Endocrine Abstracts

Background: De Quervain’s thyroiditis is a transient inflammatory thyroid disorder, characterized by neck pain, a tender goiter and a triphasic clinical course of thyroid function evolution.

Clinical Case: A 21-year-old male presented to the emergency department with 5 days of fever, agitation, palpitations, diarrhea and cough. He had a significant past medical history of aplastic anemia, in remission after an allogeneic stem cell transplant a year ago. Thyroid function test revealed a free T4 of 67.1 pmol/l (reference range 8.8 – 14.1 pmol/l) with a thyroid stimulating hormone (TSH) of < 0.1 mU/l (reference range 0.65 – 3.1 mU/l). TSH receptor antibody was negative. On physical examination, he was confused, restless and diaphoretic. He had a non-tender goitre. He was diagnosed with thyroid storm and had a Burch Wartofsky Score of 60. He was treated with oral propylthiouracil (PTU), oral Lugol’s iodine, oral propranolol and intravenous hydrocortisone. Unfortunately, he developed profoundly deranged liver function which persisted even after switching PTU to carbimazole, precluding further use of anti-thyroid drugs (ATDs). ATDs were stopped and he was started on oral colestyramine and lithium. He subsequently underwent three cycles of plasma exchange (PLEX) prior to undergoing a total thyroidectomy. Intraoperative findings were that of a vascular and mildly enlarged fibrotic thyroid. Histopathology of the resected thyroid revealed a granulomatous thyroiditis. Microbiological investigations, including acid-fast bacilli smears, were negative.

Conclusion: De Quervain’s thyroiditis may present atypically with the absence of neck pain or tenderness. The thyrotoxicosis is usually mild and temporary, but rarely may be associated with life-threatening manifestations including thyroid storm. PLEX is an effective bridge to safe definitive therapy for patients with thyroid storm in whom ATDs are ineffective or contraindicated.