Endocrine Abstracts

Introduction: Autoimmune thyroiditis is rarely painful. A tender goitre usually indicates viral thyroiditis. Here, we present a case of a persistent painful goitre due to sclerosing-type Hashimoto’s thyroiditis.

Case presentation: Our patient is a 27-year-old mother, with no significant past medical history. She was diagnosed with autoimmune hypothyroidism in October 2005 when 4 months post-partum. At diagnosis her anti-TPO titre was 2041 U/ml, and she was asymptomatic. She was managed in the community until January 2009 when she presented with exquisite thyroid tenderness and dysphagia. A diagnosis of viral thyroiditis was made and managed with analgesia and steroids. Her anti-TPO titre was 3754 U/ml, and inflammatory markers raised (CRP 125). An ultrasound revealed a diffusely enlarged gland, with no evidence of abscess, nodules or lymphadenopathy. The nuclear medicine scan showed diffusely low uptake at 0.4%, consistent with thyroiditis.

Six months later despite a prolonged course of steroids the pain persisted and her anti-TPO titre was >6500 U/ml. In view of ongoing pain she was referred to the surgeons for biopsy, and consideration of a total thyroidectomy. The biopsy demonstrated small islands of follicles separated by dense fibrous stroma, with an intense chronic lymphocytic infiltrate (polyclonal B and T cells) and an intact basement membrane. The staining demonstrated that 57% of the IgG positive cells were positive for IgG4. This is in keeping with fibrosing-type Hashimoto’s thyroiditis, and she underwent a total thyroidectomy for symptom relief.

Conclusion: We present a case of a rare sclerosing-type of Hashimoto’s thyroiditis. Thyroid pain is rarely associated with autoimmune hypothyroidism. We conclude that ongoing pain is an indication for consideration of thyroid biopsy. Sclerosing-type Hashimotos may require thyroidectomy for pain relief.