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 general practice clinic with a 1-week history of anterior neck pain radiating to her jaw and ears. She reports accompanying feverishness, palpitations, heat intolerance, and irritability. Three weeks prior to the onset of these symptoms, she experienced a mild upper respiratory tract infection that resolved spontaneously. On physical examination, she appears anxious and restless. Palpation of the anterior neck reveals a diffusely enlarged, exquisitely tender thyroid gland. There is a fine tremor observed in her outstretched hands, but no exophthalmos, pretibial myxedema, or focal thyroid nodules are present.
Vital signs
- HR
- 106 bpm
- BP
- 134/82 mmHg
- RR
- 16/min
- Temp
- 37.9 °C
- SpO₂
- 99%
Examination findings
- Diffusely enlarged, exquisitely tender thyroid gland
- Fine tremor of outstretched hands
- Absence of exophthalmos or pretibial myxedema
Investigations
| TSH | <0.05 mU/L | reference: 0.4-4.0 |
| Free T4 | 34.2 pmol/L | reference: 9.0-23.0 |
| ESR | 72 mm/hr | reference: 0-20 |
| CRP | 48 mg/L | reference: 0-5 |
Question 1 of 3
Which of the following is the most likely diagnosis?
Subacute (De Quervain's) thyroiditis classically presents 2-8 weeks after a viral upper respiratory infection with anterior neck pain radiating to the jaw, tender goitre, transient thyrotoxicosis, and marked elevation of inflammatory markers (ESR/CRP). Graves' disease presents with a painless goitre, autoimmune features (e.g., exophthalmos), and normal inflammatory markers. Toxic multinodular goitre presents in older individuals with a non-tender, nodular gland. Hashimoto's thyroiditis typically causes a painless hypothyroid goitre; although transient 'hashitoxicosis' can occur, it lacks the characteristic post-viral severe neck tenderness and elevated ESR.
Teaching point: Subacute (De Quervain's) thyroiditis should be suspected in a patient with painful thyroid enlargement, high ESR, and thyrotoxicosis following a viral illness.
Question 2 of 3
Which of the following diagnostic investigations is most appropriate to confirm the diagnosis?
A radionuclide thyroid uptake scan (Technetium-99m pertechnetate or Iodine-123) is the definitive investigation to confirm subacute thyroiditis. It demonstrates low or absent radiotracer uptake (<1%) due to follicular cell destruction and TSH suppression. In contrast, Graves' disease shows diffuse high uptake. Neck ultrasound shows non-specific hypoechogenicity and reduced vascularity during the acute phase, but uptake scanning is more definitive. Fine-needle aspiration cytology is painful, unnecessary, and reserved for suspected malignancy. TRAb testing is specific for Graves' disease and would be negative in subacute thyroiditis.
Teaching point: A low radioactive iodine or technetium uptake scan confirms destructive thyroiditis and distinguishes it from high-uptake causes of thyrotoxicosis like Graves' disease.
Question 3 of 3
Which of the following is the most appropriate initial management step for this patient?
Management of subacute thyroiditis is supportive. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are first-line to relieve thyroid pain and inflammation (oral corticosteroids are reserved for severe or NSAID-refractory pain). Beta-blockers such as propranolol control thyrotoxic symptoms (palpitations, tremor, tachycardia). Antithyroid medications like carbimazole are ineffective because thyrotoxicosis results from the release of stored hormone from damaged follicles rather than active new hormone synthesis. Levothyroxine is only required if a subsequent transient hypothyroid phase occurs and becomes symptomatic. Surgery is not indicated for this self-limiting condition.
Teaching point: Subacute thyroiditis is self-limiting and managed with NSAIDs for neck pain and beta-blockers for thyrotoxic symptoms; antithyroid drugs are ineffective.
Key learning points
- Subacute (De Quervain's) thyroiditis is a post-viral inflammatory disorder characterized by a painful tender goitre, thyrotoxicosis, and high inflammatory markers.
- Radionuclide thyroid uptake scanning shows low or absent uptake, distinguishing destructive thyroiditis from high-uptake conditions like Graves' disease.
- Initial medical management involves NSAIDs for pain control and beta-blockers for thyrotoxic symptoms; antithyroid medications (e.g., carbimazole) have no role.
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