the Case Study

History
—  52-year-old woman
—  Transient symptomatic hyperthyroidism (TSH – 0.03) followed by
hypothyroidism.
—  Current medication: Synthroid
—  Ultrasound – Left thyroid lobe occupied by a predominantly
ill-defined hypoechoic structure – suspicious for anaplastic
carcinoma
Case 1
What is your cytomorphologic diagnosis?
Surgical excision of left lobe
Sub-acute Thyroiditis (SAT) /
Granulomatous Thyroiditis
Before & After de Quervain
Granulomatous Thyroiditis
Historical Descriptions
—  “Acute inflammation of the healthy thyroid gland”
1.  Cynanche Thyroidea (Ph. Fr. Walther – 1817)
1. 
Cynanche : Any disease of the tonsils, throat, or windpipe, attended
with inflammation, swelling, and difficulty of breathing and
swallowing.
Thyroiditis acuta (Frank Joseph -1823)
3.  Angina Thyroidea (Weitenweber -1845)
2. 
THE
JOURNAL OF LARYNGOLOGY,
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VOL. IX. MARCH, 1895. No. 3.
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THYROIDITIS ACUTA SIMPLEX.1
By HOLGER MYGIXD, M.D.
De Quervain
—  Fritz de Quervain (May 4, 1868 – January 24, 1940) was a Swiss surgeon born in Sion.
He was a leading authority on thyroid disease.
—  In 1892 he received his doctorate from the University of Bern, and several years later
became director of the surgical department at a hospital in La Chaux-de-Fonds in the
canton of Neuchâtel.
—  In 1910 he was appointed to the chair of surgery at the University of Basel, and from
1918 was a professor of surgery at Bern and director of the Inselspital.
—  De Quervain published many papers devoted to thyroid disease, ranging from the
epidemiology of the disease to technical procedures on thyroidectomy. His book Spezielle
chirurgische Diagnostik (Special Surgical Diagnosis) was a leading textbook on surgery in
its day.
—  He is responsible for introducing iodized table salt in order to help prevent Goitre. Two
eponymous diseases are named after De Quervain:
Sub-acute thyroiditis (SAT)
—  Self-limiting inflammatory, possible viral associated disorder.
—  Preceding upper respiratory infection
—  Elevated titers of several viral antibodies
—  Seasonal and geographic clusters
—  Early spring and fall
—  Japan & Turkey
—  Two thirds of patients with SAT have HLA B35
—  Symptoms
—  Pain in the thyroid region – 94%
—  Weeks to months if left untreated
—  Various symptoms associated with thyrotoxicosis
Sub-acute thyroiditis (SAT)
—  Clinical features & Laboratory Evaluation - critical first 7
days (Nishihara E, et.al Intern Med 2008;47:725-9, 852 patients
with SAT 1996-2004)
—  Body temperature >100 Fahrenheit
—  Thyrotoxicosis
—  Low TSH, High FT3, FT4
—  High AST, ALT, CRP, ESR
—  Antithyroid antibodies
Ultrasound Examination - SAT
—  Hypoechoic area corresponding to the area of pain in thyroid
—  Focal
—  Diffuse
—  Hypo-echogenecity reflects the degree of inflammation – 32
patients (Omori N et.al – Endo J 2008)
SAT – Fine-needle aspiration
(Solano et.al DiCy 1997)
Most Relevant Cytologic Findings
—  Plump transformed follicular cells
—  Epitheliod granulomas
—  Multinucleated giant cells (97.2%)
—  Follicular cells with intra-vacuolar granules ( 77.7%)
—  Mature lymphocytes (100%)
—  Macrophages (100%)
—  Neutrophils ( 88.8%)
—  Oncocytic cells
—  Transformed lymphocytes
—  Hypertrophic follicular cells
—  Fire-flare follicular cells
Cellular composition of SAT
—  Numerous plasmacytoid monocytes closely associated with the granulomas. The
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giant cells were CD68+, thyroglobulin– and cytokeratin–.
Usually, small lymphocytes in the granulomas are CD3+, CD8+, CD45RO+
cytotoxic T cells.
In the non-granulomatous lesion, the follicles were often infiltrated by CD8+ Tlymphocytes, plasmacytoid monocytes and histiocytes, resulting in disrupted
basement membrane and rupture of the follicles.
Lymphoid follicles with or without active germinal centers were not observed.
Moreover, no residual follicular dendritic cell networks were detected by CD23
and CAN.42 immunostains.
In the interfollicular area, scattered plasma cells were observed among
infiltrating cells.
Neither human herpes virus 8 nor EBER-positive cells were detected
Cellular immune response may play an important role in the pathogenesis of
SAT .
SAT Clinical Follow-up
—  Recovery in most patients
—  Permanent hypothyroidism 5-31% of patients.
—  More common in patients treated with corticosteroids (Mayo
clinic data 2003)
—  Isolated cases of Graves’ disease and ophthalmopathy.
—  Recurrence of SAT – 4-10%