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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 44-45

Subacute Thyroiditis Presenting as Puo - A Case Report


1 Associate Professor, Dept. of General Medicine, IGIMS, Patna, India
2 Assistant Professor, Dept. of Pathology, IGIMS, Patna, India
3 Assistant Professor, Dept. of General Medicine, IGIMS, Patna, India
4 Associate Professor, Dept. of Endocrinology, IGIMS, Patna, India
5 Additional Professor, Dept. of Pulmonology, IGIMS, Patna, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Praveen Kumar
Assosiate Professor, Dept. of General Medicine, IGIMS, Patna
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Pyrexia of unknown origin is one of the most difficult diagnostic problems in Internal Medicine and could be caused by infection, inflammation, neoplasm and other miscellaneous causes. Subacute thyroidtis is one of the rare causes of PUO.
Case: 55 years old male who was a known diabetic on insulin was admitted with history of fever of one month duration. Clinical examination and investigation revealed tender thyromegaly, high ESR, high CRP, low TSH, high T4 and T3. Based on the above clinical and laboratory findings the diagnosis of subacute thyroiditis with diabetes mellitus was made. Patient was treated with beta-blocker, steroid, insulin and paracetamol. Patient responded with treatment.
Conclusion: Subacute thyroidits is one of the rare causes of PUO and should be considered as a differential diagnosis even if clinical symptoms of thyrotoxicosis are not present.

Keywords: PUO, Thyroiditis, Subacute thyroiditis, prolonged fever


How to cite this article:
Kumar P, Chandra K, Mishra AK, Prakash V, Shankar M. Subacute Thyroiditis Presenting as Puo - A Case Report. J Indira Gandhi Inst Med Sci 2018;4:44-5

How to cite this URL:
Kumar P, Chandra K, Mishra AK, Prakash V, Shankar M. Subacute Thyroiditis Presenting as Puo - A Case Report. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2021 Dec 4];4:44-5. Available from: http://www.jigims.co.in/text.asp?2018/4/2/44/302954




  Background: Top


Fever is an elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point.[1] Increase in hypothalamic set point is caused by release of various cytokines such as interleukin - 1, interleukin - 6, tumour necrosis factor and ciliary neurotropic factor.[1] The term pyrexia of unknown origin is a type of prolonged fever and is defined as when temperature is more 101 degree Fahrenheit on at least two occasions, illness duration more than 3 weeks, diagnosis that remain uncertain after a thorough history taking, physical examination and obligatory investigations such as CBC, ESR, CRP, KFT, LFT, lactate dehydrogenase, CPK, ferritin, ANA, RA factor, protein electrophoresis, blood culture, urine culture and tuberculin test.[2]

Pyrexia of unknown origin (PUO), first described by Petersdorf and Beeson, is among the most difficult diagnostic problems encountered in Internal Medicine.[2] PUO can be subdivided into four categories such as classical, nosocomial, neutropenic and HIV-related. This could be expanded to include the elderly as a fifth group. The causes are broadly divided into four groups: infective, inflammatory, neoplastic and miscellaneous. In 50% of patients no cause found despite adequate investigations.[3] Endocrine causes of PUO are rare. The most common endocrine disorder presenting as PUO is subacute thyroiditis.[4] We report a case of subacute thyroiditis presenting as PUO.

CASE:

55 years old male who was a known diabetic on insulin was admitted with history of fever of one month duration. Patient was treated outside at a tertiary care centre as indoor patient but any definite diagnosis of fever was not established. There was no other significant history. On examination patient was febrile, pulse was 112 per minute, regular, normal in volume and character without radio radial and radio femoral delay. BP was 130/80 mmHg. Thyroid examination revealed tender thyromegaly. His systemic examination such as CVS, RS, PA, CNS and MSK were clinically within normal limit. Lab investigations are Hb 10.7gm%, TLC 13,500/cumm, BSR - 215gm/dl, TSH 0.01mIU/L (Low), FT3 - 4.57ng/dl(high), FT4 3.64 ng/dl(high), ESR 85 after one hour, CRP- 52.1 mg/L, CXR - N, USG abdomen - hepatomegaly with prostatic enlargement. CECT abdomen and chest were normal. Blood culture and urine culture were sterile. Rapid diagnostic tests such as malarial antigen, widal and RK 39 were negative. Serology for leptospirosis, scrub typhus and brucellosis were negative. ANA was negative. Based on the above clinical and laboratory findings the diagnosis of subacute thyroiditis with diabetes mellitus was made. Patient was treated with beta-blocker, steroid, insulin and paracetamol. Patient responded with treatment.


  Discussion: Top


Pyrexia of unknown origin is a diagnostic dilemma and often requires detailed history and examination with extensive investigations. The causes are broadly divided into four groups: infective, inflammatory, neoplastic and miscellaneous.[2] Endocrine causes of PUO are rare and are commonly because of subacute thyroiditis.[4]

Thyroiditis is the inflammation of thyroid gland. Based on onset and duration clinically it can be classified as acute, subacute or chronic. Acute is because of suppurative infection characterised by tender and painful thyromegaly, fever, dysphagia and lymphadenopathy.[5] Subacute thyroiditis is commonly because of viral infection and is characterised by painful and tender thyroid gland and fever. It commonly mimics features of upper respiratory tract infection. So, the diagnosis is missed commonly. It commonly affects female patients of the age group of 40-50 years age. It is associated with inflammation and release of thyroid hormones. Laboratory investigation will show high ESR, low level of RAIU, low TSH and high T4 and T3. Patient can be diagnosed on the basis of clinical and biochemical criteria. If diagnosis is in doubt then FNAC of thyroid gland can be done.[5] Chronic thyroidits is commonly associated with autoimmunity and present as thyromegaly.[5]

Subacute thyroidits can present as pyrexia of unknown origin as observed in this case. Chamara Dalugama reported asymptomatic thyroiditis presenting as pyrexia of unknown origin. The patient was 42 years old male presented with history of fever of more than three weeks duration. On examination patient was having bilateral tender cervical lymphadenopathy. Lab investigation revealed high ESR, high CRP, low TSH, high T4 and T3, thyromegaly with increased vascularity on USG and evidence of thyroidtis on FNAC. He responded to steroids.[6] Faiz Muqtadi, Ashfaq Ahmed, Khalid Gufran, and Mariam Omer Bin Hamza reported a case of subacute thyroiditis presenting as pyrexia of unknown origin. The patient was 40 years old male with fever of 2 months duration. The patient thyroid function tests revealed elevated serum FT4 level of 3.66ng/dL and a decrease in TSH to 0.02 μIU/mL; TSH receptor antibody and thyroid peroxidase antibody test results were negative. Thyroid ultrasonography showed enlargement of both lobes, with hypoechogenicity and a heterogeneous structure. Random fine-needle aspiration (FNA) of the thyroid gland showed a result consistent with subacute thyroiditis. Based on the above- described evidence, the diagnosis of subacute thyroiditis was made. The patient's was treated with low-dose steroid (prednisolone, 10mg per day).[7] Saeed Ahmed Mahar et al. conducted a study on 26 patients with thyroidtis who attended the endocrine clinic. Mean age of patients was 41.2 ± 11.12 years. There were 18 (69.2%) females. Major symptoms reported were: sore throat (69.2%), weight loss (38.5%), upper respiratory tract infection, thyroid pain, tremor, sweating and fever of unknown origin in 26.9% cases. All the patients had raised ESR. Low Thyroid Stimulating Hormone (TSH) < 0.4 mlU/L was seen in 88.5% and 57.7% had raised Free T4 > 1.8 ng/dL. Complete recovery was seen in 88.5% patients while 11.5% had early hypothyroidism.[8]


  Conclusion: Top


Endocrine disorders could be one of the rare causes of pyrexia of unknown origin. Subacute thyroidits, a rare cause of PUO should be considered as a differential diagnosis even if clinical symptoms of thyrotoxicosis are not present. Abnormal thyroid function may be an early clue for diagnosis of subacute thyroidits.



 
  References Top

1.
Charles A, Dinarello, Reuvan Porat. Fever. Harrison's principles of internal medicine, edited by Kasper, Fauci, Hauser, Longo, Jameson, Loscalzo.19th edition. McGraw Hill education.2015.123-126.  Back to cited text no. 1
    
2.
Chantal P, Bleeker-Rovers, Jos W. M. Van der Meer. Fever of unknown origin. Harrison's principles of internal medicine, edited by Kasper, Fauci, Hauser, Longo, Jameson, Loscalzo.19th edition. McGraw Hill education.2015.135-141. 3  Back to cited text no. 2
    
3.
Fernandez C., Beeching NJ. Pyrexia of unknown origin. Clinical medicine. 2018, Vol 18. No 2: 170-4  Back to cited text no. 3
    
4.
Cunha BA. Fever of unknown origin: clinical overview of classic and current concepts. Infect Dis Clin North Am 2007; 21:867-915.  Back to cited text no. 4
    
5.
Jmaeson JL, Mandel SJ, Weetman AP. Disorders of the thyroid gland. Harrison's principles of Internal Medicine, edited by Kasper, Fauci, Hauser, Longo, Jameson, Loscalzo.19th edition. McGraw Hill education.2015.2298-2302  Back to cited text no. 5
    
6.
Dalugama C. Aymptomatic thyroidtis presenting as pyrexia of unknown origin: a cases report. J Med Case Rep 2018; 12: 51  Back to cited text no. 6
    
7.
Muqtadir F., Ahmed A., Gufran K., Hmaza MO Bin. Journal of Evolution of Medical and Dental Sciences. 2015; Vol. 4/ Issue 88: 2278-4748  Back to cited text no. 7
    
8.
Mahar SA, Sahid M., Sarfraz A., Shaikh S., Shaikh Z., and Sahid N. Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25  Back to cited text no. 8
    




 

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