A 32-year-old woman develops fever and severe anterior neck pain two weeks after an upper respiratory infection. Free T4 is elevated, TSH suppressed, ESR 82 mm/hr, and radioactive iodine uptake at 24 hours is 1%. The most likely diagnosis is:

• A Graves disease
• B Subacute granulomatous (de Quervain) thyroiditis ✓
• C Painless (silent) lymphocytic thyroiditis
• D Acute suppurative thyroiditis

Explanation

Painful neck swelling following a viral illness, a high ESR, thyrotoxicosis from leaked preformed hormone, and diffusely suppressed radioiodine uptake together define de Quervain thyroiditis. Graves disease would show raised uptake, killing option A. Painless thyroiditis has identical uptake findings but no neck pain or systemic illness, eliminating option C. Acute suppurative thyroiditis is bacterial, with localised abscess rather than diffuse suppression of uptake.

Reference: Williams Textbook of Endocrinology, 14th ed.

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