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 her GP with a 2-week history of painful anterior neck swelling radiating to her jaw, accompanied by palpitations, fatigue, and heat intolerance. She recalls having a mild upper respiratory tract viral illness approximately 3 weeks ago. Physical examination reveals a diffuse, tender thyroid gland on palpation. There is no exophthalmos, lid lag, or pretibial myxedema. Vital signs demonstrate mild fever and tachycardia. Diagnostic laboratory evaluation shows a suppressed TSH, elevated free T4, and a markedly elevated erythrocyte sedimentation rate (ESR).
Vital signs
- HR
- 104 bpm
- BP
- 132/82 mmHg
- RR
- 18/min
- Temp
- 37.8 °C
- SpO₂
- 98%
Examination findings
- Diffusely enlarged, markedly tender thyroid gland
- Fine tremor of outstretched hands
- Absence of exophthalmos, eye signs, or localized skin changes
Investigations
| TSH | <0.01 mIU/L | reference: 0.4-4.0 |
| Free T4 | 34.2 pmol/L | reference: 9.0-23.0 |
| ESR | 78 mm/hr | reference: 0-20 |
| CRP | 45 mg/L | reference: 0-5 |
Question 1 of 3
Which of the following is the most likely diagnosis?
Subacute (De Quervain's) thyroiditis typically follows a viral upper respiratory infection and presents with a tender, painful goitre, elevated inflammatory markers (ESR/CRP), and transient hyperthyroidism due to release of preformed thyroid hormone. Graves' disease causes hyperthyroidism with a non-tender goitre, exophthalmos, and elevated TSH receptor antibodies. Hashimoto's thyroiditis presents as a non-tender goitre and leads to hypothyroidism. Toxic multinodular goitre typically occurs in older adults with a nodular, non-tender thyroid gland.
Teaching point: Subacute (De Quervain's) thyroiditis should be suspected in a patient with a painful, tender thyroid gland and transient hyperthyroidism following a viral infection.
Question 2 of 3
Which of the following investigation findings would best confirm the diagnosis?
A radionuclide thyroid scan in subacute thyroiditis demonstrates diffusely low or absent uptake due to follicular cell destruction and secondary TSH suppression. High TRAb titers and diffusely increased radionuclide uptake are characteristic of Graves' disease. Elevated anti-TPO antibodies are typical of Hashimoto's thyroiditis, although low titers can non-specifically occur in other thyroid disorders.
Teaching point: A radionuclide thyroid scan showing low or absent uptake confirms destructive thyroiditis (such as subacute thyroiditis) rather than excess thyroid hormone synthesis.
Question 3 of 3
Which of the following is the most appropriate initial management step for this patient?
Initial management of mild-to-moderate subacute thyroiditis focuses on symptom control using NSAIDs (e.g., ibuprofen or naproxen) for neck pain and inflammation, combined with a beta-blocker (e.g., propranolol) for hyperthyroid adrenergic symptoms. Antithyroid drugs like carbimazole are ineffective because hyperthyroidism is caused by hormone leakage from destroyed follicles rather than new hormone synthesis. High-dose corticosteroids are reserved for severe cases or pain refractory to NSAIDs. Thyroidectomy is not indicated.
Teaching point: First-line treatment for mild-to-moderate subacute thyroiditis involves NSAIDs for neck pain and beta-blockers for hyperthyroid symptoms; antithyroid medications are ineffective.
Key learning points
- Subacute (De Quervain's) thyroiditis classically presents with painful anterior neck swelling radiating to the jaw, a tender goitre, and transient hyperthyroidism following a viral illness.
- Thyroid scintigraphy shows diffusely low radionuclide uptake due to follicular cell destruction and TSH suppression.
- Management is supportive using NSAIDs for pain and beta-blockers for hyperthyroid symptoms; antithyroid drugs have no therapeutic role.
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