Clinical presentation: a 40-year-old woman 7 months after her delivery requested a second opinion. Hyperthyroidism was diagnosed 5 weeks earlier (TSH undetectable, FT4 50.4 pM/L, aTPO 18 U/mL). Non-steroid anti-inflammatory drug was administered. Her complaints were not resolved over the previous 5 weeks. These complaints were fatigue, palpitation, subfebrility and mild neck discomfort. 2 days before the present investigation her endocrinologist suggested daily 60 mg methimazole because her hyperthyroidism had worsened (FT4 68.1 pM/L).

Palpation: the thyroids were minimally tender.

Sedimentation rate: 78 mm/H.

Ultrasonography: the thyroids were moderately hypoechogenic with several more hypoechogenic areas with blurred borders. The vascularization was decreased.

Cytological diagnosis: subacute, granulomatous de Quervain's thyroiditis.

Suggestion: steroid therapy and discontinuation of non-steroid drug and thyrostatic. The neck complaints and subfebrility stopped within 24 hours after administration of 32 mg methyl-prednisone. 2 weeks later the FT4 level and the sedimentation rate had normalized, 16.0 pM/L and 8 mm/H, respectively.

Comment: there were two deceptive circumstances in this patient. Firstly, she was in the post-partum period, secondly the degree of hyperthyroidism exceeded that observed in the usual case of thyroiditis. On the other hand, the ultrasound pattern was very specific. In the case of Graves' hyperthyroidism of such degree the vascularization would be in most if not all cases substantially increased.

 

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