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
What is your cytomorphologic diagnosis?
Case 1
Surgical excision of left lobe
Before & After de Quervain
Sub-acute Thyroiditis (SAT) /Granulomatous Thyroiditis
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.
2. Thyroiditis acuta (Frank Joseph -1823) 3. Angina Thyroidea (Weitenweber -1845)
THE JOURNAL OF LARYNGOLOGY, RHINOLOGY, AND OTOLOGY. VOL. IX. MARCH, 1895. No. 3.
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Twenty-five reprints are allowed each author. If more are required it is requested that this be stated when the article is first forwarded to this Journal.
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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
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+ T-
lymphocytes, 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%
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