Time-Lag Between Symptom Onset and Diagnosis of Subacute Thyroiditis – How to Avoid the Delay of Diagnosis and Unnecessary Overuse of Antibiotics

Abstract

Clinical symptoms of subacute thyroiditis (SAT) may be misleading and the proper diagnosis is significantly delayed, and many unnecessary therapeutic methods are used, including application of antibiotics. The purpose of the study is to analyze the reasons and frequency of delayed SAT diagnosis and unnecessary antibiotic treatment and to propose a simple algorithm to facilitate the diagnosis and prevent antibiotic abuse. Sixty-four SAT patients were divided into groups depending on the period of time from the first symptoms of SAT to diagnosis and on the unnecessary use of antibiotics. Data from medical history and laboratory test results were analyzed for individual groups to determine the reasons for delayed diagnosis and incorrect treatment. In 73% of patients, the diagnosis was delayed from over two weeks up to six months. Among 62 patients who provided data on antibiotic use, 29 (46.77%) were treated with one or more antibiotics due to SAT symptoms. Fever, preceding infection, increased C-reactive protein (CRP), and WBC were characteristic for the antibiotic treated group. Fever, preceding infection, increased CRP and WBC are typical for both SAT and infection and are the main symptoms leading to misdiagnosis and unnecessary antibiotic treatment in SAT. Thus, in all patients with neck pain or other SAT-like symptoms, thorough clinical examination of the neck is mandatory. When firm and/or tender thyroid nodule/goitre is present and erythrocyte sedimentation rate /CRP is increased, patient should be promptly referred to an endocrinologist, and antibiotics are not recommended.

Keywords

subacute thyroiditis - late diagnosis - antibiotic abuse - infection

• References

• 1 Samuels MH. Subacute, silent, and postpartum thyroiditis. Med Clin North Am 2012; 96: 223-233
• 2 Stasiak M, Michalak R, Stasiak B. et al. Clinical characteristics of subacute thyroiditis is different than it used to be – current state based on 15 years own material. Neuro Endocrinol Lett 2019; 39: 489-495
• 3 Alfadda AA, Sallam RM, Elawad GE. et al. Subacute thyroiditis: clinical presentation and long term outcome. Int J Endocrinol 2014; 794943
• 4 Fatourechi V, Aniszewski JP, Fatourechi GZ. et al. Clinical features and outcome of subacute thyroiditis in an incidence cohort: Olmsted County, Minnesota, study. J Clin Endocrinol Metab 2003; 88: 2100-2105
• 5 Daniels GH. Atypical subacute thyroiditis: preliminary observations. Thyroid 2001; 11: 691-695
• 6 Karachalios GN, Amantos K, Kanakis KV. et al. Subacute thyroiditis presenting as fever of unknown origin. Int J Clin Pract 2010; 64: 97-98
• 7 Dalugama C. Asymptomatic thyroiditis presenting as pyrexia of unknown origin: a case report. J Med Case Rep 2018; 12: 51
• 8 Stasiak M, Tymoniuk B, Adamczewski Z. et al. Sonographic Pattern of Subacute Thyroiditis Is HLA-Dependent. Front Endocrinol (Lausanne) 2019; 23: 3
• 9 Cappelli C, Pirola I, Gandossi E. et al Ultrasound findings of subacute thyroiditis: a single institution retrospective review. Acta Radiol 2014; 55: 429-433
• 10 Vural Ç, Paksoy N, Gök ND. et al. Subacute granulomatous (De Quervain’s) thyroiditis: Fine-needle aspiration cytology and ultrasonographic characteristics of 21 cases. Cytojournal 2015; 12: 9
• 11 Stasiak M, Michalak R, Lewinski A. Thyroid primary and metastatic malignant tumours of poor prognosis may mimic subacute thyroiditis – time to change the diagnostic criteria: case reports and a review of the literature. BMC Endocr Disord 2019; 19: 86
• 12 Stasiak M, Tymoniuk B, Stasiak B. et al. The risk of recurrence of subacute thyroiditis is HLA-Dependent. Int J Mol Sci 2019; 3: 20 pii:E1089
• 13 Janssen OE. Atypical presentation of subacute thyroiditis. Dtsch Med Wochenschr 2011; 136: 519-522
• 14 Qari FA, Maimani AA. Subacute thyroiditis in Western Saudi Arabia. Saudi Med J 2005; 26: 630-633
• 15 Saito Y, Hara H, Tsujie M. et al. A Case of Subacute Thyroiditis during Chemotherapy after Distal Pancreatectomy. Gan To Kagaku Ryoho 2016; 43: 621-623
• 16 Nishihara E, Ohye H, Amino N. et al. Clinical characteristics of 852 patients with subacute thyroiditis before treatment. Intern Med 2008; 47: 725-729
• 17 Tachibana T, Orita Y, Ogawara Y. et al. Time-lag between symptom onset and laboratory findings in patients with subacute thyroiditis. Auris Nasus Larynx 2014; 41: 369-372
• 18 Bulman ZP, Chen L, Walsh TJ. et al. Polymyxin Combinations Combat Escherichia coli Harboring mcr-1 and blaNDM-5: Preparation for a Postantibiotic Era. mBio 2017; 8: e00540-17
• 19 Hudson CM, Bent ZW, Meagher RJ. et al. Resistance determinants and mobile genetic elements of an NDM-1-encoding Klebsiella pneumoniae strain. PLoS One 2014; 9: e99209
• 20 Antimicrobial resistance: global report on surveillance. WHO; 2014; www.who.int
• 21 Global action plan on antimicrobial resistance. WHO; 2015; www.who.int
• 22 https://ecdc.europa.eu/en/publications-data/directory-guidance-prevention-and-control/antimicrobial-resistance-strategies
• 23 National Programme to Protect Antibiotics 2016–2020 Ministry of Health, Poland. 2016; www.mz.gov.pl