- Email: [email protected]
Subacute thyroiditis
Subacute
Thyroiditis*
Report of Two Cases ZACHARY
I-I. BENJAMIN,
Woodmere.
E
M.D.
New York the course of the next few months every time an attempt was made to reduce the daily dosage below 50 mg. there was a recurrence of the patient’s symptoms. This was accompanied by reappearance of tenderness and swelling in the thyroid gland, gradually migrating to the isthmus and then to the left lobe. By the time the disease had run its course the whole gland had been involved. Each relapse was immediately controlled within hours by increasing the dose of cortisone. On November 5, 1953, a radioactive iodine tracer study revealed almost no uptake over the whole gland. On December 14, 1953, four months after the onset of the disease, cortisone was discontinued with no recurrence. She has been asymptomatic since. CASE II. This twenty-nine year old white woman was first seen on January 15, 1954, with a chief complaint of sore throat and earache. Her illness had started one week before with sore throat and pain in the right ear, followed in a few days by headache, general malaise, nausea and fever up to 99.6”~. Examination revealed a blood pressure of 110/70, temperature of 100.2”~. and marked tenderness and slight swelling of the thyroid gland, more marked on the right. The remainder of the examination was normal. By the following day the pain in the throat became more severe, radiating to both ears. Examination revealed increased swelling and tenderness over the thyroid gland. Basal metabolic rate was plus 20, sedimentation rate 10 mm. in the first hour and blood count normal. The patient was started on cortisone, 300 mg. the first day, 200 mg. the second day, 100 mg. the third day and thereafter. She was seen several times during the following two weeks. There was no change in symptoms or signs on this regimen and by February 2, 1954, she began to show rounding of the face and increasing weight despite dietary salt restriction. The
cases of subacute thyroiditis treated with cortisone or ACTH have been reported in the literature in the past four years. 1-g In the most recent article Hunter and Sheehan report three cases9 and stress the fact that in all the reported cases, as well as their own, the result of treatment with these hormones has been uniformly excellent. There have been no reports of poor response to cortisone treatment. During a six-month period two patients with subacute thyroiditis were seen in office practice. One had a dramatic response to cortisone; the other had no response to adequate dosage over a sufficient time interval. ICHTEEN
CASE REPORTS CASE I. This forty-one year old white woman was first seen on August 8, 1953, with the chief complaint of a sore throat for one week. This had started with a feeling of soreness in the throat, worse on the right side, with radiation to the teeth and right ear. Associated with this was general malaise, headache and easy fatigability. Initial examination revealed a blood pressure of 100/70 and was otherwise negative except for a tender, firm area in the right lobe of the thyroid. Sedimentation rate was 50 mm. in the first hour. Within the next three days the temperature had risen to 101”~. The pain in the throat and ear had increased, and the area of tenderness and swelling in the right lobe of the thyroid was more prominent. On August 12, 1953, the sedimentation rate was 90 mm., the basal metabolic rate was plus 6, and the blood count was normal. The patient was started on cortisone, 300 mg. the first day, 200 mg. the second day, 100 mg. the third day and thereafter. Within twelve hours there was complete disappearance of all symptoms, fever and tenderness. During
* From the Department of Medicine, Beth Israel Hospital, New York, New York. APRIL,
1955
677
Subacute Thyroiditis-Benjamin
678
cortisone was discontinued as being ineffectual and on February 3rd the patient was started on x-ray therapy. She received a total of 1,000 r in six treatments. After the first three treatments she began to note some improvement and by February 19th, after the sixth treatment, she felt well with no residual complaints. There was still slight tenderness over the right upper pole of the gland. She was seen again on March 19, 1954, at which time all signs and symptoms had disappeared. Basal metabolic rate on that date was plus 1.
every patient in whom inspection of the pharynx does not reveal adequate cause for the complaint of sore throat. Case I shows the almost complete absence of I-131 uptake during the acute stage of the disease. Case II illustrates the temporary elevation in the basal metabolic rate that is occasionally seen in the first week of the disease, probably due to the release of stored thyroid hormone as a result of the inflammatory process in the gland. SUMMARY
COMMENTS
The clinical picture in these two patients was similar but the response to therapy was totally different. The first patient exemplifies the immediate dramatic response, within hours, of this disease to cortisone. The second patient, in contrast to all cases so far reported, had no response whatever to what most observers would consider adequate dosage of cortisone. This patient seemed to respond well to x-ray therapy but it is also possible that the disease was spontaneously subsiding by that time. In view of the results reported in the literature and in the first case report in this paper, it seems that the rational approach to the treatment of subacute thyroiditis is to start with a short trial of cortisone. If effective, it can be continued as long as necessary to keep the patient asymptomatic and able to carry on a normal life until the disease subsides. If not effective, as in Case II, one may then fall back on x-ray therapy or other forms of treatment that have been advocatediO~ll but which are not usually as effective as cortisone. Both these patients showed the characteristic picture of subacute thyroiditis. Their initial complaint was sore throat and earache and only later in the course of the disease was there any reference to spontaneous pain in the thyroid region. By “sore throat” these patients referred to soreness and pain in the pharyngeal area. This complaint, coupled with the symptoms of headache, general malaise and fever, makes it easy to overlook the thyroiditis and assume that one is dealing with a respiratory infection. Indeed it is possible that the disease is more common than reported because many mild and short duration episodes may occur without being recognized. It would be good diagnostic procedure to palpate carefully the thyroid gland in
Two cases of subacute thyroiditis are reported. Cortisone produced dramatic suppression of all signs and symptoms in one case. In the second case cortisone, carried to the point of development of undesirable side-effects, produced no change in either the symptoms or the clinical appearance of the patient. This latter patient seemed to respond rapidly to x-ray therapy. REFERENCES
1. KRUPP, M. A., SAIER, M., KEDDIE, F., TANNER, R. and SNELL, A. M. Experience with cortisone and ACTH in private clinic. California Med., 75: 6, 1951. 2. ROWE, A., JR., LAMB, G. R., TAYLOR, F. B. and KINSELL, L. W. Experience with ACTH and cortisone in private clinic. California Med., 75: 11, 1951. 3. KINSELL, 1~. W. Clinical application of pituitary adrenocorticotropic and adrenal steroid hormones. Ann. Znt. Med., 35: 615, 1951. 4. CRILE, G., JR. and SCHNEIDER,R. W. Diagnosis and treatment of thyroiditis with special reference to use of cortisone and ACTH. Cleveland Clin. Quart., 19: 219, 1952. 5. CLARK, D. E., NELSON, T. S. and RAIMAN, R. J. Subacute nonsuppurative thyroiditis treated with cortisone. J. A. M. A., 151: 551, 1953. 6. LASSER, R. P. Subacute thyroiditis treated with cortisone. J. A. M. A., 152: 1133, 1953. 7. TEITELMAN, S. L. and ROSENBERG, E. F. Acute thyroiditis treated with cortisone. Ann. Znt. Med., 38: 1062, 1953. 8. KAHN, J., SPRITZLER, R. J. and SHECTOR, W. E. Cortisone treatment of subacute non-suppurative thyroiditis: report of two cases. Ann. Znt. Med., 39: 1129, 1953. 9. HUNTER, R. C., JR. and SHEEHAN, D. J. Treatment of subacute thyroiditis with cortisone. New Enp land J. Med., 251: 174, 1954. 10. KING. B. T. and ROSELLINI. L. J. Treatment of acute thyroiditis with thiouracil. J. A. M. A., 129: 267, 1945. 11. ROBBINS, J., RALL, J. E., TRUNNELL, J. B. and RAWSON, R. W. Effect of thyroid-stimulating hormone in acute thyroiditis. J. Clin. Endocrinol., 11: 1106, 1951. AMERICAN
JOURNAL
OF
MEDICINE
Thyroiditis*
Report of Two Cases ZACHARY
I-I. BENJAMIN,
Woodmere.
E
M.D.
New York the course of the next few months every time an attempt was made to reduce the daily dosage below 50 mg. there was a recurrence of the patient’s symptoms. This was accompanied by reappearance of tenderness and swelling in the thyroid gland, gradually migrating to the isthmus and then to the left lobe. By the time the disease had run its course the whole gland had been involved. Each relapse was immediately controlled within hours by increasing the dose of cortisone. On November 5, 1953, a radioactive iodine tracer study revealed almost no uptake over the whole gland. On December 14, 1953, four months after the onset of the disease, cortisone was discontinued with no recurrence. She has been asymptomatic since. CASE II. This twenty-nine year old white woman was first seen on January 15, 1954, with a chief complaint of sore throat and earache. Her illness had started one week before with sore throat and pain in the right ear, followed in a few days by headache, general malaise, nausea and fever up to 99.6”~. Examination revealed a blood pressure of 110/70, temperature of 100.2”~. and marked tenderness and slight swelling of the thyroid gland, more marked on the right. The remainder of the examination was normal. By the following day the pain in the throat became more severe, radiating to both ears. Examination revealed increased swelling and tenderness over the thyroid gland. Basal metabolic rate was plus 20, sedimentation rate 10 mm. in the first hour and blood count normal. The patient was started on cortisone, 300 mg. the first day, 200 mg. the second day, 100 mg. the third day and thereafter. She was seen several times during the following two weeks. There was no change in symptoms or signs on this regimen and by February 2, 1954, she began to show rounding of the face and increasing weight despite dietary salt restriction. The
cases of subacute thyroiditis treated with cortisone or ACTH have been reported in the literature in the past four years. 1-g In the most recent article Hunter and Sheehan report three cases9 and stress the fact that in all the reported cases, as well as their own, the result of treatment with these hormones has been uniformly excellent. There have been no reports of poor response to cortisone treatment. During a six-month period two patients with subacute thyroiditis were seen in office practice. One had a dramatic response to cortisone; the other had no response to adequate dosage over a sufficient time interval. ICHTEEN
CASE REPORTS CASE I. This forty-one year old white woman was first seen on August 8, 1953, with the chief complaint of a sore throat for one week. This had started with a feeling of soreness in the throat, worse on the right side, with radiation to the teeth and right ear. Associated with this was general malaise, headache and easy fatigability. Initial examination revealed a blood pressure of 100/70 and was otherwise negative except for a tender, firm area in the right lobe of the thyroid. Sedimentation rate was 50 mm. in the first hour. Within the next three days the temperature had risen to 101”~. The pain in the throat and ear had increased, and the area of tenderness and swelling in the right lobe of the thyroid was more prominent. On August 12, 1953, the sedimentation rate was 90 mm., the basal metabolic rate was plus 6, and the blood count was normal. The patient was started on cortisone, 300 mg. the first day, 200 mg. the second day, 100 mg. the third day and thereafter. Within twelve hours there was complete disappearance of all symptoms, fever and tenderness. During
* From the Department of Medicine, Beth Israel Hospital, New York, New York. APRIL,
1955
677
Subacute Thyroiditis-Benjamin
678
cortisone was discontinued as being ineffectual and on February 3rd the patient was started on x-ray therapy. She received a total of 1,000 r in six treatments. After the first three treatments she began to note some improvement and by February 19th, after the sixth treatment, she felt well with no residual complaints. There was still slight tenderness over the right upper pole of the gland. She was seen again on March 19, 1954, at which time all signs and symptoms had disappeared. Basal metabolic rate on that date was plus 1.
every patient in whom inspection of the pharynx does not reveal adequate cause for the complaint of sore throat. Case I shows the almost complete absence of I-131 uptake during the acute stage of the disease. Case II illustrates the temporary elevation in the basal metabolic rate that is occasionally seen in the first week of the disease, probably due to the release of stored thyroid hormone as a result of the inflammatory process in the gland. SUMMARY
COMMENTS
The clinical picture in these two patients was similar but the response to therapy was totally different. The first patient exemplifies the immediate dramatic response, within hours, of this disease to cortisone. The second patient, in contrast to all cases so far reported, had no response whatever to what most observers would consider adequate dosage of cortisone. This patient seemed to respond well to x-ray therapy but it is also possible that the disease was spontaneously subsiding by that time. In view of the results reported in the literature and in the first case report in this paper, it seems that the rational approach to the treatment of subacute thyroiditis is to start with a short trial of cortisone. If effective, it can be continued as long as necessary to keep the patient asymptomatic and able to carry on a normal life until the disease subsides. If not effective, as in Case II, one may then fall back on x-ray therapy or other forms of treatment that have been advocatediO~ll but which are not usually as effective as cortisone. Both these patients showed the characteristic picture of subacute thyroiditis. Their initial complaint was sore throat and earache and only later in the course of the disease was there any reference to spontaneous pain in the thyroid region. By “sore throat” these patients referred to soreness and pain in the pharyngeal area. This complaint, coupled with the symptoms of headache, general malaise and fever, makes it easy to overlook the thyroiditis and assume that one is dealing with a respiratory infection. Indeed it is possible that the disease is more common than reported because many mild and short duration episodes may occur without being recognized. It would be good diagnostic procedure to palpate carefully the thyroid gland in
Two cases of subacute thyroiditis are reported. Cortisone produced dramatic suppression of all signs and symptoms in one case. In the second case cortisone, carried to the point of development of undesirable side-effects, produced no change in either the symptoms or the clinical appearance of the patient. This latter patient seemed to respond rapidly to x-ray therapy. REFERENCES
1. KRUPP, M. A., SAIER, M., KEDDIE, F., TANNER, R. and SNELL, A. M. Experience with cortisone and ACTH in private clinic. California Med., 75: 6, 1951. 2. ROWE, A., JR., LAMB, G. R., TAYLOR, F. B. and KINSELL, L. W. Experience with ACTH and cortisone in private clinic. California Med., 75: 11, 1951. 3. KINSELL, 1~. W. Clinical application of pituitary adrenocorticotropic and adrenal steroid hormones. Ann. Znt. Med., 35: 615, 1951. 4. CRILE, G., JR. and SCHNEIDER,R. W. Diagnosis and treatment of thyroiditis with special reference to use of cortisone and ACTH. Cleveland Clin. Quart., 19: 219, 1952. 5. CLARK, D. E., NELSON, T. S. and RAIMAN, R. J. Subacute nonsuppurative thyroiditis treated with cortisone. J. A. M. A., 151: 551, 1953. 6. LASSER, R. P. Subacute thyroiditis treated with cortisone. J. A. M. A., 152: 1133, 1953. 7. TEITELMAN, S. L. and ROSENBERG, E. F. Acute thyroiditis treated with cortisone. Ann. Znt. Med., 38: 1062, 1953. 8. KAHN, J., SPRITZLER, R. J. and SHECTOR, W. E. Cortisone treatment of subacute non-suppurative thyroiditis: report of two cases. Ann. Znt. Med., 39: 1129, 1953. 9. HUNTER, R. C., JR. and SHEEHAN, D. J. Treatment of subacute thyroiditis with cortisone. New Enp land J. Med., 251: 174, 1954. 10. KING. B. T. and ROSELLINI. L. J. Treatment of acute thyroiditis with thiouracil. J. A. M. A., 129: 267, 1945. 11. ROBBINS, J., RALL, J. E., TRUNNELL, J. B. and RAWSON, R. W. Effect of thyroid-stimulating hormone in acute thyroiditis. J. Clin. Endocrinol., 11: 1106, 1951. AMERICAN
JOURNAL
OF
MEDICINE