A 50-year-old man comes to the office with a 2-day history of malaise, fever, fatigue, and pain in the front of his neck. He recovered from an upper respiratory illness a week prior to the onset of his current symptoms, but he previously had felt well. The patient was seen in the clinic occasionally in the remote past for sexually transmitted infections, but his medical history is otherwise unremarkable. He lives alone and is sexually active with both men and women. Temperature is 38.5 C (101.3 F), blood pressure is 150/70 mm Hg, and pulse is 110/min. The thyroid gland is diffusely enlarged and tender. Laboratory results are as follows: Which of the following is the most likely diagnosis in this patient?

Question

A 50-year-old man comes to the office with a 2-day history of malaise, fever, fatigue, and pain in the front of his neck.  He recovered from an upper respiratory illness a week prior to the onset of his current symptoms, but he previously had felt well.  The patient was seen in the clinic occasionally in the remote past for sexually transmitted infections, but his medical history is otherwise unremarkable.  He lives alone and is sexually active with both men and women.  Temperature is 38.5 C (101.3 F), blood pressure is 150/70 mm Hg, and pulse is 110/min.  The thyroid gland is diffusely enlarged and tender.  Laboratory results are as follows:  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d12e_b9ce_bc81_13eca076ed6e_MD0003_00 This patient has primary hyperthyroidism (elevated free T4, suppressed TSH). In light of his associated fever, neck pain, tender goiter, and elevated erythrocyte sedimentation rate, this is most likely due to subacute thyroiditis. Subacute (de Quervain, subacute granulomatous) thyroiditis is thought to be due to a postviral inflammatory process and is often preceded by an upper respiratory illness. Thyrotoxicosis in subacute thyroiditis resolves spontaneously within a few weeks and may be followed by a hypothyroid phase lasting a few months. Most patients eventually recover to a euthyroid state. Treatment is symptomatic with beta blockers to control thyrotoxic symptoms and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief. Glucocorticoids are used for severe thyroid pain not responding to NSAIDs. (Choices A, B, and E) Infectious mononucleosis is characterized by pharyngitis, fever and other systemic symptoms, lymphadenopathy, and splenomegaly. Acute HIV infection can cause a mononucleosis-like illness with fever, pharyngitis, and lymphadenopathy, often with a generalized macular rash and gastrointestinal symptoms. Disseminated gonococcal infection typically presents with fever, chills, vesiculopustular rash, and polyarthralgias or purulent monoarthritis. None of these disorders is associated with a goiter or hyperthyroid state. (Choices C and D) Chronic lymphocytic (Hashimoto) thyroiditis typically presents with hypothyroidism, although patients may develop a brief hyperthyroid phase. However, the goiter seen in both Hashimoto thyroiditis and Graves disease is nontender, and fever is not common. (Choice G) Suppurative infection of the thyroid gland (infectious thyroiditis) is a rare condition causing high-grade fever and pain at the thyroid gland. The thyroid gland may be palpably enlarged due to abscess formation. However, patients are usually euthyroid as the involvement of the thyroid gland is focal. Educational objective: Subacute (de Quervain) thyroiditis is characterized by fever, neck pain, and a tender goiter following an upper respiratory illness. Patients have a self-limited thyrotoxic phase followed by hypothyroidism and eventual recovery of thyroid function. Treatment is symptomatic with beta blockers and nonsteroidal anti-inflammatory drugs. References: Subacute, silent, and postpartum thyroiditis. (http://www.ncbi.nlm.nih.gov/pubmed/22443972)

A 50-Year-Old Man Comes to the Office with a 2-Day