H. Tesfaye 1; R. Cimermanova 2; M. Cholt 3; P. Sýkorová 4; M. Pechová 1; R. Prusa 1
Department of Clinical Biochemistry and Pathobiochemistry, Faculty Hospital Motol, nd Faculty of Medicine, Charles University, Prague, Czech Republic
1; Division of Primary Care, Faculty Hospital Motol, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
2; Department of Imaging Methods, Faculty Hospital Motol, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
3; Department of Nuclear Medicine and Endocrinology, Faculty Hospital Motol, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
Čas. Lék. čes. 2009; 148: 438-441
Subacute thyroiditis is an inflammatory disease of the thyroid gland, most probably preceded by viral infection. Common symptoms include fever, thyroid tenderness associated pain, and initial hyperthyroidism sometimes followed by a transient period of hypothyroidism with generally favourable outcomes as self-limited entity. It was known that it may be confused with pharyngitis; however search on Medline using key words (dental pain, subacute thyroiditis, and differential diagnosis) in combination recently produced no reports. Herein, we report a case of subacute thyroiditis associated pain, which was initially mistaken and treated as pain of dental origin after otorhinolaryngologic examination revealed no pathology. The aim of this communication is to remind that thyroiditis as part of differential diagnosis should be considered in patients with unexplained dental pain to avoid unnecessary diagnostic procedures, which increase expenses and may delay appropriate therapeutic measures.
Key words: subacute thyroiditis, dental pain, differential diagnosis and treatment.
Thyroiditis is generally an
inflammation of the thyroid gland that may be painful and tender,
when caused by infection, radiation, or trauma, or painless when
caused by autoimmune conditions, medications, or an idiopathic
fibrotic process. The most common forms are Hashimoto’s disease,
subacute granulomatous thyroiditis, postpartum thyroiditis in women,
subacute lymphocytic thyroiditis, and drug-induced thyroiditis
(caused by amiodarone, lithium, interferon-alfa, and interleukin-2).
Subacute granulomatous thyroiditis usually is attributed to a viral
infection. The summer peak incidence of thyroiditis coincides with
the peak incidences of coxsackievirus groups A and B and echovirus
infections (1, 2). Symptoms and signs of subacute granulomatous
thyroiditis usually include a prodrome of myalgias, pharyngitis,
low-grade fever, and fatigue, followed by a tender, diffuse goitre
and neck pain that often radiates up to the ear. Neck pain
characteristically shifts from side to side and may settle in one
area, frequently radiating to the jaw and ears. As the disease
progresses there may be a “march” of tenderness across the gland,
with new parts of the thyroid becoming painful and tender as
previously involved portions become less painful. Symptoms of
hyperthyroidism are common in early stage of the disease because of
hormone release from the disrupted follicles. However, earlier report
by Volpe and Johnston (3) stated that recognizing subacute
thyroiditis based on presenting complaints is not an easy task. About
two decades later, Carenfelt (4) published that subacute thyroiditis
is often unrecognized and patients may be treated for pharyngitis,
laryngitis, otitis media or similar disorders connected with
otorhinolaryngology, illustrating difficulties encountered in making
a correct diagnosis of course leading to useless therapy in
consecutive patients initially misdiagnosed. Herein, we describe the
manifestation, course, treatment, and outcomes of subacute thyroidits
confused with dental pain.
A 41years old male with
unremarkable family and personal thyroid disease history visited his
dentist in September 2008, with apparently mild left side dental pain
at the beginning. Dental caries was excluded including by periapical
(wall-mounted) x-ray examination of the painful side. Few days later
the pain progressed so that it led to another visit to hospital
dentist with chief complaints of dental and mild anterior left
lateral neck pain. The panoramic x-ray examination proved no dental
pathology (Fig. 1).
However, interdental drainage was
performed for three consenscutive days under local mesocaine use.
Whatever the intervention was, the patient continued complaining.
Finally, the patient was referred to otorhinolarnygology department,
where the ear, nose, throat (ENT) examination findings were
reportedly normal. Fortunately, ultrasound examination of the neck
was requested and the result showed engagement of left lobe,
hyperaemic, hypoechogenic, and non-homogenic structure within the
thyroid gland (Fig. 2). With this result the patient was referred to
the department of endocrinology and nuclear medicine, where thyroid
gland was found to be swollen and tender on physical examination.
Initially, the patient was
non-febrile, free triiodothyronine (FT3)
and free tetraiodothyronine (FT4)
were within the reference range, while anti-thyroglobulin antibody
(TgAb) level was very slightly elevated only to 82 kU/L (upper
reference range up to 60 units). Levothyroxine 50 μg
per tablet /day was prescribed assuming that usually hypothyroidism
may follow. However, sleeping disturbance and extreme sweating led to
levothyroxine withdrawal by the patient himself. The patient
requested recheck earlier than previously planed as the pain in the
anterior neck became intensive and fever of 37.3 to 38 °C was
recorded despite regular use of non-steroid anti-inflammatory drug
(NSAID) namely, Ibuprofen (Ibalgin tablet) initially 400 mg every 12
hours and later every 8 hours. Then, the neck pain shifted from the
left side to the right side and was more severe in intensity than the
previous, more radiating to the jaws, occipital regions and ears.
Ultrasound control (re-examination) also revealed significant
pathological changes (diffusely hyperaemic, hypoechogenic, and
non-homogenic structure) in the right lobe compared with previous
image. Among other laboratory findings, C-reactive protein (CRP) was
elevated up 36–39 mg/L, whereas free T3
levels were significantly high indicating that the patient had
hyperthyroidism phase of the inflammatory event. Further more, an
increase in FT4
was followed by a marked decrease in TSH level (0.008 mIU/L). Auto
antibody against thyroglobulin (TgAb), which was only slightly
elevated at the beginning, reached extremely high value > 500 kU/L
(above the quantification limit of the determination method)
persistently for several weeks. Anti-thyroid peroxidase antibody
(TPOAb) was negative. Blood cells count and differential was
unremarkable. The radioactive iodine uptake (RAIU) test was not
performed in our case since all symptoms verified the entity as
subacute thyroiditis. Erythrocytes sedimentation rate (ESR) also was
not done, but based on CRP (39 mg/L), fever, and deteriorating
symptoms, a wide spectrum antibacterial drug, namely deoxymycoin was
recommended in addition to NSAID. Five days later the patient
reported unbearable pain and difficulties in swallowing due to
progressive tenderness and swollening of the gland more in the right
side. Prednisone 30 mg/day was advised to start. Remarkable
improvement of pain release was reported within two days of therapy
with corticoid. Then the dose was gradually tapered up to 10 mg per
day to stop completely after six weeks. Control FT3,
and TSH showed typical expectations after the recovery (Table 1, Fig.
3). Meanwhile, the patient is without drug therapy and no further
complaints were recorded on follow-up or no sign of reoccurrence is
observed to date.
Thyroid disease affects
relatively high number of people in different age groups as recently
well described in the review work of Limanova (5) indicating even a
rising tendency in relation to diseases like diabetes mellitus. The
same author (6) emphasised the necessity of interdisciplinary
approach for diagnosis and management of the thyroid pathology in
patients suffering from other diseases. Differentiating the various
forms of thyroiditis can be difficult as they often mimic other
disease processes. Diagnosis requires an awareness of the
distinguishing characteristics of each type of thyroiditis as well as
the overlapping features (7). Subacute thyroiditis (also known as
giant cell thyroiditis or granulomatous thyroiditis) is the most
common cause of thyroid pain. It affects four times more women than
men, and most often occurs at the age of 40 to 50 years (8). History
of an antecedent viral upper respiratory infection (URI) is common
before clinical manifestation as thyroid disease, so that diagnosis
is primarily clinical, based on finding an enlarged and tender
thyroid in patients with the appropriate clinical history. But the
history of URT infection immediately before the manifestation of the
disease symptoms was absent in our patient. Thyroid function testing
with TSH and free T3
is usually done, whereas radioactive iodine may be measured to
confirm the diagnosis. When the diagnosis is uncertain, fine needle
aspiration biopsy is useful, though invasive. Histological studies
demonstrate less lymphocyte infiltration of the thyroid than in
Hashimoto’s thyroiditis or silent thyroiditis, but there is
characteristic giant cell infiltration and follicular disruptions.
Thyroid ultrasound with colour Doppler usually shows reduced blood
flow in contrast to our case (Fig. 2). Laboratory findings early in
the disease include an increase in free T4
and a marked decrease in TSH, which is similar with what is observed
in the present case. Treatments with high doses of NSAIDs or with
corticosteroids in protracted cases are usual options. However,
antibiotic coverage was our choice provided the patient’s symptoms
in addition to laboratory findings, since literally existing atypical
laboratory manifestation (9) corresponding to acute suppurative
thyroiditis could not be excluded. Ultrasound is widely available,
relatively rapid and safe method to visualize the whole anterior neck
and it can aid in clinical decision making as already published (10).
Differentiating the various forms of thyroiditis can also be
challenging in some cases provided that features may be overlapping.
For instance, Cho et al. (11) reported a case of patient, who was
diagnosed with subacute thyroiditis based on clinical manifestation
and laboratory results, treated with glucocorticoides for six weeks,
and then followed-up for 12 months, where the final diagnosis ended
up with rare Riedel’s thyroiditis, the disease, which may also
develop in the course of subacute thyroiditis. The fact that
hyperthyroidism is seen in one half of affected individuals is
explained by that activated cytotoxic T lymphocytes damage the
thyroid follicular cells, resulting in the unregulated release of
large amounts of thyroxine (T4)
and tri-iodthyronine (T3)
into the circulation. This process usually is transient, lasting
three to six weeks and ceasing when the thyroid stores are exhausted.
A triphasic sequence is commonly observed that patients have a
transitional phase of hyperthyroidism characterised by elevated free
and suppressed thyroid-stimulating hormone (TSH) levels, after which
hypothyroidism with low free T4
and high TSH levels follows. Then, euthyroid state of recovery may
occur under favourable conditions, which was exactly demonstrated in
our patient. The disease is usually reported to resolve spontaneously
within months, which is also observed in the present case, except
persisting high level of TgAb. Nevertheless, measurement of free T4,
and TSH at 4 or 3 weekly follow-up intervals accordingly may be
appropriate to monitor the disease status in general and to identify
patients progressing in to hypothyroidism in particular. In the
present case the patient is euthyroid so far and the follow-up may
continue in long time intervals to determinate, whether permanent
hormone maintenance therapy is needed or not.
Our case observation demonstrates
that patients with unexplained dental pain and otherwise normal ORL
findings deserve examination targeting thyroid gland to rule out
thyroiditis or other conditions. Careful differential diagnosis
workup can avoid unnecessary measures and non-benefiting treatment,
which only leads to undesired outcomes and loss of scarce health care
Address for correspondence:
Hundie Tesfaye, MD, PhD.
Faculty Hospital Motol, 2nd
Faculty of Medicine, Charles University, Prague
V Úvalu 84, 155 06 Prague 5,
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