Subacute de quervain´s thyroiditis with postpartum onset: a case report

¹Department of Endocrinology and Diabetology, National Reference University Hospital, University of N'Djamena, N'Djamena, Chad, ²National Council for Nutrition Development and Department of Endocrinology, Diabetology and Nutrition, Pikine National Hospital, Dakar, Senegal, ³Department of Intensive Care, Mother and Child University Hospital, N'Djamena, Chad, ⁴Department of Internal Medicine and Rheumatology, National Reference University Hospital, N'Djamena, Chad, ⁵Department of Endocrinology, Diabetology and Nutrition, Pikine National Hospital, Dakar, Senegal

^&Corresponding author
Djikoldinguem Marschall Mouandilmadji, Department of Endocrinology and Diabetology, National Reference University Hospital, University of N'Djamena, N'Djamena, Chad

Introduction    

Subacute de quervain´s thyroiditis is an inflammatory disorder of the thyroid gland, usually of viral origin, responsible for transient hyperthyroidism due to the release of preformed thyroid hormones. It classically presents with anterior neck pain, fever, tachycardia, and a marked systemic inflammatory response. A particular form, known as the "migratoryʺ or "shiftingʺform, is characterized by successive migration of pain and thyroid lesions from one lobe to the other. Little data is available from sub-Saharan Africa regarding this specific evolutionary form. Occurrence in the postpartum period may make the diagnosis challenging because of the frequent differential diagnoses in this context. We report a case illustrating this atypical presentation and highlighting the decisive contribution of serial thyroid ultrasonography [1, 2].

Patient and observation     

Patient information: a 28-year-old woman, four months postpartum, with no significant medical history apart from a previous ectopic pregnancy. There was no personal history of hypertension or diabetes.

Clinical findings: at initial examination, the patient was febrile with a temperature of 38.1°C and tachycardic at 110 beats per minute. History taking revealed unquantified weight loss, irritability, and insomnia, with no gastrointestinal transit disturbances. Cervical palpation revealed localized pain over the left thyroid lobe, with the impression of a firm, tender nodule. The remainder of the clinical examination was unremarkable.

Timeline of the current episode: two weeks prior to consultation, the patient developed an influenza-like syndrome. This was followed by the gradual onset of left-sided cervical pain, with subsequent migration of the pain to the right thyroid lobe during the course of the illness, accompanied by complete resolution of contralateral symptoms.

Diagnostic assessment: the initial laboratory evaluation revealed biochemical hyperthyroidism with a suppressed TSH level of 0.156 mIU/L (reference range: 0.3-4) and an elevated free T4 level of 2.86 ng/dL (reference range: 0.8-2.0), associated with a marked inflammatory response, including an increased C-reactive protein level of 23.65 mg/L and a markedly elevated erythrocyte sedimentation rate (ESR) of 100 mm in the first hour and 117 mm in the second hour, while the complete blood count was normal. Initial thyroid ultrasonography showed a poorly defined hypoechoic area in the left thyroid lobe, hypovascular on Doppler imaging. Serial ultrasound examinations demonstrated migration of the lesions from one lobe to the other, without mass effect or peripheral halo (Figure 1).

Diagnosis: postpartum migratory subacute de quervain´s thyroiditis.

Therapeutic interventions: the patient was started on oral corticosteroid therapy with prednisolone, combined with symptomatic treatment using beta-blockers.

Follow-up and outcomes of interventions: at four weeks of follow-up, the clinical course was marked by a shift of pain to the contralateral right thyroid lobe, associated with a 3-kg weight loss and persistence of clinical signs of thyrotoxicosis. Biologically, a slight worsening of hyperthyroidism was noted, with a suppressed TSH level of 0.106 mIU/L and an elevated free T4 level of 5.573 ng/dL. Serial thyroid ultrasonography performed during follow-up demonstrated successive migration of hypoechoic lesions from one thyroid lobe to the other, without mass effect or peripheral halo, confirming the migratory nature of the inflammatory involvement. Two weeks later, laboratory investigations showed persistence of the inflammatory syndrome, with a C-reactive protein level of 35.26 mg/L and an erythrocyte sedimentation rate of 47 mm in the first hour and 76 mm in the second hour. Biochemical hyperthyroidism persisted, with a still suppressed thyroid-stimulating hormone (TSH) level of 0.048 mIU/L, an elevated free T4 level of 3.925 ng/dL, and a free T3 level remaining within the normal range. Three weeks later, biological evolution was characterized by gradual improvement, with mild residual hyperthyroidism, reflected by a TSH level of 0.232 mIU/L and a free T4 level of 2.591 ng/dL. Clinical evolution was rapidly favorable, with complete resolution of cervical pain and thyrotoxic symptoms. Follow-up laboratory tests showed a progressive normalization of inflammatory and thyroid parameters (Table 1). Thyroid ultrasonography performed three months after treatment initiation showed complete regression of the previously described inflammatory abnormalities, with homogeneous thyroid parenchyma, normal vascularity on color Doppler, and no residual hypoechoic lesions (Figure 2).  The echographic changes observed on follow-up examinations are summarized in Table 1. From a weight standpoint, a 3-kg weight gain was observed over one month, with a final weight of 70 kg.

Patient perspective: the patient reported a rapid improvement in her general condition and a marked relief of cervical pain.

Informed consent: the patient provided written informed consent for the publication of this case report.

Discussion     

Subacute De Quervain´s thyroiditis is a transient inflammatory disorder of the thyroid gland, most often of post-viral origin, responsible for hyperthyroidism due to the release of preformed thyroid hormones. Several respiratory viruses have been implicated in its pathophysiology, particularly viruses affecting the upper respiratory tract. In our case, the onset of symptoms in the context of an influenza-like syndrome two weeks prior to the development of cervical pain supports the viral hypothesis [1]. The disease shows a marked female predominance, with an age of onset usually between 30 and 50 years. It classically presents with anterior neck pain, fever, tachycardia, and a marked biological inflammatory syndrome, as observed in our patient. The natural course is most often triphasic, beginning with a thyrotoxic phase lasting several weeks, followed by a transient hypothyroid phase, and finally a return to euthyroidism in the majority of cases within the first year [2,3]. Data from sub-Saharan Africa remain limited. A Senegalese case series reported by Leye et al. highlighted the diagnostic challenges of subacute De Quervain´s thyroiditis in a resource-limited setting [4]. Our observation is distinguished by a typical migratory ("shiftingʺ) course, which has rarely been described in African series.

The so-called "migratoryʺ or "shiftingʺ form, characterized by successive migration of pain and thyroid lesions from one lobe to the other, remains rare and poorly described in the literature [2,5]. Nevertheless, this particular presentation constitutes a highly suggestive semiological feature of subacute thyroiditis and may help differentiate this condition from progressive nodular diseases or focal infectious thyroid disorders. In our case, the migratory evolution documented both clinically and on ultrasonography was decisive in confirming the diagnosis. Thyroid ultrasonography plays a central role in the diagnosis and follow-up of subacute thyroiditis. Typical features include poorly defined hypoechoic areas without mass effect, associated with hypovascularization on color Doppler imaging, sometimes described as a “geographic map” pattern on ultrasonography [6]. The major value of serial ultrasonography lies in its ability to monitor lesion evolution over time, as illustrated in our case by the complete disappearance of abnormalities in one lobe and their contralateral appearance. This dynamic pattern helps avoid unnecessary invasive procedures, particularly fine-needle aspiration, and provides reassurance regarding the benign and transient nature of the lesions. In the postpartum period, the main differential diagnoses are painless postpartum thyroiditis and Graves´ disease. Postpartum thyroiditis is usually painless and is not associated with a marked biological inflammatory syndrome. Graves´ disease is distinguished by the absence of cervical pain, the possible presence of ophthalmopathy, and, most importantly, diffuse hypervascularization of the thyroid gland on color Doppler imaging, which was absent in our case. Thyroid scintigraphy, which typically shows a marked reduction in radioactive iodine uptake in subacute thyroiditis, is a useful diagnostic test but is not always available in resource-limited countries [7].

Therapeutic management is mainly based on nonsteroidal anti-inflammatory drugs or corticosteroid therapy in moderate to severe forms. Corticosteroids allow rapid improvement of pain and systemic symptoms, as observed in our patient [1,8]. Beta-blockers are indicated for the control of adrenergic manifestations. Antithyroid drugs have no indication, as hyperthyroidism results from hormone release rather than increased hormone synthesis. A transient hypothyroid phase may subsequently occur and warrants close biological monitoring, with possible temporary levothyroxine supplementation. Finally, this case highlights the importance of serial thyroid ultrasonography in resource-limited settings, where access to thyroid scintigraphy, HLA typing, or cytology may be restricted. Early identification of atypical forms of subacute thyroiditis allows appropriate management, avoids unnecessary invasive investigations, and limits the use of inappropriate treatments. This case illustrates the value of a dynamic clinico-ultrasonographic approach in atypical inflammatory thyroiditis..

Conclusion     

Migratory subacute De Quervain´s thyroiditis is a rare presentation, particularly in the postpartum period. Serial thyroid ultrasonography represents an essential diagnostic and follow-up tool, particularly in atypical presentations of subacute thyroiditis.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Patient management: Djikoldinguem Marschall Mouandilmadji, Mbaye Sene, Haroun Manga Zamzam, Harine Abdel Aziz Garba, Ngone Diaba Diack, Nafy Ndiaye and Abdoulaye Leye. Data collection and analysis: Djikoldinguem Marschall Mouandilmadji, Haroun Manga Zamzam, Harine Abdel Aziz Garba and Nafy Ndiaye. Interpretation of clinical, biological, and ultrasonographic findings : Djikoldinguem Marschall Mouandilmadji, Mbaye Sene, Haroun Manga Zamzam, Ngone Diaba Diack, Nafy Ndiaye and Abdoulaye Leye. Literature review: Djikoldinguem Marschall Mouandilmadji, Mbaye Sene, Ngone Diaba Diack and Abdoulaye Leye. Manuscript drafting: Djikoldinguem Marschall Mouandilmadji. Manuscript revision: Mbaye Sene, Haroun Manga Zamzam, Harine Abdel Aziz Garba, Ngone Diaba Diack, Nafy Ndiaye and Abdoulaye Leye. Supervision: Abdoulaye Leye. All the authors have read and approved the final version of this manuscript.

Tables and figures     

Table 1: evolution of thyroid function and inflammatory parameters during subacute De Quervain's thyroiditis

Table 2: evolution of thyroid ultrasonographic findings during follow-up

Figure 1: A) Longitudinal thyroid ultrasonography showing a poorly defined hypoechoic area in the left thyroid lobe, with reduced vascularity on color Doppler and tenderness during probe pressure; B) follow-up ultrasonography showing complete resolution of the initial left-sided lesion and appearance of a new hypoechoic lesion in the right thyroid lobe, also showing reduced vascularity

Figure 2: thyroid ultrasonography performed three months after treatment initiation showing complete regression of the previously described inflammatory abnormalities, with homogeneous thyroid parenchyma, normal vascularity on color Doppler, and no residual hypoechoic lesions

References