A 33-year-old woman presents with fever and severe pain in the lower neck radiating to the jaw, following a week of upper respiratory symptoms. The thyroid is firm and exquisitely tender. Free T4 is 3.1 ng/dL, TSH is suppressed, and erythrocyte sedimentation rate is 78 mm/hour. Radioactive iodine uptake at 24 hours is 2%. What is the most likely diagnosis?

• A Graves disease
• B Hashitoxicosis
• C Toxic multinodular goitre
• D Subacute granulomatous (de Quervain) thyroiditis ✓

Explanation

Painful tender goitre, raised inflammatory markers, thyrotoxicosis, and markedly suppressed radioiodine uptake form the classic tetrad of subacute granulomatous thyroiditis, a post-viral destructive process releasing preformed hormone. In Graves disease and toxic nodular goitre the gland takes up iodine avidly, so uptake is high, which kills both distractors. Hashitoxicosis is painless and transiently hyperthyroid with high antithyroid antibodies and variable uptake.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.