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Difficulty: MediumEndocrinology and Metabolism

A 31-year-old woman comes to the office due to a 5-day history of palpitations, excessive sweating, and severe anterior neck pain that radiates to her ears. She reports having a mild sore throat and a runny nose about 3 weeks ago, which resolved without treatment. Her temperature is 38.0°C (100.4°F), pulse is 112/min, and blood pressure is 135/75 mm Hg. Physical examination shows a diffusely enlarged, exquisitely tender thyroid gland. No cervical lymphadenopathy is appreciated. Laboratory results are as follows:

Thyroid-stimulating hormone (TSH): 0.02 mU/L
Free thyroxine (T4): 2.9 ng/dL (Normal: 0.9-1.7 ng/dL)
Erythrocyte sedimentation rate: 95 mm/h

A 24-hour radioactive iodine uptake scan demonstrates 2% uptake (Normal: 15-30%). Which of the following is the most appropriate next step in management for this patient?

  1. Ibuprofen and propranololAnswer
  2. B
    Methimazole
  3. C
    Amoxicillin-clavulanate
  4. D
    Radioactive iodine ablation
  5. E
    Levothyroxine

Answer

Ibuprofen and propranolol
The patient's clinical presentation (tender goiter, fever, hyperthyroid symptoms following a viral illness) combined with laboratory findings (suppressed TSH, elevated free T4, markedly elevated ESR, and profoundly low radioactive iodine uptake) are diagnostic of subacute (De Quervain) thyroiditis. This is a destructive thyroiditis causing the release of preformed thyroid hormone into circulation. Because there is no increased hormone synthesis, antithyroid medications (e.g., methimazole) are ineffective. The most appropriate initial management is symptom control with nonsteroidal anti-inflammatory drugs (NSAIDs) for the pain and inflammation, and beta-blockers (e.g., propranolol) to manage the hyperadrenergic symptoms such as palpitations and tachycardia.

Step-by-Step Solution

1
Analyze the clinical presentation.
The patient has symptoms of hyperthyroidism, a recent viral upper respiratory infection, a tender goiter, and fever.
This classic constellation of symptoms strongly points toward subacute (De Quervain) thyroiditis.
2
Evaluate the laboratory and imaging findings.
Labs show primary hyperthyroidism (suppressed TSH, elevated free T4) with significant inflammation (high ESR) and low radioactive iodine uptake.
A low radioactive iodine uptake differentiates a destructive thyroiditis (release of preformed hormone) from conditions involving hormone overproduction (like Graves disease).
3
Determine the optimal management strategy based on the pathophysiology.
Because the thyrotoxicosis is not due to hormone synthesis, antithyroid medications are ineffective. The correct approach is supportive care with NSAIDs and beta-blockers.
NSAIDs address the intense neck pain and inflammation, while beta-blockers mitigate the hyperadrenergic symptoms (palpitations, tachycardia) until the transient hyperthyroid phase resolves.

Key Concept

Subacute (De Quervain) thyroiditis typically presents following a viral illness with a painful goiter, transient thyrotoxicosis, an elevated ESR, and decreased radioactive iodine uptake. Initial management focuses on symptom control using NSAIDs and beta-blockers.
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Topics

Endocrinology and Metabolism

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