Endocrine Abstracts

Introduction: The Quervain’s disease is an infrequent subacute thyroiditis (ST) that results in granulomatous infiltration of the gland’s parenchyma. Is usually diagnosed clinically based on cervical pain, systemic symptoms, altered thyroid function tests (TFTs) and history of upper respiratory tract infection. It is a benign self-limited condition that may share US features with malignancy which may result in improper therapy, including lobectomy.

Case report: A 47-year-old female was evaluated due to the identification of a macronodule not present in the previous year US. She had primary hypothyroidism substituted with 100 mg of levothyroxine. Previous exams (2018) showed negativity for anti-thyroid antibodies and a small sized gland without nodularity, suggestive of chronic thyroiditis. The ultrasound performed in the context of mild cervical pain (5/2019) revealed relative enlargement of the right lobe and a taller-than-wide 28 mm markedly hypoechoic, heterogenous nodule with poorly defined margins.

During medical interview (9/2019) she denied risk factors for thyroid cancer or history of respiratory infection. She complained of right-sided cervical moderate pain exacerbated by touch, that started 4–5 months before and lasted 2–3 weeks. She denied any other local signs/symptoms, viral or thyroid dysfunction associated systemic symptoms apart from a period of exacerbated anxiety in these previous months.

Upon inspection and palpation there were no inflammatory signs, the gland had normal size, no palpable node and was freely movable.

Hashimoto’s thyroiditis and a presumptive diagnosis of ST was made despite the subtleness of the history and clinical findings. Thyroid function and inflammatory parameters resulted normal. Due to the lesion’s suspicious features US guided FNA was requested. An asymmetric gland with a heterogeneous hypoechoic right lobe without individualized nodules was the only finding (11.2019).

Conclusion: ST is usually diagnosed clinically but the history/symptoms may be heterogenous, vague and the characteristic triphasic pattern of TFT may not be identified. US characteristics are focal heterogenous (markedly) hypoechoic areas of irregular and hill-defined borders. Lesions may be taller-than-wide and oedematous disruption of the perithyroidal capsular echogenic line may suggest extrathyroidal extension. Lack of microcalcifications or suspicious ganglia and a centripetal reduction in echogenicity have been reported to be the most distinctive features for ST. FNA may pose challenges to the cytopathologist and follow up US (after 2–5 months) may indetify resolution. In doubtful scenarios deliberation between FNA vs follow-up US may be considered to document normalization of echogenicity and uncover any suspicious thyroid nodules obscured by the inflammatory changes.