, usually arising in patients with underlying autoimmune thyroid disease, that releases preformed hormone in a triphasic pattern of thyrotoxicosis, hypothyroidism, and recovery without a tender gland. Treatment is symptomatic, with a beta-blocker for the thyrotoxic phase and temporary levothyroxine for a symptomatic hypothyroid phase, because thionamides and radioactive iodine have no role.
- Postpartum thyroiditis
Postpartum thyroiditis is a destructive, painless thyroiditis that occurs in the first year after delivery, typically following the same thyrotoxic-then-hypothyroid-then-recovery course as painless thyroiditis, and permanently affects thyroid function in about 20% of cases. Treatment is symptomatic, with a beta-blocker for thyrotoxic symptoms and levothyroxine for a symptomatic or persistent hypothyroid phase, since thionamides and radioactive iodine are not indicated.
- Graves disease
Graves disease is an autoimmune disorder in which thyrotropin receptor antibodies stimulate the thyroid, causing hyperthyroidism, and is the most common cause of thyrotoxicosis in iodine-sufficient regions. Diagnosis rests on a suppressed thyroid-stimulating hormone with elevated free thyroxine and positive thyrotropin receptor antibodies, and first-line treatment is a thionamide, most often methimazole, with radioactive iodine or thyroidectomy reserved for recurrence or patient preference.