A case of unilateral development of subacute thyroiditis used as a hallmark of the nervous nature of its pathogenesis

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Ushakov This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2366338/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Nov, 2024 Read the published version in AME Case Reports → Version 1 posted You are reading this latest preprint version Abstract Despite the prevailing view that the factors underlying the development of subacute thyroiditis (ST) have an infectious origin, its viral and bacterial pathogeneses remain unclear. Moreover, the hypothesis of genetic predisposition to ST is nonabsolute. In previous studies, approximately 24%-40% patients with ST manifested unilateral thyroid disease; however, the assessment of the pathogenesis of ST did not consider this fact. Nevertheless, the involvement of the nervous system in the inflammatory process and the possibility that unilateral nerve conduction affects only one of the thyroid lobes, as demonstrated in the present case, indicate that the autonomic nervous system plays a leading role in ST development. Endocrinology & Metabolism subacute thyroiditis autonomic nervous system thyroid ultrasound pathogenesis Figures Figure 1 Introduction Viral infection is considered the most common cause of subacute thyroiditis (ST), despite missing direct evidence. Serological and epidemiological data as well as the study of circulating viruses only suggest but do not confirm the role of infection in the development of ST [ 1 ]. Moreover, approximately 75% of patients do not present with a history of respiratory infection, suggesting that infectious pathogens are a rare cause of ST [ 2 ]. Some studies on ST have reported 24%-40% of ultrasound-confirmed cases of unilateral inflammation in the thyroid [ 3 – 5 ]. Additionally, unilateral pain, as a manifestation of ST, was observed in 68% of cases [ 2 ]. In 80% of cases, unilateral ST was found to be associated with human leukocyte antigen haplotype 18:01 [ 4 ]. However, this association did not reveal the pathogenesis of ST. Unilateral ST and its features can be considered important guidelines for understanding the key nature of the disease. Therefore, based on the described case, we suggest considering the facts and arguments in favor of a probable pathogenesis. Case Presentation A 31-year-old female patient (height, 165 cm; weight, 76 kg) at 20 gestational weeks visited our clinic for a consultation regarding ultrasound signs of ST. Under normal circumstances, the patient had no neck pain or other symptoms. She felt a little soreness only when more intense pressure was applied using an ultrasonic sensor on the right lobe of the thyroid gland. The anamnesis of the disease revealed no triggering factors or significant changes in well-being. She learned about the disease by chance as a result of pregnancy-related examinations. Patient’s physical examination did not reveal any abnormalities. She did not take any medications. Her arterial blood pressure at rest in the sitting position was 117/78 mm Hg, and her heart rate was 63 bpm. Blood serum examination revealed the following: thyroid-stimulating hormone 2.30 mU/L (0.35–4.94); free thyroxine 12.50 pmol/L (9.01–19.05); free triiodothyronine 4.13 pmol/L (2.63–5.70); total thyroxine 85.17 pmol/L (71.23–140.10); total triiodothyronine 1.63 nmol/L (0.90–2.20); antibodies against thyroid-stimulating hormone receptors 0.7 IU/l (< 1); thyroid peroxidase antibodies 1.7 U/mL (< 5.6) and antithyroglobulin antibodies 3.1 U/mL (< 4.1); erythrocytes 4.2 million/µl (3.8–5.1), hemoglobin 12.7 g/dl (11.7–15.5), erythrocyte sedimentation rate 17 mL/hour (0–20), C-reactive protein 1.3 mg/L(< 5). An ultrasound scan of the thyroid gland revealed almost twofold diffuse increase in the volume of the right lobe (6.6 ml) compared with the left lobe (3 ml). In the left lobe, the parenchyma was isoechogenic and mostly homogeneous (Fig. 1 B,С), with normal blood flow. The right lobe had slightly and moderately hypoechogenic parenchyma, which is a sign of swelling of stroma, and a small number of significantly hypoechogenic lobules, which is a sign of destruction and lymphoid replacement (Fig. 1 A,С). Doppler ultrasound revealed normal intensity of blood flow in the right lobe (Fig. 1 D). Peak systolic velocities were 19.6 cm/s and 27.3 cm/s on the right and left superior thyroid arteries, respectively; in the right and left common carotid arteries, these velocities were 58.6 cm/s and of 42.7 cm/s, respectively, provided the arteries were normal and the measurements were performed on the same level. Discussion The described case of unilateral ST serves as an important guide for a better understanding of the nature of the pathogenesis of diffuse thyroid pathology. After all, well-known classical theories about the mechanisms of thyropathies do not reveal the source of changes in only one lobe of the thyroid gland. However, a complex assessment of this and other facts can improve the understanding of the nature of ST and other thyroid diseases. Considering the role of the nervous system in the development of inflammation and regulation of immune processes [ 6 , 7 ] as well as the knowledge of direct isolated unilateral nervous regulation of each thyroid lobe [ 8 , 9 ], we can assume that the pathogenesis of ST originates from the nervous system. Specifically, the possibility of unilateral impact from the peripheral nerve centers of the autonomic nervous system (ANS) was considered. In contrast to the unproven hypotheses of “clonal heterogeneity” or “possible mutations anywhere in the signaling pathway of the thyroid stimulating hormone receptor involving only a part of the normal parenchyma of the thyroid gland” [ 10 ], the spread of the pathological process only to a single lobe or its specific segments (lobules, groups of lobules, etc.) can be clearly explained by the separate neurovascular supply to the left and right parts of the gland and segments of its parenchyma. This insight also enables us to explain similar manifestations in other thyropathies. Another similar pathology — the unilateral form of Graves’ disease (GD) — helps further refine the involvement of the nervous system in the pathogenesis of ST [ 10 , 11 ]. In addition, cases of nonautoimmune and nonhereditary courses of GD [ 12 ] indicate the possible primary role of the nervous system and a secondary role of the immune system in the pathogenesis of the disease. The stress-induced activation of GD with the involvement of the nervous system supports this finding [ 13 , 14 ]. In the presented case of ST, only the standard diagnostic tests were performed without assessing ANS manifestations. However, the rationale for this paper was a striking example of unilateral thyroid gland involvement and the lack of a comprehensive analysis of the pathogenesis of such cases in the literature. We believe that additional studies on the state of the peripheral ANS in such patients will improve our knowledge of ST and other thyroid pathologies. Conclusion The unilateral manifestation of subacute thyroiditis, like other thyropathies, should likely be considered with respect to the key involvement of the peripheral autonomic nervous system in its pathogenesis. Declarations The patient has given written consent to the publication of her medical diagnostic and/or treatment data. Sponsorship: No funding was used for this study. Acknowledgments: the author declares that he does not know competing financial interests or personal relationships that may appear to affect the work reported in this article. Disclosure: There is no potential conflict of interest related to this article. References Desailloud R, Hober D. Viruses and thyroiditis: an update. Virol J. 2009;12;6:5. doi: 10.1186/1743-422X-6-5 . Nishihara E, Ohye H, Amino N, Takata K, Arishima T, Kudo T, Ito M, Kubota S, Fukata S, Miyauchi A. Clinical characteristics of 852 patients with subacute thyroiditis before treatment. Intern Med. 2008;47(8):725–9. doi: 10.2169/internalmedicine.47.0740 . Cappelli C, Pirola I, Gandossi E, Formenti AM, Agosti B, Castellano M. Ultrasound findings of subacute thyroiditis: a single institution retrospective review. Acta Radiol. 2014;55(4):429–33. doi: 10.1177/0284185113498721 . Stasiak M, Tymoniuk B, Adamczewski Z, Stasiak B, Lewiński A. Sonographic Pattern of Subacute Thyroiditis Is HLA-Dependent. Front Endocrinol (Lausanne). 2019;10:3. doi: 10.3389/fendo.2019.00003 . Sencar ME, Calapkulu M, Sakiz D, Akhanli P, Hepsen S, Duger H, Unsal IO, Kizilgul M, Cakal E. The contribution of ultrasonographic findings to the prognosis of subacute thyroiditis. Arch Endocrinol Metab. 2020;64(3):306–311. doi: 10.20945/2359-3997000000253 . Tracey KJ. Reflex control of immunity. Nat Rev Immunol. 2009;9(6):418–28. doi: 10.1038/nri2566 . Pavlov VA, Tracey KJ. Neural circuitry and immunity. Immunol Res. 2015;63(1–3):38–57. doi: 10.1007/s12026-015-8718-1 . Gerendai I, Halász B. Neuroendocrine asymmetry. Front Neuroendocrinol. 1997;18(3):354–81. doi: 10.1006/frne.1997.0154 . Romeo HE, González Solveyra C, Vacas MI, Rosenstein RE, Barontini M, Cardinali DP. Origins of the sympathetic projections to rat thyroid and parathyroid glands. J Auton Nerv Syst. 1986;17(1):63–70. doi: 10.1016/0165-1838(86)90044-5 . Manthri RG, Ajit N, Vaikakkara S, Devi BV, Kalawat T. Unilateral Graves' Disease: The Lesser Known. Indian J Nucl Med. 2019;34(2):96–98. doi: 10.4103/ijnm.IJNM_11_19 . Chen LC, Green JB. First reported case of unilateral Graves' disease in the left lobe of a bilobar thyroid gland. Thyroid. 2011;21(6):683–6. doi: 10.1089/thy.2010.0343 . Ilicki A, Gamstedt A, Karlsson FA. Hyperthyroid Graves' disease without detectable thyrotropin receptor antibodies. J Clin Endocrinol Metab. 1992;74(5):1090–4. doi: 10.1210/jcem.74.5.1349025 . Vita R, Lapa D, Trimarchi F, Benvenga S. Stress triggers the onset and the recurrences of hyperthyroidism in patients with Graves' disease. Endocrine. 2015;48(1):254–63. doi: 10.1007/s12020-014-0289-8 . Falgarone G, Heshmati HM, Cohen R, Reach G. Mechanisms in endocrinology. Role of emotional stress in the pathophysiology of Graves' disease. Eur J Endocrinol. 2012;168(1):R13-8. doi: 10.1530/EJE-12-0539 . Cite Share Download PDF Status: Published Journal Publication published 12 Nov, 2024 Read the published version in AME Case Reports → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2366338","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":160726422,"identity":"5000c448-25d2-47c3-b902-ead168febb85","order_by":0,"name":"Andrey V. Ushakov","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYDCCAwwMzCCajSEZyGSQkCFGC2MzREtaAkgLD/FaGBhyDEAkYS18x5ufPy5suyfHx57z+dWNGgseBvbDRzfg0yJ55phh88y2YmM2nrfbrHOOAR3Gk5Z2A58Wgxs5jM28bQmJbRK524xz2IBaJHjMiNWS88w45x+JWpgf57YRoQXkl9k85xKAfnlmxpzbJ8HDRsgvwBB78JmnLEFOvj358eecb3Vy/OyHj+HVAgaMbGCKTQJMElQOBn/AJPMH4lSPglEwCkbBSAMABgBG5IqNVdYAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-9475-9813","institution":"Ushakov Thyroid Clinic","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Andrey","middleName":"V.","lastName":"Ushakov","suffix":""}],"badges":[],"createdAt":"2022-12-11 09:41:48","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":true,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-2366338/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2366338/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.21037/acr-24-97","type":"published","date":"2024-11-13T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":30530329,"identity":"a4038cec-ded5-4830-9cc8-e89c70e9ae8c","added_by":"auto","created_at":"2022-12-19 18:12:58","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":563009,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasound image of the thyroid lobes. A. Right lobe with hypoechoic areas, B. Left lobe with isoechoic parenchyma, C. Transverse view of the gland, D. Ultrasound Doppler of the right lobe.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2366338/v1/9ecd1e537c7bba093b7109af.jpg"},{"id":75116233,"identity":"3260fcde-1f4d-427c-b20d-32af162a7a54","added_by":"auto","created_at":"2025-01-30 16:13:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":824906,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2366338/v1/6de223bd-9f1d-4b1b-a091-d560e6d8b996.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003e\u003cstrong\u003eA case of unilateral development of subacute thyroiditis used as a hallmark of the nervous nature of its pathogenesis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eViral infection is considered the most common cause of subacute thyroiditis (ST), despite missing direct evidence. Serological and epidemiological data as well as the study of circulating viruses only suggest but do not confirm the role of infection in the development of ST [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Moreover, approximately 75% of patients do not present with a history of respiratory infection, suggesting that infectious pathogens are a rare cause of ST [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome studies on ST have reported 24%-40% of ultrasound-confirmed cases of unilateral inflammation in the thyroid [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Additionally, unilateral pain, as a manifestation of ST, was observed in 68% of cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In 80% of cases, unilateral ST was found to be associated with human leukocyte antigen haplotype 18:01 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, this association did not reveal the pathogenesis of ST.\u003c/p\u003e \u003cp\u003eUnilateral ST and its features can be considered important guidelines for understanding the key nature of the disease. Therefore, based on the described case, we suggest considering the facts and arguments in favor of a probable pathogenesis.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 31-year-old female patient (height, 165 cm; weight, 76 kg) at 20 gestational weeks visited our clinic for a consultation regarding ultrasound signs of ST. Under normal circumstances, the patient had no neck pain or other symptoms. She felt a little soreness only when more intense pressure was applied using an ultrasonic sensor on the right lobe of the thyroid gland.\u003c/p\u003e \u003cp\u003eThe anamnesis of the disease revealed no triggering factors or significant changes in well-being. She learned about the disease by chance as a result of pregnancy-related examinations.\u003c/p\u003e \u003cp\u003ePatient\u0026rsquo;s physical examination did not reveal any abnormalities. She did not take any medications. Her arterial blood pressure at rest in the sitting position was 117/78 mm Hg, and her heart rate was 63 bpm. Blood serum examination revealed the following: thyroid-stimulating hormone 2.30 mU/L (0.35\u0026ndash;4.94); free thyroxine 12.50 pmol/L (9.01\u0026ndash;19.05); free triiodothyronine 4.13 pmol/L (2.63\u0026ndash;5.70); total thyroxine 85.17 pmol/L (71.23\u0026ndash;140.10); total triiodothyronine 1.63 nmol/L (0.90\u0026ndash;2.20); antibodies against thyroid-stimulating hormone receptors 0.7 IU/l (\u0026lt;\u0026thinsp;1); thyroid peroxidase antibodies 1.7 U/mL (\u0026lt;\u0026thinsp;5.6) and antithyroglobulin antibodies 3.1 U/mL (\u0026lt;\u0026thinsp;4.1); erythrocytes 4.2\u0026nbsp;million/\u0026micro;l (3.8\u0026ndash;5.1), hemoglobin 12.7 g/dl (11.7\u0026ndash;15.5), erythrocyte sedimentation rate 17 mL/hour (0\u0026ndash;20), C-reactive protein 1.3 mg/L(\u0026lt;\u0026thinsp;5).\u003c/p\u003e \u003cp\u003eAn ultrasound scan of the thyroid gland revealed almost twofold diffuse increase in the volume of the right lobe (6.6 ml) compared with the left lobe (3 ml). In the left lobe, the parenchyma was isoechogenic and mostly homogeneous (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB,С), with normal blood flow. The right lobe had slightly and moderately hypoechogenic parenchyma, which is a sign of swelling of stroma, and a small number of significantly hypoechogenic lobules, which is a sign of destruction and lymphoid replacement (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA,С). Doppler ultrasound revealed normal intensity of blood flow in the right lobe (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). Peak systolic velocities were 19.6 cm/s and 27.3 cm/s on the right and left superior thyroid arteries, respectively; in the right and left common carotid arteries, these velocities were 58.6 cm/s and of 42.7 cm/s, respectively, provided the arteries were normal and the measurements were performed on the same level.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eThe described case of unilateral ST serves as an important guide for a better understanding of the nature of the pathogenesis of diffuse thyroid pathology. After all, well-known classical theories about the mechanisms of thyropathies do not reveal the source of changes in only one lobe of the thyroid gland. However, a complex assessment of this and other facts can improve the understanding of the nature of ST and other thyroid diseases.\u003c/p\u003e \u003cp\u003eConsidering the role of the nervous system in the development of inflammation and regulation of immune processes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] as well as the knowledge of direct isolated unilateral nervous regulation of each thyroid lobe [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], we can assume that the pathogenesis of ST originates from the nervous system. Specifically, the possibility of unilateral impact from the peripheral nerve centers of the autonomic nervous system (ANS) was considered.\u003c/p\u003e \u003cp\u003eIn contrast to the unproven hypotheses of \u0026ldquo;clonal heterogeneity\u0026rdquo; or \u0026ldquo;possible mutations anywhere in the signaling pathway of the thyroid stimulating hormone receptor involving only a part of the normal parenchyma of the thyroid gland\u0026rdquo; [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], the spread of the pathological process only to a single lobe or its specific segments (lobules, groups of lobules, etc.) can be clearly explained by the separate neurovascular supply to the left and right parts of the gland and segments of its parenchyma. This insight also enables us to explain similar manifestations in other thyropathies.\u003c/p\u003e \u003cp\u003eAnother similar pathology \u0026mdash; the unilateral form of Graves\u0026rsquo; disease (GD) \u0026mdash; helps further refine the involvement of the nervous system in the pathogenesis of ST [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In addition, cases of nonautoimmune and nonhereditary courses of GD [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] indicate the possible primary role of the nervous system and a secondary role of the immune system in the pathogenesis of the disease. The stress-induced activation of GD with the involvement of the nervous system supports this finding [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the presented case of ST, only the standard diagnostic tests were performed without assessing ANS manifestations. However, the rationale for this paper was a striking example of unilateral thyroid gland involvement and the lack of a comprehensive analysis of the pathogenesis of such cases in the literature. We believe that additional studies on the state of the peripheral ANS in such patients will improve our knowledge of ST and other thyroid pathologies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe unilateral manifestation of subacute thyroiditis, like other thyropathies, should likely be considered with respect to the key involvement of the peripheral autonomic nervous system in its pathogenesis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe patient has given written consent to the publication of her medical diagnostic and/or treatment data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSponsorship:\u003c/strong\u003e No funding was used for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e the author declares that he does not know competing financial interests or personal relationships that may appear to affect the work reported in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure:\u003c/strong\u003e There is no potential conflict of interest related to this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDesailloud R, Hober D. Viruses and thyroiditis: an update. Virol J. 2009;12;6:5. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1743-422X-6-5\u003c/span\u003e\u003cspan address=\"10.1186/1743-422X-6-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNishihara E, Ohye H, Amino N, Takata K, Arishima T, Kudo T, Ito M, Kubota S, Fukata S, Miyauchi A. Clinical characteristics of 852 patients with subacute thyroiditis before treatment. Intern Med. 2008;47(8):725\u0026ndash;9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2169/internalmedicine.47.0740\u003c/span\u003e\u003cspan address=\"10.2169/internalmedicine.47.0740\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCappelli C, Pirola I, Gandossi E, Formenti AM, Agosti B, Castellano M. Ultrasound findings of subacute thyroiditis: a single institution retrospective review. Acta Radiol. 2014;55(4):429\u0026ndash;33. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0284185113498721\u003c/span\u003e\u003cspan address=\"10.1177/0284185113498721\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStasiak M, Tymoniuk B, Adamczewski Z, Stasiak B, Lewiński A. Sonographic Pattern of Subacute Thyroiditis Is HLA-Dependent. Front Endocrinol (Lausanne). 2019;10:3. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fendo.2019.00003\u003c/span\u003e\u003cspan address=\"10.3389/fendo.2019.00003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSencar ME, Calapkulu M, Sakiz D, Akhanli P, Hepsen S, Duger H, Unsal IO, Kizilgul M, Cakal E. The contribution of ultrasonographic findings to the prognosis of subacute thyroiditis. Arch Endocrinol Metab. 2020;64(3):306\u0026ndash;311. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.20945/2359-3997000000253\u003c/span\u003e\u003cspan address=\"10.20945/2359-3997000000253\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTracey KJ. Reflex control of immunity. Nat Rev Immunol. 2009;9(6):418\u0026ndash;28. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/nri2566\u003c/span\u003e\u003cspan address=\"10.1038/nri2566\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePavlov VA, Tracey KJ. Neural circuitry and immunity. Immunol Res. 2015;63(1\u0026ndash;3):38\u0026ndash;57. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12026-015-8718-1\u003c/span\u003e\u003cspan address=\"10.1007/s12026-015-8718-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerendai I, Hal\u0026aacute;sz B. Neuroendocrine asymmetry. 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Role of emotional stress in the pathophysiology of Graves' disease. Eur J Endocrinol. 2012;168(1):R13-8. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1530/EJE-12-0539\u003c/span\u003e\u003cspan address=\"10.1530/EJE-12-0539\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"Ushakov Thyroid Clinic","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"subacute thyroiditis, autonomic nervous system, thyroid ultrasound, pathogenesis","lastPublishedDoi":"10.21203/rs.3.rs-2366338/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2366338/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDespite the prevailing view that the factors underlying the development of subacute thyroiditis (ST) have an infectious origin, its viral and bacterial pathogeneses remain unclear. Moreover, the hypothesis of genetic predisposition to ST is nonabsolute.\u003c/p\u003e \u003cp\u003eIn previous studies, approximately 24%-40% patients with ST manifested unilateral thyroid disease; however, the assessment of the pathogenesis of ST did not consider this fact. Nevertheless, the involvement of the nervous system in the inflammatory process and the possibility that unilateral nerve conduction affects only one of the thyroid lobes, as demonstrated in the present case, indicate that the autonomic nervous system plays a leading role in ST development.\u003c/p\u003e","manuscriptTitle":"A case of unilateral development of subacute thyroiditis used as a hallmark of the nervous nature of its pathogenesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-12-19 18:12:53","doi":"10.21203/rs.3.rs-2366338/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"17839c22-87ae-4c6d-a638-4867ca6add71","owner":[],"postedDate":"December 19th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":17616080,"name":"Endocrinology \u0026 Metabolism"}],"tags":[],"updatedAt":"2025-01-30T16:13:04+00:00","versionOfRecord":{"articleIdentity":"rs-2366338","link":"https://doi.org/10.21037/acr-24-97","journal":{"identity":"ame-case-reports","isVorOnly":true,"title":"AME Case Reports"},"publishedOn":"2024-11-13 00:00:00","publishedOnDateReadable":"November 13th, 2024"},"versionCreatedAt":"2022-12-19 18:12:53","video":"","vorDoi":"10.21037/acr-24-97","vorDoiUrl":"https://doi.org/10.21037/acr-24-97","workflowStages":[]},"version":"v1","identity":"rs-2366338","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2366338","identity":"rs-2366338","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}