Introduction
Subacute thyroiditis (SAT) is a self-limiting inflammatory disorder of the thyroid gland, often triggered by viral infections. The clinical incidence of SAT is estimated to be approximately 4.9 cases per 100,000 individuals annually, accounting for 0.5% to 2.0% of all clinically recognized thyroid diseases, with a reported increasing incidence in recent years[
1]. The disease is clinically characterized by thyroid pain and tenderness, fever, general malaise, and symptoms of thyrotoxicosis. Current pharmacological management is determined by symptom severity. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy for mild to moderate cases, while corticosteroids such as prednisone are reserved for more severe manifestations[
2]. However, treatment challenges remain, including suboptimal response to NSAIDs in some patients and the significant adverse effects associated with prolonged corticosteroid use. These limitations highlight an urgent need for novel therapeutic strategies that offer improved efficacy and a more favorable safety profile.
In recent years, traditional Chinese medicine (TCM) has emerged as a potential complementary approach for managing thyroid disorders, demonstrating promising outcomes in some clinical settings[
3]. From TCM perspective, SAT classifies as a form of “goiter” (瘿病, Ying Bing), and its pathogenesis is primarily attributed to liver Qi stagnation, which is believed to impair spleen function and promote phlegm formation, ultimately leading to phlegm stagnation in the anterior neck region. Consequently, the corresponding therapeutic principle involves soothing the liver to regulate Qi flow, strengthening the spleen, and resolving phlegm nodules[
4]. This case report describes the successful management of a SAT patient using an integrated Western and TCM approach. The combined therapy not only effectively alleviated the patient’s symptoms but also circumvented the side effects commonly associated with conventional NSAID or corticosteroid regimens. We suggest that such an integrative strategy may represent a valuable alternative for the management of SAT and warrant further systematic investigation.
Case presentation
A 43-year-old female was referred to the endocrinology outpatient clinic with a chief complaint of a three-week history of persistent neck pain, manifested as sore throat and dysphagia. She denied concomitant fever, cough, sputum production, or symptoms suggestive of thyrotoxicosis such as palpitations, anxiety, or chest tightness. A prior three-day course of oral ibuprofen, administered for a presumed diagnosis of acute pharyngitis, had failed to alleviate her symptoms. Although her sister had a documented history of hyperthyroidism, the patient reported no other significant epidemiological exposures or family history of thyroid disorders, malignancy, or autoimmune diseases among her first-degree relatives.
Upon initial presentation, the patient exhibited marked facial discomfort, odynophagia, and sleep disturbances due to the pain. Physical examination revealed no cervical lymphadenopathy, thyromegaly, petechiae, or signs of hemorrhage. Given the clinical suspicion of SAT, a comprehensive diagnostic workup was initiated to confirm the diagnosis and exclude other thyroid pathologies or respiratory infections. Laboratory investigations revealed leukocytosis (11.12 × 109/L; reference range: 3.50 × 109–9.50 × 109/L) with elevated neutrophils (6.79 × 109/L; reference range: 1.80 × 109–6.30 × 109/L). Inflammatory markers were significantly elevated, with a C-reactive protein (CRP) level of 46.3 mg/L (reference: < 3 mg/L) and an erythrocyte sedimentation rate (ESR) of 82.0 mm/h (reference: < 20 mm/h). Serological testing for Mycoplasma pneumoniae antibodies was negative. Thyroid function tests indicated thyrotoxicosis: suppressed thyrotropin (TSH < 0.015 μIU/mL; reference: 0.27–4.2 μIU/mL), elevated free thyroxine (FT4 30.04 pmol/L; reference: 12–22 pmol/L) and free triiodothyronine (FT3 9.29 pmol/L; reference: 3.1–6.8 pmol/L). Thyroid antibody assays, including TSH receptor antibody (TRAb) and anti-thyroid peroxidase antibody (TPOAb), were within normal limits, while anti-thyroglobulin antibody (TGAb) was detectable but below the clinical threshold for autoimmune thyroid disease (109.10 IU/mL; reference: < 115 IU/mL) (Table 1). Chest computed tomography (CT) revealed no pulmonary infiltrates or consolidations but did note heterogeneous thyroid density. Thyroid ultrasonography confirmed heterogeneous echotexture with a hypoechoic area in the right lobe, consistent with inflammatory changes (Figure 1). A definitive diagnosis of severe SAT was made based on the constellation of clinical symptoms, biochemical thyrotoxicosis, significantly elevated inflammatory markers, and characteristic imaging findings. The treatment regimen included intravenous methylprednisolone to address thyroid inflammation. Additionally, empirical antibiotic therapy with cefuroxime (0.5 g/day) and amoxicillin (1.5 g/day) was initiated to preclude superimposed bacterial infection.
On the 7th day of hospitalization, the patient reported no substantial symptomatic improvement. Follow-up laboratory investigations corroborated the lack of clinical response, demonstrating persistent leukocytosis (10.58 × 109/L), elevated neutrophils (7.51 × 109/L), a CRP level as high as 47.1 mg/L, and an ESR as high as 72 mm/h. Given the poor efficacy of the conventional treatment regimen and the fact that the patient was experiencing low mood and fatigue, which were severely affecting her daily life, we considered that these side effects might be attributable to the use of methylprednisolone. We therefore suspended the Western medical treatment, initiated a comprehensive treatment plan incorporating TCM, and admitted the patient to the hospital for close monitoring. Based on TCM syndrome differentiation, the condition was identified as “goiter”, specifically characterized as Liver Qi Stagnation pattern. The pathogenesis was interpreted as follows: chronic emotional distress, particularly excessive worry, resulted in liver depression and impairment of Qi dynamics. Stagnant liver Qi then invaded the spleen, leading to spleen deficiency and loss of its fortifying function. This dysfunction promoted the internal generation of phlegm and turbidity. The subsequent intermingling of phlegm and stagnant Qi ascended along the meridians to congregate in the anterior neck region. The TCM diagnostic findings included a reddish tongue with a thin, white coating and a slippery pulse, both consistent with patterns of liver depression and Qi stagnation. In summary, the core pathogenesis of this case is attributed to liver dysfunction, with the primary pattern identified as liver Qi stagnation.
Treatment
Based on the TCM syndrome differentiation of liver Qi stagnation, a customized herbal decoction was prescribed to soothe the liver, resolve stagnation, and alleviate discomfort. The formula comprised: Pinellia ternate (Ban Xia) 15 g, Curcuma aromatica (Yu Jin) 12 g, Albizia julibrissin (He Huan Hua) 12 g, Rosa rugosa (Mei Gui Hua) 12 g, Polygonum multiflorum (Ye Jiao Teng) 15 g, Ziziphus jujuba (Suan Zao Ren) 15 g, Poria cocos (Fu Ling) 12 g, Perilla frutescens (Zi Su Zi) 9 g, Lonicera japonica (Jin Yin Hua) 12 g, Isatis tinctoria (Ban Lan Gen) 12 g, and Mentha haplocalyx (Bo He) 12 g. To augment the treatment, auricular acupuncture was applied to key points (Endocrine, Thyroid, Shenmen, Subcortical, Sympathetic, and Heart) with the aim of regulating autonomic nervous function and improving sleep quality.
By day 14 of hospitalization, the patient’s primary symptoms of neck pain and dysphagia had markedly improved. However, she reported emerging complaints of a persistent globus sensation in the throat, alongside abdominal distension and newfound cold intolerance in the lower extremities. In response, the herbal formula was modified to address these patterns that were likely indicative of evolving spleen Qi deficiency and Yang deficiency, with the addition of Zingiber officinale (Gan Jiang) 6 g to warm the triple energizer, Coix lacryma-jobi (Yi Yi Ren) 9 g to resolve dampness, Glycyrrhiza uralensis (Zhi Gan Cao) 15 g to harmonize the formula and tonify the spleen, and Atractylodes macrocephala (Bai Zhu) 9 g to strengthen spleen function. Concurrently, to manage the cold limbs, mid-frequency pulse electrotherapy was administered bilaterally at the acupoints Quchi (LI11) and Zusanli (ST36) to promote Qi and blood circulation. Furthermore, an herbal fumigation therapy was prescribed for the lower limbs utilizing a formula designed to warm the channels and expel cold, containing Speranskia tuberculata (Tou Gu Cao) 30 g, Lycopodium clavatum (Shen Jin Cao) 30 g, Cinnamomum cassia (Gui Zhi) 30 g, Carthamus tinctorius (Hong Hua) 15 g, Ligusticum chuanxiong (Chuan Xiong) 30 g, Notopterygium incisum (Qiang Huo) 30 g, Clematis chinensis (Wei Ling Xian) 30 g, and Corydalis yanhusuo (Yan Hu Suo) 30 g.
By day 21 of hospitalization, a near-complete resolution of the throat irritation, pain, and dysphagia was observed. The ancillary symptoms of abdominal distension, lower limb coldness, and insomnia had also substantially improved. Follow-up laboratory investigations revealed significant amelioration of the inflammatory and thyrotoxic state: TSH 0.021 μIU/mL, FT4 24.34 pmol/L, FT3 5.50 pmol/L, CRP 2.4 mg/L, and ESR 18.0 mm/h. Hematological parameters remained within normal limits (leukocyte count 8.09 × 109/L, neutrophil count 6.48 × 109/L). Given the marked clinical and biochemical improvement, the patient was discharged. Subsequent outpatient follow-up visits at regular intervals over one year confirmed sustained remission, with no reports of recurrent pharyngeal pain or dysphagia. Neither colour Doppler ultrasound nor laboratory tests revealed any abnormalities, as shown in Figure 1 and Table 1. This indicates a favorable long-term prognosis, with no recurrence observed (Figure 2 for the patient’s treatment process).
Discussion
SAT is a self-limiting inflammatory disorder of the thyroid gland, frequently associated with viral infections[
5]. The disease demonstrates a significant gender disparity, with a higher prevalence among middle-aged women and a reported male-to-female ratio ranging from 1:3 to 1:6[
6]. Its onset often exhibits a seasonal pattern, typically peaking in winter, and is commonly preceded by an upper respiratory tract infection. The clinical presentation of SAT is usually acute, characterized by systemic viral-like symptoms including fever, headache, and malaise. A pathognomonic feature is spontaneous pain or tenderness in the thyroid region, observed in approximately 90% of patients. This pain may radiate to the submandibular area, behind the ears, or across the neck, and is frequently exacerbated by swallowing. However, the absence of localized thyroid symptoms in about 10% of patients—who may present instead with prolonged fever or significant weight loss—often leads to diagnostic confusion. Such cases are frequently misdiagnosed as upper respiratory tract infections or pharyngitis, contributing to an initial misdiagnosis rate exceeding 50% in some reports[
7]. This highlights a critical need for heightened clinical vigilance. Diagnosis relies on a combination of clinical features—such as acute onset, fever, and a painful, enlarged, firm thyroid gland—and supportive laboratory findings, including a markedly elevated ESR and transiently elevated serum thyroid hormone concentrations.
First-line management of SAT is guided by symptom severity. Mild cases are typically treated with NSAIDs, while moderate to severe cases often require glucocorticoid therapy. Prednisone is widely employed for its potent anti-inflammatory effects and generally leads to a favorable prognosis, with the disease course typically resolving within 2 to 3 months. However, glucocorticoid use is associated with significant adverse effects, including weight gain, osteoporosis, hypertension, hyperglycemia, glaucoma, cataracts, and dermal changes. Furthermore, disease relapse following drug tapering or discontinuation is a common clinical challenge. In contrast, TCM employs syndrome differentiation to guide individualized treatment. This approach can effectively alleviate clinical symptoms while potentially mitigating the side effects associated with conventional steroids. Recent clinical studies have increasingly demonstrated that an integrated Chinese and Western medicine strategy yields satisfactory outcomes in SAT management, improving recovery rates and reducing relapse[
8].
The TCM understanding of SAT, historically categorized under “goiter”, is elaborated in classical texts such as Zhu Bing Yuan Hou Lun [Treatise on the Origins and Manifestations of Diseases]. The core pathogenesis often involves liver Qi stagnation. For instance, the middle-aged female patient described in this report presented with a history of emotional distress and chronic anxiety, which in TCM theory can impair the liver’s function of ensuring the free flow of Qi. This leads to liver depression and Qi stagnation. The stagnant liver Qi may then “invade” the spleen transversely, disrupting its function in transportation and transformation, resulting in internal phlegm generation. The concomitant upward rebellion of phlegm and Qi along the meridians to the throat manifests as the characteristic neck swelling and pain. This pattern was further corroborated by her TCM signs: a reddish tongue with a thin, white coating and a slippery pulse, collectively indicative of liver Qi stagnation with incipient phlegm formation.
The initial herbal formula was designed to address the patient’s core TCM pattern through multiple synergistic actions. Pinellia ternata, Poria cocos, and Perilla frutescens functioned collectively to dry dampness, strengthen spleen function, regulate Qi, and resolve phlegm. Concurrently,
Curcuma aromatica,
Albizia julibrissin, and
Rosa rugosa acted to soothe the liver and resolve depression. Polygonum multiflorum and Ziziphus jujuba were included to alleviate depression and tranquilize the mind. Finally, Lonicera japonica, Mentha haplocalyx, and Isatis tinctoria served to clear heat, remove toxins, cool the blood, and benefit the throat. Following three days of this treatment regimen, the patient reported a notable alleviation of her sore throat symptoms. However, subsequent dietary indiscretion involving greasy food reportedly led to the emergence of new symptoms: increased phlegm production in the throat and abdominal distension. This clinical shift suggested an exacerbation of dampness and further impairment of spleen function. In response, the formula was modified with the addition of
Coix lacryma-jobi and
Atractylodes macrocephala to enhance the formula’s capacity to resolve dampness, transform phlegm, and fortify the spleen. Auricular acupuncture was employed as an adjunctive therapy. Pressure stimulation of specific otopoints is believed to modulate meridian conduction and facilitate the functional recovery of corresponding internal organs. Modern research suggests that auricular therapy may promote blood circulation, enhance metabolic processes, and regulate immune function. Recent clinical applications have demonstrated its efficacy, particularly in managing functional and immune-related disorders[
9]. In this case, we targeted the Endocrine, Thyroid, Shenmen, Subcortical, Sympathetic, and Heart otopoints with the dual therapeutic aim of regulating Yin-Yang equilibrium and sedating the mind to improve sleep quality.
The patient’s presentation of coldness in the lower extremities was interpreted within the TCM framework as a consequence of phlegm-dampness obstruction in the throat, leading to impaired circulation of Qi and blood throughout the body, with consequent accumulation of pathogenic factors in the lower limbs resulting in coldness. This pattern was identified as upper-heat and lower-cold. A multimodal approach was initiated to address this complication.
A herbal fumigation therapy was prescribed to dispel wind-cold-dampness pathogens and harmonize the cold-heat disparity. The fumigation formula included Speranskia tuberculata and Lycopodium clavatum to dispel wind-cold and relax tendons; Cinnamomum cassia to harmonize the nutritive (ying) and defensive (wei) Qi and alleviate limb pain; Carthamus tinctorius to activate blood circulation and dispel stasis; Ligusticum chuanxiong and Notopterygium incisum to invigorate blood, move Qi, and relieve pain; and Clematis chinensis and Corydalis yanhusuo to dispel wind-dampness, unblock meridians, and stop pain. The core therapeutic principle was to dispel wind-dampness and unblock meridian obstructions. Complementing this, mid-frequency pulse electrotherapy was applied bilaterally to the acupoints Quchi (LI11) and Zusanli (ST36) to stimulate local metabolism and promote the circulation of Qi and blood. This combined intervention led to a significant improvement in the patient’s lower limb coldness.
The patient’s overall health status and quality of life markedly improved following this integrated protocol. This case suggests that augmenting oral herbal medicine with auricular acupuncture, herbal fumigation, and electrotherapy may not only effectively alleviate the core symptoms of SAT but also facilitate a global adjustment of the patient’s Qi, blood, Yin, and Yang, thereby resolving systemic comorbidities such as abdominal distension, insomnia, and cold limbs.
As a single-case report, this study cannot definitively establish the specific efficacy of each therapeutic modality (herbal medicine, electrotherapy, fumigation, and auricular acupuncture) for SAT. To further substantiate these preliminary findings, a randomized controlled trial (RCT) is warranted.
To our knowledge, this is the first report to describe the combined use of customized herbal medicine, auricular acupuncture, herbal fumigation, and mid-frequency electrotherapy for SAT management, resulting in a favorable patient outcome.
The Author(s) 2026. This article is published by Higher Education Press at journal.hep.com.cn.
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