A 46-year-old man comes to the physician with anterior neck pain, night sweats, and palpitations for the past 3 weeks after an upper respiratory infection. The pain is severe and continues to bother him at night. He has tried over-the-counter acetaminophen and ibuprofen without significant relief. He has no other medical problems.
His temperature is 37.8 C (100 F), blood pressure is 144/72 mm Hg, and pulse is 121/min. He appears restless. Eye examination shows mild lid lag. The thyroid gland is markedly tender bilaterally. He has fine hand tremors. There is no proptosis or pretibial myxedema.
Laboratory testing shows normal complete blood count and basic chemistry profile. Other laboratory results are as follows:

A 24-hour radioactive iodine uptake is 1%.
In addition to a beta blocker, what is the most appropriate next step in management of this patient?

Question

A 46-year-old man comes to the physician with anterior neck pain, night sweats, and palpitations for the past 3 weeks after an upper respiratory infection.  The pain is severe and continues to bother him at night.  He has tried over-the-counter acetaminophen and ibuprofen without significant relief.  He has no other medical problems.
His temperature is 37.8 C (100 F), blood pressure is 144/72 mm Hg, and pulse is 121/min.  He appears restless.  Eye examination shows mild lid lag.  The thyroid gland is markedly tender bilaterally.  He has fine hand tremors.  There is no proptosis or pretibial myxedema.
Laboratory testing shows normal complete blood count and basic chemistry profile.  Other laboratory results are as follows:

A 24-hour radioactive iodine uptake is 1%.
In addition to a beta blocker, what is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation of fever, anterior neck pain, tender thyroid gland, and symptoms of thyrotoxicosis are suggestive of subacute granulomatous thyroiditis, also known as de Quervain thyroiditis. These patients usually have a preceding viral infection prior to development of the postviral inflammatory process. Neck pain is the dominant presenting symptom in most patients, and pain can radiate to the jaw. Fatigue, malaise, anorexia, and fever may also be present. The thyroid may be enlarged but is almost always tender to palpation. Patients usually follow a predictable clinical course of hyperthyroidism, followed by euthyroidism, hypothyroidism, and thyroid function recovery. Each phase can last up to 8 weeks. However, some patients may have only the hyperthyroid or hypothyroid phase. ESR and CRP are elevated. Radioactive iodide uptake scan done during the hyperthyroid phase shows low uptake. Treatment of subacute thyroiditis involves symptomatic pain relief. High-dose nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen 1200-3200 mg/day) are usually helpful. If pain is not relieved in 2-3 days with NSAIDs, they should be discontinued and treatment with prednisone (40 mg/day) should be initiated. Prednisone can also be used as initial therapy for patients with severe pain. Thyrotoxicosis is present in about 50% of cases in the early phases of the disease. These symptoms are best managed with beta blockers. However, thionamides and radioactive iodine therapy (Choices C and E) are not useful as symptoms are due to the release of preformed thyroid hormones. Most individuals do not need treatment for the hypothyroid phase of subacute thyroiditis. Thyroid function tests should be measured every 2-8 weeks in all patients. About 95% of patients recover completely, and only 5% develop permanent hypothyroidism. (Choice A) Patients with thyroid cancer may present with fever, weight loss, lymphadenopathy, and a rapidly enlarging neck mass. Thyroid enlargement is bilateral but usually asymmetric with 1 or more hard nodules. Thyroid function tests are usually normal. CT scan of the neck and mediastinum is indicated for the diagnosis and staging of thyroid cancers. (Choice B) Acute infectious thyroiditis must be ruled out with thyroid ultrasound and fine-needle aspiration biopsy in patients presenting with fever, leukocytosis, and thyroid pain and tenderness. Educational objective: Subacute granulomatous thyroiditis is caused by preceding viral infection. Patients usually present with anterior neck pain, a diffusely tender thyroid, and features of thyrotoxicosis. Treatment is supportive with NSAIDs for mild to moderate thyroid pain and glucocorticoids for severe pain. Thionamides and radioactive iodide therapy are not useful in the treatment of subacute granulomatous thyroiditis. __________ References: Subacute, silent, and postpartum thyroiditis. (http://www.ncbi.nlm.nih.gov/pubmed/22443972) Eponym : de Quervain thyroiditis. (http://www.ncbi.nlm.nih.gov/pubmed/20886353)

A 46-Year-Old Man Comes to the Physician with Anterior Neck