At the onset of symptoms the patient began experiencing intense chest pain associated with chest pressure and low-grade fever lasting for 3 days. The clinical picture also included at least ten sneezes per day, fatigue, insomnia, a choking sensation, weight loss, difficulty swallowing, dry nose and mouth, discomfort when touching the trachea and above all a lowering of the voice.

 

Following tests and an examination by an endocrinology specialist, the patient was diagnosed with autoimmune and subacute thyroiditis, and prescribed cortisone treatment with Deflan for a predetermined period of time.

 

The medical treatment improved the symptoms except for the voice lowering, which still persisted on alternate days, as well as the constant nose and mouth dryness.

 

Seven months later a further episode of the symptoms coinciding with the initial ones occurred, so that cortisone treatment was resumed (same dosage as the previous cycle), which the patient is still following with a fair improvement, but even in this case the voice lowering and nose and mouth dryness persist.

 

A thyroid ultrasound scan showed a diffuse glandular hyperplasia; in the paramedian basal area from the right symptomatic side, a formation typical of a small hyperplastic nodule of about 7 mm can be observed. In the subcapsular area of the middle third, upper pole of the left lobe, a small discoidal cystic formation of just 4 mm can be observed.

 

Online Doctor Consultation – Medical Questions:

1. Are diagnosis and treatment correct? If the answer is yes, how long can the treatment be continued?

2. Is complete recovery possible or will the patient have to undergo treatment for the rest of her life?

3. Are there any contraindications in case of pregnancy? What are the risks in this case?

 

 

History of Present Illness:

 

This 38-year-old female with an undefined prior medical history is described to have had the onset of chest pain and pressure that was accompanied by a low-grade fever of 3 days duration. She also experienced tenderness about the trachea, hoarseness, fatigue, insomnia, choking sensation and dysphagia, and an undefined amount of weight loss over an undefined period of time. At an unclear point in time she was seen by an endocrinologist and diagnosed with autoimmune sub-acute thyroiditis and prescribed tapering glucocorticoid therapy. This therapy improved the symptoms except for the hoarseness and nose and mouth dryness. A second episode of symptoms occurred similar to the first and glucocorticoid treatment was resumed and symptoms improved again except for hoarseness and dry nose and mouth.

 

Laboratory Data: (first set): TSH 0.007, FT3 5.31, FT4 1.61, anti-TPO 351 (4 months later): anti-TG 271, anti-TPO 201.

 

Radiological Data: Thyroid ultrasound showed one 7mm and one 4 mm nodule in what appears to be a heterogeneous background echotexture.

 

Impression: The initial diagnosis of sub-acute thyroiditis is possible given the presenting symptoms of tenderness about the thyroid gland with fever in the setting of what is described as a possible upper respiratory infection. Lab testing was not reported at the initial presentation and thus the ability to make a definitive diagnosis is limited. Classically, sub-acute thyroiditis presents the described symptoms of tenderness about the thyroid along with laboratory data and symptoms of hyperthyroidism and an elevated erythrocyte sedimentation rate (ESR). Sub-acute thyroiditis should respond completely and rapidly to glucocorticoid therapy which should be continued until the resolution of thyroid tenderness (usually 1-2 weeks) and then typically will progress from biochemical hyperthyroidism (lasting 2-6 weeks) to hypothyroidism and eventual normalization over a period of 3-8 months. About 15% of patients with sub-acute thyroiditis will remain hypothyroid. She apparently had a relapse of her symptoms seven months later; at this time she did have laboratory evidence of hyperthyroidism and thyroid autoimmunity. While sub-acute thyroiditis can be recurrent it is not typical of the condition. The anti-TG and anti-TPO tests are non-specific and can be found in normal people and in those with either Graves disease or thyroiditis. Her thyroid ultrasound description is non-specific and can be found in Graves disease, chronic lymphocytic thyroiditis, or sub-acute thyroiditis; no significant nodularity was noted.

 

The cause of her hyperthyroidism remains unresolved. A 2 and 24-hour radioiodine uptake should be able to distinguish hyperthyroidism due to Graves disease versus hyperthyroidism from thyroiditis or multinodular goiter.

 

Normalization of her thyroid function or progression to hypothyroidism would be consistent with a diagnosis of thyroiditis; continued hyperthyroidism would be suggestive of Graves disease. Pregnancy should not be considered prior to the elucidation of the cause of her hyperthyroidism. While pregnancy is not problematic after resolution of subacute thyroiditis, testing should be done prior to and during the pregnancy to be sure a euthyroid status is maintained and thyroid hormone should be supplemented, if required, to maintain a TSH between 0.5 and 2.5. Graves disease should be definitively treated with radioactive iodine or surgery and a euthyroid state achieved at least six months prior to a planned pregnancy. It is not advised to become pregnant while on anti-thyroid drugs but pregnancy is safe while taking appropriately dosed thyroid hormone.