Let's go on to another case.
A 19 year old woman comes to see you complaining
of neck pain which radiates to her ears.
She has neck swelling and dysphagia.
She thinks the symptoms were precipitated by
an upper respiratory infection two weeks ago.
She also feels anxious and has loose stools.
On physical exam, she has an increased heart rate,
tenderness to palpation over her anterior neck
and a mild tremor in her hands.
What is the most likely diagnosis?
So again here, we have symptoms
of pain over the thyroid.
She has difficulty swallowing,
dysphagia or odynophagia,
usually difficulty swallowing,
the medical term is dysphagia,
pain with swallowing is odynophagia.
And these two could be differentiated further
by asking more questions on history.
Further history indicates that she had a
recent upper respiratory tract infection
but she also has symptoms
of anxiety and loose stool.
Again, pointing two potential
On physical exam, she has a tachycardia
or increased heart rate and a tremor.
Again, this differs somewhat
from Graves' disease
and that she is presenting with pain over her thyroid
where it's true, Graves' disease is pain-less.
Another important clue here to the potential cause of
her hyperthyroidism is the recent viral infection.
The most likely diagnosis in this particular patient
is the condition known as post-viral thyroiditis
otherwise known as de Quervain syndrome.
Post-viral thyroiditis is a self
limited inflammatory condition
which causes the release of preformed
thyroid hormone into the circulation.
The natural history of the condition starts with
a thyroid toxic phase for 2 to 6 weeks.
This is then followed by a hypothyroid phase for
6 to 12 weeks before complete resolution.
The different forms of thyroiditis include
painful lesions and painless lesions.
We'll start with the painful thyroid lesions.
These usually are also associated with a
negative thyroid peroxidase antibody.
And the first one is de Quervain's disease
or subacute thyroiditis as in our case.
Other causes of painful thyroiditis
includes post viral inflammatory processes,
infectious thyroiditis for other reasons like
bacterial infections or immunocompromised patients
who have thyroid infections from staphylococcus
or streptococcal bacterial infections.
and then finally, in order to treat these
conditions, we use anti-inflammatory drugs
like non steroidals or in severe
cases, systemic glucocorticoids.
The causes of painless thyroiditis tend to occur more
commonly with positive thyroid peroxidase antibodies
and the classic example here is the
condition known as Hashimoto's thyroiditis.
Other causes can include thyroiditis induced in the
postpartum state or thyroiditis caused by drugs.
Subacute thyroiditis usually presents
biochemically as a low TSH and elevated T4
and when evaluating this
by radioactive uptake scan,
uptake within the thyroid is low,
invariably less than 10%.
This is a very useful differentiating
factor when comparing it to other causes
of primary hyperthyroidism.