A 26-year-old woman comes to the office due to fever, sweating, heat intolerance, and shortness of breath. Her symptoms began a week ago and have become progressively worse. The patient has also had severe pain in the anterior neck, which radiates to the angle of the jaw and ears and is worse when she turns her head. She adds that she has "been under a lot of stress lately since I was laid off from my job. I have been babysitting to make some extra money, but I think one of the kids gave me 'the flu.' I had a runny nose, cough, and fever a few weeks ago." Medical history is unremarkable, and the patient takes no medications. She has smoked a pack of cigarettes a day for the last 7 years, and smoked marijuana for a few months as a teenager. The patient is not sexually active and has never been pregnant. Her last menstrual period was 2 weeks ago. She is adopted, and her family history is unknown. Temperature is 38.3 C (100.9 F), blood pressure is 156/60 mm Hg, pulse is 110/min, and respirations are 22/min. The thyroid gland is diffusely enlarged, firm, and very tender. The extremities are warm and moist. Eye examination shows lid lag but no proptosis. The remainder of the examination is unremarkable. Laboratory results are as follows:

A radioactive iodine uptake with scintigraphy in this patient is mostly likely to show which of the following?

Question

A 26-year-old woman comes to the office due to fever, sweating, heat intolerance, and shortness of breath. Her symptoms began a week ago and have become progressively worse. The patient has also had severe pain in the anterior neck, which radiates to the angle of the jaw and ears and is worse when she turns her head. She adds that she has "been under a lot of stress lately since I was laid off from my job. I have been babysitting to make some extra money, but I think one of the kids gave me 'the flu.' I had a runny nose, cough, and fever a few weeks ago." Medical history is unremarkable, and the patient takes no medications. She has smoked a pack of cigarettes a day for the last 7 years, and smoked marijuana for a few months as a teenager. The patient is not sexually active and has never been pregnant. Her last menstrual period was 2 weeks ago. She is adopted, and her family history is unknown. Temperature is 38.3 C (100.9 F) , blood pressure is 156/60 mm Hg, pulse is 110/min, and respirations are 22/min. The thyroid gland is diffusely enlarged, firm, and very tender. The extremities are warm and moist. Eye examination shows lid lag but no proptosis. The remainder of the examination is unremarkable. Laboratory results are as follows:

A radioactive iodine uptake with scintigraphy in this patient is mostly likely to show which of the following?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bedb_aa55_8f63_2932d1c11500_MD0005_00 This patient has primary hyperthyroidism (elevated T4, suppressed TSH). In light of her fever, neck pain, tender goiter, and elevated erythrocyte sedimentation rate, this is most likely due to subacute thyroiditis. Subacute (de Quervain, subacute granulomatous) thyroiditis (ST) is often preceded by an upper respiratory illness and is thought to be due to a postviral inflammatory process. Thyrotoxicosis in ST is caused by release of stored thyroid hormone due to follicular injury. Other possible findings include leukocytosis, mild anemia, and mild elevation of liver enzymes, as seen in this patient. Due to suppression of TSH, patients with ST have decreased organification of iodine and thyroid hormone synthesis. As a result, they will typically have a very low radioiodine uptake on thyroid scintigraphy. Decreased uptake is also seen in silent (painless) thyroiditis, postpartum thyroiditis, surreptitious thyroid hormone abuse, and iodine-induced thyroiditis. (Choices B and D) Focal radioiodine uptake (ie, a "hot" nodule in a "cold" thyroid background) suggests a hyperfunctioning adenoma. Patchy uptake is seen in toxic multinodular goiter. These patients may have symptomatic hyperthyroidism but are less likely to have fever or thyroid tenderness and usually have nodular rather than diffuse enlargement. In addition, the incidence of toxic nodular disease increases with age and is uncommon in young patients. (Choice C) Diffusely increased uptake is seen in Graves disease, which is due to thyrotropin receptor autoantibodies that stimulate iodine uptake and thyroid hormone synthesis. In Graves disease, goiter is less likely to be tender than in ST. Educational objective: Subacute thyroiditis is characterized by fever and a painful, diffusely enlarged thyroid, often associated with thyrotoxicosis. It is due to acute inflammation of the thyroid and release of stored thyroid hormone, leading to suppressed TSH and decreased radioactive iodine uptake. References: Subacute, silent, and postpartum thyroiditis. (http://www.ncbi.nlm.nih.gov/pubmed/22443972)

A 26-Year-Old Woman Comes to the Office Due to Fever