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Carcinomatous involvement of the thyroid presenting as subacute thyroiditis.

Carcinomatous involvement of the thyroid is a most unusual cause of hyperthyroidism and thyroiditis, with only a few cases reported in the literature. The authors present a 35-year-old woman with signs, symptoms, and laboratory findings of hyperthyroidism, and subacute thyroiditis that was due to extensive replacement of the thyroid gland by adenocarcinoma (shown by fine needle aspiration). After chemotherapy with vincristine and cisplatin, the swelling of the thyroid resolved, thyroidal uptake of radioactive iodine increased, and mild hypothyroidism developed. Despite the improvement in her thyroid status, she died from progressive malignancy. This case illustrates the value of fine needle aspiration cytology where doubt exists in the diagnosis of thyroid disorders.

Adenocarcinoma↗

[Proceedings: Pituitary thyroid axis in subacute thyroiditis (author's transl)].

We studied 10 patients with subacute thyroiditis. All had an increase in free thyroxine index, PBI, T4 and PBI/T4 ratio, an absence of thyroidal radioiodine uptake and no increase in plasma TSH after TRH injection. Exogenous TSH increased the uptake in 6/9 patients. The three patients who did not respond to TSH had higher PBI/T4 ratio than others. After treatment for one month there was either a normalization of laboratory tests either a subnormal thyroid function associated with an absence of response to TRH. All tests became normal two months later.

Humans↗

Lymphocyte transformation in response to human thyroid extract in patients with subacute thyroiditis.

Seven patients with subacute thyroiditis were studied for evidence of cell-mediated immunity (CMI) to human thyroid extract, as judged from lymphocyte transformation responses, measured by the increase in labeled thymidine uptake in vitro. Significant transformation was observed in lymphocytes from five of the seven patients with active subacute thyroiditis, and in the lymphocytes from only three of 15 patients with Graves disease (x2, P EQUALS 0.036). Repeated studies of lymphocyte transformation were done in four of the patients with subacute thyroiditis, three of whom initially showed abnormal responses. By eight weeks after initial studies, when all patients were in clinical remission without treatment, transformation responses were within the normal range. Thyroid antibodies were absent or present in low titer (is less than 1:100) in sera of patients with subacute thyroiditis, and became undetectable by eight weeks in those patients initially positive. In contrast, significant titers of antithyroid antibodies were frequently present in patients with Graves' disease. The present studies have shown the occurence of CMI to thyroid antigens during the active phase of subacute thyroiditis. The abnormality was transient, however, since it disappeared when the disease had resolved. These findings strongly suggest that the release of thyroid antigen leading tothe development of a cell-mediated immune responses is not in itself sufficient to initiate chronic immunological disease of the thyroid. If, as some have suggested, Hashimoto's disease or Graves' disease are characterized by a permanent disorder of CMI, then in these diseases either the antigenic stimulus is persistent or there exists an intrinsic disorder of immune surveillance.

Acute Disease↗

Subacute thyroiditis: fine-needle aspiration cytology of 14 cases presenting with thyroid nodules.

Subacute thyroiditis (SAT) is usually diagnosed clinically without the need for fine-needle aspiration. The cytologic literature on this condition is therefore rare. We report on 14 cases of SAT presenting with thyroid nodules. The majority of patients were women with a mean age of 46 yr. All had pain/tenderness in the thyroid area accompanied by fever or an elevated ESR. The salient cytologic features included cellular smears; multinucleated giant cells in 100% of cases, some ingesting colloid or neutrophils; fibrous fragments with enmeshed inflammatory cells were a constant feature; follicular cells were scant to absent in most cases. Granulomas were rare. Colloid, when present was thick, with central cracks and frayed edges. One case was suspicious for malignancy. We conclude that the cytologic features of SAT are predictable, particularly, in the appropriate clinical setting. FNA is also helpful in ruling out concomitant neoplastic conditions.

Adult↗

Painful subacute thyroiditis (de Quervain's thyroiditis).

Painful subacute thyroiditis (de Quervain's thyroiditis) usually occurs in association with systemic viral illnesses. This disorder may be manifested in various clinical forms. Primary care physicians must be aware of the clinical features of this disorder to make the correct diagnosis and treat appropriately. Three cases are reported to illustrate the different clinical manifestations of this disorder.

Adult↗

Follicular thyroid carcinoma masquerading as subacute thyroiditis. Diagnosis using ultrasonography and radionuclide thyroid angiography.

The rare presentation of a follicular thyroid carcinoma mimicking the clinical and radionuclide features of subacute thyroiditis is described. Granulomatous thyroiditis was initially suspected on the clinical basis of acute onset of a hard, tender right lobe thyroid enlargement with associated systemic symptoms, modest elevation of thyroid hormone levels and suppressed thyroid RAIU. Fine needle aspiration cytology specimens were unsatisfactory for characterization. Three weeks later the thyroid RAIU was normal. The thyroid enlargement persisted, now being clearly visualized as a hypofunctional nodule on scintiscan. Repeat fine needle aspiration cytology was suggestive of acinar proliferation with hyperfunction. Ultrasonography revealed a solid nodule with a peripheral sonolucent halo. Radionuclide angiography showed intense arterial flow of Tc-99m pertechnetate through the right lobe thyroid enlargement suggestive of malignant thyroid pathology. Surgical excision and histopathological examination revealed a follicular carcinoma involving the right lobe. The possibility of carcinomatous involvement should be considered in those patients where initially tender thyroid nodularity persists longer than expected for a benign inflammatory disease, careful follow-up and relevant investigations being necessary to confirm the diagnosis.

Adenocarcinoma↗

Failure in detection of Epstein-Barr virus and cytomegalovirus in specimen obtained by fine needle aspiration biopsy of thyroid in patients with subacute thyroiditis.

To study the possible role of viral infection in the etiology of subacute thyroiditis (SAT), we measured serum virus-specific antibodies to measles, rubella, mumps, type I herpes, chicken pox, human parvovirus B19 and cytomegalovirus (CMV) in 10 patients with SAT during the course of illness. In spite of the presence of IgG to each virus in more than 70% of patients, no significant changes in the IgG titers were observed except those to measles, rubella, chicken pox or CMV in only 10% of patients, respectively. Then we examined the presence of virus DNA in specimens of 9 patients with SAT obtained by fine-needle aspiration biopsy (FNAB) of the thyroid. DNA was amplified to detect that of Epstein-Barr virus and CMV by polymerase chain reaction. However, none of them were detected in all the specimens. Whereas previous studies suggest the involvement of viral infection in the pathogenesis of SAT, we failed to demonstrate significant changes in serum antiviral antibody titers or to detect viral DNA in the specimens obtained by FNAB of the thyroid. Thus further studies are clearly required to establish the definite role of viral infection in the pathogenesis of SAT.

Antibodies, Viral↗

[Thyroid nodule secondary to subacute thyroiditis. 8 cases (author's transl)].

This description of 8 cases of thyroid nodules secondary to subacute thyroiditis serves to emphasise the relative prevalence of the circumscribed forms. These nodules, variable in size, firm and painful, developed after a period of cervical discomfort and pain. A contrast between a raised or normal blood hormone level and a very low uptake of I131 was found in five cases. It was all the more valuable when there was no iodine overload. Scintigraphy showed the nodule to be cold in 6 cases, isofixing in one and hot in one case. An essential diagnostic criterion is the rapidly favourable course: 4 nodules disappeared completely, 3 regressed in less than 6 months and one persisted, justifying excision with histopathological examination since localised thyroiditis of this type may be the presenting feature of a carcinoma.

Adult↗

Serum concentrations of osteocalcin in patients with hyperthyroidism, hypothyroidism and subacute thyroiditis.

Serum concentration of osteocalcin (OC) was measured in sera from untreated patients with Graves' disease, hypothyroidism due to Hashimoto's thyroiditis, and subacute thyroiditis. Serum concentration of OC in Graves' disease and hypothyroidism were 14.1 +/- 5.6 micrograms/L and 3.8 +/- 2.7 micrograms/L, respectively which were significantly different from that of healthy subjects (Graves' disease, p less than 0.001, hypothyroidism, p less than 0.01). Serum concentration of OC in patients with subacute thyroiditis was 8.0 +/- 3.5 micrograms/L which was not statistically different from age-matched normal controls. Serial measurement of serum OC for 24 mo in 15 patients with Graves' disease after initiation of antithyroid drugs disclosed that the decline of serum OC was obtained only 24 mo after antithyroid drug therapy. On the other hand, in hypothyroid patients, increased serum OC was observed after 1-2 months treatment of L-T4. Correlation coefficients between serum concentrations of OC and T3, T4, FT3 or FT4 in all the patients with thyroid disorders were 0.66, 0.51, 0.50 and 0.54, respectively, which were statistically significant (all, p less than 0.001). These results suggest that osteoblastic activity is enhanced in hyperthyroidism and suppressed in hypothyroidism. In hyperthyroid patients, despite of normalization of FT4 concentration in relatively short period (within 3-4 mo), it took 24 mo after initiation of antithyroid drugs for OC to normalize, suggesting not only thyroid hormone per se but also some unknown factor(s) participates in serum OC secretion. In contrast to thyrotoxic patients, rapid increase in serum OC after initiation of supplemental L-T4 treatment in hypothyroidism was observed, suggesting a direct effect of thyroid hormone on the osteoblasts in patients with hypothyroidism.

Adult↗

Subacute thyroiditis.

The term "subacute thyroiditis" has come to be applied to two rather distinct forms of inflammation of the thyroid gland, both of which run courses lasting several weeks to several months. While it is clear that the term "subacute thyroiditis" connotes a temporal quality only, and could conceivably apply to any inflammatory process of intermediate severity and duration, by current usage it excludes several forms of infective (ie, bacterial fungal) thyroiditis. On the other hand, it specifically includes a painful form of thyroiditis of probable viral origin (de Quervain or pseudogranulomatous thyroiditis), and a painless form of thyroiditis, which may be called "subacute lymphocytic thyroiditis." The latter term does not necessarily imply that there is any relationship to chronic lymphocytic thyroiditis, as will be discussed carefully below.

Autoimmune Diseases↗

[Acute suppurative thyroiditis in a patient with prior subacute thyroiditis].

Acute suppurative thyroiditis is an uncommon thyroid disorder usually caused by bacterial infection. The most common route of infection is a fistula that originates from the fundus of the pyriform sinus. Pre-existing thyroid disease, most commonly nodular goiter, has been reported to be present in acute suppurative thyroiditis. A 44 year old man presented a subacute thyroiditis, resolved by nonsteroidal antiinflammatory treatment. One year later, the patient abruptly complained of fever and painful swelling in the thyroid region. A relapse subacute thyroiditis was diagnosed and prednisone treatment was started. A few days later owing to a worsening of the pain and of the clinical features the patient was referred to our department. He presented dysphagia and he was feverish, the overlying skin of the neck swelling was erythematous and warm. There was a neutrophilia (83.7%). Plasma FT4, FT3 and TSH were normal. Anterior neck region ultrasonography showed an enlargement of the left thyroid lobe with poorly defined shapes and inhomogeneous parenchyma while the right lobe of the gland was normal. The 131-I thyroid scan showed a large cold area in the upper part of the left thyroid lobe and preserved radionuclide uptake in the residual parenchyma. The RAIU was normal. We diagnosed acute suppurative thyroiditis and started antibiotics treatment. The day after the patient was still feverish and he gave out from the mouth a great quantity of sero-purulent material with a swelling reduction and improvement of the neck pain. Barium swallow examination did not show any fistula in the cervical esophagus. The fistula opening was demonstrated by indirect laryngoscopy in the postero-lateral side of hypopharynx.(ABSTRACT TRUNCATED AT 250 WORDS)

Abscess↗

Blood mononuclear cells with suppressor activity in patients with thyroid disorders: increased levels of T gamma cells in subacute thyroiditis.

Blood T lymphocytes with suppressor activity [stable T cells, low affinity T cells and T cells with Fc receptors for IgG (T gamma cells)] were enumerated, using rosette tests, in patients with Graves' hyperthyroidism, Hashimoto's thyroiditis, silent thyroiditis, primary hypothyroidism, Graves' ophthalmopathy and subacute thyroiditis. General suppressor function, assessed as inhibition of pokeweed mitogen induced plasma cell generation by concanavalin-A stimulated T cells was measured in patients with Graves' hyperthyroidism, Hashimoto's thyroiditis and subacute thyroiditis. Suppressor T cell numbers were found to be essentially normal in patients with Graves' hyperthyroidism, Hashimoto's thyroiditis, Graves' ophthalmopathy, silent thyroiditis and hypothyroidism, although % T gamma cells were increased in 5 of the 7 patients with subacute thyroiditis tested. Suppressor cell function was normal in patients with graves' hyperthyroidism, Hashimoto's thyroiditis and subacute thyroiditis. It is likely that the putative deficiency of suppressor T cells in thyroid autoimmunity is restricted to a few clones of cells allowing retention of thyroid directed effector cells. The mechanism for increased T gamma cells in subacute thyroiditis is unclear although likely to reflect either a physiological response to sensitization following thyroid antigen release or a non-specific effect of the viral infection.

Adolescent↗