Exam & Basic Workup

1. 136 102 15 97 3.4 25 0.9 Ca, Mg, Phos normal T Protein: 9.0 Albumin: 4.1 T Bili: 0.8 AST: 18 ALT: 30 AP: 100 13.1 8.6 284 39.5 MCV 79 Right lobe sagittal Left lobe sagittal Bilateral lobe transverse No Yes Neck Pain RAIU Symptoms Hyperthyroid  uptake No uptake Hypothyroid Microbial inflammatory thyroiditis Subacute granulomatous thyroiditis RAIU Chronic lymphocytic thyroiditis No uptake  uptake • Viral caused (theory) • ESR elevated (usually > 50) • Anti-TPO negative • Fever/thyrotoxicosis more common than painless form • Autoimmune and drug caused • ESR normal • Anti-TPO positive (> 50%) • Fever/thyrotoxicosis less common than painful form Graves’ Disease Subacute lymphocytic thyroiditis When “A Pain in the Neck” May Have HelpedA Sweatt MD 1and M Mascolo MD 2 1 Department of Internal Medicine at University of Colorado Denver, Aurora, CO; 2 Department of Hospital Medicine at Denver Health, Denver, CO • Patients with fever of unknown origin (FUO) frequently endure multiple and prolonged hospitalizations Subacute Granulomatous Thyroiditis Differential Diagnosis Making the Diagnosis History of Present Illness • Thyroid studies • TSH: Undetectable (< 0.01) • Free T4: Markedly elevated (6.8 --> 7.8 --> 7.4) • Thyroid US: Diffusely heterogeneous, hyperemic, and enlarged gland • Thyroiditis workup • Extremely broad differential in the setting of FUO • Infection:Indolent bacterial (subacute osteo or endocarditis, mycobacterial, nocardia, actinomycosis, etc), viral (encephalitis, adeno, CMV, HIV, echo, hepatitis, etc), fungal (blasto, histo, coccidio, etc) or parasitic (malaria, etc) • Malignancy: Multiple carcinomas, lymphoma, myeloproliferative; carcinoid, CNS, myxoma • Collagen-vascular and autoimmune diseases: PAN, RA, and mixed CTDs have non-specific presentations; Still’s disease, Takayasu’s arteritis, other vasculitis • Endocrine abnormality: Adrenal insufficiency, thyroiditis, pheochromocytoma • Miscellaneous: Drug fever, abdominal abscess, PE/DVT, factitious, neuroleptic malignant syn, hereditary periodic fever d/o, hematoma, alcohol hepatitis, mastocytosis, histiocyte disorders, sarcoidosis, hyper-IgD syndrome, autoimmune enteritis • Clinical presentation • Prodrome of sore throat, fevers, malaise, and myalgias • Followed by neck pain and thyrotoxicosis • Natural course • 6-8 weeks of thyrotoxicosis (in >50% of patients) • Subsequent 2-4 months of mild hypothyroidism may occur • Ultimate return to euthyroid state in 90-95% of patients • 5-10% of patients will require long term thyroid replacement • Diagnosis • Hallmark is an elevated ESR • No uptake on radioactive iodine uptake scan • Anti-TPO, anti-thyroglobulin, and others usually negative • Genetic factor: Increased risk associated with HLA-B35 • Treatment goals • Pain component: first-line NSAIDs, ?systemic steroids if unresponsive • Thyrotoxicosis component: indicated if tachycardic, febrile, diaphoretic, anxious, etc. • Beta-blocker therapy --> propranolol ( periph T3 to T4) or atenolol • May need more frequent dosing due to heightened metabolic state • A 45 year-old Nepalese male immigrant presented with complaints of: • Episodic feverfor3 weeks unresponsive to prn APAP • Daily febrile episodes lasting 1-2 hours with associated rigors • Episodes occurred at different times each day • Malaise, myalgias, sore throat,and dull headaches • Weight lossof 10 pounds in 3 weeks; “food not appealing” • Night sweatson occasion for 1 week • “Feeling progressively anxious” Medical History Further Workup • Malaria • Treated in 2006, unknown species and regimen • Latent Tuberculosis • Positive PPD in 2008, treated with isoniazid for 9 months • Otherwise healthy • No prior surgery, no prescribed medications • Infectious • Other • Autoimmune Social & Family History Patient Follow-Up • Ibuprofen 600 mg PO q6h and propranolol tid were scheduled: • Symptoms resolved and patient was discharged home • Labs at post-discharge outpatient visits: • Approach to thyroiditis • Immigrant from Nepal: 4 years prior, was a community leader before move • Currently employed as a chef: no known exposures;no incarceration • No history of substance abuse: denied active or prior EtOH, tob, or illicits • Non-contributory family history: no malignancy, VTE, TB, or periodic fevers Exam & Basic Workup • Imaging • CT chest/abdomen/pelvis with contrast:no evidence of malignancy, lymphadenopathy, thrombus, hematoma, or abscess • TTE:no evidence of vegetation, valve disease, ventricular dysfunction, or effusion Conclusion • This case demonstrates an uncommon cause of FUO and an atypical • presentation of subacute granulomatous thyroiditis • This case reminds the internist evaluating FUO to: • Have a broad differential diagnosis • Avoid premature resource utilization and unnecessary treatments in stable patients • Frequently re-assess patients, obtain thorough histories, and perform detailed physical exams Interval History & Exam • Nearly one week into hospital course: • Persistent daily spiking fevers (2-3 daily, exceeding 39°C) with associatedtachycardia (HR > 120) • Subjective vague neck painelicited by eager medical student on pre-rounds • Mildly tender and enlarged thyroid gland (R>L) and brisk LE reflexes (diffusely) on exam • The Diagnosis: SUBACUTE GRANULOMATOUS (aka DeQuervain’s) • THYROIDITIS References Bindra A et al. Thyroiditis. Amer Fam Phys, 2006; 73 (10): 1769-76 Burke C et al. Fever of unknown origin: Clinical Overview of Classic and Current Concepts. Infect Dis Clin N Amer 2007; 21: 867-915 Lazarus JH. Acute and subacute, and Reidel’s thyroiditis. Thyroid Disease Manager. Chapter 19, revised Aug 2010 Lazarus JH. Seminar: Hyperthyroidism. The Lancet 1997; 349: 339-43 Pearce E et al. Current Concepts: Thyroiditis. N Engl J Med, 2003; 348: 2646-55 • Chest X-Ray: Unremarkable