A 34-year-old woman comes to the office due to a 1 week history of mood swings, difficulty concentrating, and hand tremors. She also has pain at the front of her neck that radiates to her ears and is worse with swallowing. The patient initially attributed her symptoms to a flu-like illness that she had a few weeks earlier. She has no other medical conditions and takes no medications. Blood pressure is 140/80 mm Hg and pulse is 105/min. The thyroid gland is very tender on palpation. After initial laboratory testing, a thyroid scan is performed and reveals diffusely decreased radioiodine uptake. Erythrocyte sedimentation rate is 105 mm/hr. Which of the following pathological changes would be most likely on biopsy of this patient's thyroid gland?

Question

A 34-year-old woman comes to the office due to a 1 week history of mood swings, difficulty concentrating, and hand tremors.  She also has pain at the front of her neck that radiates to her ears and is worse with swallowing.  The patient initially attributed her symptoms to a flu-like illness that she had a few weeks earlier.  She has no other medical conditions and takes no medications.  Blood pressure is 140/80 mm Hg and pulse is 105/min.  The thyroid gland is very tender on palpation.  After initial laboratory testing, a thyroid scan is performed and reveals diffusely decreased radioiodine uptake.  Erythrocyte sedimentation rate is 105 mm/hr.  Which of the following pathological changes would be most likely on biopsy of this patient's thyroid gland?

Quizplus · Accepted Answer

11ec160b_391b_62dd_9249_27006718cba9_MD0001_00 This patient with painful enlargement of the thyroid gland has subacute granulomatous thyroiditis (SGT), also called de Quervain thyroiditis. SGT typically follows an acute viral illness and is thought to be due to a cross-reacting immune response against viral proteins or tissue antigens released during cellular injury. Patients may experience a transient hyperthyroid phase (elevated thyroxine [T4], suppressed TSH) due to release of stored thyroid hormone. Radioiodine uptake is decreased in SGT as the low TSH levels suppress synthesis of new thyroid hormone. The disease is self-limited and resolves in <6 weeks, although patients may have a brief hypothyroid phase before returning to a euthyroid state. SGT is initially characterized by a neutrophilic infiltrate with microabscess formation, which, as the disease progresses, is replaced by a more generalized inflammatory infiltrate with macrophages and multinucleated giant cells. The inflammatory process is reflected by elevated serum acute-phase markers (eg, C-reactive protein, erythrocyte sedimentation rate). (Choice A) Papillary thyroid cancer is characterized by branching papillary structures with concentric calcifications (psammoma bodies). This malignancy would typically present with nodular enlargement rather than acute pain and tenderness. (Choice B) Riedel thyroiditis is characterized by extensive fibrosis of the thyroid gland that extends into surrounding tissues. The thyroid gland is hard and nontender. (Choice C) Diffusely hyperplastic follicles with tall, crowded cells forming intrafollicular projections can be seen in Graves disease, which would show increased radioiodine uptake due to excessive TSH receptor stimulation. (Choice E) Chronic lymphocytic (Hashimoto) thyroiditis is characterized by diffuse, painless thyroid enlargement, often with symptoms of hypothyroidism (eg, fatigue, cold intolerance). Biopsy reveals diffuse lymphocytic infiltration with formation of germinal centers. Educational objective: Subacute granulomatous (de Quervain) thyroiditis is characterized by painful thyroid enlargement and usually follows a viral illness. Biopsy shows a mixed inflammatory infiltrate with macrophages and multinucleated giant cells. __________ References: Subacute granulomatous (De Quervain's) thyroiditis: Fine-needle aspiration cytology and ultrasonographic characteristics of 21 cases. (http://www.ncbi.nlm.nih.gov/pubmed/26085833)

A 34-Year-Old Woman Comes to the Office Due to a 1