Endocrine and metabolic · Moderate
This case is fictional and exists for study. It describes no real patient.
38 years · female
A 38-year-old female presents to the outpatient clinic with a 2-week history of painful neck swelling, heat intolerance, palpitations, and fatigue. She reports experiencing a mild viral upper respiratory tract infection approximately 3 weeks prior to the onset of neck pain. On physical examination, she appears anxious, with mild diaphoresis and a fine resting tremor in both outstretched hands. Thyroid examination reveals a diffusely enlarged and markedly tender thyroid gland on palpation. She has no exophthalmos, lid lag, or pretibial myxedema. Cardiovascular examination confirms sinus tachycardia without murmurs.
Vital signs
- HR
- 108 bpm
- BP
- 132/84 mmHg
- RR
- 18/min
- Temp
- 37.8 °C
- SpO₂
- 98%
Examination findings
- Diffusely enlarged, markedly tender thyroid gland
- Fine tremor of outstretched hands
- Mild neck erythema without overlying fluctuation
Investigations
| TSH | <0.05 mIU/L | reference: 0.4-4.0 |
| Free T4 | 32.5 pmol/L | reference: 9.0-23.0 |
| ESR | 68 mm/hr | reference: 0-20 |
| CRP | 45 mg/L | reference: 0-5 |
Question 1 of 3
What is the most likely diagnosis?
Subacute (De Quervain's) thyroiditis typically presents following a viral respiratory illness with a painful, tender goitre, thyrotoxic symptoms due to follicular destruction and release of stored hormones, and high inflammatory markers (ESR/CRP). Graves' disease presents with a non-tender goitre, often with eye signs or pretibial myxedema. Toxic multinodular goitre causes non-tender nodular thyroid enlargement in older patients. Hashimoto's thyroiditis causes a non-tender goitre and typically presents with hypothyroidism.
Teaching point: A painful, tender goitre with thyrotoxicosis following a viral upper respiratory infection strongly suggests subacute (De Quervain's) thyroiditis.
Question 2 of 3
Which of the following is the most appropriate next investigation to confirm the aetiology of her thyrotoxicosis?
A radionuclide (technetium or iodine) thyroid uptake scan is the diagnostic test of choice to differentiate subacute thyroiditis from Graves' disease. In subacute thyroiditis, follicular damage and suppressed TSH cause low/absent uptake (<1-2%). In Graves' disease, uptake is diffusely increased. Neck ultrasound is non-specific in early thyroiditis. Fine-needle aspiration cytology is unnecessary and excessively painful in a tender gland. TRAb testing is specific for Graves' disease.
Teaching point: Subacute thyroiditis characteristically shows markedly reduced radionuclide uptake on thyroid scan due to follicular cell destruction and TSH suppression.
Question 3 of 3
Which of the following is the most appropriate initial management step for this patient's pain and thyrotoxic symptoms?
First-line symptomatic management for mild-to-moderate subacute thyroiditis includes NSAIDs (e.g., ibuprofen) for pain/inflammation and a beta-blocker (e.g., propranolol) to control adrenergic symptoms of thyrotoxicosis. Antithyroid drugs such as carbimazole are ineffective because hyperthyroidism is caused by the release of pre-formed hormone, not excess synthesis. High-dose steroids are reserved for severe pain refractory to NSAIDs. Surgery is not indicated.
Teaching point: Subacute thyroiditis is self-limiting and treated symptomatically with NSAIDs for pain and beta-blockers for thyrotoxic symptoms; antithyroid medications are ineffective.
Key learning points
- Subacute (De Quervain's) thyroiditis manifests with a painful tender goitre and transient thyrotoxicosis following a viral prodrome.
- Thyroid radionuclide uptake scanning reveals characteristic low/absent uptake during the acute destructive phase.
- Management focuses on symptom control using NSAIDs for mild-to-moderate neck pain and beta-blockers for adrenergic hyperthyroid symptoms; antithyroid drugs play no role.
This is one of 158 free cases
AskPreceptor is a study tool for medical students: answer first, then see the reasoning — including why each wrong option is wrong. Free, no sign-up required.