Is the thyroid to blame?
Your patient says his neck hurts. Could his pain indicate a thyroid problem?
In 50% of ST patients, thyroid-stimulating hormone (TSH) is suppressed, and thyroid hormone levels are elevated.4 Patients with hyperthyroidism exhibit the usual signs and symptoms associated with high levels of the hormone: tremor, palpitations, heat intolerance, and diarrhea. After a few weeks, thyroid hormone levels normalize and then drop to below normal in the 4 to 6 months that follow. Levels return to normal in 95% of patients after 6 to 12 months. ST recurs in only 2% of patients.4
Sedimentation rates are almost always elevated in ST, reflecting the significant inflammation associated with the disease. Cytotoxic T lymphocytes damage thyroid follicles, causing release of preformed thyroid hormone, in turn suppressing TSH.4 Radioactive iodine scans show low uptake because TSH is needed for the uptake of iodine.10
Treatment of ST should focus on reducing inflammation and pain. NSAIDs may be sufficient, but patients with moderate to severe symptoms may require prednisone 40 mg daily, tapered over 4 to 6 weeks.2 If the patient is hyperthyroid, you’ll need to control symptoms with beta-blockers.
Ruptured thyroid cyst: An ST look-alike
The clinical presentation of a ruptured cyst closely mimics that of ST: thyroid pain, history of a recent cold, sore throat, aches, and pains. Laboratory and nuclear medicine evaluations, however, reveal significant differences:
- TSH is not suppressed;
- ESR is not elevated;
- Radioactive iodine uptake is normal.
Palpation may reveal a thyroid nodule. You can confirm the diagnosis by ultrasound and a needle aspiration.
CASE The right diagnosis for Sam
Sam’s initial clinical presentation suggested St, and he was started on prednisone 40 mg daily to control his pain. but when laboratory and nuclear medicine evaluations became available the next day, the St diagnosis didn’t hold up: TSH, ESR, and radioactive iodine uptake were all normal.
When Sam came in for a follow-up visit 3 days later, his thyroid pain was gone and he was feeling much better. palpation of his thyroid revealed a slightly tender nodule that went undetected in the initial exam. Subsequent thyroid ultrasound showed a 2x2 cm nodule in the right lobe. a fine needle aspiration revealed a colloid cyst. the cyst had ruptured, causing acute pain from hemorrhage and inflammation.
CORRESPONDENCE Dean Gianakos, MD, 2323 Memorial Drive, #10, Lynchburg Family Medicine Residency, Lynchburg, VA 24501; deangianakos@yahoo.com
