Ultrasound-Guided Capsular Thyroid Injection Therapy With Dexamethasone and Lidocaine Mixture for Subacute Thyroiditis: A Single-Center Study.

OBJECTIVES: Subacute thyroiditis (SAT) is a self-limiting, inflammatory thyroid disease possibly caused by viral infection. In recent years, the incidence of SAT is increasing, especially during the pandemic of the COVID-19. This study aimed to evaluate the efficacy, safety, and recovery time of capsular thyroid injection therapy under ultrasound guidance for SAT. METHODS: A total of 73 patients with SAT were divided into two groups. Patients in group A (n = 48) received an ultrasound-guided capsular injection consisting of dexamethasone (DEX) and lidocaine in the thyroid lesion area, while patients in group B (n = 25) received oral prednisolone (PSL). The two groups were compared for pain relief and treatment duration, the recovery time of thyroid function, recurrence rates, hypothyroidism incidence, and drug-related side effects. RESULTS: The follow-up time was 1 year. In group A, the duration of pain relief, treatment, and recovery time of thyroid function were significantly shorter than that in group B (P < .05), and no statistically significant differences in recurrence rate or incidence of hypothyroidism were observed (P > .05). Weight gain was significantly higher in group A at the end of treatment (P < .001). CONCLUSIONS: Compared with oral PSL treatment, ultrasound-guided local injection of DEX and lidocaine into the capsular thyroid is a safe and effective procedure that can significantly reduce the treatment time of SAT.

Post-COVID Subacute Thyroiditis and Bronchiolitis in a Lung Transplant Recipient: A Case Report.

Lung transplant recipients are at risk for life-threatening infections including severe acute respiratory syndrome coronavirus 2-associated COVID-19. Several viral infections have been associated with the development of chronic lung allograft dysfunction. Long-term outcomes of COVID-19 on graft function are not known. A 53-year-old female patient, who underwent bilateral lung transplantation 3 years before because of stage IV sarcoidosis and secondary pulmonary hypertension was admitted in the second wave of the pandemic because of COVID-19 with symptoms including dry cough. Chest computed tomography showed ground glass opacities affecting 25% to 50% of the lung parenchyma. She was admitted to the COVID-19 Unit of our clinic. She received oxygen via nasal cannula, remdesivir, and low-dose methylprednisolone while mycofenolate acid administration was stopped. Her clinical condition improved. The first follow-up visit 1 month after the infection demonstrated deterioration in lung function. Computed tomography scan showed almost complete resolution; transbronchial biopsy was performed and proved acute allograft rejection. During the hospitalization a new onset atrial fibrillation was confirmed. In the background of atrial fibrillation and simultaneous neck pain, severe hyperthyroidism was proven. Because of thyroiditis and lung allograft rejection, high-dose steroid treatment was initiated and everolimus was added to the immunosuppressive therapy. Donor specific antibodies were also detected, hence plasmapheresis was indicated and continued with photoferesis. On the follow-up spirometry the values were stable; however, they did not reach pre-COVID levels. In lung transplant recipients COVID-19 might trigger allograft rejection in addition to virus-related thyroid disease.

Subacute thyroiditis after SARS-Cov2 vaccination: A review of the cases being described and personal experience.

Objective. The present study evaluates the occurrence of subacute thyroiditis in temporal connection with SARS-Cov2 vaccinations described in the literature last year and confirmed by our clinical routine. Methods. Systematic literature search in Medline for studies reporting diagnosis of subacute thyroiditis in temporal connection with vaccinations against Covid 19. Results. The literature search yielded 24 relevant references out of which 22 were "case reports" and two "Letters to the Editor" and encompassed 37 patient cases, in total. They had received a SARS-Cov2 vaccination shortly before the diagnosis (median interval to vaccination six days). In none of these cases, infection of the upper respiratory tract had previously been identified as a classic trigger of the disease. Newly occurring hyperthyroidism and increased laboratory signs of inflammation were described in 78% and 74% of cases, respectively. Atypical clinical pictures (asymptomatic, euthyroid, no inflammation marks) have been observed in both the literature and our patients suspected of thyroid cancer referred to surgery. Conclusions. In times of pandemics and the resulting vaccination, new rapidly occurring sonographic changes in the thyroid gland should be revaluated after 2-3 weeks, or recommended to undergo a fine-needle biopsy, in order to avoid unnecessary surgical interventions.

Successful use of caplacizumab in a case of refractory acquired thrombotic thrombocytopenic purpura following subacute thyroiditis.

Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare condition mainly characterized by microangiopathic hemolytic anemia, thrombocytopenia, reported in approximately three cases per one million adults per year. Some reports describing co-occurrence of aTTP and other autoimmune disorders, as Graves' thyroiditis, are reported. To the best of our knowledge this is the first report describing co-occurrence of subacute thyroiditis and aTTP. The patient was refractory to conventional therapy with plasma exchange, steroids and rituximab but was successfully treated with the addition of caplacizumab, an anti-VWF bivalent variable-domain-only immunoglobulin fragment that inhibits interaction between VWF multimers and platelets.

Subacute thyroiditis with airway compromise in a 5-year-old boy.

A 5-year-old boy presented with intermittent fever for 1 month, painful neck swelling associated with dysphagia, hoarseness of voice for 3 weeks and dyspnoea of 1-day duration. On evaluation, he had elevated serum thyroglobulin levels and inflammatory markers. There was a diffuse glandular thyroid enlargement with hypoechoic areas on neck ultrasonography. Fine-needle aspiration cytology was suggestive of subacute thyroiditis (SAT), and MRI of the neck confirmed narrowing of the trachea by the enlarged thyroid. He received steroids to relieve airway compression. Levothyroxine was started. On follow-up, he was symptom-free and euthyroid; steroids and levothyroxine were discontinued. SAT presenting with compression of trachea is rare in children. This highlights the need for identifying the type of thyroiditis to determine treatment modality.

Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series.

CONTEXT: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected more than 18 million people worldwide and the pandemic is still spreading. After the first case we reported, we observed 4 additional cases of subacute thyroiditis (SAT) related to SARS-CoV-2 infection. OBJECTIVES: The objective of this work is to describe additional cases of SAT associated with SARS-CoV-2 infection to alert physicians that SAT may be a manifestation of SARS-CoV-2 infection. METHODS: We describe clinical, biochemical, and imaging features of 4 patients with SAT related to SARS-CoV-2 infection. RESULTS: All patients were female (age, 29-46 years). SAT developed 16 to 36 days after the resolution of coronavirus disease 2019 (COVID-19). Neck pain radiated to the jaw and palpitations were the main presenting symptoms and were associated with fever and asthenia. One patient was hospitalized because of atrial fibrillation. Thyroid function tests (available for 3 individuals) were suggestive of destructive thyroiditis, and inflammatory markers were high. At neck ultrasound the thyroid was enlarged, with diffuse and bilateral hypoechoic areas and (in 3 patients) absent vascularization at color Doppler. Symptoms disappeared a few days after commencement of treatment (prednisone in 3 patients and ibuprofen in 1). Six weeks after the onset of SAT, all patients were asymptomatic and inflammatory markers had returned to normal range. Two patients were euthyroid, whereas 2 were diagnosed with subclinical hypothyroidism. CONCLUSIONS: SAT may be an underestimated manifestation of COVID-19. Clinicians should keep in mind the possible occurrence of SAT during and after SARS-CoV-2 infection.

Successful Management of Recurrent Subacute Thyroiditis by Adding Colchicine to Glucocorticoid Treatment: A Case Series Study.

Although subacute thyroiditis (SAT) is thought to be a self-limited inflammatory thyroid disease, the recurrence rate of SAT is approximately 10-20%. It is difficult for these patients to stop glucocorticoid treatment, and they are usually bothered with recurrent pain and the side effects of glucocorticoids for more than several months. We describe three cases who were diagnosed with recurrent subacute thyroiditis after a reduction in prednisolone (PSL) dose, either immediately upon the cessation of PSL or shortly thereafter. Their symptoms, including the adverse effects of PSL, severely impacted their quality of life. After a complete assessment, we administered colchicine at 1 mg per day for 1-2 months to control the recurrence of SAT and monitored their routine blood parameters every two weeks. All 3 patients were successfully tapered off of PSL treatment and were free of frequently recurrent SAT. Colchicine may be therapeutic in patients with prednisolone-refractory, recurrent SAT. However, a large-scale, double-blind, controlled, prospective multicenter study is required to provide a solid body of evidence.

Two-Years Prospective Follow-Up Study of Subacute Thyroiditis.

Purpose: The aim of the present prospective follow-up study was to explore the early indicators of hypothyroidism and the final changes in thyroid volume in subacute thyroiditis (SAT) patients. Methods: We enrolled 61 SAT patients and followed them up for 2 years to assess the incidence of hypothyroidism and changes in thyroid volume. Binary logistic regression and receiver operating characteristic (ROC) curves were used for data analysis. Results: During the 2 years follow-up period, we found that the volumes of the thyroid gland in SAT patients at 1 and 2 years were significantly smaller than those in the healthy control group, which were significantly smaller compared to the initial thyroid volumes after SAT onset (p < 0.001). Also, the thyroid volumes of SAT patients with hypothyroidism were significantly smaller than those of SAT patients without hypothyroidism. The early maximum thyroid-stimulating hormone (TSH) values (within 3 months after SAT onset) were closely related to the incidence of hypothyroidism at 2 years. The OR value was 1.18 (95% CI = 1.01-1.38, p = 0.032). The early maximum TSH value had a maximum area under the ROC curve (AUC) of 0.866 for the development of hypothyroidism 2 years after SAT onset vs. euthyroidism (p < 0.001). Conclusions: The thyroid volumes of patients increased significantly after the onset of SAT, while during the follow-up these volumes decreased; the thyroid volumes at 1 and 2 years were significantly smaller than those of normal healthy subjects, especially in SAT patients with hypothyroidism. Furthermore, the early maximum TSH value could be used as an effective indicator of the development of hypothyroidism 2 years after the onset of SAT.

Diagnostic cytological features and differential diagnosis of subacute granulomatous (De Quervain's) thyroiditis.

BACKGROUND: The aims of the study are to identify the diagnostic cytological features of subacute granulomatous thyroiditis (SGT), to compare our results with previous literature studies, and to investigate the cytological changes in SGT that mimic other thyroid lesions. METHODS: This retrospective study was conducted with 69 cases. The cytology slides were re-evaluated. The diagnostic cytomorphological features of the disease were identified. The results were compared with the literature. Differential diagnosis of the disease is discussed with the results obtained. RESULTS: The diagnostic cytological features consisted of lymphocytes, multinucleated giant cells, loose epithelioid histiocyte groups, granulomas, isolated epithelioid histiocytes, colloid, and neutrophil leukocytes. The highest degree of concordance between our results and the published literature was the presence of giant cells while the lowest was for microfollicles. Some reactive cytological features of SGT were similar to other benign or malignant diseases of the thyroid. CONCLUSION: SGT is a rare and self-limiting disease. Cytological features are not specific. The diagnosis should be confirmed by clinical and laboratory results. Reactive atypia in the early phase of the disease and microfollicles in the late phase may lead to a false cytological diagnosis, thus resulting in unnecessary resection. To prevent such misdiagnoses, cytopathologists should be aware of the reactive cytological changes in this disorder.

Thyroid primary and metastatic malignant tumours of poor prognosis may mimic subacute thyroiditis - time to change the diagnostic criteria: case reports and a review of the literature.

BACKGROUND: The diagnosis of subacute thyroiditis (SAT) is based mainly on the presence of painful thyroid goitre and a significant increase in erythrocyte sedimentation rate (ESR). Proceeding according to these diagnostic criteria may lead to an incorrect diagnosis and treatment. Extremely dangerous is the situation when the diagnosis of SAT is erroneously made based on criteria other than ultrasound (US) image and fine needle aspiration biopsy (FNAB), which leads to delayed diagnosis of malignant tumour with poor prognosis. CASE PRESENTATION: Five patients with typical SAT symptoms are presented. In all of them, anaplastic thyroid cancer or metastatic thyroid tumours were finally diagnosed as the cause of the initial symptoms resembling SAT. Most of the patients were initially misdiagnosed and the proper diagnosis of malignancy was delayed. CONCLUSIONS: The authors have proposed the new diagnostic criteria for SAT, and strongly suggest that thyroid gland US should be included in the main criteria of SAT diagnosis, together with FNAB result excluding the presence of malignant tumour.

A Comparative Study of ARHI Imprinted Gene Detection and Fine-Needle Aspiration Cytology in the Differential Diagnosis of Benign and Malignant Thyroid Nodules.

Aims: To compare fine-needle aspiration cytology (FNAC) with imprinted gene detection in the differential diagnosis of benign and malignant thyroid nodules. Methods: A total of 34 patients (35 cases of thyroid nodules) were examined using fine-needle puncture biopsy under ultrasound guidance, and the biopsy tissues were examined by cytologic examination and imprinted gene detection. Combined with postoperative pathology and follow-up results, the diagnostic value and consistency of the two methods were analyzed and compared. Results: The detection of benign and malignant thyroid nodules by ARHI imprinted gene had a high consistency with FNAC, and ARHI imprinted gene detection had a higher detection rate, sensitivity, and accuracy. Conclusions: Imprinted gene detection has high accuracy and sensitivity in the differential diagnosis of benign and malignant thyroid nodules. It provides a scientific reference for clinical treatment and should be incorporated into diagnostic protocols for thyroid tumor.

Putting All the Pieces Together: Clinical, Macroscopic and Microscopic Characteristics of Subacute Thyroiditis.

Subacute thyroiditis (SAT) is a self-limiting inflammatory condition of the thyroid gland in which multinucleated giant cells constitute a key histological finding. SAT is generally a clinical diagnosis and consequently its histological features are rarely encountered by pathologist. Herein, we present a case that exemplifies the characteristic clinical and pathological features of this entity. In addition, we compare SAT to other thyroid disorders characterized by the presence of multinucleated giant cells.

Prevalence of papillary thyroid cancer in subacute thyroiditis patients may be higher than it is presumed: retrospective analysis of 137 patients.

Background The association of subacute thyroiditis (SAT) and papillary thyroid carcinoma is a rare finding. In this study, we aimed to investigate the prevalence of differentiated thyroid cancer in a cohort of patients followed with the diagnosis of SAT. Patients and methods We retrospectively screened medical records of Endocrinology and Metabolism outpatient clinic in the past 20 years for patients with SAT. Patients with nodules and suspicious ultrasonography findings who underwent fine needle aspiration biopsy (FNAB) and operated due to malignancy risk were identified. Results We identified 137 (100 females, 37 males) patients with reliable records to confirm the diagnosis of SAT. The mean age of female patients was 41.1 ± 9.1 (range, 20-64) and of male patients was 43.0 ± 9.3 (range, 20-65). One or more FNAB was performed in 23 of the patients (16.8%) at the beginning and/or during the follow-up period when needed. Seven patients with suspicious FNAB findings were operated, and histopathological examination of the nodules confirmed the diagnosis of papillary thyroid carcinoma in 6 patients (4.4%). Conclusions Our observations suggesting a relatively higher prevalence of thyroid cancer in a small series of SAT patients warrant further studies to identify the real frequency of differentiated thyroid cancer and its association with inflammatory pathogenesis of SAT. This finding is compatible with the trend of increased thyroid cancer incidence all over the world. A repeat ultrasonography after resolution of clinical and inflammatory findings, and FNAB should be recommended to all patients with suspicious nodules.

[Atypical subacute thyroiditis in combination with Grave's disease:Diagnostic difficulties in a case report]. / Atypisk subakut tyreoidit gav differentialdiagnostiska problem - Ovanligt fall av Graves tyreotoxikos i kombination med subakut tyreoidit med atypisk klinisk bild.

Subacute thyroiditis is a common inflammatory disorder of the thyroid gland, possibly of viral etiology, that typically presents with neck pain, fever and tenderness on palpation of the thyroid gland. Graves' disease is an autoimmune thyroid disorder caused by stimulation of the thyroid gland by thyrotropin receptor antibodies (TRAb). The development of Graves´ disease and subacute thyroiditis simultaneously is an uncommon condition and only a few cases have been reported. In this article we present a case of a 46-year old woman diagnosed with Graves´ disease who was started on thiamazole and weeks later developed high fever. Several differential diagnoses were considered such as infection, lymphoma and vasculitis due to thiamazole. Finally, the fine needle aspiration of the thyroid gland displayed histopathological features of subacute thyroiditis. Remarkably, our patient did not have neck pain or tenderness on palpation of the thyroid gland and overall the clinical presentation of subacute thyroiditis was atypical. Thus, subacute thyroiditis may be considered as a potential cause of fever of unknown origin.

Granulomatous Thyroiditis: A Case Report and Literature Review.

BACKGROUND: Granulomatous disease in the thyroid gland has been linked to viral, bacterial and autoimmune etiologies. The most common granulomatous disease of the thyroid is subacute granulomatous thyroiditis, which is presumed to have a viral or post-viral inflammatory cause. Bacterial etiologies include tuberculosis, actinomycosis, and nocardiosis, but are extremely rare. Disseminated actinomycosis and nocardiosis more commonly affect organ-transplant patients with the highest susceptibility within the first year after transplant surgery. CASE: A 45-year-old African American male, who received his third kidney transplant for renal failure secondary to Alport Syndrome, presented with numerous subcutaneous nodules and diffuse muscle pain in the neck. Further workup revealed bilateral nodularity of the thyroid. Fine needle aspiration of these nodules demonstrated suppurative granulomatous thyroiditis. Subsequent right thyroid lobectomy showed granulomatous thyroiditis with filamentous micro-organisms, morphologically resembling Nocardia or Actinomyces. CONCLUSION: Disseminated granulomatous disease presenting in the thyroid is very rare, and typically afflicts immune-compromised patients. The overall clinical, cytologic and histologic picture of this patient strongly points to an infectious etiology, likely Nocardia, in the setting of recent organ transplantation within the last year.

Risk Stratification of Thyroid Nodules With Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance (AUS/FLUS) Cytology Using Ultrasonography Patterns Defined by the 2015 ATA Guidelines.

PURPOSE: The purpose of this study was to evaluate the predictive value of ultrasonography (US) patterns based on the 2015 American Thyroid Association (ATA) guidelines for malignancy in atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) nodules. METHODS: From January 2014 to August 2015, 133 thyroid nodules that were initially diagnosed as AUS/FLUS on fine needle aspiration (FNA) were included in this study. Each nodule was assigned a category with US patterns defined by the ATA guidelines. Clinical characteristics and US patterns were compared between the benign and malignant nodules, and malignancy rates were calculated according to the ATA guidelines. RESULTS: The malignancy rate in the very low suspicion group was 0.0% in AUS/FLUS nodules. When applying the ATA guidelines, significant differences existed for US patterns between the benign and malignant nodules in the AUS group ( P = .032) but not the FLUS group ( P = .168). CONCLUSIONS: Ultrasonography patterns by the 2015 ATA guidelines can provide risk stratification for nodules with AUS cytology but not for ones with FLUS cytology. For nodules with AUS/FLUS cytology with the very low suspicion pattern of the ATA guidelines, follow-up US might be recommended instead of repeat FNA.

Lesson of the month 1: Subacute thyroiditis: a rare cause of fever of unknown origin.

Fever of unknown origin (FUO) is sometimes a diagnostic dilemma for clinicians. Endocrine causes reported in the literature include subacute thyroiditis, thyrotoxicosis, adrenal insufficiency and pheochromocytoma. Among these, subacute thyroiditis is often overlooked as it can occasionally lack typical symptoms. This case illustrates the fact that subacute thyroiditis should be considered as a possible cause of fever even if signs and symptoms of hyperthyroidism and thyroid tenderness are absent.

de Quervain's thyroiditis: A review of experience with surgery.

BACKGROUND: de Quervain's thyroiditis is an inflammatory condition of the thyroid mostly treated medically, rarely requiring surgical treatment. We intend to review the surgical experience with de Quervain's thyroiditis at a tertiary cancer center over a period of 22years. METHODS: A retrospective review of medical records from 1992 to 2014 at a tertiary cancer center was performed and all patients with a histopathological diagnosis of de Quervain's thyroiditis were included. RESULTS: Ten patients with a histopathological diagnosis of de Quervain's thyroiditis were included in the study. One patient in the study presented with dysphagia due to the goiter. The remaining patients presented with thyroid nodules. None presented with typical symptoms of the disease. Seven of the ten patients that had been evaluated for a goiter at an outside facility underwent fine needle aspiration cytology. Of the seven patients, one patient was suspected to have medullary carcinoma of the thyroid, two had follicular neoplasia, and the others had indeterminate nodules. Eight of the ten patients underwent surgery for suspected malignancy, with eight receiving a total thyroidectomy and two patients getting a thyroid lobectomy with isthmusectomy. Two patients had an abnormally hard gland to palpate during surgery with the others not having any suspicious findings. Seven of the ten of the patients had lymph node sampling from level 6 and all were benign on final pathology. The mean duration of post-operative follow-up was 15months. There was no morbidity associated with surgery in any of these patients with eight of the ten patients requiring thyroid hormone replacement. None of the patients needed further neck surgery for thyroid disease. CONCLUSION: de Quervain's thyroiditis is an inflammatory condition of the thyroid that is rarely treated surgically. However when presentation is atypical and the FNAC is inconclusive or is suspicious for a malignancy, patients receive surgery putting them at a risk for morbidity. Good clinical assessment with combined use of ultrasound with FNAC especially read by an experienced cytopathologist has the potential to reduce unnecessary operative intervention.

Painful thyroid nodule, a misleading presentation of subacute thyroiditis.

Typical presentation of subacute thyroiditis (SAT) is an anterior neck pain radiating up to the jaw and ear, often associated with asthenia and fever. Biology shows hyperthyroidism and inflammation. The thyroid uptake is low at scintigraphy. However, the clinical presentation of SAT may be misleading. We report two cases of SAT whose initial manifestation was a painful thyroid nodule suspected of malignancy. In both cases, ultrasound feature was a heterogeneous, hypoechoic, ill-defined area with a low vascularization on colour Doppler. These areas were interpreted by radiologist as nodules. Surgery was then considered. Such a presentation should be known by clinicians to prevent unnecessary surgery.

Co-occurrence of subacute granulomatous thyroiditis and papillary microcarcinoma.

Subacute thyroiditis, which is most commonly observed after a viral infection and may heal spontaneously, is an inflammatory thyroid disease. The co-occurrence of subacute thyroiditis and papillary carcinoma is quite rare. A 58-year-old male patient who applied to our hospital with the complaints of sore throat and neck swelling was performed total thyroidectomy following physical examination, ultrasound, and laboratory analysis. In histopathological examination, many granuloma structures were observed in both lobes, and a papillary microcarcinoma focus of 2 mm in diameter was seen in the left lobe. The co-occurrence of subacute thyroiditis and papillary carcinoma was deemed worthy of presentation as it is rarely observed.