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RRóóżżne oblicza choroby de ne oblicza choroby de QuervainaQuervaina-- trudnotrudnośści diagnostyczne ci diagnostyczne
ENDOCRINUS Studenckie Endokrynologiczne
Koło Naukowe przy Klinice Chorób Wewnętrznych i
Endokrynologii WUM
Sara Zawadzka
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Plan prezentacji•• Opis przypadkuOpis przypadkuna podstawie artykułu What might cause pain in the thyroid gland? Report of a patient with subacute
thyroiditis of atypical presentation(Polish Journal of Endocrinology, 2/2012)
•• Choroba de Choroba de QuervainaQuervaina– Epidemiologia – Diagnostyka– Różnicowanie– Leczenie
•• Podsumowanie, wnioskiPodsumowanie, wnioski
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Case Report
Październik 2010r., GP:
• 39-letnia kobieta• Nawracające stany podgorączkowe• Ból lewej strony szyi, promieniujący do ucha• Obfite poty nocne• Złe samopoczucie, osłabienie
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Wywiad
• Infekcja górnych dróg oddechowych w połowie września 2010r.
• Operacja wycięcia guza jajnika w 2008r.• Przewlekłe zapalenie żołądka• Nietolerancja NLPZ
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Leczenie• Amoxycylina 1mg/d po 10 dniach brak poprawy
• Listopad: konsultacja otolaryngologiczna
• USG tarczycy: hypoechogeniczna, nieregularna zmiana w lewym płacie twarda i bardzo bolesna przy dotyku
• BACC tarczycy: zmiana łagodna, obecny naciek zapalny
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Badania laboratoryjne wykonane w XI 2010r.
• OB 9 [mm/h] 0–12• CRP 0.28 [mg/L] 0–5• WBC 5.79 × 103 [1/μL] 3.9–11.0 × 103
• RBC 4.27 × 106 [1/μL] 3.5–5.2 × 106
• TSH 0.82 [μIU/mL] 0.27–4.2• TPOAb 6 [IU/mL] 0–34• TgAb 91 [IU/mL] 10–115• TRAb 0.26 [IU/L] 0–2
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DIAGNOZA:
Podostre ziarniniakowe zapalenie tarczycy
Ibuprofen 1mg/d p.o.
Ketoprofen 100mg/d i.v.
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Pogorszenie stanu
• Cała tarczyca bardzo bolesna• Dysfagia• Spadek apetytu• Utrata masy ciała• Osłabienie• Gorączka 39,8 oC
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Grudzień 2010
• Prednizon 40 mg/d p.o. bóle żołądka, RR
Powtórzone badania laboratoryjne:• OB 8 [mm/h] 0–12• CRP 0.83 [mg/L] 0–5• TSH 0.67 [μIU/mL] 0.27–4.2
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Ponowienie diagnostyki
• USG• Scyntygrafia • BACC
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Obraz sonoelastograficzny (powyżej) i ultrasonograficzny (poniżej)
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Scyntygrafia tarczycy Tc-99m
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BACC
• Komórki zapalne: limfocyty, histiocyty, pojedyncze wielojądrowe kom. olbrzymie
• Kilka grup komórek pęcherzykowych
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• Metyloprednizolon 1x120mg i.m.
ZAPALENIE TARCZYCY
• totalna tyreoidektomia – styczeń 2011
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Obraz makroskopowy preparatu operacyjnego potyreoidektomii
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Badanie histopatologiczne preparatu operacyjnego
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Podostre ziarniniakowezapalenie tarczycy
DIAGNOZA ostateczna:
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Choroba de Quervaina(Podostre ziarniniakowe zapalenie tarczycy,
bolesne podostre zapalenie tarczycy)
• Najczęściej: kobiety (4-7 : 1), 20-50 r.ż.• Etiologia: nieznana
– Powikłanie wirusowego zakażenia górnych dróg oddechowych
– Predyspozycja genetyczna (antygen HLA-B35 ?)
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Fritz de Quervain(1868–1940)
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• Powiększone pęcherzyki z hiperplazją nabłonka i zniszczeniem błony podstawnej
• Naciek: komórki jednojądrowe, limfocyty, neutrofile• Włóknienie miąższu
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Klinicznie:• Złe samopoczucie, zmęczenie• Możliwa gorączka, bóle mięśniowe• Bolesność uciskowa gruczołu tarczowego lub
ból szyi, promieniujący do żuchwy, ucha lub górnej części klatki piersiowej
• Zaczerwienienie, zwiększone ucieplenie skóry wokółtarczycy
Laboratoryjnie:• OB., CRP, WBC w normie
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Klasyczny przebieg: 4 fazy
• Tyreotoksykoza – kilka tyg. do 2 mies.• Eutyreoza – 1-3 tyg.• Hipotyreoza – kilka tyg./mies.• Regeneracja (eutyreoza)
do 9 miesięcy
(średnio ok. 3 mies)
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Badania dodatkowe:• USG obszary hipoechogeniczne• Scyntygrafia osłabiony wychwyt znacznika,
czasem ‘zimne guzki’
Leczenie:• 2/3 samoistne wyzdrowienie bez powikłań• Przeciwbólowo: ASA / NLPZ / GKS• Zwykle nie stosujemy:
– Leków przeciwtarczycowych w tyreotoksykozie– L-tyroksyny w hipotyreozie
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Powikłania:rzadkie!
• Przejściowa niedoczynność tarczycy: 20-56%• Stała niedoczynność: 5-15%• Leczenie GKS ryzyko wystąpienia
niedoczynności w długoterminowych follow-up• Nawrót choroby: 2%
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Diagnostyka różnicowa
• Krwotok do guzka / torbieli tarczycy• Zmiany złośliwe w obrębie tarczycy• Sarkoidoza• Inne formy zapalenia tarczycy…
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Classification of Thyroiditis
Riedel's struma, Riedel's thyroiditisInvasive fibrous
Suppurative thyroiditis, acute thyroiditisMicrobial inflammatory
Subacute granulomatous thyroiditis, de Quervain's thyroiditis
Granulomatous
Subacute lymphocytic thyroiditis: (1) postpartum thyroiditis and (2) sporadic painless thyroiditis
Subacutelymphocytic
Chronic lymphocytic thyroiditis, Hashimoto's thyroiditis
Chronic lymphocytic
SynonymsHistologicclassification
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Clinical Manifestations of Thyroiditis Subtypes
VariableokokVariableNoUnknownInvasive fibrous
+NoAutoimmuneHashitoxicosis
-okokVariableYesBacterial, fungal, parasitic
Microbial inflammatory
+NoAutoimmuneSubacute lymphocytic
-YesViralSubacutegranulomatous
+VariableVariableVariableNoAutoimmuneHashimoto's disease
Thyroid autoantibT4TSHRAIUNeck
painEtiologySubtype
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Podsumowanie
• Objawy kliniczne zapalenia• Destrukcja nabłonka pęcherzyków
tarczycy, ziarnina, włóknienie• Charakterystyczny obraz zestawu OB., CRP, WBC• Obniżony wychwyt jodu w scyntygrafii• Samoistne ustąpienie bez powikłań• Skojarzenie z wirusowym zakażeniem G.D.O.
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Najczęstszy powód błędnych diagnoz:
Brak czujności endokrynologicznej !!!!
Najczęstsze błędne rozpoznania: PharyngitisPharyngitis, , inne zapalenia tarczycy, nowotwory tarczycyinne zapalenia tarczycy, nowotwory tarczycy
BACC tarczycy jest badaniem rozstrzygającym, ale zwykle jest niepotrzebna
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LITERATURA
• „Thyroiditis” Burgi H., 1994 Schweiz Rundsch Med. Prax• „Subacute thyroiditis of the Quervain” British Medical
Journal• „Eponim de Quervain thyroiditis” P. Engkakul 2011
Pediatr• „Painful subacute thyroiditis (de Quervain’s thyroiditis)”
Sebastian A. Peter, MD Brooklyn, New York• „Thyroiditis: Differential Diagnosis and Management” J.
Slatosky, B. Shipton, H. Wahba, M.D., 2000, Mercy Hospital, Pittsburgh, Pennsylvania Am Fam Physician.
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Dziękuję za uwagę
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