622 SUBACUTE AUTOIMMUNE THYROIDITIS SIMULATING DE QUERVAIN’S THYROIDITIS

SIR,-Patients with subacute De Quervain’s thyroiditis present with fever and pain in the neck which may

typically

be described

throat and be

misdiagnosed as acute tonsillitis, although an upper-respiratory-tract infection can precede the condition.’ The finding of a tender, diffuse goitre on examination is usually associated with a clinical diagnosis of De Quervain’s thyroiditis. Rarely, Hashimoto’s thyroiditis as a sore

may present in the same way.



We thank Prof. H.

Keen, Prof.

M. H.

Lessof, and Dr M. N. Maisey

permission and encouragement to report these cases. S.N.T.F. is supported by a research grant from the Guy’s Hospital Special Trus-

for

tees.

Department of Endocrinology and Nuclear Medicine and Department of Medicine, Guy’s Hospital, London SE1 9RT

antibiotics for a sore throat and fever following dental extraction. Over the next 3-4 weeks a painful, tender, diffuse goitre developed, with increasing lassitude. She was referred to hospital. She had no history or family history of thyroid disease. She was apyrexial but very lethargic. She had a moderate sized, firm, tender, diffuse goitre without any other abnormal physical signs. Hb 14.1g/dl; white blood-cells 6400/µl, erythrocyte-sedimentation rate 3 mm in lst hour; serum-thyroxine 17 nmol/1 (normal range 70-190); serum-thyroid-stimulating hormone 40 mU/1 (normal range 0-5), and thyroid microsomal antibodies +++. Technetium-99m thyroid scan showed a diffusely enlarged thyroid gland with a high uptake of 9% at 30 min (normal range 1-2—2%). Because her symptoms had worsened when she was reviewed 2 weeks later she was started on thyroxine 0-15 mg daily. She improved and her goitre got smaller. Her serum-T4 rose to 149 nmol/1 and serum-T.s.H. fell to 1.7 mU/l. After 6 months’ treatment, thyroxine was stopped for 4 weeks for reassessment of thyroid status. Her serum-T fell to 70 nmol/1, serum-T.s.H. rose to 9 mU/1, while her thyroid antibodies remained strongly positive (+++). A

roiditis is associated with a high incidence of permanent hypothyroidism, it is clearly important that a correct diagnosis be made in any patient with subacute onset of thyroiditis.

S. NG TANG FUI

D.B.JEFFERYS

14-year-old girl was given

A 16-year-old girl presented with a 3-day history of painful diffuse goitre. 10 days previously, she had had a fever, malaise, and a productive cough, for which ampicillin had been prescribed. She had no history of thyroid disease. She seemed well and was apyrexial with a moderate sized goitre. She had a rather hoarse voice but no other abnormal physical signs. Hb 14.4 g/dl, white blood-cells 5200/µl; E.s.R. 2 mm in first hour; serum-T4 63 nmol/1, serum-T.s.H. 27.6 mU/1, and thyroid microsomal antibodies +++. Technetium-99m thyroid scan showed a diffuse goitre with a raised uptake of 2.6% at 30 min. While the results of her investigations were awaited, her goitre increased in size and became more painful. She was given a 2-week course of prednisolone, starting with 30 mg daily, with improvement of her pain and goitre. As her serum-T.s.H. was still 35mU/1 after the course of steroids, with thyroid antibodies ++, she was started on thyroxine and maintained on a dose of 0.2mg daily. The rapid development of a diffuse, painful, tender goitre associated with recent fever in these girls suggested subacute De Quervain’s thyroiditis. However, the strongly positive autoantibodies, high thyroidal uptake of technetium-99m, and the biochemical evidence of primary hypothyroidism pointed to autoimmune (Hashimoto’s) thyroiditis with a subacute onset. Autoimmune thyroiditis simulating De Quervain’s thyroiditis clinically has been reported by Doniach et al.2 who also observed that iodine uptake could be normal, increased, or decreased. The iodine uptake was low in patients with hypothyroidism but normal or raised in those without hypothyroidism at presentation. Thyroid uptake of technetium was high in both our patients who were biochemically hypothyroid as evidenced by sensitive radioimmunoassay measurement of serum T.S.H.

SIR,-Previous studies in our laboratory have demonstrated significant differences in the extent of protease reactivity with M.U.G.B. (4-methylumbelliferyl guanidinobenzoate, a sensitive active site titrant of many serine proteases’) when plasma and cultivated skin fibroblasts from patients with cystic fibrosis (c.F.), obligate heterozygotes, and controls were compared.2-5 Because of these observations and the potential value of amniotic fluid for the prenatal detection of cystic fibrosis, these studies were extended to human amniotic fluid obtained by amniocentesis done for the intrauterine detection of genetic and other fetal abnormalities. Over 200 second-trimester amniotic fluids have been assayed for M.U.G.B. reactivity (unpublished). The mean M.U.G.B. titre value obtained was 12-21+2-65 (nmol M.U. formed/ml); the

specific activity was 2-66+0-43 (nmol M.u. formed/mg protein). An amniotic-fluid sample obtained from a woman who was subsequently delivered of a baby with c.F. showed a much reduced level of M.U.G.B. reactivity (3-01 nmol M.U. formed/ml: 1.06 nmol M.u. formed/mg protein) similar to the relative deficiency observed in plasma and cultivated skin fibroblasts from patients with C.F.2-5 In addition, after isoelectric focusing on polyacrylamide gels subsequently reacted with M.U.G.B. or x-N-benzoyl-L-arginine ethyl ester, a substrate of the arginine esterases, a single band (pI 5-1-5-4) was consistently absent in the c.F. amniotic fluid. Two additional amniotic-fluid samples from pregnancies which resulted in

mean

children with c.F. were identified out of a group of coded samples sent from other laboratories. The M.U.G.B. titre values were 4-73 and 4-32 with specific activities of 1-24 and 1.30, respectively. These fluids also gave one less activity band upon isoelectric focusing than did the controls. These observations suggest that amniotic-fluid protease activity may be a useful marker for the prenatal detection of C.F. Although these results are promising, we would like to obtain additional samples of amniotic fluid obtained during the second or third trimester from women who have subsequently been delivered of a child with c.F. or who are at-risk of having a child with c.F. These samples will permit us to validate our findings rapidly before we embark on a large prospective study. Only 2 or 3 ml of frozen cell-free amniotic fluid is required. We would prefer to be sent samples as coded unknowns and will reimburse transport costs. Division of Genetics, Children’s Memorial Hospital, Chicago, Illinois 60614, U.S.A.

M. M. WALSH HENRY L. NADLER

and T4

Since the thyroid gland in De Quervain’s thyroiditis usually reverts to normal within a few weeks, while autoimmune thy1. Volpe, R. in The

Thyroid (edited by

S. C. Werner and S. H.

York. 1978. 2.

METHYLUMBELLIFERYL-GUANIDINOBENZOATE REACTIVE PROTEASES IN AMNIOTIC FLUID: POSSIBLE MARKER FOR CYSTIC FIBROSIS

Doniach, D., Hudson, R. V., Roitt, I. M. Br. med. J. 1960, i, 365.

Ingbar). New

1. 2

Jameson, G. W., Roberts, D. W, Adams, R. W., Kyle, W. S. A., Elmore, D. T. Biochem J. 1973, 131, 107. Walsh-Platt, M., Rao, G. J. S., Nadler, H. L. Am. J. hum. Genet. 1977, 29,

111A. 3. Rao, G. I. S., Walsh-Platt, M., Nadler, H. L. Enzyme, 1978, 23, 314. 4. Walsh-Platt, M., Rao, G. J. S., Simpson, S., Nadler, H. L. Pediat. Res. 1978.

12,129. 5 Walsh-Platt, M., Rao, G. J.

S., Nadler, H. L. ibid. 1978, 12, 874.

Subacute autoimmune thyroiditis simulating De Quervain's thyroiditis.

622 SUBACUTE AUTOIMMUNE THYROIDITIS SIMULATING DE QUERVAIN’S THYROIDITIS SIR,-Patients with subacute De Quervain’s thyroiditis present with fever and...
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