Case: A 46-years-old anaesthetist presented with 2 weeks history of general malaise, sore throat, and fever. Symptoms started while on holiday. A diagnosis of subacute thyroiditis was made overseas based on presentation and suppressed TSH level. He was started on betamethasone 4mg and ibuprofen for 2 weeks with rapid symptomatic improvement. He felt well enough to travel back to UK. He then presented to our hospital with recurrent symptoms as above.
Investigation and treatment: On examination he was found to have diffusely enlarged and tender thyroid gland with suppressed THS<0.001 μ/l, raised T4 of 28.2 pmol/l and negative thyroid peroxidase antibodies.
Initial thyroid ultrasound showed diffusely enlarged gland. The technetium thyroid scan supported the diagnosis of subacute thyroiditis with low thyroid uptake (0.08%). He was started on propranolol and diclofenac. His symptoms improved and was discharged. On subsequent review in 2 weeks he had recurrent symptoms. TSH remained suppressed at <0.001 μ/l with elevated T4 of 24.0 pmol/l. He required increased ibuprofen dose and continuation of propranolol. This was followed by third recurrence within 2 weeks with raised T4 of 26.0 pmol/l and suppressed TSH. He was started on prednisolone 25 mg for 2 weeks. He then continued to improve. Repeat thyroid ultrasound scan showed recovery of the inflamed thyroid parenchyma, reduced size of both lobes with peripheral increased vascularity due to thyroiditis. His thyroid function then normalized within 8 weeks to TSH 2.03 μ/l, T4 of 15.3 pmol/l. This patient had significant recurrence of subacute thyroiditis with fluctuating and debilitating symptoms over the course of few month. He required phased retune to work.
Discussion and conclusion: Subacute thyroiditis which is considered to be a viral illness rarely recurs after a complete recovery. Recurrent disease could be debilitating. Prompt assessment, treatment, and follow-up are of paramount. Risks and benefits of antithyroid treatment should be considered on individual basis.