WBR0946

Author	[[PageAuthor::William J Gibson (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pharmacology
Sub Category	SubCategory::Endocrine
Prompt	[[Prompt::A 36-year-old man presents to his primary care physician for anxiety, palpitations, and insomnia over the past week. The patient also reports dysphagia and unintentional weight loss. Physical examination is remarkable for a heart rate of 110/min and a tender neck mass. Radionuclide thyroid scan is abnormal and reveals a deceased uptake. Which of the following is the most appropriate therapy to manage this patient's condition?]]
Answer A	AnswerA::Methimazole
Answer A Explanation	AnswerAExp::Methimazole is an anti-thyroid drug that inhibits thyroperoxidase, an enzyme essential for the synthesis of T4. Because De Quervain’s thyroiditis eventually causes hypothyroidism, an anti-thyroid drug is not recommended.
Answer B	AnswerB::Propylthiouracil
Answer B Explanation	[[AnswerBExp::Propylthiouracil (PTU) is an anti-thyroid drug that inhibits thyroperoxidase, an enzyme essential for the synthesis of T4. It also inhibits the conversion of T4 to T3 peripherally. Because De Quervain’s thyroiditis eventually causes hypothyroidism, an anti-thyroid drug is not recommended.]]
Answer C	AnswerC::Surgery
Answer C Explanation	AnswerCExp::De Quervain’s thyroiditis usually self-resolves, and surgery is not recommended.
Answer D	AnswerD::Aspirin
Answer D Explanation	AnswerDExp::Patients with De Quervain’s thyroiditis should be treated with NSAIDs to decrease inflammation and a beta-blocker to manage the symptoms of hyperthyroidism in the acute phase.
Answer E	AnswerE::Levothyroxine
Answer E Explanation	AnswerEExp::At this stage, the patient is displaying symptoms of hyperthyroidism. Eventually, patients with De Quervain’s thyroiditis return to a euthyroid state.
Right Answer	RightAnswer::D
Explanation	[[Explanation::De Quervain’s thyroiditis is a subacute thyroiditis that often develops following a viral infection and usually self-resolves. Patients typically present with symptoms of hyperthyroidism followed by hypothyroidism. A hyperthyroid period occurs as the thyroid follicles are destroyed, releasing abundant colloid and thyroid hormone into the circulation. Patients typically then become hypothyroid as the pituitary reduces TSH production and the inappropriately released colloid is depleted before patients resolve to a euthyroid state. In contrast to other inflammatory thyroid conditions, the thyroid may become enlarged and tender, causing dysphagia. Classically, multinucleated giant cells are present on thyroid biopsy, and in some cases, patients will test positive for anti-thyroid antibodies. The clinical presentation during the hyperthyroid phase can mimic those of either diffuse toxic goiter or Graves' disease. In such cases, a radionuclide thyroid uptake and scan can be helpful, since subacute thyroiditis will result in decreased isotope uptake, while Graves' disease will generally result in diffusely increased uptake. Patients typically respond to NSAIDs (e.g. aspirin) and beta-blockers. Educational Objective: De Quervain’s thyroiditis is characterized by an acute hyperthyroid period followed by hypothyroidism. It typically manifests with thyroid tenderness and dysphagia, with decreased isotope uptake on radionuclide thyroid scan. References: First Aid 2015 page 328.]]
Approved	Approved::Yes
Keyword	WBRKeyword::Thyroid, WBRKeyword::Thyroiditis, WBRKeyword::Autoimmune, WBRKeyword::De Quervain’s thyroiditis, WBRKeyword::Radionuclide thyroid scan, WBRKeyword::Aspirin
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