Clinical Endocrinology (1992) 37,468-469
Case of the Month
Painful thyroid gland: an atypical presentation of Graves’ disease Julia M. Stanley and Samlr S. NaJlar Division of Endocrinology, The Children’s Hospital, 300 Longwood Avenue, Boston MA 02715, U S A (Received 30 September 1991; returned for revision 3 December 1991; finally revised 17 March 1992; accepted 8 April 1992)
Summary An adolescent with Graves’ dlsease presentedwith acute painful swelllng of the thyroid gland and overlylng erythema simulating acute suppurative or subacute thyroiditis. She had an elevated radloactlve iodine uptake, thyroid stimulating antibodies, thyrotrophln blndlng lnhibltlng immunoglobulins, and a normal sedimentation rate and ieucocyte count. The course of the thyrotoxlcosis and palntut thyrold was protracted, and the pain and tenderness ofthe thyroid recurred on two subsequent relapses.
The causes of a painful thyroid gland include: (1) subacute thyroiditis, (2) acute suppurative thyroiditis, (3) Hashimoto’s thyroiditis, (4) haemorrhage into a thyroid cyst, (5) invasive fibrous thyroiditis (Riedel’s thyroiditis struma), (6) primary or metastatic malignancy, and (7) radiation thyroiditis (Geva & Theodore, 1988; Szabo & Allen, 1989; Zimmerman et al., 1986; Shigemasa et al., 1989) Clinical presentatlon
A 13-year, 8-month-old Caucasian female presented with a red, tender and swollen neck preceded by an upper respiratory infection. The pain and swelling involved the left side of the neck and were accompanied by a low grade fever. She was seen in the emergency department where her pulse was 146 per minute, respiratory rate 16 per minute, blood pressure 150/66mmHg and temperature 37°C. She had a large area of erythema over the left side of the neck which was exquisitely tender. A blood count revealed 8000 leucocytesper mm3with 60% segmented neutrophils, 9% monocytes, and 3 1Yo lymphocytes. The haemoglobin level was 13.6 g/dl and the haematocrit was 39.3%. A diagnosis of acute suppurative thyroiditis was made and she was given 500 mg i.m. of cephalexin once after blood cultures were taken. The cultures were subsequently found to be sterile. She received three more doses of Cephalin 500 mg each orally. In the Endocrine Division 34 hours later she had improved. The gland was still very tender but the erythema had markedly diminished and there was scaIing of the skin over the involved area. On examination the right. lobe of the thykid measured Correspondence: Dr Samir S.Naiar, Division of Endocrinology, The Children’s Hospital, 3 Hunnewell, 300 Longwood Avenue, Boston, Massachusetts 021 15. USA. 468
5 x 3.8 cm and the left 5 x 5 cm.The left lobe was extremely tender with indurated border and a faint erythema of its lower aspect, The skin overlaying the left lobe was desquamative. Other findings included: a lid lag but no proptosis, tachycardia of 113 per minute, BP of 132152 mmHg, and mild tremor of the outstretched fingers. Initial laboratory values revealed an erythrocyte sedimentation rate of 7 mm/hour, leucocyte count of 5540 per mm3 with 58% segmented neurophils, I % bands, 28% lymphocytes, 7% monocytes, 6% eosinophils. Serum T4 was 305 nmol/l (normal 51-142), total T37.6 nmol/l (normal 1.2-3.4), TSH
Case of the Month
Painful thyroid gland: an atypical presentation of Graves’ disease Julia M. Stanley and Samlr S. NaJlar Division of Endocrinology, The Children’s Hospital, 300 Longwood Avenue, Boston MA 02715, U S A (Received 30 September 1991; returned for revision 3 December 1991; finally revised 17 March 1992; accepted 8 April 1992)
Summary An adolescent with Graves’ dlsease presentedwith acute painful swelllng of the thyroid gland and overlylng erythema simulating acute suppurative or subacute thyroiditis. She had an elevated radloactlve iodine uptake, thyroid stimulating antibodies, thyrotrophln blndlng lnhibltlng immunoglobulins, and a normal sedimentation rate and ieucocyte count. The course of the thyrotoxlcosis and palntut thyrold was protracted, and the pain and tenderness ofthe thyroid recurred on two subsequent relapses.
The causes of a painful thyroid gland include: (1) subacute thyroiditis, (2) acute suppurative thyroiditis, (3) Hashimoto’s thyroiditis, (4) haemorrhage into a thyroid cyst, (5) invasive fibrous thyroiditis (Riedel’s thyroiditis struma), (6) primary or metastatic malignancy, and (7) radiation thyroiditis (Geva & Theodore, 1988; Szabo & Allen, 1989; Zimmerman et al., 1986; Shigemasa et al., 1989) Clinical presentatlon
A 13-year, 8-month-old Caucasian female presented with a red, tender and swollen neck preceded by an upper respiratory infection. The pain and swelling involved the left side of the neck and were accompanied by a low grade fever. She was seen in the emergency department where her pulse was 146 per minute, respiratory rate 16 per minute, blood pressure 150/66mmHg and temperature 37°C. She had a large area of erythema over the left side of the neck which was exquisitely tender. A blood count revealed 8000 leucocytesper mm3with 60% segmented neutrophils, 9% monocytes, and 3 1Yo lymphocytes. The haemoglobin level was 13.6 g/dl and the haematocrit was 39.3%. A diagnosis of acute suppurative thyroiditis was made and she was given 500 mg i.m. of cephalexin once after blood cultures were taken. The cultures were subsequently found to be sterile. She received three more doses of Cephalin 500 mg each orally. In the Endocrine Division 34 hours later she had improved. The gland was still very tender but the erythema had markedly diminished and there was scaIing of the skin over the involved area. On examination the right. lobe of the thykid measured Correspondence: Dr Samir S.Naiar, Division of Endocrinology, The Children’s Hospital, 3 Hunnewell, 300 Longwood Avenue, Boston, Massachusetts 021 15. USA. 468
5 x 3.8 cm and the left 5 x 5 cm.The left lobe was extremely tender with indurated border and a faint erythema of its lower aspect, The skin overlaying the left lobe was desquamative. Other findings included: a lid lag but no proptosis, tachycardia of 113 per minute, BP of 132152 mmHg, and mild tremor of the outstretched fingers. Initial laboratory values revealed an erythrocyte sedimentation rate of 7 mm/hour, leucocyte count of 5540 per mm3 with 58% segmented neurophils, I % bands, 28% lymphocytes, 7% monocytes, 6% eosinophils. Serum T4 was 305 nmol/l (normal 51-142), total T37.6 nmol/l (normal 1.2-3.4), TSH
