Thyroiditis encompasses a group of disorders characterized by thyroid inflammation and is often associated with a painful thyroid. Silent or painless thyroiditis accounts for approximately 0.5 to 5% of cases of thyrotoxicosis and is usually not recurrent. We report the case of a young female with recurrent silent thyroiditis and complete thyroid function recovery.
A 32 y/o female with a previous episode of thyrotoxicosis 10 years ago which was initially treated with anti-thyroidal therapy for presumed Grave's disease. The therapy was discontinued after 1 month due to prompt resolution of the thyrotoxicosis. She remained asymptomatic and with normal thyroid function studies until presenting with 2 weeks history of fatigue, palpitations, chest tightness, heat intolerance, 10 pounds weight loss and hair loss. She denied neck pain but reported mild swallowing difficulties. Vitals signs were normal except for a heart rate of 102/min. Physical examination showed a thin woman with a normal sized, firm thyroid gland without nodules or tenderness.
Laboratory studies: TSH 0.01 (0.36-3.74 mIU/L), free T4 4.01 (0.76-1.46 ng/dL), free T3 >10.0 (2.3-4.2 pg/mL), AST 116 (0-40 IU/L), ALT 305 (0-68 IU/L), TPO <1.00 (0.0-9.0 IU/mL) and TRAB <1.00 (0.0-1.75 IU/L). Thyroid radioiodine uptake was low with an uptake of 0.5%. She was started on propranolol 10 mg TID. The TSH remained suppressed and free T4 and free T3 elevated for 5 weeks. At the time of the patient's 2 months follow up, her TSH was 9.49 with normal free T4 levels and normal liver function test. Patient was without hypothyroid symptoms. TSH returned to normal in 5 months.
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Silent thyroiditis is considered a variant form of chronic autoimmune thyroiditis, suggesting that it is part of the spectrum of thyroid autoimmune disorder. The condition is characterized by transient hyperthyroidism, often followed by transient hypothyroidism, and eventual thyroid recovery. Factors described that can initiate silent thyroiditis are: medications (e.g. lithium, immune checkpoint inhibitors, interferon alfa), SLE, idiopathic thrombocytopenia purpura, and others. Silent thyroiditis is self-limited and beta-blockers are used to relieve palpitations in symptomatic patients. This case is unusual in that only 10% of patients experience additional episodes.
Silent thyroiditis is a rare cause of thyrotoxicosis. Patients affected with this condition can have recurrences in the future, but this is also very rare. Many etiologies have been described in the literature as the presentation of this condition but no precipitating factors were identified in this case.
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