2019 04-30 noon conference [stephen slade]

1. Noon Conference
2019-04-30
Stephen Slade, MD
stephen.slade@virginiamason.org

2. Subacute granulomatous (De
Quervain) thyroiditis

3. Background
•Self-limited, often following viral
infection
•Including coxsackievirus, mumps,
measles, adenovirus
•Possible ↑ in summer? Not shown in all
studies
•HLA-B35 association

4. Presentation
•Neck/jaw pain
•↑↑tender thyroid
•↑ESR
•↑LFTs

5. Differential Diagnoses
•acute infectious (suppurative) thyroiditis
•can distinguish with ultrasound, WBC
•autoimmune thyroid disease (Hashimoto or
Graves)
•severe pain rarer in these
•Graves → ↑↑RAIU vs. ↓↓in subacute
thyroiditis
•thyroid cancer or lymphoma
•can distinguish with ultrasound
•giant cell arteritis

6. Thyroid Function
•Can have varying thyroxine levels
throughout course
•~10% of patients develop permanent
hypothyroidism

7. Pathophysiology
•Infection or inflammation → thyroid
follicular injury
•Thyroglobulin proteolysis → unregulated
T4, T3 release → ↑thyroidism
•↓hormone synthesis + exhausted stores
→ ↓thyroidism
•time → ↓inflammation → follicular
regeneration → euthyroidism

9. TSH (dates NOT to scale)
0
50
100
150
200
250
12/12/18 12/15/18 3/16/19 4/5/19
TSH

10. 0
0.4
0.8
1.2
1.6
2
12/12/18 12/15/18 3/16/19 4/5/19
T4
Free T4 (dates NOT to scale)

11. Layered (WITHOUT ↓T4 shown)

12. 0
50
100
150
200
250
12/12/18 12/15/18 3/16/19 4/5/19
TSH
0
0.4
0.8
1.2
1.6
2
12/12/18 12/15/18 3/16/19 4/5/19
T4
Layered

14. Supportive Treatment
•NSAIDs
•Beta-blockers - often non-selective
•NOT thionamides (MMI, PTU)
•⇏ thyroid hormone synthesis

15. Contrast:
Adult Stills

16. Adult Stills
•Autoinflammatory syndrome
•Presentation:
•Quotidian fevers
•Arthritis
•Evanescent rash
•±pharyngitis

17. Yamaguchi Classification
Criteria

19. Illness Script
Disease Subacute thyroiditis Adult Stills
Pathophysiology
viral infection vs. post-
infectious inflammation
Unclear autoimmune -
infectious trigger??
Epidemiology
12.1 cases/100,000
people/yr; age ~25, 35
0.16 cases/100,000 people/yr;
bimodal ~ages 20 and 40
Time course
subacute with classically
distinct phases
variable
Clinical
Presentation
pain in/around neck,
constitutional symptoms,
fevers
quotidian fevers, arthritis,
evanescent rash; ±
pharyngitis, LAD, HSM
Diagnostics ↓↑TSH, ↑↓FT4, ↑LFTs
↑ESR, CRP, ferritin, WBC,
LFTs
Therapeutics
symptomatic (NSAIDs ±
steroids, BB) ± T4
immunosuppression

20. References Include
•Feingold KR, Anawalt B, Boyce A, et al.,
editors. South Dartmouth (MA): MDText.com,
Inc.; 2000-.
https://www.ncbi.nlm.nih.gov/books/NBK279
084/
•UpToDate
•Agarwal et al. A Case of Adult Stills Disease:
Not So Uncommon Cause of Fever of Unknown
Origin.
https://www.researchgate.net/publication/32
4797918_A_Case_of_Adult_Stills_Disease_Not
_So_Uncommon_Cause_of_Fever_of_Unknown
_Origin

21. Images
•https://www.uptodate.com/contents/image?i
mageKey=RHEUM%2F75048&topicKey=RHEU
M%2F5611&search=adult%20onset%20still%
20disease&source=outline_link&selectedTitle=
1~43

22. Questions?