A 32-year-old woman develops anterior neck pain radiating to the jaw two weeks after a febrile sore throat. She has tremor, palpitations, free T4 of 3.1 ng/dL, suppressed TSH, ESR of 72 mm/hr, and thyroid radioiodine uptake of 2% at 24 hours. What is the most appropriate initial management?

• A Radioiodine ablation
• B Lifelong levothyroxine replacement
• C Total thyroidectomy
• D Propranolol with NSAIDs for pain ✓

Explanation

Subacute granulomatous (de Quervain) thyroiditis follows a viral illness and causes painful enlargement with a characteristically suppressed radioiodine uptake because damaged follicles leak preformed hormone rather than synthesising new hormone. The thyrotoxic phase is transient, so beta blockade controls symptoms and NSAIDs relieve neck pain; glucocorticoids are added if symptoms persist. Ablation and surgery are inappropriate because uptake is negligible and recovery is expected. Levothyroxine may be needed later if a hypothyroid phase becomes permanent, which happens in only a minority.

Reference: Williams Textbook of Endocrinology, 14th ed.

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Written and medically reviewed by the StethoPrep medical team.