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:
Which of the following is the best treatment for this patient?

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:
 Which of the following is the best treatment for this patient?

Quizplus · Accepted Answer

Explanation: Subacute thyroiditis (ST) is a self-limited condition. The hyperthyroid phase may last a few weeks, followed by a transient hypothyroid phase and eventual return to a euthyroid state. Treatment is primarily supportive, and most cases can be managed with a nonsteroidal anti-inflammatory drug to relieve pain; glucocorticoids can be used in severe or refractory cases. In addition, patients can be given a beta blocker (eg, propranolol, atenolol) to minimize the hyperadrenergic symptoms of thyrotoxicosis (eg, sweating, palpitations). (Choices A and E) Suppurative infection of the thyroid gland (infectious thyroiditis) is a rare condition that causes high-grade fever and pain at the thyroid gland. Patients will often have evidence of a thyroid abscess on examination or ultrasound, but are usually euthyroid as involvement of the thyroid gland is focal. Bacterial thyroid infections are treated with systemic antibiotics, and surgical drainage may be required. (Choice B) Thyrotoxicosis in ST is due to release of preformed thyroid hormone. Antithyroid drugs (eg, methimazole), which work by decreasing the synthesis of thyroid hormones, are ineffective. (Choice D) Radioiodine thyroid ablation is used for definitive treatment of Graves disease and nodular thyroid disease. It is not necessary in ST, which is a self-limited illness, and would not be effective as thyroid uptake of the radioiodine dose is very low. Educational objective: Subacute thyroiditis is a self-limited condition. Treatment consists primarily of nonsteroidal anti-inflammatory drugs for pain relief and beta blockers to minimize thyrotoxic symptoms. Severe or refractory cases may require glucocorticoid therapy.

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