- A 63-year-old female presented with neck pain, recurrent fevers, difficulty swallowing, and cough. Tests found low TSH and hypervascular thyroid on ultrasound. - Nuclear scans were equivocal due to recent contrast exposure. Antibody tests later found the patient had early stage Hashimoto's thyroiditis. - Hashimoto's thyroiditis can initially present similarly to Graves' disease on ultrasound and cause fevers. Follow-up tests are needed to determine the final diagnosis. - The patient was discharged on symptomatic treatment and asked to follow-up after antibody results and further evaluation.

1. Endocrinology grand rounds
Cleveland Clinic
ABHIMANYU AGGARWAL
International Visiting Physician
Maulana Azad Medical College, University of Delhi
India

2. Case
•63 year old female presented to the ER with pain in right side of neck for 3-4
days along with recurrent fevers and difficulty swallowing.
•It was associated with dry cough and feeling of fullness in ears. She
completed a course of Augmentin for 5 days but did not get relief.
•She was found to be tachycardic and CECT Chest was performed that was
negative for Pulmonary Embolism.
•TSH was found to be low and so endocrine was consulted.

3. ROS
• WEIGHT: she lost 10 lb in 1 month
• HYDRATION: no polydipsia or thirst
• CARDIAC: no chest pain, dyspnea,
• RESPIRATORY: positive for dry cough, no wheezing or
shortness of breath
• GI: no nausea, fullness, vomiting, diarrhea, constipation
• GU:no dysuria, frequency, hesitancy, hematuria, polyuria or
nocturia
• SKIN: normal
• NERVOUS SYSTEM: occasional paresthesias in her hands
• ALL OTHER SYSTEMS: normal

4. PAST MEDICAL HISTORY
• Ovarian Cyst
• Endometriosis
• Posterior Vitreous Detachment
• No history of thyroid disorder
PAST SURGICAL HISTORY
• Laparoscopy for endometrioma
FAMILY HISTORY:
• Mother: Cataract
• Father: Colon Cancer, Cataract
• Sister: Hashimoto’s Hypothyroidism
SOCIAL HISTORY:
• Tobacco Use: Never
• Alcohol Use: Yes (rare)

5. Physical Examination
BP 124/68 mmHg | Pulse 87 | Temp(Src) 36.9 °C (98.4 °F) (Oral) | Resp 18 | Ht 160
cm (5' 3") | Wt 58.605 kg (129 lb 3.2 oz) | BMI 22.89 kg/m2 | Body mass index is
22.89 kg/(m^2).
Appearance well appearing, alert, in no acute distress, well-hydrated, well nourished
EYES: PERRLA, conjunctiva and sclera normal, no signs of opthalmopathy
NECK Supple, no adenopathy; thyroid mildly enlarged R lobe > L, non-tender, could
not appreciate discrete nodule, bruit heard on R
HEART: RRR without murmur, gallop, or rubs. No ectopy
LUNGS: lungs clear to auscultation, no wheezing or rhonchi
ABDOMEN: soft, non-tender, non-distended, non-tender
EXTREMITIES: mild tremor in fingertips
NEURO: Awake, alert and oriented x 3

6. Laboratory

7. Thyroid Ultrasound
• RIGHT LOBE:
Size: 5.0 x 2.0 x 2.5 cm, mildly enlarged; Echotexture: Homogeneous
Nodules: None.
LEFT LOBE:
Size: 4.7 x 2.4 x 2.1 cm, mildly enlarged; Echotexture: Homogeneous
Nodules: 1.0 cm posterior lower pole complex cystic nodule, 0.7 cm mid pole mid lobe
nodule, partially calcified.
ISTHMUS:
AP diameter: 7 mm
Nodules: 0.4 cm complex cystic, predominantly solid nodule in the right side of the
isthmus.
 Vascularity to each thyroid lobe is symmetrically increased.

8. Ultrasound images

9. Is the increased vascularity suggestive of Graves’
disease?

10. • A total of 194 patients with Graves’ disease and 21 patients with
painless thyroiditis were enrolled.
• All patients underwent thyroid volume measurement, mean
Superior Thyroid Artery PSV measurement, power Doppler
sonography and proper blood testing.
• Patients from both categories were further subdivided into four
patterns based on vascularity – Pattern 0 through Pattern 3, with
Pattern 0 being the least vascular and Pattern 3 the most vascular

11. Results
• In the comparison between patients with Graves’ disease and Pattern 0 and
patients with Painless Thyroiditis and Pattern 0, there was not much difference,
except Superior Thyroid Artery PSV.
• PSV was found to be moderately useful, with a sensitivity and specificity of
75%.

12. 40 premenopausal euthyroid patients on
treatment for Hashimoto’s thyroiditis along
with 46 healthy control subjects were
enrolled for investigation.
• It was inferred that during early phases of
Hashimoto’s thyroiditis, doppler examination
may show diffuse hypervascularisation
similar to Graves’ disease; followed by
decreased vascularity in the later stages due
to fibrotic changes.
Isin Ceylan et al

13. What should have been the next step towards a
definitive diagnosis?
Briefly, we have a patient with low TSH, high levels of free
thyroid hormones and hypervascular thyroid with recent
contrast exposure

14. Initial flow images demonstrate prominent uptake of tracer, suggesting hyperemia.
Rate of tracer clearance may be prolonged. Scintigraphic findings are suggestive of
Thyroiditis. However, it is uncertain if Hyperthyroid Graves’ disease could produce a
similar picture. Correlation with Technetium-99M Scan could prove useful for
further evaluation; Decreased uptake on the Pertechnetate Scan would favor
Thyroiditis as opposed to Hyperthyroid Grave’s disease.
Nuclear Technetium sestamibi scan

15. • 23 patients on oral amiodarone for at least 3 months had thyroid scintigraphy and
uptake measure using Tc-99m Pertechnetate and Tc-99m Sestamibi scan.
• In 14-18% of amiodarone treated patients, there is overt thyroid dysfunction, either
amiodarone-induced thyrotoxicosis (AIT) or amiodarone-induced hypothyroidism
(AIH).
• The thyroid uptake of SESTAMIBI is not mediated by the same mechanisms as iodine or
pertechnetate, and apparently does not require preparation with low iodine intake.
• All patients underwent the pertechnetate and sestamibi thyroid uptakes and
scintigraphy studies with a time interval of 4 to 15 days between the studies.
Oki et al Clinical Nuclear Medicine. 35(4):223-227, April 2010

16. Oki et al Clinical Nuclear Medicine. 35(4):223-227, April 2010
Reference range for uptake in normal subjects: Pertechnetate (0.35-1.7%); Sestamibi (0.03-0.23%)
•All hypothyroid patients - uptake of both tracers ( statistically significant)
Result and Conclusion

17. Result and Conclusion
Oki et al Clinical Nuclear Medicine. 35(4):223-227, April 2010
Reference range for uptake in normal subjects: Pertechnetate (0.35-1.7%); Sestamibi (0.03-0.23%)
• All euthyroid patients – pertechnetate uptake, sestamibi uptake (not statistically
significant).
• All hyperthyroid patients – one had Graves’ disease with markedly uptake of both
tracers; the other three had pertechnetate uptake and sestamibi uptake (group was
too small to be statistically significant).

18. Meanwhile, we treated our patient symptomatically with Naproxen and Atenolol 25mg
q12 hrly.
Labs for TRAbs, Microsomal Ab, Thyroglobulin Ab and Thyroglobulin levels sent.
Rheumatology was consulted for fevers and they wanted to know if thyroiditis/Graves’ can
cause fevers.
Disease course

20. Primary team wanted to discharge the patient.
Definitive diagnosis was not made and Antibodies were in process.
Would you have discharged the patient on Methimazole?

21. Patient was discharged on syptomatic treatment and asked to
follow up in clinic after 3 weeks.
In the meanwhile, Antibody screen showed up.

22. Summary
• Patient with hyperthyroidism, hypervascular thyroid, equivocal nuclear uptake and
scan in the setting of recent contrast exposure was diagnosed with early stage of
Hashimoto’s thyroiditis.
• Hashimoto’s thyroiditis can be associated with fevers.
• Ultrasound features and Power Doppler USG of thyroid of patients with varied TFT
are moderately reliable for a diagnoses of thyroid disorder, but should be
accompanied with scheduled follow-ups and repeated TFTs and USG for a final
diagnosis.
• Sestamibi scans, due to lack of adequate studies, are yet to be assigned a suitable
role in the diagnosis and management of patients with hyper- or hypothyroidism.
• The only advantage is that they can be used independent of dietary intake or
contrast administration to the patient.

23. Thank you!