What is De Quervain Thyroiditis (Giant Cell Thyroiditis)?

Thyroiditis is an inflammation, or swelling, of the thyroid gland in your neck. This condition can have many forms and might result in an overactive, underactive or normal thyroid gland. Some forms of thyroiditis can cause pain, while others do not.

The symptoms, as well as the medical and family history, play a key role in differentiating between the various types of thyroiditis. The presence or lack of neck pain is a particularly important factor to consider.

Generally, thyroiditis that causes pain often results from radiation exposure, physical injury, or infection. On the other hand, painless thyroiditis is usually caused by autoimmune diseases or by certain medications.

There are many subtypes of both painful and painless thyroiditis. Painful thyroiditis can be broken down into subtypes like subacute granulomatous thyroiditis, suppurative thyroiditis, or thyroiditis resulting from trauma or radiation. Painless thyroiditis can be classified into subtypes like Hashimoto thyroiditis, postpartum thyroiditis, subacute lymphocytic thyroiditis, drug-inflicted thyroiditis, or Riedel thyroiditis.

This text mainly discusses a type of painful thyroiditis known as subacute granulomatous thyroiditis. Also referred to as subacute thyroiditis or de Quervain thyroiditis, this condition is a rare cause of an overactive thyroid. The usual symptoms include neck pain, sensitivity to touch, and a predictable cycle involving temporary overactivity or underactivity of the thyroid gland before returning to normal.

What Causes De Quervain Thyroiditis (Giant Cell Thyroiditis)?

Subacute thyroiditis, a type of inflammation of the thyroid, is often thought to be caused by viral infections. Many people with this condition have had a viral upper respiratory infection – a kind of common viral illness – a couple of weeks to two months before their thyroiditis developed. The most frequent cause of pain in the thyroid or neck area is a type of this condition known as De Quervain thyroiditis.

Research suggests this condition occurs more during the times of year when certain viruses like coxsackievirus (groups A & B) and echovirus are most common. It’s also been linked with other viruses such as mumps, measles, influenza, SARS-CoV-2, and others.

Unlike other types of thyroid inflammation, autoimmune reactions – where the body’s immune system attacks its own cells – don’t play a major role in subacute thyroiditis. However, it’s frequently seen in people with a particular human leukocyte antigen (HLA), known as B35. This is a protein that plays a key role in the immune system.

There’s a similarity between the structure of follicular thyroid cells, which are found in the thyroid, and viral antigens, proteins that can trigger an immune response. Viral antigens or particles from damage caused by the virus and human tissue can bind to HLA B35. This results in the activation of specific immune cells called cytotoxic T cells, which can also harm thyroid follicular cells.

Risk Factors and Frequency for De Quervain Thyroiditis (Giant Cell Thyroiditis)

Subacute thyroiditis is a condition that primarily develops in people aged 25 to 35, and it’s more common in women than men – occurring 4 to 5 times more often. A study done in Olmstead County, Minnesota, USA from 1960 to 1997 showed that there were 4.9 cases per 100,000 people each year. The most frequent symptom was pain, experienced by 96% of people. Although most people recovered completely and maintained a balanced thyroid state, about 15% needed ongoing thyroid replacement therapy. In a small percentage, between 1.6 and 4%, the condition recurred after the initial episode. Interestingly, the occurrence of subacute thyroiditis seems to be linked with seasons, as most cases happen in the summer and fall.

  • Subacute thyroiditis mainly affects people aged 25 to 35.
  • It’s more common in women, happening 4 to 5 times more often than in men.
  • A study found an average of 4.9 cases per 100,000 people each year.
  • The main symptom is pain, experienced by 96% of patients.
  • While most people recovered completely, about 15% needed ongoing thyroid replacement therapy.
  • A small percentage, between 1.6 and 4%, experienced a recurrence after the first episode.
  • The condition seems to occur more often in the summer and fall.

Signs and Symptoms of De Quervain Thyroiditis (Giant Cell Thyroiditis)

When diagnosing a patient, it is important to gather information about the timing and length of their symptoms, any recent illnesses, and any relevant family or personal medical history. This background can help understand the reason for their symptoms better. If the patient is mentally not clear, family members can be a useful source of necessary details. The most common symptom is pain, which may spread to the jaw, upper chest, neck, and throat. This pain may increase when they turn their head, cough, or swallow. Other common symptoms include fever, tiredness, overall body ache, loss of appetite, and symptoms of an overactive thyroid like rapid heartbeat, excessive sweating, restlessness, and weight loss. Notably, neck pain is often the primary concern.

In a physical examination, the health professional will check the patient’s head, eyes, ears, nose, and throat comprehensively to eliminate other possible causes of neck pain. The thyroid gland, located in the neck, may be slightly enlarged and sensitive to touch. In most cases, both parts of the thyroid gland are affected at first. In rare instances, the problem might start on one side and then spread to the other, a phenomenon called “creeping thyroiditis.”

  • Pain spreading to the jaw, upper chest, neck, and throat
  • Pain that increases with turning the head, coughing, or swallowing
  • Fever
  • Tiredness
  • Overall body ache
  • Loss of appetite
  • Rapid heartbeat
  • Excessive sweating
  • Restlessness
  • Weight loss
  • Neck pain as the primary concern

Testing for De Quervain Thyroiditis (Giant Cell Thyroiditis)

Diagnosing a condition is a combination of factors, including the patient’s medical history, symptoms, physical examinations, and lab tests. When it comes to de Quervain thyroiditis, standard tests in the emergency department often include thyroid studies like thyroxine (T4), T3 and thyroid-stimulating hormone levels (TSH), as well as erythrocyte sedimentation rate (ESR), and C-reactive protein tests. Depending on symptoms, additional tests might be needed.

In the early stages of the disease, lab results usually show signs of hyperthyroidism; slightly high levels of T4 and T3 and low TSH. This state of hyperthyroidism lasts for 2 to 8 weeks and is followed by a short phase of asymptomatic or subclinical hypothyroidism. It’s important that labs’ interpretation is based on a thorough patient examination and history to avoid mistakes.

Patients with de Quervain thyroiditis may show increased ESR and CRP levels, high thyroglobulin concentrations, anemia, and slight leukocytosis or white blood cell elevation. When the disease is in its hyperthyroid phase, liver function tests can also be abnormal, but usually, turn normal after 2 to 3 months. Antibodies directed against thyroid peroxidase and thyroglobulin are typically at low normal levels or undetectable. Because patients often have fever, doctors often perform a septic workup, which includes tests for infection. An EKG or heart test is performed if the patient has a fast heart rate.

The stages of the disease change over weeks to months. Initially, patients exhibit hyperthyroidism, then move to the euthyroid or normal thyroid functioning phase, followed by hypothyroidism, and finally back to normal thyroid function. During the hyperthyroid phase, the thyroid cells are attacked by cytotoxic T cells, leading to the large release of T4 and T3 hormones. This state lasts until the thyroid hormone stores deplete. During this time, lab results are likely to show elevated T4 and low TSH.

Hyperthyroidism in de Quervain thyroiditis can be distinguished from a similar disease, Graves disease, by the lack of exophthalmos (prominent eyes) and pretibial myxedema (skin thickening). De Quervain also shows mild elevation in T3 and normal thyroid vascularity on ultrasonography. When the disease transitions to the hypothyroid phase, TSH levels are high and free T4 is low. Inadequate diagnosis could arise from both TSH and T4 being low during this phase, leading one to falsely diagnose with central hypothyroidism.

On ultrasound, the thyroid gland may appear slightly big or normal, showing a general or detailed decrease in echogenicity or ability to produce an echo. Misshaped hypoechoic lesions in the thyroid signify subacute thyroiditis. Color Doppler sonography can show reduced flow of blood during the hyperthyroid state, unlike Graves disease where flow is increased. Radioiodine or technetium imaging during the initial state of hyperthyroidism may show reduced uptake.

Subacute thyroiditis diagnosis is a clinical one. Having neck pain with tenderness in the thyroid gland is usually enough to diagnose the disease. Symptoms of hyperthyroidism may also be present. For an exact diagnosis, these symptoms must be confirmed with low TSH, high T4 and T3, ESR, C-reactive protein, and low radioiodine uptake. Radioiodine imaging can be omitted if hyperthyroidism from subacute thyroiditis is not severe. Thyroid ultrasonography can help find cysts, abscesses, or mass lesions in patients with less obvious clinical symptoms and examination results. Doppler sonography can help differentiate from Graves’ disease. In rare cases, needle aspiration might be needed to distinguish from diseases like lymphoma, thyroid cancer, and hemorrhage.

Treatment Options for De Quervain Thyroiditis (Giant Cell Thyroiditis)

The primary aim of treating subacute thyroiditis, a condition involving inflammation of the thyroid, is to alleviate pain and manage symptoms. Do keep in mind that these recommended treatments are based more on observation and medical opinion as there are no specific clinical trials done to find the best treatment for this disease.

If you are experiencing mild to moderate neck pain due to de Quervain’s thyroiditis, rest and certain medications can help. Pain relievers like salicylic acid, naproxen, or ibuprofen can be taken at regular intervals as advised by your doctor. But, if the neck pain becomes unbearable, a daily dose of Prednisone which is a type of corticosteroid may be advised. This tends to reduce pain within a couple of days. If your condition isn’t improving after two or three days, stronger dosages could be explored, but you should also be screened for any other potential causes of the pain. Steroids are usually prescribed for about two months. If pain recurs during this period, the dosage can be increased.

Minor symptoms of hyperthyroidism (overactive thyroid gland) that accompany subacute thyroiditis often don’t need any treatment. However, symptoms like rapid heart rate, anxiety, and shakiness may be controlled with medications like propranolol or atenolol. It is not advisable to use certain drugs like thionamides or radioiodine therapy in this case because they don’t address the root cause of the disorder, namely the excessive discharge of existing thyroid hormones.

Mostly, subacute thyroiditis gets back to normal in a matter of three to four months. Sometimes, however, it can cause hypothyroidism (underactive thyroid), which may be temporary or permanent. If your Thyroid Stimulating Hormone (TSH) levels go above 10 microU/L or if you have symptoms of an underactive thyroid, you may need to take levothyroxine for one to two months. This medicine helps replace a hormone normally produced by the thyroid gland. In some cases, longer-term use may be necessary.

After being diagnosed with sub-acute thyroiditis, it’s important to get your thyroid monitored regularly, roughly every 2 to 8 weeks, to track your recovery and the course of the disease until your thyroid function tests normalize.

When diagnosing thyroid inflammation (also known as de Quervain thyroiditis), doctors would consider ruling out the following similar conditions:

  • Acute infectious thyroiditis
  • Hemorrhagic thyroid nodule
  • Painless thyroiditis
  • Thyroiditis after childbirth
  • Thyroiditis triggered by a drug called amiodarone
  • Thyroiditis triggered by immune checkpoint inhibitors
  • Thyroiditis triggered by radiation
  • Palpation thyroiditis, which is inflammation caused by pressing on the thyroid
  • Thyroid cancer
  • Lymphoma of the thyroid
  • Painful Hashimoto thyroiditis, an autoimmune condition

To work out what’s causing thyroid inflammation, your doctor may conduct tests to check thyroid function, a cell count to look for infection, visual checks for an abscess, and tests to measure iodine in urine. In some cases where patients only have a fever of unknown origin, the underlying condition might be de Quervain thyroiditis.

What to expect with De Quervain Thyroiditis (Giant Cell Thyroiditis)

De Quervain thyroiditis, a type of thyroid disorder, typically resolves on its own, with patients returning to their normal thyroid function within a few months. It’s uncommon for this condition to come back, but it can happen in about 2% of patients. Additionally, there is a possibility of 5% of these cases resulting in permanent hypothyroidism, which means the body can’t produce enough thyroid hormones.

Possible Complications When Diagnosed with De Quervain Thyroiditis (Giant Cell Thyroiditis)

Subacute thyroiditis usually gets better and fully resolves on its own. However, in rare instances, it may cause permanent hypothyroidism – an underactive thyroid. Sometimes, people may experience severe symptoms from hypothyroidism, but it’s usually temporary. In very rare cases, subacute thyroiditis has been associated with severe conditions like:

  • Thyroid storm – a sudden and severe increase in thyroid hormones
  • Ventricular tachycardia – a rapid heart rate
  • Fever of unknown origin

Preventing De Quervain Thyroiditis (Giant Cell Thyroiditis)

Patients should know that their medical condition is expected to last for a few weeks, provided there are no unforeseen complications. They are encouraged to connect with their primary care doctor as soon as possible. This way, they can continue to monitor their TSH (thyroid-stimulating hormone) levels and undergo RAIU (radioactive iodine uptake) testing, which are essential in managing their health condition.

Frequently asked questions

De Quervain Thyroiditis, also known as subacute granulomatous thyroiditis or subacute thyroiditis, is a type of painful thyroiditis. It is a rare cause of an overactive thyroid and is characterized by symptoms such as neck pain, sensitivity to touch, and a predictable cycle of temporary overactivity or underactivity of the thyroid gland before returning to normal.

The signs and symptoms of De Quervain Thyroiditis (Giant Cell Thyroiditis) include: - Pain that spreads to the jaw, upper chest, neck, and throat. - Pain that increases when turning the head, coughing, or swallowing. - Fever. - Tiredness. - Overall body ache. - Loss of appetite. - Rapid heartbeat. - Excessive sweating. - Restlessness. - Weight loss. - Neck pain as the primary concern. In addition to these symptoms, the thyroid gland, located in the neck, may be slightly enlarged and sensitive to touch. It is worth noting that in most cases, both parts of the thyroid gland are affected at first, but in rare instances, the problem might start on one side and then spread to the other, which is known as "creeping thyroiditis."

De Quervain Thyroiditis (Giant Cell Thyroiditis) is often caused by viral infections, such as coxsackievirus, echovirus, mumps, measles, influenza, and SARS-CoV-2.

The doctor needs to rule out the following conditions when diagnosing De Quervain Thyroiditis (Giant Cell Thyroiditis): - Acute infectious thyroiditis - Hemorrhagic thyroid nodule - Painless thyroiditis - Thyroiditis after childbirth - Thyroiditis triggered by a drug called amiodarone - Thyroiditis triggered by immune checkpoint inhibitors - Thyroiditis triggered by radiation - Palpation thyroiditis, which is inflammation caused by pressing on the thyroid - Thyroid cancer - Lymphoma of the thyroid - Painful Hashimoto thyroiditis, an autoimmune condition

The types of tests that are needed for De Quervain Thyroiditis (Giant Cell Thyroiditis) include: - Thyroid studies: T4, T3, and TSH levels - Erythrocyte sedimentation rate (ESR) test - C-reactive protein (CRP) test - Antibodies directed against thyroid peroxidase and thyroglobulin - Liver function tests - Septic workup tests for infection - EKG or heart test if the patient has a fast heart rate - Ultrasound of the thyroid gland - Color Doppler sonography to assess blood flow - Radioiodine or technetium imaging to evaluate thyroid uptake These tests help in diagnosing and monitoring the different stages of De Quervain Thyroiditis, including hyperthyroidism, euthyroid phase, hypothyroidism, and normal thyroid function. They also help differentiate it from other thyroid conditions like Graves' disease.

If you are experiencing mild to moderate neck pain due to de Quervain's thyroiditis, rest and certain medications can help. Pain relievers like salicylic acid, naproxen, or ibuprofen can be taken at regular intervals as advised by your doctor. But, if the neck pain becomes unbearable, a daily dose of Prednisone which is a type of corticosteroid may be advised. This tends to reduce pain within a couple of days. If your condition isn't improving after two or three days, stronger dosages could be explored, but you should also be screened for any other potential causes of the pain. Steroids are usually prescribed for about two months. If pain recurs during this period, the dosage can be increased.

When treating De Quervain Thyroiditis (Giant Cell Thyroiditis), there can be some side effects. These may include: - Mild to moderate neck pain - Rapid heart rate - Anxiety - Shakiness It is important to note that the recommended treatments for De Quervain Thyroiditis are based on observation and medical opinion, as there are no specific clinical trials for this disease. Treatment options may include rest, pain relievers like salicylic acid, naproxen, or ibuprofen, and in some cases, a daily dose of Prednisone (a corticosteroid) to reduce pain. Medications like propranolol or atenolol may be used to control symptoms like rapid heart rate, anxiety, and shakiness. Thionamides or radioiodine therapy are not advisable as they do not address the root cause of the disorder. Regular monitoring of thyroid function tests is important to track recovery and the course of the disease. In rare instances, De Quervain Thyroiditis may cause permanent hypothyroidism or severe conditions like thyroid storm, ventricular tachycardia, or fever of unknown origin.

The prognosis for De Quervain Thyroiditis (Giant Cell Thyroiditis) is generally good. Most patients recover completely and return to normal thyroid function within a few months. Recurrence of the condition is uncommon, but can happen in about 2% of patients. In about 5% of cases, permanent hypothyroidism may occur, meaning the body is unable to produce enough thyroid hormones.

An endocrinologist or a primary care doctor should be consulted for De Quervain Thyroiditis (Giant Cell Thyroiditis).

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