Subacute thyroiditis of de Cervan

Subacute thyroiditis of de Kerven, or granulomatous thyroiditis, is one of the most common forms of the disease.

There is an increase in the incidence of diseases in the autumn-winter period. Women are 4 times more likely than men, the age of patients may be different, but the greatest number of cases falls on 30-40 years.

[1], [2], [3], [4]

Causes of the subacute thyroiditis de Carewen

After measles, infectious mumps, adenovirus diseases, the number of cases of subacute thyroiditis increases. It develops in 3-6 weeks after the transferred viral infections. Penetrating the cells inside, the virus causes the formation of atypical proteins, to which the body reacts with an inflammatory reaction.

[5]

Pathogenesis

Thyroiditis of de Kerven is accompanied by a symmetrical or asymmetric enlargement of the gland. Its tissue is dense, on a section of a dull, heterogeneous structure. Microscopically detected numerous granulomas formed by giant and pseudo-giant cells (clusters of histiocytes surrounding colloidal drops), spewed from the follicles with colloid, macrophages, neutrophils, eosinophils. Follicles in the areas of granuloma formation are destroyed, and the epithelium is desquamated and necrotic.

In the interstitial tissue around and between the granulomas - mucoid edema and lymphoid infiltration, including plasma cells; there are macrophages, eosinophils, mast cells. In the preserved follicles cells with signs of increased functional activity, the basal membrane is thickened. Sometimes the granulomas are suppressed with the formation of microabscesses. Over time, marked fibrosis of the stroma with lime deposition, as well as regenerative processes: the formation of follicles in the islets from the interfollicular epithelium and the cells of the destroyed follicles.

[6], [7]

Symptoms of the subacute thyroiditis de Carewen

There is a sharp feeling of malaise, pain in the neck with irradiation in the ear, increasing with swallowing and movement. Body temperature rises to 38-39 ° C, but may be subfebrile. The gland increases in size (with diffuse lesions), a feeling of pressure appears on the front surface of the neck, weakness, sweating, nervousness, and general malaise increase. From the first days of the disease in the clinical analysis of blood there is a rapidly increasing ESR - up to 60-80 mm / h (in some cases up to 100 mm / h) - with a normal or slightly elevated white blood cell content without a change in the blood formula.

During the course of the disease, several stages can be identified, during which there are various indicators of laboratory tests. Thus, in the first, acute stage (duration 1 - 1.5 months), an increased content of alpha2-globulins, fibrinogen and thyroid hormones in the blood is observed with a reduced capture of the iodine isotope by the gland. Clinically, symptoms of thyrotoxicosis are observed. Such a discord between scan data and clinical symptoms is due to the fact that the inflamed gland loses its ability to fix iodine; Previously synthesized hormones and thyroglobulin come into the blood as a result of increased vascular permeability against the background of inflammation. After 4-5 weeks, a violation of the synthesis of hormones leads to a normalization of their level in the blood, and then to a decrease.

Soreness in the gland decreases, it remains only when palpation. ESR is still increased, the elevated content of alpha2-globulins and fibrinogen remains. Lowering the level of thyroxin and triiodothyronine activates the release of the thyroid-stimulating hormone by the pituitary gland and the increase in the capture of the iodine isotope by the thyroid gland. Approximately by the end of the 4th month after the disease, ^{131 131} absorption  can be increased with mild clinical symptoms, dry skin. These phenomena pass independently, as the function of the gland is restored and the stage of recovery comes. The size of the gland is normalized, the pain disappears, the ESR decreases, T4, T3 and TTG values come to normal. In spontaneous flow, it takes 6-8 months, but the disease is prone to recurrence, especially under the influence of adverse factors (hypothermia, overfatigue, repeated viral infections).

Diagnostics of the subacute thyroiditis de Carewen

The diagnosis of subacute thyroiditis of de Kerven is based on anamnestic data, clinical symptoms, increased ESR with normal blood count, low absorption of  ¹³¹ 1 by the thyroid gland with a simultaneous high content of thyroid hormones in the blood, the presence of giant multinucleated cells in puncture biopsies, and a good effect in the treatment of glucocorticoids. With the use of  ultrasound of the thyroid gland, when specific structural changes are observed (echo-negative zones without clear boundaries disappearing against the background of anti-inflammatory therapy after 4-6 weeks), puncture biopsy is rarely used. Scanning is used only if there is a suspicion of malignancy.

[8]

Differential diagnosis

Depending on the stage of subacute thyroiditis, a differential diagnosis is performed with various diseases. First, it is necessary to differentiate from acute purulent thyroiditis, to carefully study the patient's data on previous diseases, bearing in mind that viral thyroiditis is much more common than purulent. Extremely increased ESR at normal leukocyte levels without changes in the blood formula, an increase in the level of alpha2-globulins and fibrinogen is characteristic of subacute thyroiditis. The absence of the effect of antibiotic treatment for 5-7 days is an additional argument in favor of this disease.

In the case of a flattened onset of the disease, without a marked rise in body temperature and iron pain, the patient may consult a doctor only in the stage of hyperthyroidism, and it is necessary to differentiate thyroiditis from the initial form of diffuse toxic goiter. With diffuse toxic goiter, the clinical picture of thyrotoxicosis coincides with increased absorption of the isotope gland, a high level of thyroid hormones in the blood and a low content of thyroid-stimulating hormone. In thyroiditis, a high level of hormones in the blood is accompanied by a low uptake of the isotope and a normal or decreased level of TSH.

With clinical symptoms of hypothyroidism, autoimmune thyroiditis should be excluded. This helps to make the definition of classical antithyroid bodies, the detection of which in high titres is characteristic of this disease. With subacute thyroiditis, antibodies to thyroglobulin appear in titres not exceeding several hundred. The low content of thyroid hormones in the blood coincides with autoimmune thyroiditis with a high level of TSH and low absorption of the isotope iron. With subacute thyroiditis, elevated levels of TSH are accompanied by an increased uptake of I (in the recovery stage). A puncture biopsy is also shown: the characteristic morphological changes allow us to clarify the diagnosis.

In focal and focal subacute thyroiditis, the portion of the lobe of the gland is affected, which, when palpated, is defined as a painful compaction. This form of thyroiditis should be differentiated from carcinoma. With both diseases, clinical symptoms (pain, irradiation points, size, density) do not allow even tentatively to stop on a particular diagnosis (a valuable addition may be anamnestic data on the transferred virus infection). Of the additional research methods should be indicated on the indirect lymphography of the thyroid gland, when a contrast agent is injected into the lower poles of the lobes with the patient's vertical position.

After 60 minutes the iron is contrasted. Radiography for thyroiditis is characterized by a change in the structure of the gland pattern, which takes the form of coarse granules and broken trabeculae. Regional lymph nodes with thyroiditis are contrasted after 24 hours, with carcinoma lymph nodes are blocked. According to S. Yu. Serpukhovitin, the data of thyroid gland coincide with the results of histological examination in 93% of cases. There is also a puncture biopsy, about which there is no consensus.

However, most authors are supporters of this method of diagnosis. A specific marker of the thyroid carcinoma is an increased level of thyroglobulin in the blood. But the method of its determination is not available universally (in medullary carcinoma, such a marker is a high level of calcitonin in the blood). In the case of technical difficulties, diagnostic treatment with glucocorticoids can be recommended: the absence of effect within 2 weeks with the intake of 40-60 mg of prednisolone per day speaks against the inflammatory genesis of the gland in the gland, the patient is shown a puncture biopsy.

Treatment of the subacute thyroiditis de Carewen

Treatment of subacute thyroiditis is conservative. The administration of antibiotics is pathogenetically unfounded. The fastest effect is given by the appointment of  glucocorticoids  in doses of their optimal anti-inflammatory effect: 30-40 mg of prednisolone per day. Duration of treatment is due to the timing of normalization of ESR and elimination of pain syndrome. As practice has shown, the administration of the drug every other day is less effective, and a relatively short course of treatment (1.5-2 months) does not disrupt the normal interrelation between the pituitary and adrenal glands of the patient, and with gradual withdrawal of the drug, no manifestations of adrenal insufficiency are observed. Doses of glucocorticoids are reduced under the control of ESR. When it accelerates, you must return to the previous dose. Instead of glucocorticoids, preparations of the salicylic or pyrazolidone series are indicated. Their appointment together with glucocorticoids is not justified because the ulcerogenic effect of these substances on the gastric mucosa is summarized, and the anti-inflammatory effect of glucocorticoids is greater than that of salicylates. The use of Mercazolilum in the hyperthyroid phase is inexpedient, since thyrotoxicosis is due to the accelerated intake of previously synthesized hormones into the blood, and Mercazolil reduces their formation.

It is recommended the appointment of beta-blockers, eliminating tachycardia and contributing to the peripheral transition of T4 to the inactive, reversible form of T3. The dose of beta-blockers usually ranges from 40 to 120 mg / day, the duration of treatment is about a month. The appointment of thyroid hormones with a decrease in their level in the blood is indicated only in the presence of severe clinical symptoms of hypothyroidism, the daily dose usually does not exceed 0.1 g of thyroidin, the duration of treatment is 3-4 weeks.

The disease is prone to recurrence, and the duration of treatment with glucocorticoids sometimes reaches 4-6 months. In this case, the symptoms of glucocorticoid overdose may appear in patients: weight gain, facial rounding, appearance of striae, elevation of blood pressure, hyperglycemia. If you do not succeed in stopping glucocorticoid therapy within 6-8 months, surgical treatment is indicated - resection of the corresponding lobe of the gland.

Therapy can be carried out alone salicylates in a dose of 2.5-3 g / day. However, the effect is more slowly achieved than with glucocorticoids. A mandatory condition for the use of salicylates is their uniform distribution during the day.

In case of a positive result, the dose of glucocorticoids is reduced to the minimum maintenance dose (usually 10 mg of prednisolone per day), then naprosin, aspirin or rheopyrin are connected, and prednisolone decreases to 1/2 tablet in three days.

Forecast

Subacute thyroiditis de Kervena has a favorable prognosis. The working capacity of patients is usually restored within 1.5-2 months. Dispensary observation for 2 years from the date of the onset of the disease.