Subacute Thyroiditis Clinical Presentation

Updated: Apr 17, 2017
  • Author: Stephanie L Lee, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Presentation

History

Patient presentation depends on the etiology of the thyrotoxicosis. Subacute granulomatous thyroiditis is associated with an acute, viruslike illness with fevers and myalgias with a painful thyroid. A recent birth signals postpartum thyroiditis. Often, thyrotoxicosis caused by subacute lymphocytic thyroiditis, postpartum thyroiditis, or the surreptitious use of thyroid hormone is symptomatic because of persistent tachycardia, nervousness, and weight loss. Symptoms of thyrotoxicosis that persist for longer than 2 months are probably not caused by subacute thyroiditis.

Subacute granulomatous thyroiditis

Some patients experience a flulike prodromal episode 1-3 weeks prior to the onset of clinical disease. The natural course of the disease can be divided into the following 4 phases, which usually unfold over a period of 3-6 months:

  • Acute phase - Lasts 3-6 weeks and presents primarily with pain; symptoms of hyperthyroidism also may be present
  • Transient asymptomatic and euthyroid phase - Lasts 1-3 weeks
  • Hypothyroid phase - Lasts from weeks to months; it may become permanent in 5-15% of patients
  • Recovery phase - Characterized by normalization of thyroid structure and function

The diagnosis is made based on clinical findings. Prodromal flulike symptoms (fevers, myalgia, malaise) or known infectious disease, such as pharyngitis, measles, mumps, Q fever, or typhoid fever, may occur. In young patients, de Quervain thyroiditis may develop following an episode of Henoch-Schönlein purpura. However, a history of prodromal symptoms often cannot be obtained.

Local symptoms

Local symptoms can include the following:

  • Dysphagia
  • Hoarseness (uncommon)
  • Pain over the thyroid area that is gradual or of sudden onset

Pain is the presenting symptom in over 90% of cases. It usually involves both lobes of the thyroid; in 30% of cases, it starts on one side and then migrates contralaterally within a few days. While the pain may be limited to the region of the thyroid, it may also involve the upper neck, throat, jaw, or ears. Some patients may first consult an otolaryngologist.

The pain may be so severe that the patient cannot tolerate palpation of the neck. The pain is most commonly bilateral. Occasionally, it may be unilateral, beginning in one lobe and spreading to the opposite side (creeping thyroiditis). Coughing, swallowing, or even tightening a necktie aggravates pain.

Constitutional symptoms

Constitutional symptoms (often absent) can include the following:

  • Fever
  • Malaise
  • Anorexia
  • Fatigue
  • Muscle aches

Symptoms of hyperthyroidism

Hyperthyroidism is usually is mild, becoming severe only in rare cases. The symptoms are transient, typically lasting 3-6 weeks. Symptoms of hyperthyroidism occurring in the acute phase of subacute granulomatous thyroiditis include the following:

  • Tachycardia
  • Tremulousness
  • Heat intolerance
  • Sweating
  • Nervousness
  • Warm skin
  • Frequent bowel movements

Symptoms of hypothyroidism

Symptoms of hypothyroidism occur in the late phase of the disease in up to 50% of cases. The hypothyroidism is most often mild or moderate. It is also transient, lasting weeks to months in 90-95% of cases. Symptoms of hypothyroidism occurring during the second phase of subacute granulomatous thyroiditis include the following:

  • Fatigue
  • Dry skin
  • Lethargy
  • Eyelid swelling
  • Cold intolerance
  • Constipation

Atypical symptoms

Atypical presentations of subacute granulomatous thyroiditis—that is, extremely rare symptoms that have been documented as case reports—can include the following:

  • Thyroid storm [12]
  • Fever of unknown origin
  • Painless subacute granulomatous thyroiditis
  • Occult de Quervain disease mimicking giant cell arteritis
  • Prominent prostration and confusion lasting several weeks
  • Solitary painless nodule

Subacute lymphocytic thyroiditis

This form of subacute thyroiditis is associated with a painless, firm enlargement of the thyroid gland and high thyroid hormone levels. Only suspicion by the clinician and use of radioactive iodine uptake measurement can distinguish Graves hyperthyroidism from subacute lymphocytic thyroiditis.

Subacute postpartum thyroiditis

This condition is associated with a painless, firm enlargement of the thyroid gland and high thyroid hormone levels. The identifying feature is its occurrence 1-6 months after childbirth. Patients may report lack of sleep, nervousness, fatigue, and easy weight loss. [13, 7]

Autoimmune hyperthyroidism from Graves disease can also occur for the first time postpartum and must be distinguished from postpartum thyroiditis. Both conditions are associated with high antithyroid antibody titers.

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Physical Examination

All conditions described are associated with thyrotoxicosis and the signs and symptoms of hypermetabolism. None of the forms of subacute thyroiditis is associated with the thyroid eye disease observed primarily with Graves hyperthyroidism. The presence of bilateral proptosis and chemosis with high thyroid hormone levels and goiter is highly suggestive of Graves disease.

Subacute granulomatous thyroiditis

Patients often present with an acute, viruslike illness characterized by high, spiking fever; malaise; myalgia; fatigue; and prostration.

Thyroid pain is usually symmetrical. In 30% of cases, however, it starts on one side and then migrates contralaterally within a few days. While the pain may be limited to the region of the thyroid, it may also involve the upper neck, throat, jaw, or ears. In many patients, the pain is so severe that he or she cannot tolerate palpation of the neck. The pain may be intense enough to prevent the swallowing of saliva, liquids, and food.

Thyroid enlargement, however, is usually symmetrical and mild, occasionally with areas of localized firmness. Erythema and hyperesthesia of the overlying skin may be present at the onset of severe cases. Cervical lymphadenopathy is uncommon. Lid retraction is rare, and exophthalmos does not occur.

Thyroid hormone levels are often extremely elevated, resulting in marked signs and symptoms of thyrotoxicosis. Cases of lesser severity also exist, and the etiology may be confusing.

Symptoms of hyperthyroidism occurring in the acute phase of subacute granulomatous thyroiditis include the following:

  • Tachycardia
  • Tremulousness
  • Heat intolerance
  • Sweating
  • Nervousness
  • Warm skin
  • A rapid relaxation phase of tendon reflexes

Subacute lymphocytic thyroiditis

Patients present with a nonpainful thyroid enlargement and elevated thyroid hormone levels. This condition must be distinguished from Graves thyrotoxicosis because antithyroid medication is not indicated in this temporary condition.

Subacute postpartum thyroiditis

Patients present 1-6 months postpartum with painless thyroid enlargement and elevated thyroid hormone levels. Sometimes, distinguishing between the usual postpartum changes in physiology and additional thyroid pathology is difficult. [13, 7]

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