What is the approach to investigation and management of De Quervain's thyroiditis?

Approach to Investigation and Management of De Quervain's Thyroiditis

De Quervain's thyroiditis is a self-limiting inflammatory thyroid disorder that requires primarily symptomatic management with NSAIDs or corticosteroids, with careful monitoring of thyroid function through its typical phases of transient thyrotoxicosis followed by hypothyroidism before resolution. 1, 2

Clinical Presentation and Diagnosis

• Painful thyroid enlargement with tenderness that may radiate to the ear, often appearing approximately two weeks after an upper respiratory viral infection 1, 2
• Systemic symptoms may include fever, fatigue, and general discomfort 1, 3
• Laboratory findings typically show markedly elevated erythrocyte sedimentation rate (ESR), normal or slightly elevated C-reactive protein (CRP), and normal or slightly elevated white blood cell count 1, 2
• Thyroid function tests reveal a characteristic pattern that evolves through phases:
  • Initial thyrotoxic phase (elevated free T4/T3 with low or suppressed TSH) in approximately 50% of cases 2, 4
  • Followed by euthyroid phase
  • Then transient hypothyroid phase (elevated TSH, low free T4)
  • Finally return to euthyroidism 1, 2
• Serum thyroglobulin levels are typically elevated 2

Diagnostic Workup

• Thyroid function tests (TSH, free T4, free T3) to determine current phase of disease 1, 2
• Inflammatory markers (ESR, CRP) 1, 2
• Thyroid autoantibody testing (thyroid peroxidase antibodies) to help differentiate from autoimmune thyroid disorders 1
• Thyroid imaging:
  • Ultrasound typically shows diffuse hypoechogenic structure, though nodules may also be present 1
  • Radioactive iodine uptake scan shows decreased uptake during the inflammatory phase, which is a key diagnostic feature 2, 4
• Fine needle aspiration cytology may be performed if the presentation is atypical or to rule out malignancy, showing granulomatous changes with giant cells 1, 5

Management Approach

• Symptomatic treatment is the mainstay of therapy as the condition is self-limiting 2, 3
• Pain management:
  • Mild to moderate pain: Non-steroidal anti-inflammatory drugs (NSAIDs) or salicylates 3
  • Severe pain: Corticosteroids (prednisone starting at 40 mg daily with gradual tapering over several weeks) provide rapid symptom relief within 24-48 hours 3
• Thyroid function management:
  • Thyrotoxic phase: Beta-blockers may be needed for symptomatic relief if signs of hypermetabolism (tachycardia, tremor, anxiety) are present 6
  • Hypothyroid phase: Thyroid hormone replacement may be initiated if symptomatic hypothyroidism develops, but can usually be discontinued after resolution 3
• Monitoring:
  • Repeat thyroid function tests every 2-3 weeks to monitor disease progression through its phases 6
  • Most patients recover completely within 6-12 months without complications 2

Special Considerations

• Recurrence occurs in a small percentage of patients and may require restoration of higher corticosteroid doses 3
• Permanent hypothyroidism is rare but has been reported in some patients, necessitating long-term thyroid hormone replacement 2
• Surgery is rarely indicated and should be considered only in the very small minority of patients with repeated relapses despite appropriate treatment 5, 3
• Differential diagnosis should include other causes of thyrotoxicosis, particularly Graves' disease, which would require different management 6

When to Refer to Specialist

• Atypical presentation or uncertain diagnosis 5
• Severe symptoms not responding to standard therapy 3
• Recurrent episodes 3
• Development of complications or persistent thyroid dysfunction 2