Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Home Print this page Email this page
Users Online: 364



 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 49-51

Thyroid abscess: A rare case report and review of literature


Department of Endocrinology, SMS Medical College, SMS Medical College, Jaipur, Rajasthan, India

Date of Web Publication23-Mar-2018

Correspondence Address:
Dr. Balram Sharma
SMS Medical College, JLN Road, Jaipur - 302 015, Rajasthan
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/trp.trp_47_17

Rights and Permissions
  Abstract 


Acute suppurative thyroiditis (AST) leading to thyroid abscess is a quite uncommon clinical entity. Both thyroid abscess and AST represent only 0.1%–0.7% of thyroid pathologies which may require surgical management. AST especially affects patients with Hashimoto's thyroiditis or thyroid cancer. In children, AST is associated with the persistence of a canal originating from the 3rd or 4th bronchial pouch that may lead to recurrent thyroid abscess. The left lobe of thyroid gland is more frequently involved. AST can be life threatening if left untreated, resulting in mortality of 12% or higher.

Keywords: Acute suppurative thyroiditis, immunocompromised, odynophagia, tachycardia, thyroid abscess


How to cite this article:
Sharma B, Bhavi VK, Nehra HR, Kumar A, Saran S, Mathur SK. Thyroid abscess: A rare case report and review of literature. Thyroid Res Pract 2018;15:49-51

How to cite this URL:
Sharma B, Bhavi VK, Nehra HR, Kumar A, Saran S, Mathur SK. Thyroid abscess: A rare case report and review of literature. Thyroid Res Pract [serial online] 2018 [cited 2018 Sep 21];15:49-51. Available from: http://www.thetrp.net/text.asp?2018/15/1/49/228380




  Introduction Top


Acute suppurative thyroiditis (AST) leading to thyroid abscess is a rare clinical entity. Thyroid abscess resulting from AST is of a rare clinical occurrence. Both thyroid abscess and AST represent only 0.1%–0.7% of thyroid pathologies managed surgically. AST especially affects patients with Hashimoto's thyroiditis or thyroid cancer. In children, AST is associated with local anatomic defects. In particular, the condition is associated with the persistence of a canal originating from the 3rd or 4th bronchial pouch that may lead to recurrent thyroid abscess. In most cases, the infection spreads to thyroid gland through pyriform sinus fistula. The left lobe of thyroid gland is more frequently involved. AST can be life threatening if left untreated, resulting in mortality of 12% or higher.[1]

As thyroid abscess is a rare condition and has unusual clinical features, its diagnosis is often delayed. Rarity of thyroid abscess is attributed to anatomic and physiologic characteristics of the gland and imparts a unique quality of infection of resistance, bactericidal property of colloid material, increased vascularity, and the presence of iodine in the thyroid gland as important mechanisms. Thyroid abscess presents as acutely painful swelling. The differential diagnosis for a painful thyroid gland is limited, with subacute and chronic thyroiditis being the most common.[2]


  Case Report Top


A 48-year-old female on prednisolone 5 mg for the last 2 months, prescribed by a private internist for low random cortisol, presented with an enlarging painful neck swelling of 1-month duration [Figure 1]. There was a history of mild-to-moderate degree fever and odynophagia since the onset of the swelling. Pain was described as constant and radiating to the occipital region. On examination, the patient was febrile, tachycardia, and restriction of neck movements but no evidence of respiratory distress. Examination of the neck revealed a diffuse swelling occupying in the region of thyroid more prominent on the right than on the left with erythema on the overlying skin. The swelling was tender, warm, and fluctuant, movement with deglutition was present, and there was no movement with protrusion of the tongue. No cervical lymphadenopathy was found.
Figure 1: Diffuse erythematous swelling of the thyroid (right > left)

Click here to view


Laboratory investigations revealed leukocytes count of 19,650 with 84% of polymorphs, hemoglobin of 9.3 g%, erythrocyte sedimentation rate (ESR) of 48 mm/h, and blood culture was sterile. Thyroid function test showed T3 - 1.17 ng/ml (0.6–1.81 ng/ml), T4 -14.33 mcg/dl (4.5–10.9 mcg/dl), and thyroid-stimulating hormone (TSH) - 0.24 mU/L (0.35–5.5 mU/L), suggestive of mild thyrotoxicosis. Anti-thyroid peroxidase was <28 IU/L. Basal cortisol was 3.28 mcg/dl, which was low for stress, so low-dose prednisolone continued. Ultrasonography (USG) of the neck demonstrated a well-defined cystic area with echoes seen in the right thyroid lobe measuring 17.7 mm × 16.3 mm × 14.3 mm, showing peripheral vascularity, suggestive of thyroid abscess [Figure 2]. Few clear cysts were also seen in the right lobe. The left lobe is normal in size and echotexture. There was no evidence of lymphadenopathy. Barium studies did not show any kind of abnormality including pyriform sinus fistula. Needle aspiration of the swelling obtained thick yellow pus, and microscopic examination showed dense collection of neutrophil and lymphocyte in hemorrhagic background with culture yielding Staphylococcal aureus [Figure 3]. Urine examination showed 25–30 pus cell/hpf and culture also yielded the same organism. The patient underwent ultrasound-guided aspiration with wide bore needle and given intravenous antibiotics for 14 days according to the culture sensitivity report. The patient was followed up after 1 month and there was gross regression in the size of swelling and pain.
Figure 2: Ultrasonography neck showing abscess in the right lobe of the thyroid gland

Click here to view
Figure 3: Dense collection of neutrophil and lymphocyte in hemorrhagic background (Leishman-Giemsa, ×10)

Click here to view



  Discussion Top


Primary thyroid abscess resulting from AST is a rare type of head and neck infection.[3] Thyroid gland is well known to resist infections. The protective mechanisms include rich blood supply and lymphatic drainage, high glandular content of iodine which is considered as bactericidal, separation of the gland from other structures of the neck by facial planes, and hydrogen peroxide generation within the gland for the synthesis of thyroid hormone.[4]

Thyroid abscess formation most commonly arises in pediatric population with anatomic anomalies of the hypopharyngeal region, leading to the development of a pyriform sinus fistula. In the adults, multiple etiologies have been proposed. Abscess formation secondary to direct trauma from foreign bodies, such as fine-needle aspiration (FNA), fishbone, and chicken bone penetration, has been reported and also extension from neighboring anatomic structures.[5],[6],[7] However, the most common cause of infection is hematogenous spreading from a distant site though the exact infectious source or pathology is frequently unknown.[8] About 92% of the affected patients are children, and there is no gender preference for thyroid abscess formation.[9] Clinical features often include fever, sore throat, tenderness, anterior midline swelling in the neck, dermal erythema, dysphagia, hoarseness, and limitation of head movements.[10]

The left lobe is commonly involved than the right. Tachycardia, leukocytosis, and increased ESR are common and typically associated with normal thyroid function tests.[4] However, exceptions have also been reported: in one study, 12% of patients were reported to have thyrotoxicosis and 17% were reported with hypothyroidism.[11] Ultrasound of the neck region adequately demonstrates intra- or extra-thyroid abscesses and solid or mixed lesions of the thyroid gland and also adjacent inflammatory nodes.[12] A barium swallow is indicated to identify the presence of a pyriform sinus fistula as it has good sensitivity in detecting the presence of such fistulas.[13] FNA can differentiate between AST and subacute thyroiditis as well as provides a good means for identifying the bacteriologic source of the condition, and thus, a more precise antibiotic can be selected.[14]

Our patient matched most of the criteria of AST with thyroid abscess although her T4 level was higher and TSH was suppressed. AST responds well to antibiotics with or without incision drainage of the abscesses and rarely causes external fistula. Our patient was a female aged 48 years with immunocompromised state due to exogenous steroid presented with painful swelling in the region of thyroid and underwent USG-guided aspiration of the pus and culture showed S. aureus and she was managed with intravenous antibiotics for 14 days. Follow-up was done after 1 month, and there was complete regression of the swelling and pain.


  Conclusion Top


Our patient was in immunocompromised state due to chronic exogenous steroid intake as suggested by low basal serum cortisol. hence she predisposed to infection. she presented with painful swelling in the region of thyroid which upon USG-guided aspiration revealed pus and culture showed S. aureus. she was managed with intravenous antibiotics for 14 days. Follow-up done after 1 month showed complete regression of the swelling and pain

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ghaemi N, Sayedi J, Bagheri S. Acute suppurative thyroiditis with thyroid abscess: A case report and review of the literature. Iran J Otorhinolaryngol 2014;26:51-5.  Back to cited text no. 1
[PUBMED]    
2.
Lamani YP, Basarkod SI, Telkar SR, Goudar BV, Ambi U. Thyroid abscess in immuno compromised patient: A case report. J Clin Diagn Res 2012;6:106-7.  Back to cited text no. 2
    
3.
Ogale SB, Tuteja VG, Chakravarty N. Acute suppurative thyroiditis with thyroid abscess. Indian Pediatr 2002;39:1156-8.  Back to cited text no. 3
[PUBMED]    
4.
Herndon MD, Christie DB, Ayoub MM, Duggan AD. Thyroid abscess: Case report and review of the literature. Am Surg 2007;73:725-8.  Back to cited text no. 4
[PUBMED]    
5.
Hazard JB. Thyroiditis: A review-Part I. Am J Clin Pathol 1995;25:289-98.  Back to cited text no. 5
    
6.
Coret A, Heyman Z, Bendet E. Thyroid abscess resulting from transoesophageal migration of a fish bone: Ultrasound appearance. J Clin Ultrasound 1993;21:152-4.  Back to cited text no. 6
    
7.
Yung BC, Loke TK. Fan WC. Acute suppurative thyroiditis due to foreign body induced retropharyngeal presented as thyrotoxicosis. Clin Nucl Med 2000;35:249-52.  Back to cited text no. 7
    
8.
Jacobs A, Gros DC, Gradon JD. Thyroid abscess due to Acinetobacter calcoaceticus: Case report and review of the causes of and current management strategies of thyroid abscesses. South Med J 2003;96:300-7.  Back to cited text no. 8
    
9.
Pearce E, Farewell P, Braverman LE. Thyroiditis. N Engl J Med 2003;348:2646-55.  Back to cited text no. 9
    
10.
Brent GA, Larsen PR, Davis TF. Hypothyroidism and thyroiditis. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, editor. Williams Text Book of Endocrinology. 11th ed. Philadelphia: Saunders Elsevier; 2008. p. 377-410.  Back to cited text no. 10
    
11.
Yu EH, Ko WC, Chuang YC, Wu TJ. Suppurative Acinetobacter baumanii thyroiditis with bacteremic pneumonia: Case report and review. Clin Infect Dis 1998;27:1286-90.  Back to cited text no. 11
[PUBMED]    
12.
Clair MR, Mandelblatt S, Roger S, Bains EP, Goodman K. Sonographic features of acute suppurative thyroiditis. J Clin Ultrasound 1983;11:222-4.  Back to cited text no. 12
    
13.
Masuoka H, Miyauchi A, Tomoda C, Inoue H, Takamura Y, Ito Y, et al. A Imaging studies in sixty patients with acute suppurative thyroiditis. Thyroid 2011;21:1075-80.  Back to cited text no. 13
[PUBMED]    
14.
Paes JE, Burman KD, Cohen J, Franklyn J, McHenry CR, Shoham S, et al. Acute bacterial suppurative thyroiditis: A clinical review and expert opinion. Thyroid 2010;20:247-55.  Back to cited text no. 14
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed328    
    Printed15    
    Emailed0    
    PDF Downloaded51    
    Comments [Add]    

Recommend this journal