Endocrine Abstracts

JOINT98

We report on a patient with likely de Quervain thyroiditis who presented with clinical features of an aggressive thyroid malignancy. A 46-year-old female was referred from the ENT department with a 4-week history of weight loss, feeling hot, and fullness of her neck which was becoming increasingly painful. There was no family history of thyroid disorders. The patient did not mention any clear predating symptoms of any viral catarrh or relevant history. Initial biochemistry through her doctor showed thyrotoxicosis with elevated T4, and T3 and suppressing TSH. Examination revealed a large irregular tender mass over the left lobe of the thyroid and multiple tender palpable lymph nodes in the neck. The patient was clinically thyrotoxic with tachycardia of 110 beats per minute and fine tremors over her outstretched hands but no clinical signs of any thyroid eye disease. An ultrasound of the thyroid revealed a poorly defined hypoechoic mass over the left lobe with a possible extension through the thyroid capsule and several level 3 and level 5 cervical lymph nodes. Thyroid antibodies were negative. She was initially commenced on carbimazole and propranolol for symptomatic control of her thyrotoxicosis while choosing simple analgesia over steroids for her neck soreness. An ultrasound-guided FNAC was carried out 2 weeks later. This revealed only scant follicular epithelial cells and hence labelled as Thy1. The patient made good progress with the carbimazole with good symptom control of her thyrotoxicosis and biochemical improvement. A repeat ultrasound-guided FNAC was carried out 2 weeks later which however showed very scant cells and hence relabelled as Thy1. The ultrasound at this stage however confirmed a sizeable reduction in the left lobe thyroid mass and now insignificant cervical lymphadenopathy. The patient was monitored for her thyroid biochemistry every 3 to 4 weeks with a titrating regime of carbimazole. The initial ENT opinion and a further review after 4 weeks concurred with the clinical diagnosis of likely thyroiditis. Further monitoring was deemed to be under endocrinology, and a further thyroid ultrasound in 3 to 6 months was agreed upon. The patient had come off her carbimazole after 6 weeks and remained euthyroid without any intervening hypothyroid phase. This case serves to highlight the need for clinical assessment and pertinent investigations to avoid overdiagnosis and potentially unhelpful surgical intervention. Hyperthyroidism can very rarely be a manifestation of metastatic follicular thyroid cancer which however was not the case in our patient.