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 complaining of neck pain, palpitations, and heat intolerance for the past ten days. She notes that the neck pain radiates up towards her ears and jaw, making swallowing uncomfortable. Three weeks prior to the onset of these symptoms, she experienced a self-limiting upper respiratory tract infection with a sore throat and low-grade fever. On examination, she appears mildly anxious and diaphoretic. Neck palpation reveals a diffusely enlarged thyroid gland that is markedly tender to touch. There are no thyroid bruits, exophthalmos, or pretibial oedema. Cardiovascular examination reveals sinus tachycardia.
Vital signs
- HR
- 102 bpm
- BP
- 128/78 mmHg
- RR
- 16/min
- Temp
- 37.8 °C
- SpO₂
- 99%
Examination findings
- Diffusely enlarged, markedly tender thyroid gland on palpation
- Sinus tachycardia without murmurs
- No exophthalmos, tremor, or lid lag
Investigations
| TSH | <0.01 mU/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 | 42 mg/L | reference: 0-5 |
Question 1 of 3
Which of the following is the most likely diagnosis?
Subacute (De Quervain's) thyroiditis typically presents following a viral upper respiratory infection with tender goitre, neck pain radiating to the jaw or ears, elevated inflammatory markers (ESR/CRP), and transient hyperthyroidism due to follicular destruction. Graves' disease presents with non-tender goitre, eye signs, and elevated thyroid autoantibodies. Toxic multinodular goitre occurs mostly in older individuals, presenting as non-tender nodular hyperthyroidism without a viral antecedent. Acute suppurative thyroiditis is a rare bacterial infection causing severe localized throat pain, high fever, fluctuating mass, and marked leukocytosis rather than diffuse thyroid tenderness.
Teaching point: Subacute (De Quervain's) thyroiditis should be suspected in a patient presenting with a painful, tender thyroid gland and thyrotoxicosis following a recent viral respiratory infection.
Question 2 of 3
Which of the following is the most appropriate next investigation to confirm the aetiology of her thyroid dysfunction?
A radionuclide iodine or technetium-99m uptake scan is the test of choice to differentiate subacute thyroiditis from Graves' disease. In subacute thyroiditis, damaged follicular cells cannot take up iodine, resulting in low or absent radioiodine uptake (<1%), whereas Graves' disease demonstrates diffusely high uptake. Ultrasound-guided fine-needle aspiration cytology is indicated for cold thyroid nodules to rule out malignancy, not diffuse painful thyroiditis. MRI of the neck is non-specific and unnecessary. TSH receptor antibodies (TRAb) confirm Graves' disease but are negative in subacute thyroiditis and lack the functional diagnostic value of an uptake scan in this context.
Teaching point: A radionuclide thyroid uptake scan shows markedly reduced or absent uptake in subacute thyroiditis, distinguishing it from Graves' disease.
Question 3 of 3
What is the most appropriate initial management step for this patient's condition?
Management of subacute thyroiditis is supportive. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or high-dose aspirin relieve pain and inflammation (oral corticosteroids like prednisolone are reserved for severe or refractory pain). Beta-blockers (e.g., propranolol) control thyrotoxic symptoms like tachycardia and anxiety. Antithyroid medications such as carbimazole are ineffective because hyperthyroidism in subacute thyroiditis results from the release of pre-formed thyroid hormones due to glandular destruction, not increased de novo synthesis. Surgical resection and radioactive iodine are permanent ablative therapies inappropriate for a self-limiting inflammatory process.
Teaching point: Antithyroid medications like carbimazole are ineffective in subacute thyroiditis; initial management relies on NSAIDs for pain and beta-blockers for symptomatic control of thyrotoxicosis.
Key learning points
- Subacute (De Quervain's) thyroiditis presents with a tender goitre, neck pain radiating to the jaw/ears, and hyperthyroid symptoms after a viral illness.
- Radionuclide thyroid uptake scan reveals low/absent uptake in subacute thyroiditis due to follicular cell injury and TSH suppression.
- Treatment is supportive using NSAIDs for neck pain and beta-blockers for thyrotoxic symptoms, as antithyroid drugs are ineffective against pre-formed hormone release.
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