Introduction: Granulomatous thyroiditis (GT) is one of the various types of autoimmune thyroiditis. It usually occurs in women of reproductive age in perigestational period. Clinical picture in is predominantly painful goiter with radiating pain to ears with low grade fever lasting for few days, sometimes associated with mild hyper or hypothyroidism. The treatment is symptomatic and supportive with no curative option. There are meagre anecdotal reports of thyroidectomy role for cure. In this context, we report an unusual clinical presentation and impact of total thyroidectomy on GT.
Case details: A 60 year old gentleman had history of continuous low fever since 4 months with quotidian spikes up to 1001010F. These spikes were sometimes associated with chills. Gets symptomatic relief with paracetomol and steroids. He was worked with a battery of investigations for chronic liver disease, renal disease, viral causes, tuberculosis and any autoimmune connective tissue disorders such as SLE, scleroderma etc., All the investigations were within normal limits with no definite etiology. Fine needle aspiration of goiter showed picture of thyroiditis with few macrophages and colloid. He was empirically started on anti-tuberculous medications (ATT) since 3 months with no significant alleviation from fever. At this stage he was referred to our hospital. On clinical evaluation, there was a large grade 2 diffuse firm, slightly tender goiter and no cervical regional lymphadenopathy. No evidence any neurocutaneous markers of any autoimmune syndromes. Biochemical profile was suggestive of subclinical hyperthyroidism. Anti-thyroid peroxidase antibody titer was 45 IU/L (034). ESR was 86 mm/hr. After careful intradepartmental discussion and patient (family) counseling, we withdrew ATT and planned total thyroidectomy suspecting thyroiditis as cause for this pyrexia of unknown origin (PUO).
Results: Total thyroidectomy was performed with uneventful morbidity. No postoperative complications or hypocalcemia occurred. Surprisingly, from 5th postoperative day his fever has resolved completely with no further spikes. ESR was 15 mm/hr at 2 weeks after surgery. Histopathology was reported as Granulomatous thyroiditis with non- caseating granulomas, macrophages, destroyed follicles and lymphocytic infiltrates. Body temperature has normalized and he never experienced any episodes of fever till last followup at 6 months.
Conclusions: Granulomatous thyroiditis can have protean clinical manifestations. Here, GT unusually presented with pyrexia of unknown origin. Exact pathophysiology is enigmatic, but pyrogenic cytokines released by GT process may cause PUO. Total thyroidectomy appears to be a viable curative option for GT causing PUO, probably by reversing this pathophysiology.
18 - 21 May 2019
European Society of Endocrinology