Thyroidectomy for Painful Thyroiditis Resistant to Steroid Treatment: Three New Cases with Review of the Literature

Abstract

Thyroidal pain is usually due to subacute thyroiditis (SAT). In more severe forms prednisone doses up to 40 mg daily for 2-3 weeks are recommended. Recurrences occur rarely and restoration of steroid treatment cures the disease. Rarely, patients with Hashimoto's thyroiditis (HT) have thyroidal pain (painful HT, PHT). Differently from SAT, occasional PHT patients showed no benefit from medical treatment so that thyroidectomy was necessary. We report three patients who did not show clinical response to prolonged high dose prednisone treatment: a 50-year-old man, a 35-year-old woman, and a 33-year-old woman. Thyroidectomy was necessary, respectively, after nine-month treatment with 50 mg daily, two-month treatment with 75 mg daily, and one-month treatment with 50 mg daily. The two women were typical cases of PHT. Conversely, in the first patient, thyroid histology showed features of granulomatous thyroiditis, typical of SAT, without fibrosis or lymphocytic infiltration, typical of HT/PHT, coupled to undetectable serum anti-thyroid antibodies. Our data (1) suggest that not only PHT but also SAT may show resistance to steroid treatment and (2) confirm a previous observation in a single PHT patient that increasing prednisone doses above conventional maximal dosages may not be useful in these patients.

Fever of Unknown Origin as a Sole Presentation of Subacute Thyroiditis in an Elderly Patient: A Case Report with Literature Review

“…Rarely, patient may need treatment with thyroidectomy for persistent neck pain despite treatment with steroids. Mazza et al reported a case series of 3 patients who required thyroidectomy for persistent thyroid pain despite treatment with high dose steroid (prednisone 40 mg daily) for 2-3 weeks [ 25 ].…”

Recurrent Painful Hashimoto Thyroiditis Successfully Treated by Thyroidectomy

“…Most cases of the latter reveal a diffuse heterogeneous hypoechoic change of the thyroid. If there is any hypoechoic nodule within the thyroid, Doppler sonography always shows an increased flow in the lesion (4,8,10). After the treatment, neck pain persists, regardless of the blood flow status, which could be decreased (4) or unchanged (8).…”

“…Treating patients with painful HT is challenging, as there is no consensus on how to manage this rare disorder. The majority of patients in the previous studies received corticosteroids (2,(4)(5)(6)(7)(8)10,(13)(14)(15)(16). However, less than 30% of patients experienced sustained pain relief.…”

“…Antithyroid antibodies are always high in patients with painful HT, while are usually absent in patients with SAT. In a cohort of 73 patients with painful thyroiditis, a large proportion of patients had elevated levels of antithyroid antibodies, but only 2 patients were diagnosed with painful HT on the basis of the final pathology examination (8). SAT is usually characterized by a transient thyrotoxicosis, with 5% of patients becoming hypothyroid afterward.…”

“…In patients with SAT, the thyroid gland appears diffusely hypoechoic with decreased blood flow and may show ill-defined hypoechoic thyroid lesions (19). On the other hand, in painful HT the gland reveals a diffuse heterogeneous hypoechoic pattern, and an increased vascular flow to hypoechoic lesions, if present (4,8,10,16). Only pathology examination can give a definitive diagnosis.…”