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This "hyperthyroid" patient became hypothyroid after anti-nail treatment, but the director said that as long as the symptomatic treatment is good?

 Last Update: 2023-02-01
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Hyperthyroidism should be classified and treated, otherwise it will fall into confusion
.

AuthorChief Physician of Department of Endocrinology, Beijing Hepingli Hospital Li Changqi

Subacute thyroiditis does not have abnormal thyroid function in most cases, and only a subset of patients with subacute thyroiditis may develop hyperthyroidism due to individual differences ^[1-3].
If subacute thyroiditis occurs hyperthyroidism, sometimes there is no need to rush to use anti-hyperthyroid drugs for treatment, because after a period of time may occur hypothyroidism, it will be counterproductive, overkill, please see the following cases
.

I Case Summary

: Patient Park Dae-in-law accidentally caught a cold before the onset of illness, and then developed goiter pain, but she did not care at the time, thinking that it was caused
by a cold.
Soon fatigue, fatigue, heat intolerance and sweating, moist skin, excessive food and hunger, significant weight loss, etc
.
In addition, there are also symptoms such as hyperactivity, nervousness and anxiety, anxiety and irritability, insomnia, lack of concentration, memory loss, and tremor of the hands and eyelids
.

Sister-in-law Park immediately went to the outpatient clinic of the hospital's endocrinology department, the first consultation was a young doctor, she looked at the patient's clinical signs and symptoms, said that it may be hyperthyroidism, and after the thyroid examination did confirm her judgment, which made her very proud
.
She also did not recognize the importance of accurate classification of hyperthyroidism, and directly gave patients intensive anti-thyroid therapy
.

However, within a few days, the patient developed symptoms
such as cold intolerance, dry skin, and less food and lazy speech.
Immediate review of thyroid function showed that the patient had developed hypothyroidism
.
This made her puzzled, how long did she get hypothyroidism without treatment? This time, she did not blindly treat hypothyroidism, but asked the director to consult with the patient when he went out of the expert clinic tomorrow
.

The next day, the director consulted the patient and believed that the patient was not a simple Graves disease, but a transient hyperthyroidism caused by thyroiditis, and due to improper treatment of hyperthyroidism, hypothyroidism appeared early in the course of thyroiditis
.
The director did not have anti-hypothyroid treatment, but gave symptomatic treatment according to the patient's clinical symptoms and signs, and soon the patient's clinical symptoms and signs disappeared and returned
satisfied.

Director interpretation and analysis

The patient in this case has subacute thyroiditis rather than hyperthyroidism, but can cause symptoms of transient hyperthyroidism during the course of subacute thyroiditis
.
Subacute thyroiditis is a subacute inflammation of the thyroid gland that occurs after a viral infection, and in the course of subacute thyroiditis, due to the destruction of thyroid follicular cells, the hormones stored in thyroid follicular cells are released into the bloodstream, thus causing transient symptoms of hyperthyroidism, such as palpitation, hyperphagia, weight loss and other hypermetabolic symptoms
.

The director especially reminds that hyperthyroidism caused by subacute thyroiditis is transient hyperthyroidism, with the release of stored hormones in thyroid follicular cells, transient hypothyroidism will occur before the follicular cell repair is completed, and then thyroid function will gradually return to normal
.
Fortunately, the doctor attending the case did not continue blind anti-hypothyroidism treatment, otherwise the patient would be left with the adverse consequences
of permanent hypothyroidism.

Knowledge link: Subacute thyroiditis with hyperthyroidism

Subacute thyroiditis, also known as subacute granulomatous thyroiditis, (pseudo)giant cell thyroiditis, non-infectious thyroiditis, migratory thyroiditis, viral thyroiditis, DeQuervain thyroiditis, granulomatous thyroiditis or giant cell thyroiditis, etc.
, are more common in middle-aged women
.
The disease is mostly caused by viral infection of the thyroid gland, and the onset is seasonal, especially in summer ^[4-5].

If hyperthyroidism occurs in acute thyroiditis, the first thing to do is to measure the level of thyroid hormones, and then judge whether anti-hyperthyroid treatment
is required according to the actual situation.
But most of our patients with subacute thyroiditis do not have an abnormal thyroid hormone level, and it is a self-healing disease
.

Table 1 Compared with ultrasonography, nuclide imaging can improve the detection rate of
subacute thyroiditis and severe subacute thyroiditis, and its sensitivity and diagnostic compliance rate are higher ^[4-5].
。

▎Cognition of subacute thyroiditis and hyperthyroidism: 1.
Subacute thyroiditis is a self-limiting thyroiditis
related to viral infection.
2.
Hyperthyroidism is a common endocrine disease
caused by excessive secretion of thyroid hormones.

▎Clinical symptoms: The subacute thyroiditis stage can be divided into three stages
: early stage with hyperthyroidism, middle stage with hypothyroidism and recovery period.

1.
Early stage: sudden onset, fever, accompanied by chills, cold intolerance, fatigue and loss of appetite
.
Pain and tenderness in the thyroid gland are the most characteristic manifestations, radiating to the submandibular, behind the ears, or neck, and worsening with chewing and
swallowing.

2.
Medium term: serum thyroid hormone concentration can be reduced to hypothyroidism
.

3.
Recovery period: symptoms gradually improve, goiter or nodules gradually disappear
.

Differential diagnosis and treatment

The disease
can be diagnosed according to systemic symptoms such as acute onset, fever and thyroid pain, enlargement and hardness, combined with the two-way separation phenomenon of significant increase in erythrocyte sedimentation rate, increased serum thyroid hormone concentration and decreased thyroid iodine uptake rate.

Subacute thyroiditis should be differentiated from the following thyroid disorders:

Acute purulent thyroiditis

Redness, swelling, heat, pain and significant systemic inflammatory reactions in local or adjacent tissues of the thyroid gland, sometimes adjacent or distant foci of infection can be found, white blood cells are significantly increased, the nucleus shifts left, and the thyroid function and iodine uptake rate are mostly normal
.

Nodular goiter bleeding

Sudden bleeding may be accompanied by thyroid pain, bleeding site with a sense of fluctuation, but no constitutional symptoms, no elevated erythrocyte sedimentation rate, thyroid ultrasound is helpful
.

Hashimoto's thyroiditis

A small number of cases may have thyroid pain and tenderness, and the active erythrocyte sedimentation rate may be mildly elevated, and transient thyrotoxicosis and iodine uptake may be reduced; However, there are no systemic symptoms, and the serum thyroglobulin antibody and thyroid peroxidase antibody titer are increased
.

Painless thyroiditis

This disease is a variant of Hashimoto's thyroiditis, a type
of autoimmune thyroiditis.

There is goiter with clinical manifestations of thyrotoxicosis, hypothyroidism, and recovery of thyroid function in 3 stages, similar
to subacute thyroiditis.

Iodine-derived hyperthyroidism

The iodine uptake rate in iodine-induced hyperthyroidism or hyperthyroidism is inhibited by exogenous iodide, and T3 and T4 are increased, but the iodine uptake rate is reduced
.
It can be differentiated
according to the course of the disease, constitutional symptoms, thyroid pain, T3/T4 ratio in hyperthyroidism, and erythrocyte sedimentation rate.

▎ Treatment: First of all, you should pay attention to rest, avoid fatigue, avoid excessive emotional tension, ensure sleep, and pay attention to drinking more water
.
Do not do strenuous exercise, and do not stretch and vibrate
the neck.

Secondly, if it is accompanied by fever and neck pain, oral antiviral drugs can be used, and nonsteroidal anti-inflammatory and analgesic drugs, such as indomethacin or ibuprofen capsules, can
be used.
If the pain is severe, oral hormone therapy may be required, but care should be taken to administer the medication under the
guidance of a doctor.

Subacute thyroiditis is a self-limiting disease that is treated with the aim of reducing inflammation and pain, and β blockers
can be used when thyrotoxicosis is obvious.

The treatment cycle of this disease is 2~3 months
.

Treatment is twofold: to reduce local symptoms and to target the effects
of thyroid dysfunction.

In general, most patients are treated symptomatically
.

Aspirin or other painkillers
are used in mild cases.
For example, acetamidophenol or salicylate can control symptoms
.

For severe cases, such as pain, fever can be short-term use of other non-steroidal anti-inflammatory drugs, or the use of glucocorticoids, such as prednisone, can quickly alleviate the clinical manifestations, about 5% of patients need corticosteroids to reduce symptoms, continue to use for 1~2 weeks or even 4~8 weeks after reducing the dose, sharing 6~8 weeks
.

Antithyroid drugs are generally not used when accompanied by hyperthyroidism, and non-specific drugs, such as oral blockers - propranolol ^{[4, 6].}

brief summary

Subacute thyroiditis is not hyperthyroidism, but in the course of subacute thyroiditis, it can cause symptoms of transient hyperthyroidism, remember not to blindly anti-thyroid treatment!

References:

[1] Li Changqi, Jiang Shuwen, and Dong Jinglin
, eds.
New progress in the diagnosis and treatment of hyperthyroidism[M].
Heilongjiang Science and Technology Press.
Harbin 1996 First Edition 188-208.
.
.
[2] Chinese Medical Association, Chinese Medical Association Clinical Pharmacy Branch, Journal of Chinese Medical Association, etc.
Guidelines for rational drug use at the primary level of hyperthyroidism[J].
Chinese Journal of General Practitioners,2021,20(5):515-519.
) .
[3] Guidelines for the diagnosis and treatment of common diseases at the grassroots level.
Guidelines for the primary diagnosis and treatment of hyperthyroidism (2019).
[4]CHESEREK M J,WU G,SHEN L,et al.
Evaluation of the relationship between subclinical hypothyroidism and metabolic syndrome components among workers[J].
International journal of occupational medicine and environmental health,2014,27(2):175-187.
[5] Xie Wen.
Application value of nuclide imaging and ultrasound in the diagnosis of subacute thyroiditis[J].
China Medical Device Information,2022,01:97-99[6]YANG Jinhong,CHEN Hualing.
Experience in the diagnosis and treatment of 120 cases of subacute thyroiditis in primary hospitals[J].
Chinese Community Physician,2021,19:65-66+69

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