Diagnosis Case # 3        De Quervains thyroiditis (Subacute thyroiditis)  

Based on clinical, biochemical and cytological data, the diagnosis in this case was deQuervains thyroiditis. Thyroid antibody titres were not sought due to the extremely small percentage of patients showing antibodies in case of deQuervains thyroiditis.

Leishman stained smears from both sides of the gland including the nodule on the right side showed similar morphology. Cellularity was good with a dirty background (Fig. 2). A mixed infiltrate of lymphocytes, histiocytes, epithelioid cells and large number of multinucleate giant cells was seen in addition to the degenerated follicular epithelium (Fig. 3 & 4). Coarse blue ‘paravacuolar’ granules were seen in the cytoplasm of the epithelial cells (Fig. 5). Colloid was abundant (Fig. 6).

FOLLOW UP:  The patient was placed on treatment with tab diclofenac, tab paracetamol and tab neomercazole. On review after 2 weeks the pain and swelling were reduced and symptoms of hyperthyroidism abated. She is on follow up with regular thyroid function tests to ascertain the biochemical status of the gland and to watch for development of hypothyroidism.



Synonyms- Granulomatous thyroiditis, Subacute thyroiditis

De Quervain (subacute granulomatous) thyroiditis is the most common cause of a painful thyroid gland. It is a transient inflammation of the thyroid, the clinical course of which is highly variable. Most patients have pain in the region of the thyroid, which usually is diffusely tender, and some have systemic symptoms. Hyperthyroidism often occurs initially, sometimes followed by transient hypothyroidism. Complete recovery in weeks to months is characteristic.

A viral infection or a post viral inflammatory response is considered to be the etiology. A number of viruses including coxsackie virus, mumps, measles, adenovirus, echovirus, and influenza have been implicated based on viral antibody titres. A strong association exists with human leukocyte antigen (HLA)-B35.  De Quervains thyroiditis is more common in females in the fourth and fifth decades of life.

Patients usually experience a prodromal flu like episode one to three weeks before the onset of symptoms. They usually present with pain over the thyroid area and dysphagia along with constitutional symptoms of fever, malaise, lethargy and body aches. Symptoms of hyperthyroidism (tremors, palpitations, heat intolerance) occur in the early phase of the disease and subsequently may evolve into symptoms of hypothyroidism as the gland is destroyed by the inflammatory process.

The diagnosis is essentially clinical and is supported by lab evidence of hyperthyroidism, raised ESR and raised serum thyroglobulin levels. Antibodies to thyroglobulin and thyroid peroxidase are usually absent.

FNAC is useful for diagnosis especially when the presentation is atypical or when a solitary nodule is palpable.

Cytological findings include the presence of abundant and large multinucleate giant cells and inflammatory cells including macrophages and lymphocytes. A dirty background with debris and colloid is usually present. Epithelioid cells are seen. The follicular epithelium is degenerated and may show dark blue (paravacuolar) granules.

Treatment involves treatment for pain and for hormonal status. Patients with mild symptoms are treated with non steroidal anti inflammatory drugs like ibuprofen or aspirin which may be continued for 2-6 weeks. If NSAIDs provide insufficient pain relief in 2-3 days, steroids may be given. In the initial phase of De Quervain thyroiditis, symptomatic hyperthyroidism can be treated with beta-blockade (propranolol 10-20 mg qid or atenolol 25-50 mg/d), although mild symptoms may not require treatment. Beta-blockade, if needed, usually can be withdrawn in 2-6 weeks.