Diagnostic Considerations

It is important to determine whether elevated thyroid hormone levels are from the causes listed in this article rather than from excess synthesis of thyroid hormone. Generally, the conditions described here are temporary and therefore do not require definitive therapy, such as thyroid surgery, radioactive iodine treatment, or antithyroid therapy. Radioactive iodine treatment and antithyroid therapy are never appropriate for these forms of subacute thyroiditis.

Conditions to consider in the differential diagnosis of subacute thyroiditis include the following:

Acute hemorrhage into a thyroid cyst, nodule, or neoplasm
Infectious thyroiditis
Radiation-induced thyroiditis
Trauma- or palpation-induced thyroiditis
Riedel or fibroid thyroiditis
Graves thyrotoxicosis
Toxic thyroid adenoma
Toxic multinodular goiter
Acute suppurative thyroiditis

The last disorder in the above list, acute suppurative thyroiditis, is most commonly caused by a bacterial infection of the thyroid via the conduit of a congenital pyriform sinus fistula. This pain and swelling in the early stages can be confused with subacute thyroiditis. A study by Masuoka et al of 60 patients with acute suppurative thyroiditis found that careful imaging can provide clues to an early diagnosis of this condition, which can develop into a life-threatening endocrine emergency.^[23]

Differential Diagnoses

Workup

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Media Gallery

Three multinucleated, giant cell granulomas observed in a fine-needle aspiration biopsy of the thyroid; from a patient with thyrotoxicosis resulting from subacute granulomatous thyroiditis.
Absence of iodine-123 (123I) radioactive iodine uptake in a patient with thyrotoxicosis and lymphocytic (subacute painless) thyroiditis. Laboratory studies at the time of the scan demonstrated the following: thyroid-stimulating hormone (TSH), less than 0.06 mIU/mL; total thyroxine (T4), 21.2 mcg/dL (reference range, 4.5-11); total triiodothyronine (T3), 213 ng/dL (reference range, 90-180); T3-to-T4 ratio, 10; and erythrocyte sedimentation rate (ESR), 10 mm/h. The absence of thyroid uptake, the low T3-to-T4 ratio, and the low ESR confirm the diagnosis of lymphocytic thyroiditis.
Example of laboratory values as they vary over the course of subacute granulomatous thyroiditis. The entire episode may evolve through all 3 phases of the disorder over a period of as long as 6 months.
Ultrasonogram of subacute granulomatous thyroiditis. A. Transverse image. B. Sagittal image with Doppler analysis. The echotexture is very heterogeneous and hypoechoic. The vascular flow is absent in much of the affected hypoechoic regions of the lobe and much less than would be expected if this were Graves disease hyperthyroidism.

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Author

Stephanie L Lee, MD, PhD Associate Professor, Department of Medicine, Boston University School of Medicine; Director of Thyroid Health Center, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center; Fellow, Association of Clinical Endocrinology

Stephanie L Lee, MD, PhD is a member of the following medical societies: American College of Endocrinology, American Thyroid Association, Endocrine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sonia Ananthakrishnan, MD Assistant Professor of Medicine, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston University School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Romesh Khardori, MD, PhD, FACP (Retired) Professor, Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

Mark R Allee, MD Associate Professor, Department of Medicine, University of Oklahoma Health Sciences Center

Mark R Allee, MD is a member of the following medical societies: American College of Physicians