What might cause pain in the thyroid gland? Report of a patient with subacute thyroiditis of atypical presentation

Subacute granulomatous thyroiditis (SAT), also known as de Quervain's thyroiditis or painful subacute thyroiditis, is the commonest thyroid condition responsible for neck tenderness. Other causes of pain in the thyroid gland should be taken into consideration during differential diagnosis, especially when a patient presents with misleading or equivocal signs and symptoms. We report the case of a 39 year-old woman diagnosed as having SAT whose clinical, biochemical and radiological presentation varied significantly from the common SAT manifestation. A tentative diagnosis of SAT was made based on the presented symptoms, ultrasonography and fine-needle biopsy results. However, biochemical analysis suggested neither inflammatory process nor the presence of thyrotoxicosis. Moreover, technetium scan of the thyroid revealed normal uptake of the isotope and there was neither clinical nor ultasonographic response for corticosteroids. The patient's symptoms, despite being prescribed typical treatment, gradually deteriorated and the pain became increasingly debilitating. Eventually, the patient underwent total thyroidectomy. As a result, she has become free of symptoms, but the macroscopic picture of thyroid gland, noted during the operation, gave a suspicion of neoplastic process. Nevertheless, histological study of flow samples confirmed the tentative diagnosis of de Quervain's thyroiditis, despite all previous findings that were not suggestive of it. This report confirms the likelihood that SAT can present atypically. Additionally, it indicates that surgical treatment may be considered in patients with severe, debilitating, persistent thyroid gland pain connected with SAT clinical course.     

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A 51-year-old woman presented with a painful, rapidly enlarging thyroid gland. The serum concentrations of the thyroid hormones were initially at the upper limit of normal, and the uptake of radioactive iodine by the thyroid was completely depressed. Although subacute thyroiditis was suspected, a biopsy specimen from the thyroid showed malignant disease and no evidence of inflammation. At the time of right subtotal lobectomy metastatic breast carcinoma was diagnosed. Thus, primary or secondary malignant disease of the thyroid can simulate thyroiditis and present a serious problem in differential diagnosis.     

Association of different pathologic processes of the thyroid gland in fine needle aspiration samples

OBJECTIVE: To evaluate the possible significant association between different pathologic processes of the thyroid gland. STUDY DESIGN: From a series of 10,039 fine needle aspiration biopsies of the thyroid gland, a total of 1,330 cases were aspirated involving two or more palpable nodules. In 103 (1%) cases, two different pathologic processes were cytologically diagnosed. Statistical analysis was performed through four two-tailed chi 2 tests to evaluate the following events: (1) mononodularity and multinodularity vs. neoplasms, (2) colloid goiter and neoplasms, and (3) all neoplasms vs. colloid goiter and lymphocytic thyroiditis. All tests were performed using < .05 as the probability level. RESULTS: Simultaneous pathologic processes observed were: goiter and chronic lymphocytic thyroiditis (32), goiter and Hashimoto's thyroiditis (21), goiter and subacute granulomatous thyroiditis (8), goiter and follicular neoplasm (9), and goiter and papillary carcinoma (14). In 12 cases we found goiter and Hürthle cell tumor, goiter and medullary thyroid carcinoma (2), papillary thyroid carcinoma and Hashimoto's thyroiditis (2), Graves' disease and lymphocytic thyroiditis (2), and follicular neoplasm and lymphocytic thyroiditis (1). Statistical analysis showed significant association between multinodularity and neoplasms (P < .001), while the association between goiter and any type of neoplasia was not statistically significant. All the neoplasms taken together were associated with lymphocytic thyroiditis and goiter (P < .005). CONCLUSION: While there may be no statistically significant associations between the individual pathologies, it seems that having one pathology increases the risk of developing another. All the palpable nodules in the same gland should be investigated by fine needle aspiration in order to improve diagnostic sensitivity and to identify occult neoplasms.     

Urinary N-acetyl-beta-D-glucosaminidase (NAG) activity in patients with Graves' disease, subacute thyroiditis, and silent thyroiditis: a longitudinal study.

Urinary N-acetyl-beta-D-glucosaminidase (NAG) activity was measured longitudinally in 12 patients with Graves' disease, 5 patients with subacute thyroiditis, and 1 patient with silent thyroiditis, and compared with that of 36 normal controls. The patients with Graves' disease and subacute thyroiditis were treated with anti-thyroid drug (methimazole or propylthiouracil) and prednisolone, respectively. On the other hand, no treatment was given to the patient with silent thyroiditis. Since two patients with Graves' disease clearly showed transient deterioration of the thyroid function during the treatment period, data from these two patients were separately investigated. Urinary levels of NAG in the remaining ten patients with Graves' disease before, 1, 3, 6 and 12 months after the treatment were 15.59 +/- 7.93 (SD), 8.96 +/- 6.82, 4.39 +/- 2.33, 3.46 +/- 2.24, and 3.63 +/- 2.38 U/g.creatinine (g.Cr.), respectively. Those obtained before, 1 and 3 months after the treatment were significantly higher than those of the controls (2.85 +/- 1.12 U/g.Cr.). Free thyroid hormone levels became normal or low 3 months after the treatment. The two Graves' patients mentioned above showed a transient increase in urinary NAG with concomitant changes in free thyroid hormone levels. Urinary NAG levels in the patients with subacute thyroiditis before, 2, 4, and 6 weeks after the treatment were 16.56 +/- 10.97, 6.76 +/- 2.79, 3.14 +/- 0.48 and 3.70 +/- 1.44 U/g.Cr., respectively. Those obtained before and 2 weeks after the treatment were significantly higher than those of the controls. Free thyroid hormones were normal 2 weeks after therapy. Urinary NAG in the patient with silent thyroiditis was 9.60 U/g.Cr. on the first visit and gradually decreased.(ABSTRACT TRUNCATED AT 250 WORDS)     

Subacute thyroiditis manifesting as a thyroid mass, vocal cord paralysis, and hypercalcemia

ObjectiveTo report a case of subacute thyroiditis manifesting as a thyroid mass, vocal cord paralysis, and hypercalcemia.MethodsWe describe the clinical, laboratory, and radiologic findings in a patient with an unusual clinical course of subacute thyroiditis.ResultsA 65-year-old woman presented with a hoarse voice and an enlarging tender mass in the right side of the neck. On admission, thyroid function was consistent with thyrotoxicosis from subacute thyroiditis. Laboratory studies showed a corrected serum calcium concentration of 11.4 mg/dL, intact parathyroid hormone of 125 pg/mL, 25-hydroxyvitamin D of 12 ng/mL, and creatinine of 1.8 mg/dL. Computed tomography of the neck without use of a contrast agent showed a heterogeneous mass in the right side of the neck in conjunction with deviation of the trachea from right to left but without invasion of the trachea. Thyroid ultrasonography disclosed a heterogeneous mass in the right thyroid lobe measuring 4.7 cm by 5.5 cm by 4.5 cm. Flexible laryngoscopy revealed right vocal cord paralysis. Treatment with a course of prednisone yielded normalization of the serum calcium level, improvement in her voice, and a decrease in size of the thyroid mass. Four months after initial presentation of the patient, thyroid hormone levels became normal, she was clinically euthyroid, and she had a full recovery of her voice. Her serum calcium concentration was normal (9.8 mg/dL) in association with a near-normal parathyroid hormone level of 90 pg/mL. The 25-hydroxyvitamin D and creatinine values were also normal. Repeated thyroid ultrasonography showed a smaller right thyroid lobe with a dominant nodule measuring 2.0 cm by 1.3 cm by 1.4 cm in the right upper pole.ConclusionThis case illustrates that subacute thyroiditis can have the unusual initial manifestations of a thyroid mass, vocal cord paralysis, and hypercalcemia. In similar patients, a trial of corticosteroid therapy may be warranted in an effort to improve clinical symptoms and thus avoid unnecessary surgical treatment. (Endocr Pract. 2012;18:e17-e20)     

A case study on Hashimoto's thyroiditis induced electrolyte imbalance

Lymphocytic thyroiditis is an autoimmune condition where auto-antibodies are produced against the thyroid gland. Initially, there might be a hyperthyroidism condition where T3 and T4 levels are high and external inflammation of thyroid gland might be seen, but over the course of time the destruction of thyroid gland can result in hypothyroidism where the complete destruction of thyroid gland. Electrolyte imbalances notably hypokalemia and hypomagnesemia with Hashimoto thyroiditis is a rare condition, in this article we will discuss about the course of treatment a 40-year-old female patient who presented with atypical symptoms of Hashimoto thyroiditis during her stay in the hospital.     

Painful subacute thyroiditis in Hawaii.

Between 1960 and 1982 we prospectively studied 269 patients with painful subacute thyroiditis to determine the demographic characteristics, seasonality, and natural course of the disease. The mean age for all patients was 37.1 years. The female:male ratio was 6.7:1. At the first visit, disease was bilateral in 69%. No epidemic or seasonal pattern was identified. The mean duration of thyroid tenderness was 2.2 months and that of palpable thyroid lumps was 2.8 months. This time difference, sometimes lasting many months, left a painfree "window" during which the palpable hard residual mass of subacute thyroiditis may be confused with other thyroid problems, especially cancer.     

Transient subclinical hypothyroidism in early pregnancy

In the present study, a new clinical state of transient subclinical hypothyroidism in 12 early pregnant women is documented. The incidence of transient subclinical hypothyroidism was 18 (0.19%) among 9,453 pregnant women examined in this series in Sapporo. The characteristics of transient subclinical early gestational hypothyroidism in our study may be summarized as follows: temporarily increased TSH in the blood (11.7 +/- 6.3 microU/ml; mean +/- S.D.) in early pregnant women at 8.5 +/- 2.4 weeks of gestation, accompanied with or without reduced FT4 which spontaneously return to normal at 17.9 +/- 7.1 weeks; no subjective complaints and no previous history of thyroid disease; small struma; positive titers of antimicrosome antibody and antithyroglobulin antibody; normal serum hCG; negative results for TSH receptor antibody. None of the infants show any physical abnormality such as struma and none of the patients had neck pain or fever suggesting subacute thyroiditis. The presence of autoantibody to the thyroid gland and echographical findings strongly suggest the existence of Hashimoto's thyroiditis in early pregnant women with transient subclinical hypothyroidism, although the cause of transient subclinical early gestational hypothyroidism remains obscure.     

Post-partum transient thyrotoxicosis: report of two cases

Two patients with post-partum transient thyrotoxicosis associated with painless thyroiditis and low radioactive iodine uptake were described. The surreptitious use of thyroid hormones or iodine was excluded. Although the clinical course was compatible with that of subacute thyroiditis, passing through the hyperthyroid, euthyroid, hypothyroid and recovery phase, the patients showed a sustained elevation of serum anti-thyroglobulin antibody titer during the entire phase of the disease. Moreover, the histological findings obtained by the thyroid biopsy performed in a case were characteristic of chronic lymphocytic thyroiditis. Furthermore, it was of interest that the disease recurred following every delivery in 2 cases, suggesting the possible role of immunological changes induced by pregnancy and delivery in the etiology of this disease.     

RET/PTC Rearrangements Are Associated with Elevated Postoperative TSH Levels and Multifocal Lesions in Papillary Thyroid Cancer without Concomitant Thyroid Benign Disease

RET/PTC rearrangements, resulting in aberrant activity of the RET protein tyrosine kinase receptor, occur exclusively in papillary thyroid cancer (PTC). In this study, we examined the association between RET/PTC rearrangements and thyroid hormone homeostasis, and explored whether concomitant diseases such as nodular goiter and Hashimoto''s thyroiditis influenced this association. A total of 114 patients diagnosed with PTC were enrolled in this study. Thyroid hormone levels, clinicopathological parameters and lifestyle were obtained through medical records and surgical pathology reports. RET/PTC rearrangements were detected using TaqMan RT-PCR and validated by direct sequencing. No RET/PTC rearrangements were detected in benign thyroid tissues. RET/PTC rearrangements were detected in 23.68% (27/114) of PTC tissues. No association between thyroid function, clinicopathological parameters and lifestyle was observed either in total thyroid cancer patients or the subgroup of patients with concomitant disease. In the subgroup of PTC patients without concomitant disease, RET/PTC rearrangement was associated with multifocal cancer (P = 0.018). RET/PTC rearrangement was also correlated with higher TSH levels at one month post-surgery (P = 0.037). Based on likelihood-ratio regression analysis, the RET/PTC-positive PTC cases showed an increased risk of multifocal cancers in the thyroid gland (OR = 5.57, 95% CI, 1.39–22.33). Our findings suggest that concomitant diseases such as nodular goiter and Hashimoto''s thyroiditis in PTC may be a confounding factor when examining the effects of RET/PTC rearrangements. Excluding the potential effect of this confounding factor showed that RET/PTC may confer an increased risk for the development of multifocal cancers in the thyroid gland. Aberrantly increased post-operative levels of TSH were also associated with RET/PTC rearrangement. Together, our data provides useful information for the treatment of papillary thyroid cancer.     

Detection of the novel autoantibody (anti-UACA antibody) in patients with Graves' disease

Uveal autoantigen with coiled coil domains and ankyrin repeats (UACA) is an autoantigen in patients with panuveitis such as Vogt-Koyanagi-Harada disease. The prevalence of IgG anti-UACA antibodies in patients with uveitis is significantly higher than healthy controls, suggesting its potential role as an autoantigen. Originally, UACA was cloned from dog thyroid tissue following TSH stimulation. So, we presumed UACA could be a novel autoantigen in autoimmune thyroid diseases. We measured serum anti-UACA antibody titer using ELISA in patients with autoimmune thyroid diseases (Graves' disease, Hashimoto's thyroiditis, subacute thyroiditis, and silent thyroiditis). The prevalence of anti-UACA antibodies in Graves' disease group was significantly higher than that in healthy group (15% vs. 0%). Moreover, the prevalence of anti-UACA antibodies in Graves' ophthalmopathy was significantly higher than that in Graves' patients without ophthalmopathy (29% vs. 11%). Especially, 75% of severe ocular myopathy cases showed high UACA titer. Immunohistochemical analysis revealed that UACA protein is expressed in eye muscles as well as human thyroid follicular cells. Taken together, UACA is a novel candidate for eye muscle autoantigens in thyroid-associated ophthalmopathy.     

Apathetic Thyrotoxicosis Secondary to Atypical Subacute Thyroiditis

ObjectiveTo report a case of apathetic thyrotoxicosis with an etiology of subacute thyroiditis.MethodsWe describe the patient’s clinical findings, laboratory findings, and clinical course.ResultsAn 85-year-old woman with no history of thyroid disease presented with severe obtundation and altered mental status. Laboratory testing documented elevated free thyroxine and free triiodothyronine concentrations and a suppressed thyrotropin concentration. Thyroid antibodies were absent. A radioactive iodine study revealed severely diminished uptake, suggestive of thyroiditis. After a short course of steroids, the patient’s mental status returned to baseline. Follow-up laboratory testing showed normalizing thyroid function.ConclusionEven in the absence of a history of thyroid disease, we recommend considering thyroid dysfunction in the differential diagnosis of patients who present with altered mental status, particularly in the elderly population. (Endocr Pract. 2012;18:e127-e129)     

Detection of thyroid-stimulating antibody in patients with inflammatory thyrotoxicosis.

The detection of thyrotropin-binding inhibitory immunoglobulins (TBII) and/or thyroid-stimulating antibody (TSAb) has been reported in some patients with painless thyroiditis (PT) or subacute thyroiditis (SAT). However, its mechanism is unknown. TBII and TSAb measured using cultured FRTL-5 thyroid cells were evaluated in 18 patients with PT, 11 patients with SAT and a patient with SAT-like symptoms. In PT, we detected both TBII and TSAb activities in only 1 patient. This case had first come to our attention with subclinical hypothyroidism and had already had weakly positive TSAb activity (205.9%) 1 year before the present onset of PT. This patient had a transient thyrotoxicosis with a low uptake (24 h) of 123I (4.3%) and 821.0% TSAb activity, and subsequently developed a transient subclinical hypothyroidism. Even after 2 years, she still had positive TSAb activity (382.3%). In SAT, TBII and TSAb activities were not detected during the courses of any patients. A patient with transient thyrotoxicosis, who had a high uptake (30 min) of 99mTc (5.6%) and SAT-like symptoms (painful tenderness on right thyroid lobe and markedly accelerated erythrocyte sedimentation rate), showed positive activities of TBII (34.9%) and TSAb activity (1,366.9%). Histological findings by thyroid needle biopsy performed in the thyrotoxic phase showed coexistence of granulomatous inflammatory changes and hyperplasia with papillary folds of some residual follicular cells.(ABSTRACT TRUNCATED AT 250 WORDS)     

Serum free thyroxine and thyroxine-binding globulin concentrations in early phase of subacute thyroiditis

Serum total thyroxine (T4), total triiodothyronine (T3), T4-binding globulin (TBG), free T4(FT4) and free T3(FT3) concentrations and the T3-uptake(T3-U) value were estimated in 11 patients with subacute thyroiditis, and compared with the same parameters in 11 patients with Graves' disease, whose serum T4 concentrations were similar to the former group. Seven patients with subacute thyroiditis, who were treated with dicrofenac sodium alone, were investigated as to the sequential changes in serum parameters during their clinical courses. The mean serum T3-U value and FT4, T3 and FT3 concentrations in patients with subacute thyroiditis were increased, but all were significantly lower than those in patients with Graves' disease (p less than 0.01, p less than 0.001, p less than 0.001 and p less than 0.001, respectively). Three patients with subacute thyroiditis, who showed shorter duration of symptoms than 10 days, had serum TBG excess. Thus the mean (+/- SD) serum TBG concentration (26.5 +/- 8.4 micrograms/ml) was significantly higher than that (18.3 +/- 2.9 micrograms/ml) in patients with Graves' disease (p less than 0.02). The ratios of serum T3 to T4 and FT3 to FT4 in patients with subacute thyroiditis were also significantly lower than those in patients with Graves' disease (p less than 0.001 and p less than 0.001, respectively). The serum FT4 in 7 patients treated with dicrofenac sodium alone decreased to the normal range after 3 to 8 weeks from the onset of the illness. In 3 patients with TBG excess and one patient (TBG; 29.0 micrograms/ml), serum TBG declined in consequence of the serum FT4 normalization.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transient hypothyroidism associated with increased anti-microsomal antibodies.

An unusual case of transient hypothyroidism during the course of chronic thyroiditis was reported. A 25 years old female noticed the remarkable enlargement of thyroid gland 3 months after paturition and was developed to be hypothyroidism with decreased blood thyroid hormone and increased serum TSH. The patient recovered to be euthyroid spontaneously in association with the decrement of goiter size. Anti-thyroid microsomal antibody increased concomitantly with hypothyroid period and decreased parallel with the recovery of thyroid function. The ratio of TSH potency estimated by bioassay to that by immunoassay changed during the course. Possible etiologic factors of this transient changes were discussed.     

Fine Needle Aspiration Cytodiagnosis of Subacute (De Quervain's) Thyroiditis In an Endemic Goitre Area

Between 1977 and 1989 252 fine needle aspirates (FNAs) of the thyroid from patients with a clinical suspicion of subacute granulomatous (de Quervain's) thyroiditis were examined in the Department of Pathology of the University of Innsbruck, Austria. In the same period 31 cases with preoperative FNA were diagnosed histologically as subacute thyroiditis. Only in three of these cases were the cytological features of de Quervain's thyroiditis found in the preoperative FNA. However, in 13 of these 31 cases a cytological suspicion of malignancy was obtained. Subsequent histological examination revealed an acute phase inflammation of de Quervain's thyroiditis in most of these cases. We conclude that an accurate FNA diagnosis of de Quervain's thyroiditis, particularly in the acute stage, may cause difficulties due to a lack of typical features and the appearance of atypical thyroid follicular cells. For the cytopathologist, accurate clinical information relating to the possibility of de Quervain's thyroiditis is essential if unnecessary surgery is to be avoided.     

Thyroid dysfunction and aneuploidy in offspring

The intercommunication between thyroid gland dysfunction in parents and aneuploid karyotype formation in offspring was studied using cytogenetic and immunogenetic approaches. It was determined, that increased risk for children being born with Down or Turner diseases depends upon a presence of following HLA-antigenes in parents, partcularly in motheritract. The intercommunication between thyroid gland dysfunction in parents and aneuploid karyotype formation in offspring was studied using cytogenetic and immunogenetic approaches. It was determined, that increased risk for children being born with Down or Turner diseases depends upon a presence of following HLA-antigenes in parents, particularly in mother's genome: B10, B40, B41, B51 and allele DQA*0301 of gene DQA of major histocompatibility complex. The presence of antigens B40, B51 and allele DQA*0301 was also associated with autoimmune thyroiditis. Thus, thyroid gland function disturbance, namely autoimmune thyroiditis can be considered as a risk factor of aneuploid karyotype formation.     

Five patients with painless thyroiditis simultaneously developed in a nursery school

Painless (silent) thyroiditis (PT) occurred simultaneously in 1 male and 4 females aged 21 to 52 years working at a nursery school. Clinical symptoms did not include goiter, or pain or tenderness of the neck in any of the patients but were characterized by edema of the lower legs as well as palpitation and loss of body weight as observed in subacute thyroiditis. General blood analysis showed that all patients were negative for C-reactive protein (CRP) and 3 had mild impairment of liver function. Examination of thyroid function suggested transient thyrotoxicosis accompanied by a marked reduction in radioactive iodine uptake (RAIU), but antithyroglobulin hemagglutination antibody (TGHA) and antithyroid microsomal hemagglutination antibody (MCHA) were negative in all patients. Examination of various viral antibodies showed no significant changes in their titers. Thyrotoxicosis was transient and disappeared without treatment or by glucocorticoid administration. Our results suggested that PT observed in this study was caused by some environmental factor. The possibility of an unidentified virus as a factor cannot be ruled out.     

Destructive Thyroiditis Followed by Hypothyroidism Associated with Infliximab Therapy

ObjectiveTo present the rare case of a patient who developed destructive thyroiditis accompanied by transient thyrotoxicosis resulting from infliximab therapy for the treatment of psoriasis.MethodsThe clinical presentation and management of a case with infliximab-associated thyroiditis is described with a brief review of the literature.ResultsA 57-year-old male who suffered from psoriasis was treated with infliximab therapy for 4 years. Thyroid function tests were normal before infliximab therapy. When the patient presented in our clinic, he had thyrotoxicosis and was using propylthiouracil. A 99m Technetiumpertechnetate thyroid scintigraphy scan showed no visualization of either thyroid lobe or decreased thyroid iodine uptake. Thyroid-stimulating hormone (TSH) receptor antibody, thyroid peroxidase antibody (anti-TPO Ab) and thyroglobulin antibody (anti-Tg Ab) were negative. Thyroid ultrasonography revealed a heterogeneous thyroid gland without nodules. After stopping propylthiouracil therapy, we advised monitoring of his thyroid function tests in the following weeks, and infliximab therapy for psoriasis was continued. Four weeks later, his thyroid function tests showed an elevated TSH level with normal levels of free triiodothyronine and thyroxine (FT3 and FT4, respectively), and levothyroxine treatment was administered to the patient. Thyroid function tests normalized after levothyroxine treatment. One year later, infliximab therapy was stopped because of clinical remission. Simultaneously, levothyroxine treatment was also stopped. His thyroid function tests were normal 6 weeks after the cessation of levothyroxine treatment.ConclusionTo our knowledge, the present report is the third infliximab-associated thyroid disorder case. Periodic follow-up of thyroid function tests is necessary during infliximab therapy. (Endocr Pract. 2014;20:e207-e210)     

Cytomorphologic aspects of thyroiditis. A study of 51 cases with functional, immunologic and ultrasonographic data

Fine needle aspiration provided material for detailed cytomorphologic study in 51 cases of thyroiditis, 40 of which were diagnosed as Hashimoto's (autoimmune) thyroiditis. Of these 40 cases, 22 were found to be euthyroid on clinical examination and radioimmunoassay (RIA), 10 were hyperthyroid and 8 were hypothyroid. Of the 11 cases of subacute thyroiditis, 4 were thyrotoxic and 7 were euthyroid. Radioactive iodine uptake (RAIU) showed decreased to negligible uptake in ten and normal uptake in one case of subacute thyroiditis, whereas all of the thyrotoxic cases of Hashimoto's thyroiditis showed markedly increased RAIU. Echography showed a hypoechoic or anechoic pattern in most of the cases. Antimicrosomal and/or antithyroglobulin antibodies were positive in 25 cases of Hashimoto's thyroiditis and in 1 case of subacute thyroiditis. The cytologic features that characterized subacute thyroiditis were the presence of multinucleated giant cells and a polymorphonuclear and lymphocytic population associated occasionally with epithelioid-cell granulomas. Hashimoto's thyroiditis was characterized by Hürthle-cell changes and a significant lymphoid population consisting of mature and transformed lymphocytes, often impinging on follicular cells. There was an overlap in the cytomorphologic features between some cases of Hashimoto's and subacute thyroiditis. In such cases, the final diagnosis was arrived at by an integrated approach incorporating all of the diagnostic parameters available.