Subacute granulomatous thyroiditis de quervain E06.1

Fritz de Quervain, 1904 (Swiss surgeon)

Subacute granulomatous thyroiditis de Quervain (SAT) is a self-limiting granulomatous inflammation of the thyroid gland with systemic involvement. It is the häufigste cause of painful thyroiditis. The main clinical symptom of this general disease is the acutely occurring, painful inflammation of the thyroid (Jonas C et al. 2016).

w:m=5:1; Incidence: 5/100.000 persons

Unclear, often following viral infections (coxsackie, mumps, influenza, cytomegalovirus, echo, adenovirus (Michas G et al. 2014; André R et al. 2016). The concordant occurrence with a hand-foot-mouth disease was described (Engkakul P et al. 2011). Furthermore, the occurrence of the disease was described in a psoriatrist treated with TNF-alpha-blocker (Wei YA et al. 2018). A genetic disposition is likely (in the presence of the HLA-Bw35 haplotype there is an up to 50-fold increased risk of Quervain thyroiditis).

Preferably women in the 3rd - 5th decade of life; accumulation of thyroiditis in spring and autumn.

The disease is seasonally more frequent in spring and autumn. Characteristically, pain occurs in the neck area, increasingly in the area of the thyroid gland, which often radiates acutely to the jaw and ear. The feeling of being ill with flu-like symptoms varies in severity. The inflammatory reaction of the thyroid gland organ leads to destruction of the thyroid cells with release of thyroid hormones. This sudden increase of thyroid hormones in the blood leads to a passagere hyperthyroidism, which usually lasts for several weeks. It is not uncommon for hypothyroidism to develop following the inflammatory phase, which then has to be permanently substituted.

Sonographically a low-echo thyroid gland with confluent "map-like" thyroid areas is visible. In about 65% of the patients, sonographically reactive enlarged lymph nodes can be detected.

Scintigraphy: strongly reduced radionuclide uptake of the thyroid gland.

Significantly increased blood sedimentation; CRP massively increased, thyroid function initially increased, normalizes in the course of the disease. A passagere (rarely permanent) hypofunction requiring treatment is possible.

Granulomatous thyroiditis with giant Langhans cells and epithelial cells.

The differential diagnosis must above all exclude acute purulent (bacterial) thyroiditis (painful thyroid gland under pressure, painful regional lymphadenitis, skin over the thyroid gland is often reddened; in thyroid sonography, possible detection of abscesses).

Palpation thyroiditis: caused by frequent palpation of the thyroid gland.

Hashimoto's thyroiditis: often also slightly painful thyroid swelling (antibody detection: anti-TPO-Ac detectable in 95% of cases).

Physical protection is especially important at the beginning of the illness! In general NSARs are sufficient. For more severe local complaints, use of systemic glucocorticosteroids (1mg prednisolon/kgKG). This includes prompt response within 24 hours. If no therapeutic success is achieved, the diagnosis should be checked! Temporary hyperthyroidism does not require treatment. Treatment for tachycardia (beta blocker).

Remark: Therapeutically, thyrostatics do not play a role, because there is no increased production of thyroid hormones, but only an increased release of already produced hormones.

Unlike Hashimoto's thyroiditis, subacute thyroiditis occurs relatively suddenly (subacute). Spontaneous healing in 80%.

1. André R et al (2016) Cytomegalovirus subacute thyroiditis in a patient treated by infliximab for psoriatic arthritis. Joint Bone Spine 83:109-110.
2. de Quervain F (1904) Acute non-purulent thyroiditis. Notes from the border areas of medicine and surgery (Suppl. 1): 165.
3. Engkakul P et al (2011) de Quervain thyroiditis in a young boy following hand-foot-mouth disease. Eur J Pediatr 170:527-529.
4. Frates MC et al (2013) Subacute granulomatous (de Quervain) thyroiditis: grayscale and color Doppler sonographic characteristics. J Ultrasound Med 32:505-511.
5. Jonas C et al (2016) Painful thyroid nodule, a misleading presentation of subacute thyroiditis. Acta Chir Belg 116:301-304.
6. Michas G et al (2014) De Quervain thyroiditis in the course of H1N1 influenza infection. Hippocratia18:86-87.
7. Ohsako N et al (1995): Clinical characteristics of subacute thyroiditis classified according to human leukocyte antigen typing. J Clin Endocrinol Metab 80: 3653-3656.
8. Schatz, H (1975) On thyroiditis de Quervain. German medical weekly 100: 2377-2380
9. Wei YA et al (2018) Subacute thyroiditis in a patient with psoriasis treated with a tumor necrosisfactor-α
   inhibitor. Int J Dermatol 57:869-871.