A 28-year-old woman presents with acute onset of severe neck pain, fever, and palpitations for 3 days. Examination reveals a tender, enlarged thyroid. Thyroid function tests show suppressed TSH with elevated free T4. Which is the most common cause of acute thyroiditis in this clinical presentation?

Question

Accepted Answer

B. De Quervain thyroiditis. ## Acute Thyroiditis: De Quervain Thyroiditis ### Clinical Presentation Recognition **Key Point:** De Quervain (subacute granulomatous) thyroiditis is the most common cause of **acute symptomatic thyroiditis** presenting with sudden onset of severe neck pain, fever, and signs of thyroid inflammation. **High-Yield:** The triad of acute thyroiditis presentation is: (1) severe neck pain, (2) fever, (3) thyroid tenderness. This clinical picture is pathognomonic for De Quervain thyroiditis. ### Pathophysiology 1. **Etiology:** Post-viral inflammation (mumps, influenza, adenovirus, EBV, CMV) 2. **Pathology:** Granulomatous inflammation with giant cells and follicular destruction 3. **Mechanism:** Viral infection triggers thyroid inflammation → follicular disruption → release of preformed thyroid hormones → transient thyrotoxicosis 4. **Timeline:** Self-limited course over 4–12 weeks ### Clinical Phases ```mermaid flowchart TD A[Viral infection]:::outcome --> B[Phase 1: Thyroiditis
Acute pain + fever]:::action B --> C[Follicular destruction]:::outcome C --> D[Phase 2: Thyrotoxicosis
High T4, suppressed TSH]:::outcome D --> E[Phase 3: Hypothyroidism
Low T4, high TSH
2-8 weeks]:::outcome E --> F[Phase 4: Recovery
Normal function]:::outcome ``` ### Diagnostic Features | Feature | De Quervain | Hashimoto | Suppurative | |---------|-------------|-----------|-------------| | **Onset** | Acute (days) | Insidious (months–years) | Acute (hours–days) | | **Pain** | Severe, neck pain | Absent or mild | Severe, localized | | **Fever** | Present | Absent | High fever, sepsis | | **Thyroid tenderness** | Marked | Absent | Marked, fluctuant | | **ESR/CRP** | Markedly elevated | Normal/mildly elevated | Elevated | | **Antibodies** | Absent (TPO/Tg negative) | Present (TPO+, Tg+) | Absent | | **Thyroid function** | Thyrotoxic phase early | Hypothyroid | Variable | | **Ultrasound** | Heterogeneous echotexture | Hypoechoic, diffuse | Focal abscess/collection | | **Culture** | Sterile | Sterile | Positive (S. aureus, streptococci) | **Clinical Pearl:** The presence of **suppressed TSH with elevated free T4** in the acute phase is characteristic of De Quervain thyroiditis, reflecting the thyrotoxic phase from follicular disruption and hormone release, not true thyroid hyperfunction. **Warning:** Hashimoto thyroiditis presents insidiously over months to years with progressive hypothyroidism, NOT acute pain and fever. It is a chronic autoimmune condition, not an acute inflammatory process. **Warning:** Suppurative (bacterial) thyroiditis is rare and usually follows a focus of infection (pharyngitis, dental abscess) or is secondary to immunosuppression. It presents with localized abscess formation and positive culture, not the self-limited course of De Quervain. **Mnemonic:** **DeQ** = **De** Quervain is **Qu**ick (acute), **Q**uells (self-limited), **Q**uintessential post-viral thyroiditis. ### Management 1. **NSAIDs:** First-line for pain and inflammation (ibuprofen, naproxen) 2. **Beta-blockers:** For symptomatic thyrotoxicosis (propranolol) 3. **Corticosteroids:** Reserved for severe cases or NSAID failure (prednisolone 40 mg tapering) 4. **Levothyroxine:** Only if hypothyroidism persists beyond 6–12 weeks 5. **Supportive care:** Rest, hydration ### Prognosis - **Self-limited:** Complete resolution in 4–12 weeks in >90% of cases - **Recurrence:** Rare (<5%) - **Permanent hypothyroidism:** Uncommon (<5%) [cite:Harrison 21e Ch 405]

Answer

A. Hashimoto thyroiditis

Answer

C. Suppurative (bacterial) thyroiditis

Answer

D. Riedel thyroiditis

A 28-year-old woman presents with acute onset of severe neck pain, fever, and palpitations for 3 days. Examination reveals a tender, enlarged thyroid. Thyroid function tests show suppressed TSH with elevated free T4. Which is the most common cause of acute thyroiditis in this clinical presentation?

Explanation

Acute Thyroiditis: De Quervain Thyroiditis

Clinical Presentation Recognition

Pathophysiology

Clinical Phases

Diagnostic Features

Management

Prognosis

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Feature	De Quervain	Hashimoto	Suppurative
Onset	Acute (days)	Insidious (months–years)	Acute (hours–days)
Pain	Severe, neck pain	Absent or mild	Severe, localized
Fever	Present	Absent	High fever, sepsis
Thyroid tenderness	Marked	Absent	Marked, fluctuant
ESR/CRP	Markedly elevated	Normal/mildly elevated	Elevated
Antibodies	Absent (TPO/Tg negative)	Present (TPO+, Tg+)	Absent
Thyroid function	Thyrotoxic phase early	Hypothyroid	Variable
Ultrasound	Heterogeneous echotexture	Hypoechoic, diffuse	Focal abscess/collection
Culture	Sterile	Sterile	Positive (S. aureus, streptococci)