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Most common cause of a painful thyroid gland. It is caused by transient nonbacterial inflammation. Hyperthyroidism often occurs initially and can be followed by hypothyroidism. (Table Q-1)

Table Q-1 Characteristic Course of de Quervain Thyroiditis

Granulomatous Giant Cell Thyroiditis; De Quervain Subacute Struma; Quervain Syndrome; Subacute Painful Thyroiditis.

An acquired disease that was first described by Fritz de Quervain, (1868-1940), a Swiss surgeon, in 1904.

Five percent of all patients with thyroid pathology. Peak incidence in the fourth and fifth decade of life; sex ratio female:male 3.5:1. Most common during summer and fall. High incidence of HLA-B35 positivity.

Presumably caused by a viral infection or postviral inflammatory response. A proposed mechanism is that a viral antigen binds to HLA-B35 molecules and that the complex activates cytotoxic T lymphocytes that damage thyroid follicular cells because of their similarity with the infection-related antigen. Destruction of follicular epithelium involves the release of thyroid-binding globulin into blood. T3 and T4 concentration in serum is increased and thyroid-stimulating hormone secretion is suppressed. The thyroid follicles then regenerate and thyroid hormone synthesis and secretion resume.

Made on clinical grounds (history, pain, symptom of hyperthyroidism), ultrasound; thyroid-stimulating hormone and free T4 measurement to determine the cause of hyperthyroidism; serum thyroglobulin (elevated) and erythrocyte sedimentation rate (>50 mm/h). Thyroid biopsy shows characteristic giant cell inflammation.

Features include gradual onset of pain in the region of the thyroid gland (aggravated with swallowing and head movement), dysphagia, fever, weakness, and fatigue. Weight loss and diarrhea may occur. Symptoms of moderate hyperthyroidism (palpitations, tremor, heat intolerance, nervousness, sweating, skeletal muscle weakening) appear in the initial phase, usually over 3 to 6 weeks. The initial phase is followed by the transient asymptomatic phase over the next 1 to 3 weeks. In 50% of patients, symptoms of hypothyroidism occur in the late phase. It may become permanent in 5 to 10% of patients. Acute complications (severe hyperthyroidism, pancreatitis) are exceptional.

Evaluate thyroid function (clinical, thyroid-stimulating hormone, T3, free T4). Laboratory investigations should include serum levels of calcium, phosphate and amylase. Preoperative ECG is recommended. Evaluate tracheal intubation in case of voluminous thyroid (clinical, CT, fiberoptic). Evaluate hydration in case of diarrhea and fever (clinical, electrolytes).

Nonurgent surgery should be postponed until the clinical situation has stabilized. Tracheal intubation can (rarely) be difficult. An adapted anesthetic management for thyroid imbalance may be required. Perioperative invasive blood pressure and cardiac monitoring are recommended.

Adapt doses to increased metabolism. Use beta-sympathetic blocker in case of tachycardia. Avoid anticholinergic drugs.

Duininck TM, van Heerden JA, Fatourechi V, et al: de ...

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