RECURRENT PAINFUL HASHIMOTO THYROIDITIS SUCCESSFULLY TREATED BY THYROIDECTOMY

Abstract

Objective: Painful Hashimoto thyroiditis (HT) is a rare HT variant characterized by neck pain. The clinical differentiation between painful HT and subacute thyroiditis is challenging, as the diagnosis cannot be confirmed without histopathological evidence. Here we present a patient who had anterior neck pain who was diagnosed with HT.

Methods: We present the patient's clinical examinations and laboratory findings (white blood cell count, thyroid-stimulating hormone, free thyroxine, thyroid peroxidase antibody, and erythrocyte sedimentation rate). Ultrasound images of the thyroid gland and pathology images representative of marked HT with positive IgG4 immunohistochemical stain after thyroidectomy are also presented.

Results: A 42-year-old female with a 3-year history of HT developed recurrent anterior neck pain with bilateral radiation to the ears as well as a tender, enlarging thyroid goiter. She had no signs of fever or a preceding infection of the upper respiratory tract. Her pain was only temporarily alleviated by oral corticosteroids. According to the serial ultrasound records, both thyroid lobes decreased in size after 2 pain episodes. She eventually underwent total thyroidectomy and remained pain-free for 1.5 years, up to the last office follow-up visit. Histopathology confirmed the diagnosis of HT.

Conclusion: In patients with HT, recurrent thyroid pain despite steroid treatment is the clinical hallmark of diagnosis of painful HT. The reference standard of diagnosis is pathology. Thyroidectomy may be considered after recurrent painful episodes.

Fig. 1.

Ultrasound of the thyroid gland showing both the left (A) and right (B) lobes. Bilateral lobes showed heterogeneous echogenicity. There was no evidence of discrete nodules.

Fig. 2.

Histopathology of the thyroid gland under hematoxylin and eosin stain (A and B) and IgG4 immunohistochemical stain (C and D). Low-power view of the Hashimoto thyroiditis with its recognizable germinal centers and low-to-moderate levels of fibrosis (A). High-power view of a group of germinal centers with entrapped thyroid follicles and marked lymphocytic and plasmacytic infiltrate (B). Panels C and D show the same area stained with IgG4 immunohistochemistry, revealing many interspersed IgG4-positive plasma cells (up to 50 per high-power field).