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At a glance

Most common cause of a painful thyroid gland. It is caused by transient nonbacterial inflammation. Hyperthyroidism often occurs initially and can be followed by hypothyroidism.

Synonyms

Granulomatous Giant Cell Thyroiditis; de Quervain Subacute Struma; Quervain Syndrome; Subacute Painful Thyroiditis; Struma Granulomatosa.

History

An acquired disease that was first described by Fritz de Quervain, a Swiss surgeon, in 1904.

Incidence

Five percent of all patients with thyroid pathology. Peak incidence in the fourth and fifth decade of life; sex ratio female:male 4 to 7:1. Rare in children. Possible seasonal trend.

Genetic inheritance

High incidence of human leukocyte antigen (HLA)-B35 positivity. Likely the result of viral infection in genetically predisposed individuals.

Pathophysiology

Presumably caused by a viral infection or postviral inflammatory response. A proposed mechanism is that a viral antigen binds to HLA-B35 molecules and that the complex activates cytotoxic T lymphocytes that damage thyroid follicular cells because of their similarity with the infection-related antigen. Destruction of follicular epithelium involves the release of thyroid-binding globulin into blood. Triidothyronine (T3) and thyroxine (T4) concentration in serum is increased and thyroid-stimulating hormone secretion is suppressed. The thyroid follicles then regenerate and thyroid hormone synthesis and secretion resume.

Diagnosis

Made on clinical grounds (history, pain, symptom of hyperthyroidism), ultrasound; thyroid-stimulating hormone and free T4 measurement to determine the cause of hyperthyroidism; serum thyroglobulin (elevated) and erythrocyte sedimentation rate (>50 mm/h). (See Table Q-1.) Thyroid biopsy shows characteristic giant cell inflammation.

TABLE Q-1Characteristic Course of de Quervain Thyroiditis

Clinical aspects

Features include gradual onset of pain in the region of the thyroid gland (aggravated with swallowing and head movement), dysphagia, low-grade fever, weakness, and fatigue. Weight loss and diarrhea may occur. Symptoms of moderate hyperthyroidism (palpitations, tremor, heat intolerance, nervousness, sweating, skeletal muscle weakening) appear in the initial phase, usually over 3 to 6 weeks. The initial phase is followed by the transient asymptomatic phase over the next 1 to 3 weeks. In 50% of patients, symptoms of hypothyroidism occur in the late phase. It may become permanent in 5 to 10% of patients. Acute complications (severe hyperthyroidism, pancreatitis) are exceptional. Treatment with glucocorticoids in severely ill patients. Usually resolves without sequelae within 6 to 12 months.

Precautions before anesthesia

Evaluate thyroid function (clinical, thyroid-stimulating hormone, T3, free T4). Laboratory investigations should include serum levels of calcium, phosphate, and amylase. Preoperative ECG is recommended. ...

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