X_ypical clinical symptoms and f by fjhuangjun


									Subacute Thyroiditis (de Quervain) Presenting
as a Painless "Cold" Nodule
Piet C. Bartels and Robbert O. Boer
St. Franciscas Hospital, Department of Nuclear Medicine, The Netherlands

A 49-yr-old woman presented with a solid, painless, nontender nodule in the left thyroid lobe.
Thyroid scintigraphy revealed a solitary "cold" area in the left lobe and a slightly decreased
24-hr radioactive iodine thyroid uptake (9%). Although there were no specific clinical or
biochemical signs suggesting thyroiditis needle aspiration cytology showed the presence of a
subacute thyroiditis. Approximately 1 mo later the entire thyroid gland was affected leading to
a completely suppressed thyroid radioiodine uptake and elevated serum thyroid hormone
concentrations. This case illustrates that in the early phase of the disease, subacute
thyroiditis may present as a solitary, painless, "cold" nodule and should be considered in the
differential diagnosis of such lesions.

J NucÃ- ed 28:1488-1490,1987

X,   ypical clinical symptoms and features of subacute
thyroiditis vary widely during the course of illness. In
                                                                    nodule and euthyroid function without the character
                                                                    istic clinical features suggesting thyroiditis.
the early stage, characteristic clinical symptoms are
local pain, extreme tenderness of the gland and pain                CASE REPORT
frequently radiating to the ears and increasing during
swallowing. Otherwise symptoms may be totally absent                   A 49-yr-old clinically euthyroid woman visited our outpa
("silent thyroiditis"). The gland is typically two to three
                                                                    tient internal medicine department in December 1984. Some
times normal size and often asymmetrically enlarged                 months earlier, she had developed complaints of sore throat,
(7). Involved parts of the gland are firm and usually               pain in the anterior part of the neck, fatigue, and general
extremely tender. In some cases only nodules appear.                weakness after an influenza-like illness. Previously she had
In ~10% of the subjects with subacute thyroiditis only              been seen by an otolaryngologist, who found a painless, non-
one nodule is present (2). Regional involvement of the              tender nodule in the left lobe of the thyroid gland. This finding
gland may change very quickly. Despite the fact that                was confirmed by our own examination. We found a focal,
subacute thyroiditis may appear as a focal or migrating             swelling in the left lobe of the thyroid gland with a diameter
                                                                    of ~2 cm. The nodule was not painful on examination.
condition (3,4), scintigraphy usually reveals a uniform
                                                                    Initially, no signs of hyperthyroidism were present and thyroid
depression of activity. In cases in which the disease is            hormone levels in serum were normal. Thyroid scintigraphy
restricted only to a circumscribed part of the gland, the           with Na'23I revealed homogeneous accumulation of radio-
concomitant thyrotoxicosis will lead to suppressed pi               nuclide except a solitary "cold" nodule partly involving the
tuitary-thyroid function. Thyrotoxicosis results from               mid-left lateral lobe (Fig. 1A). There was no thyroid enlarge
leakage of thyroid hormone from the affected part of                ment. The 24-hr radioactive iodine thyroid uptake was 9%.
the gland. The remainder of the thyroid is then sup                 Needle aspiration from the nodule in the left lobe showed
pressed. The 24-hr radioactive iodine thyroid uptake is             findings characteristic and conclusive for subacute thyroiditis
decreased or undetectable during the acute phase of the             de Quervain (Cell-rich material consisting of loosely coherent
disease in which thyroid hormone levels in serum are                clusters of thyrocytes, some multinucleated giant cells and
high. We describe a serial scintigraphically documented             histocytes. Macrophages and lymphocytes were rarely ob
history of a subject initially showing a single "cold"              served).
                                                                       One month later, she had more specific complaints of
                                                                    thyroiditis combined with thyrotoxicosis (anterior neck pain,
                                                                    general weakness, reduced heat tolerance, agitation, and
  Received May 5, 1986; revision accepted Apr. 17, 1987.            weight loss) supported by typical laboratory findings [elevated
  For reprints contact: Robbert O. Boer, St. Franciscus Hospital,   values for ESR, Tj. T4, and FTI, alkaline phosphatase activity
Dept. of NucÃ-.
              Medicine, Boerhaavelaan 25,4708 AE Roosendaal,        was 160 U/l. (normal range 20-110 U/l)]. An extremely
The Netherlands.

1488        Bartels and Boer                                                                     The Journal of Nuclear Medicine
                                                    2                         "••••;•
                                              -•::-. ; K-/»V:

FIGURE     1
Scintigrams in various stages of subacute thyroiditis in this case report. A: December 19th 1984: Cold nodule in the
center of the left lateral lobe. B: January 23rd 1985: No demonstrable thyroid uptake. C: June 27th 1985: Normal
distribution of iodine in the thyroid gland.

tender nodule in the right thyroid lobe was now present and       may become low in the third phase with a compensatory
the nodule previously found in the left lobe was barely pal       increased secretion of TSH. However, normalization of
pable.                                                            biochemical parameters is not seen before the thyroid
   Scintigraphy (Fig. IB) showed no thyroid I2il uptake. Thy
                                                                  gland is sufficiently recovered (last phase).
roid specific antibodies (hemagglutination technique) against
                                                                     If a single nodule is found in an euthyroid subject
colloid were positive and against cytoplasm slightly positive.
                                                                  without typical clinical symptom and/or biochemical
   Five months later, the patient was entirely free of symptoms
and thyroid palpation was normal. All laboratory results were     evidence of thyroiditis, the cause of such an unilateral
within the normal range. Thyroid Scintigraphy (Fig. 1C)           swelling should be further elucidated. Increased alkaline
showed even distribution of radionuclide in both lobes. Mid-      phosphatase activity in serum is present in ~50% of
lateral in the left lobe only a small region with decreased       subjects with subacute thyroiditis (14). Since alkaline
concentration of activity was observed. The 24 radioiodine        phosphatase is routinely measured in many laborato
uptake was 36%. Based on the findings in course of time           ries, it may serve as a diagnostic clue for the physician.
combined with the clinical presentation, the diagnosis "sub-
acute thyroiditis de Quervain" could be established.              A close chronological association between the rise and
                                                                  fall in serum alkaline phosphatase level and serum
                                                                  thyroxine has been demonstrated (13). However, in our
DISCUSSION                                                        patient the alkaline phosphatase was normal in the
                                                                  initial stage of the subacute thyroiditis. In a thyroid
    The findings of moderately elevated serum thyroxine           clinic, one is frequently confronted as in this case with
                                                                  the differential diagnosis of whether a "cold" nodule is
concentration, a tender enlarged thyroid, and a low
radioiodine thyroid uptake are characteristic of sub-             malignant or benign. In most cases it is possible to
acute thyroiditis. Unfortunately, the disorder does not           differentiate a benign from a malignant lesion in a
                                                                  "cold" nodule by examination of a needle aspiration
always present in the classic way and that is why sub-
acute thyroiditis may escape recognition (3,6,7). The             biopsy. In the presented patient we preferred to exclude
initial stage of subacute thyroiditis may be confused             the diagnosis of thyroid carcinoma early; microscopic
with pharyngitis (5) and other infections of the upper            interpretation of the aspirate demonstrated the classic
respiratory tract (5,6). In about one-third of all cases of       picture of subacute thyroiditis (12).
subacute thyroiditis differential diagnosis is not clear
because only a less specific symptom is manifest, e.g.,
painless goiter, palpable nodules, thyrotoxicosis, atrial         ACKNOWLEDGMENTS
fibrillation, or fever of unknown origin may form the
                                                                    The authors thank Dr. E.P. Krenning, Dijkzigt Hospital,
clinical picture (9).
                                                                  Rotterdam for critically reading the manuscript and Vera
    Volpe (10) classified the course of subacute thyroid          Meeus for providing excellent secretarial assistance.
itis in four stages. The first stage includes a thyrotoxic
phase with a low radioactive iodine thyroid uptake.
Mild thyrotoxicosis may result from release of stored             REFERENCES
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1490       Bartels and Boer                                                              The Journal of Nuclear Medicine

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