Endocrine Abstracts

Thyroidal pain is usually due to subacute thyroiditis. It seldom occurs in patients with Hashimoto’s thyroiditis (HT), and then its name is painful HT (PHT). Differently from subacute thyroiditis, occasional PHT patients show no benefit from medical treatment so that thyroidectomy is frequently needed. We report two women diagnosed of PTH and successfully treated with intrathyroidal corticosteroid injection after initial unsuccessful treatment with L-thyroxine replacement and oral corticosteroids.

Case 1: A 36-year-old woman presented in January 2015 with a 9-month history of episodic pain on the anterior neck and otalgia. Physical examination showed diffusely enlargement of both thyroid lobes with a firm consistency and marked tenderness in right lobe. Thyroid function tests revealed subclinical autoimmune hypothyroidism (TSH 6.57; FT4 12.0 pmol/l, AcTPO>600 UI/l). Thyroid ultrasound (US) revealed a diffusely enlarged thyroid gland with heterogeneously hypoechoic pattern involving the entire area of both lobes. She received a short course of prednisone without relief, and substitutive thyroxine was started, with initial improvement and greater interval between episodes. Two years later, euthyroid (TSH: 1.23) pain flared-up, and intrathyroid corticosteroid injection was proposed. US-guided injection of 40 mg of triamcinolone was performed in both lobes aimed to the areas of hypoechogenicity. After treatment, the patient experienced almost total relief of pain and tenderness, and thyroid became less consistent at palpation.

Case 2: A 47-year-old woman, consulted on December 2016 because of 6-month thyroidal pain. Before the pain appeared, she was taken levothyroxine for 8 years because autoimmune hypothyroidism, with normal TSH. Pain had been attributed to subacute thyroiditis, although she had normal sedimentation rate and lymphocytic infiltration on FNAC, and was treated with oral corticosteroids (up to 45 mg of prednisone) and NSAIDs without success. Thyroid ultrasonography revealed marked hypoechogenity and high vascularization on Doppler exam. Intrathyroidal corticosteroids were proposed. US-guided injection of 40 mg of triamcinolone throughout the gland was performed. After first injection, pain was relieved, with residual tenderness. As she had residual discomfort that limited her to speak loudly, treatment was repeated at six and eleven months improving with every injection. After last injection the pain relief was complete.

Conclusion: US-guided intrathyroidal injection of corticosteroids can be an effective to treat painful HT. This technique can avoid surgery to treat this rare presentation of Hashimoto’s thyroiditis.