Endocrine Abstracts

Hashimoto’s thyroiditis is the most common cause of hypothyroidism in iodine-sufficient areas of the world, cause is thought to be a combination of genetic susceptibility and environmental factors. The pathology of the disease involves the formation of antithyroid antibodies that attack the thyroid tissue, causing progressive fibrosis. We present the case of a 38 year old male with history of hypertension, type 2 Diabetes and pre-existing hypothyroidism who presented with 2 weeks history of painful neck swelling, odynophagia, cough and fatigue. On examination, he had a 3 cm firm and tender swelling in right lobe of thyroid. Blood tests showed FT4 17.8, TSH 7.86, WBC 11.9, CRP 133.3 and TPO>600. Ultrasound neck showed features of thyroiditis and marked right cervical lymphadenitis. He was treated with IV antibiotics and oral steroids. Repeat US scans showed a persistent subcentimetre abnormal level 6 lymph node. Thyroid biopsy was advised. FNAC was attempted but unsuccessful as the nodule was found to be extremely firm in consistency. A core biopsy was then arranged. It showed damage to the thyroid follicles with replacement of normal architecture by diffuse fibrosis. Immunohistochemistry showed an extensive lymphocytic infiltrate with germinal centre formation and features in keeping with Hashimoto thyroiditis. The patient had to be continued on steroids for 7 months as attempts at stopping steroids resulted in recurrence of painful thyroiditis. Six months after stopping steroids, he presented again with symptoms of neck pain but milder rise in CRP. Steroids were restarted at a dose of 20 mg with plans to wean down gradually. US scan was unchanged, but less vascularity was noted. Hashimoto’s thyroiditis usually presents as painless, diffuse enlargement of the thyroid. In our case, symptoms of painful thyroiditis are persistent 15 months after initial presentation. Discussion in MDT+/- surgical option may need to be explored.