Integrative and Complementary Approach to Subacute Thyroiditis (De Quervain's)

When you hear the phrase “pain in the neck”, what comes to mind? Usually, people think of something (or someone!) that is bothersome. However, in the context of thyroid problems, it takes on a more literal meaning.

For patients with subacute thyroiditis, "pain in the neck" becomes a very real sensation. In fact, neck pain is one of the most common complaints. This disorder, often following a viral illness, is more prevalent in women than in men and typically affects those between the ages of 25 and 35.

In this article, we will delve into what subacute thyroiditis is, its causes, and the symptoms to be aware of. Additionally, we'll explore integrative and complementary approaches to therapy, including recommendations for testing and treatment.

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What is Subacute Thyroiditis (De Quervain's)?

Subacute thyroiditis, also known as De Quervain thyroiditis or granulomatous thyroiditis, refers to a self-limited inflammation of the thyroid gland situated in the neck, just above where the collarbones converge. This condition typically follows an immune reaction, which often arises after an upper respiratory infection. While the exact cause of subacute thyroiditis remains unknown, studies have repeatedly indicated a link between it and certain viral infections. 

Notably, the recent SARS-CoV-2 pandemic has been associated with the development of this condition in a number of cases. The condition is known for its triphasic clinical progression, encompassing transient thyrotoxicosis, followed by a hypothyroid phase, and eventually a return to normal thyroid function, which is seen in over 90% of patients. Only a small percentage of individuals may end up with permanent hypothyroidism, necessitating thyroid hormone replacement.

Subacute Thyroiditis (De Quervain's) Signs & Symptoms

Subacute thyroiditis primarily presents with pain in the neck, a symptom seen in about 96% of patients, resulting from an inflamed and swollen thyroid gland. The pain can be either sudden or gradual in onset and can spread to areas like the jaw, ears, upper neck, throat, and even the upper chest. Other manifestations include (2-4): 

• Thyroid gland tenderness: The gland becomes sensitive to even gentle pressure, and in severe cases, palpation might be intolerable for the patient.
• Swelling of the thyroid: The gland may be diffusely or asymmetrically enlarged. While it commonly affects both thyroid lobes from the onset, it can sometimes start unilaterally and later involve the other side, termed "creeping thyroiditis."
• Difficulty in swallowing and hoarseness.
• General symptoms: These encompass fatigue, fever, feeling weak, malaise, anorexia, and muscle pain (myalgia).

Hyperthyroidism symptoms (often transient)(2-4): 

• More frequent bowel movements
• Hair loss
• Intolerance to heat
• Irregular or very light menstrual cycles for women
• Mood alterations
• Tremors, particularly in the hands
• Heart palpitations
• Sweating
• Weight loss paired with an increased appetite

Hypothyroidism symptoms (this phase may follow the hyperthyroid phase)(2-4): 

• Cold intolerance
• Constipation
• Fatigue
• Irregular or heavy menstrual cycles for women
• Weight gain
• Dry skin
• Mood changes

Subacute Thyroiditis (De Quervain's) Possible Causes 

Subacute thyroiditis is believed to stem from viral infections. Many affected individuals report having a viral upper respiratory infection between 2 to 8 weeks before the onset of thyroiditis. The pattern of thyroiditis cases seems to align with the peak incidences of coxsackievirus (groups A & B) and echovirus infections. Additionally, mumps, measles, influenza, and, notably, SARS-CoV-2 are associated viruses. This condition often surfaces after a viral infection, especially infections of the ear, sinus, or throat, such as mumps, the flu, or the common cold. Middle-aged women, particularly those who exhibited symptoms of a viral upper respiratory tract infection in the recent past, are more susceptible (3). 

While subacute thyroiditis isn't primarily driven by the body's immune system mistakenly attacking its own cells (a process called autoimmunity), there is a connection to a specific protein in our body named HLA-B35. Think of this protein as a kind of "docking station" on the surface of thyroid cells. Some viral infections can mimic parts of the thyroid cell, leading our immune system to confuse the two. When the immune system targets these "docking stations," thinking they're harmful, it inadvertently damages the thyroid cells (3). 

Functional Medicine Labs to Test for Root Cause of Subacute Thyroiditis (De Quervain's)

Functional medicine labs offer a variety of tests that can help tailor treatment to patients, allowing providers to optimize management strategies.

Comprehensive Thyroid Panel

In subacute thyroiditis, the initial stages of illness reveal laboratory evidence of hyperthyroidism - specifically, mildly elevated serum-free T4 and T3 and low TSH concentrations. These changes are transient, lasting 2 to 8 weeks. As the illness progresses, there may be a period of transient hypothyroidism, during which TSH levels would be elevated, and free T4 levels would be decreased (3). 

Using this comprehensive thyroid panel will assist in mapping out these transitions and understanding the phase of illness an individual is in. This helps in differentiating subacute thyroiditis from other thyroid-related conditions, like Graves' disease, which lacks the signature fluctuations and other distinguishing features (3). 

C-Reactive Protein

C-reactive protein (CRP) is a marker of inflammation. An elevated CRP is a hallmark of subacute thyroiditis and distinguishes it from other types of thyroid diseases. Monitoring the levels of CRP can provide insights into the extent of inflammation and the progress of treatment, ensuring that measures taken are effective in managing the condition (3). 

Sedimentation Rate (ESR)

The erythrocyte sedimentation rate (ESR) test is another marker for inflammation. Similar to CRP, patients typically present with an elevated ESR, often ranging between 50 and 100. This test is valuable in confirming inflammation in the body and, when used alongside CRP, provides a more comprehensive understanding of the inflammatory status (3). 

Gut Health 

Gut health can influence systemic inflammation and immune function. A comprehensive stool test can provide insights into the gut microbiome, potential pathogens, and markers of inflammation that may be contributing to the body’s inflammatory load.

Micronutrient Testing

Checking levels of vitamins, minerals, and other nutrients can help in managing inflammation and support thyroid health. For example, selenium and zinc are important for thyroid function (5).

Additional Lab Tests 

Additional lab tests that may be ordered include thyroid ultrasonography, which can spot issues like cysts, abscesses, or unusual growths, especially in patients who don't show clear symptoms. Another test, Doppler sonography, helps tell the difference between subacute thyroiditis and Graves' disease. In rare cases, a needle aspiration might be done to make sure it's not other conditions like lymphoma, thyroid cancer, or bleeding within the thyroid (3). 

Conventional Treatment for Subacute Thyroiditis (De Quervain's)

The primary goals of conventionally treating subacute thyroiditis are to alleviate pain and manage symptoms. Anti-inflammatory medications, like aspirin or ibuprofen, are often recommended, while more intense neck pain might be treated with corticosteroids like prednisone. Hyperthyroidism symptoms typically resolve on their own, but heart palpitations and anxiety may require beta-blockers; however, standard hyperthyroidism treatments like thionamides aren't used. Most patients recover naturally in a few months, but some may develop lasting hypothyroidism, necessitating ongoing thyroid function monitoring and potential long-term treatment (3).

Functional Medicine Treatment for Subacute Thyroiditis (De Quervain's)

Functional medicine targets the root cause of Subacute thyroiditis by integrating traditional and alternative treatments. It emphasizes personalized interventions through nutrition, supplements, and complementary therapies such as stress reduction techniques and exercise.

Nutrition For Subacute Thyroiditis (De Quervain's)

Given that subacute thyroiditis is an inflammatory condition, nutritional recommendations should focus on reducing levels of inflammation in the body and optimizing general health. The Anti-Inflammatory Diet and the Mediterranean Diet serve as excellent models to achieve these aims. Both prioritize the consumption of whole foods, rich in antioxidants and essential nutrients, to mitigate inflammation. 

The Anti-Inflammatory Diet emphasizes the intake of omega-3 fatty acids from sources like fatty fish, the incorporation of healthy fats from avocados, nuts, and seeds, and the use of anti-inflammatory spices such as turmeric and ginger. It also suggests limiting sugars and refined carbohydrates and ensuring proper hydration. 

On the other hand, the Mediterranean Diet is abundant in plant-based foods, including fruits, vegetables, whole grains, and legumes. It highlights olive oil as a primary fat source, leans towards poultry, fish, and beans for protein, and promotes moderate amounts of cheese and yogurt. 

Both diets caution against trans fats, processed meats, and excessive alcohol, underscoring the importance of fresh, natural ingredients in promoting overall health and the management of inflammatory conditions like subacute thyroiditis.

Using Supplements For Thyroiditis Relief

Supplements may offer symptomatic relief from thyroiditis and support during the recovery phase. Essential nutrients like selenium and zinc play pivotal roles in the production and activation of thyroid hormones. Supplementation with selenium can be particularly beneficial as it's known to decrease thyroid antibodies, potentially mitigating the inflammatory response. Vitamin D, another critical nutrient, not only aids thyroid hormone production but also modulates immune responses, potentially helpful in an inflammatory condition like subacute thyroiditis (7). 

L-carnitine, an amino acid derivative, can be beneficial, especially when subacute thyroiditis leads to a thyrotoxicosis state. During hyperthyroid conditions, l-carnitine levels may decrease, and replenishing it can alleviate some symptoms linked to hyperthyroidism. Omega-3 fatty acids, renowned for their anti-inflammatory properties, could also be beneficial. They help reduce systemic inflammation, which might be particularly helpful considering the inflammatory nature of subacute thyroiditis (7). 

Complementary and Integrative Medicine

Complementary and integrative medicine therapies provide effective avenues for reducing total-body inflammation, especially relevant for patients with thyroiditis. Mindfulness-based stress reduction (MBSR) offers a way to face stressors with resilience, emphasizing present-moment awareness. 

Acupuncture aids in balancing the body's energy flow. This practice has been linked to deeper relaxation, countering the common "fight-or-flight" stress reactions, and managing mood by influencing chemicals like endorphins and serotonin.

Massage therapy goes beyond mere relaxation, offering measurable benefits like improved heart rate variability (HRV), an indicator of the body's stress response adaptability. Chiropractic care potentially supports the nervous system, demonstrating preliminary effects on pain perception, muscle function, and inflammation markers. Additionally, physical exercise plays a crucial role in further reducing inflammation, contributing to overall health (14). 

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Summary

In summary, subacute thyroiditis, often referred to as De Quervain's, is an inflammatory thyroid disorder primarily affecting women aged between 25 and 35, with a characteristic progression from a hyperthyroid phase, potentially transitioning to a hypothyroid stage before eventually returning to normal function. 

While its primary cause seems to be viral infections, it is intricately linked with the HLA-B35 protein and the immune system's inadvertent attack on the thyroid cells. Conventional treatments focus on symptom alleviation, but functional medicine underscores the benefits of personalized nutrition, supplementation, and complementary therapies. 

Approaches such as dietary adjustments, supplements, and integrative methods like acupuncture and massage reinforce the significance of a holistic strategy in managing this condition.