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• W2130169127 abstract "The cause of elevated thyroid levels usually can be ascertained on the basis of the clinical features. In some cases, however, the presentation can be misleading. In particular, neck pain with thyrotoxicosis can pose a diagnostic dilemma, and a seemingly typical clinical picture can be deceptive. A 25-year-old woman presented to the emergency department with a 2-day history of anterior neck pain and body aches. Her temperature was 100.2°F, pulse rate was 144 beats/min, blood pressure was 127/66 mm Hg, and white blood cell count was 10.7/mm3. On physical examination, there was a diffusely enlarged and bilaterally tender thyroid gland, a coarse tremor of the outstretched hands, brisk deep tendon reflexes, and no exophthalmos, photophobia, or nuchal rigidity. A 15-lb weight loss was noted in the “Review of Systems.” The patient was febrile with mild leukocytosis and tachycardia, so we performed a lumbar puncture, which revealed no evidence of meningitis. Thyroid-stimulating hormone was <0.005 mIU/mL, free thyroxine was 5.69>ng/dL (normal, 0.76-1.46 dL), and free triiodothyronine was 27.90 pg/mL (normal, 2.18-3.98 pg/mL). The admitting hospitalist diagnosed subacute thyroiditis and started therapy with prednisone and propranolol. Computed tomography (CT) of the neck and soft tissues to rule out a local abscess only confirmed diffuse thyroid enlargement (“consistent with thyroiditis,” per radiologist's reading). After 3 days of inpatient stay, endocrinology was consulted to arrange for outpatient follow-up. A family history of thyroid disorder, several months of weight loss and palpitations, an emergency department visit 2 months previously for similar symptoms that were attributed to an acute viral illness, and bilateral thyromegaly raised the suspicion for Graves' disease. CT iodinated contrast administration precluded obtaining a radioactive iodine uptake. Ultrasound with color flow Doppler showed an enlarged heterogeneous gland with diffuse intense hypervascularity (Figure 1). Thyroid-stimulating immunoglobulin activity was 183 units (normal, <122 units), consistent with Graves' disease, and thyroid levels were persistently elevated 10 days later. Antithyroid therapy with methimazole was begun. Neck pain or tenderness is often associated with subacute (de Quervain's) thyroiditis but also may occur in those with Graves' disease,1Chao C.S. Lin S.Y. Sheu W.H. Graves' disease presented as painful goiter.Horm Res. 2002; 57: 53-56Crossref PubMed Scopus (2) Google Scholar toxic adenoma, cyst, or malignancy. Our patient was probably thyrotoxic for several months and appeared to have a concomitant upper respiratory febrile illness that only served to reinforce the impression of subacute thyroiditis.2Akahori H. Takeshita Y. Saito R. Kaneko S. Takamura T. Graves' disease associated with infectious mononucleosis due to primary Epstein-Barr virus infection: report of 3 cases.Intern Med. 2010; 49: 2599-2603Crossref PubMed Scopus (14) Google Scholar The simultaneous occurrence of Graves' disease and subacute thyroiditis has been described,3Hoang T.D. Mai V.Q. Clyde P.W. Shakir M.K. Simultaneous occurrence of subacute thyroiditis and Graves' disease.Thyroid. 2011; 21: 1397-1400Crossref PubMed Scopus (17) Google Scholar and leukocytosis can be a feature of both. The search for an infectious cause led to a lumbar puncture and a neck CT, whereas subacute thyroiditis was assumed on clinical grounds only. The evidence for Graves' disease was compelling, but the test of choice with the best discriminatory ability—the radioactive iodine uptake—could not be performed because of recent iodinated CT contrast use. Of note, most intravenous CT contrast preparations, both ionic and nonionic, have 300 to 370 mg/mL of iodine, and 100 to 150 mL of the agent typically is administered. The large amount of iodine load saturates the thyroid gland for many weeks thereafter and interferes with traditional thyroid scanning and uptake testing. The radioactive iodine uptake is almost invariably elevated in Graves' disease (>35%), whereas it is low in the active phase of subacute thyroiditis (<5%), clearly differentiating the 2 entities. On ultrasound, the thyroid is usually enlarged with Doppler blood flow increased in Graves' disease and reduced in thyroiditis, characteristics that, although helpful, overlap often enough in ambiguous situations to prevent a confident diagnosis.4Ota H. Amino N. Morita S. et al.Quantitative measurement of thyroid blood flow for differentiation of painless thyroiditis from Graves' disease.Clin Endocrinol (Oxf). 2007; 67: 41-45Crossref PubMed Scopus (77) Google Scholar Although ultrasound is quick, easy, and less expensive, it has not yet supplanted the radioactive iodine uptake for diagnostic purposes. An elevated thyroid-stimulating immunoglobulin titer supports Graves' disease, but by itself lacks sufficient sensitivity or specificity. It is useful to bear in mind that unusual presentations of a common disease are generally more common than usual presentations of an uncommon illness. Timely objective testing is pivotal in the evaluation of hyperthyroxinemia and neck pain to avoid diagnostic pitfalls. A radioactive iodine uptake test remains the “gold standard” to differentiate Graves' disease from subacute thyroiditis when the clinical picture is unclear. Management of the 2 entities is fundamentally different, and clinical similarity often occurs. However, the ubiquitous use of iodinated contrast in the increasingly widespread use of CT and other imaging tests in acute care settings invalidates the use and interpretation of the radioactive iodine uptake." @default.
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• W2130169127 date "2013-08-01" @default.
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• W2130169127 title "Thyrotoxicosis and Neck Pain: Getting the Right Test at the Right Time" @default.
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• W2130169127 doi "https://doi.org/10.1016/j.amjmed.2013.02.019" @default.
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