A 32-year-old woman develops severe anterior neck pain radiating to the jaw two weeks after an upper respiratory infection. The thyroid is firm and exquisitely tender. TSH is 0.03 mIU/L, free T4 is mildly elevated, and ESR is 72 mm/h. Radioactive iodine uptake at 24 hours is under 2%. What is the diagnosis?

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

Explanation

Painful tender goitre, high ESR following a viral illness, thyrotoxicosis with a nearly abolished radioiodine uptake defines de Quervain thyroiditis, caused by follicular destruction releasing preformed hormone. Graves is excluded by the suppressed uptake, since Graves shows diffusely increased uptake. Silent thyroiditis gives the same biochemical picture but is painless with a normal ESR, killing option B. Acute suppurative thyroiditis is bacterial, with high fever, focal abscess, and systemic toxicity rather than a diffuse tender gland.

Reference: Williams Textbook of Endocrinology, 14th ed.

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Written and medically reviewed by the StethoPrep medical team.