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Old 10-18-2011
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Thyroid Painful thyroid disease!

A 24-year-old woman comes to clinic complaining of a painful lump in her neck and a new tremor. For the past three weeks, she has suffered from tremulous hands, which seems to be fairly constant with activity or rest, and is somewhat worse at night. About the same time as the tremor started, she noticed a small, painful “lump” in the front of her neck. While she denies any dysphagia or odynophagia, the mass hurts more when she yawns or extends her neck. Additionally, she has had an unexpected weight loss of 10 pounds during the last three weeks, a development she admits she is not too displeased with. A complete review of systems reveals some other interesting findings; she reports diarrhea, insomnia, and general irritability. Vital signs are: blood pressure 145/85 mm Hg, pulse 114/min, and respirations 22/min. Examination reveals an exquisitely tender, diffusely enlarged thyroid, which is slightly asymmetric. A mild tremor is present when the patient extends her arms, but the rest of the exam is unremarkable. Thyroid function tests confirm a hyperthyroid state, with an elevated free thyroxine level and a low thyroid-stimulating hormone level. The patient is started on NSAIDs, and, over the next three weeks, her symptoms improve. Which of the following findings is most likely associated with her condition?

A. Antecedent acute or subacute bacterial infection
B. Erythrocyte sedimentation rate within normal rangecream
C. Infiltrative dermopathy in the skin overlying the shins
D. Prodrome of fever, fatigue, malaise, and myalgias
E. Strong family history of thyroid disease
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  #2  
Old 10-19-2011
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D

Painful thyroid= subacute thyroiditis. Treated with aspirin
Usually has a prodrome of fever, fatigue, malaise, and myalgias
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Old 10-19-2011
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D. Prodrome of fever, fatigue, malaise, and myalgias
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Old 10-19-2011
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Correct Answer Answer

The correct answer is D. This patient has suffered from a subacute thyroiditis, also known as de Quervain’s thyroiditis. The typical triad includes neck pain, diffuse goiter (though nodules and asymmetry may be present), and a hyperthyroid state that commonly lasts for 2 to 6 weeks. The condition is often post-viral, as is commonly proceeded by or associated with fever, fatigue, malaise, and myalgias.
An antecedent bacterial infection (choice A) is unlikely; most cases of subacute thyroiditis are felt to be either idiopathic or viral related. In severely immunocompromised hosts, bacterial infections should, however, be included in the differential diagnosis.
The ESR is usually elevated, not normal (choice B). The pathophysiology of this condition involves inflammatory damage to the thyroid, which induces colloid leak. The inflammatory response results in an elevated ESR.
Pretibial myxedema is an infiltrative dermopathy most commonly seen in the skin overlying the shins (choice C). It is associated with Grave’s disease, and is an extremely unlikely finding in subacute thyroiditis.
A family history of thyroid disease (choice E) is unlikely. While there are HLA associations with de Quervain’s thyroiditis, it is not a familial disease.
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