A 25-year-old woman comes to the office due to a 2-week history of neck pain. The patient had an upper respiratory infection a month ago, during which she experienced nasal congestion, rhinorrhea, and a cough productive of clear sputum; her respiratory symptoms lasted for 5 days and resolved spontaneously. The patient then felt well until 2 weeks ago, when she developed pain in the anterior neck associated with mild fever, palpitations, and excessive sweating. She is otherwise healthy and takes no medications. Pulse is 110/min. The thyroid gland is tender to palpation and diffusely enlarged. Other findings include sweaty palms, fine hand tremor, and brisk deep tendon reflexes. Laboratory studies show suppressed TSH and elevated free thyroxine levels. Erythrocyte sedimentation rate is 70 mm/hr. Which of the following additional findings is most likely to be present in this patient at this time?

Question

A 25-year-old woman comes to the office due to a 2-week history of neck pain.  The patient had an upper respiratory infection a month ago, during which she experienced nasal congestion, rhinorrhea, and a cough productive of clear sputum; her respiratory symptoms lasted for 5 days and resolved spontaneously.  The patient then felt well until 2 weeks ago, when she developed pain in the anterior neck associated with mild fever, palpitations, and excessive sweating.  She is otherwise healthy and takes no medications.  Pulse is 110/min.  The thyroid gland is tender to palpation and diffusely enlarged.  Other findings include sweaty palms, fine hand tremor, and brisk deep tendon reflexes.  Laboratory studies show suppressed TSH and elevated free thyroxine levels.  Erythrocyte sedimentation rate is 70 mm/hr.  Which of the following additional findings is most likely to be present in this patient at this time?

Quizplus · Accepted Answer

11ec160b_3cba_5bb4_9249_054fab9d700a_MD0001_00 This patient has primary hyperthyroidism (ie, intrinsic thyroid disease), confirmed with elevated free thyroxine and low TSH. Common nonspecific findings in hyperthyroidism include diaphoresis, tachypalpitations, tremor, brisk reflexes, and lid lag. In addition, she has features suggesting subacute (granulomatous, de Quervain) thyroiditis (ST), including fever; a painful, tender goiter; and an elevated erythrocyte sedimentation rate (nonspecific marker for inflammation). ST characteristically follows a viral infection and is thought to be due to a cross-reacting inflammatory response with activation of cytotoxic T lymphocytes. Diagnostic findings in ST include: elevated thyroid hormone levels (ie, thyroxine [T4], triiodothyronine [T3]) due to the destruction of thyroid follicles and release of preformed thyroid hormone. elevated thyroglobulin, which is released from thyroid follicles with thyroid hormone. suppressed TSH due to feedback inhibition by thyroid hormone on the pituitary. low radioactive iodine uptake (ie, radioiodine thyroid scintigraphy) reflecting decreased thyroid metabolic activity and organification of iodine due to loss of TSH stimulation. diffuse enlargement of the gland with decreased blood flow on thyroid ultrasound. Following the hyperthyroid phase, patients experience transient hypothyroidism due to depletion of thyroid colloid and then slowly return to a euthyroid state. (Choice A) Thyroid peroxidase antibodies are a marker for autoimmune thyroid disorders, including postpartum and chronic lymphocytic (Hashimoto) thyroiditis and Graves disease. Goiter is common in these conditions but is painless and nontender. (Choice C) Exogenous thyroid hormone intake (eg, levothyroxine, porcine thyroid extract) can cause hyperthyroidism with suppression of TSH and decreased endogenous release of thyroid hormone and thyroglobulin. However, the native thyroid is not enlarged and is often atrophic. (Choice D) Euthyroid sick syndrome (low T3 syndrome) is a characteristic set of thyroid function abnormalities in patients with severe systemic illness. It resembles mild, central hypothyroidism with normal/low TSH and low T3 levels. The thyroid is not enlarged or tender, and the syndrome is not usually seen following ordinary upper respiratory illnesses. Educational objective: Subacute (granulomatous, de Quervain) thyroiditis presents with fever; a painful, tender goiter; and an elevated erythrocyte sedimentation rate. Patients initially develop hyperthyroidism due to the destruction of thyroid follicles and release of preformed thyroid hormone. TSH is suppressed due to feedback inhibition on the pituitary; as a result, thyroid metabolic activity and organification of iodine are decreased, and radioactive iodine uptake is low.

A 25-Year-Old Woman Comes to the Office Due to a 2-Week