|Year : 2014 | Volume
| Issue : 3 | Page : 131-132
Thyroid abscess: A rare entity?
DS Nirhale, VS Athavale, Gaurav Goenka, Mohit Bhatia
Departments of General Surgery, Padm, Dr. D.Y. Patil Medical College, Pimpri, Pune, India
|Date of Web Publication||13-Aug-2014|
1, Bank Colony, Opposite Old Sessions Courts, Ambala City, Haryana 134 003
Source of Support: None, Conflict of Interest: None
A thyroid abscess is an infrequently encountered condition with a rarity that is attributable to anatomic and physiologic characteristics of the gland that impart a unique quality of infection resistance. The differential diagnosis for a painful thyroid is limited, with sub-acute and chronic thyroiditis being the most often-encountered processes. Acute suppurative thyroiditis with abscess formation, although rare, is a formidable clinical scenario with morbid complications. The common causative organisms responsible for thyroid abscess are Staphylococci and Streptococci species. We describe a case of thyroid abscess due to methicillin resistant Staphylococcus aureus in young female. The patient was successfully treated with open surgical drainage and appropriate antimicrobial agents.
Keywords: Methicillin resistant Staphylococcus aureus, suppurative thyroidits, thyroid abscess
|How to cite this article:|
Nirhale D, Athavale V, Goenka G, Bhatia M. Thyroid abscess: A rare entity?. Thyroid Res Pract 2014;11:131-2
| Introduction|| |
Acute suppurative thyroditis (AST) leading to thyroid abscess is a rare clinical entity.  AST, specially affects patients with pre-existing thyroid gland pathology and in childhood it is associated with local anatomic defects.  Because of its rarity and unusual clinical features, the diagnosis of thyroid abscess is often delayed. Organisms commonly responsible for bacterial thyroiditis are those that colonize the skin and oropharynx.  Staphylococcus aureus is the most common organism cultured from thyroid abscesses. Progress to abscess formation may then occur with all the inherent dangers of advanced suppuration in the neck. Early biopsy and cultures are needed for prompt anti-microbial therapy.Surgical drainage is required for a large abscess.  We report a case of a 30-year-old female, who presented with acute suppurative thyroiditis with impending abscess.
| Case report|| |
A 35-year-old female presented with swelling on the anterior aspect of neck with dysphagia, intermittent episodes of fever, and hoarseness of voice since 20 days. History was of cough and cold 25 days back. Swelling of 2 × 2 cm present in anterior aspect of neck with mild tenderness, local rise of temperature, which moves with deglutition and lower margin, is seen. On admission, laboratory investigations revealed leukocyte count of more than 15,000 with 80% of polymorphs; hemoglobin of 9%, thyroid profile showed hyperthyroid state. X-ray neck showed tracheal compression by a homogenous soft-tissues density pushing the trachea to right; Ultrasound neck showed hypo echoic lesions seen in both lobes of thyroid with no lymphadenopathy suggestive of thyroid abscess. USG guided aspiration was done and pus culture sensitivity report showed methicillin resistant Staphylococcus aureus (MRSA). Contrast-enhanced computed tomography (CT) neck-thyroid abscess with retrosternal extension with effacement of ipsilateralpyriform sinus with few enlarged cervical nodes seen at level 1A and 1B with central necrosis. Anti-thyroglobulin antibody and anti-microsomal antibody were negative.Indirect laryngoscope showed right vocal cord palsy, collection of pus in post-cricoids region. Patient was started with tablet neomercazole 10mg tds and tablet Propranol 10 mg bid.Patient was taken up for surgery and she underwent an incision and drainage procedure under General Anaesthesia that yielded 150 ml of greenish pus. After course of intravenous antibiotics; she improved her post-operative day 7 Thyroid Function Tests were normal. All anti-thyroid drugs were stopped and patient was discharged on 18 th post-operative day.
| Discussion|| |
Infections of thyroid are rare, because the gland is resistant to infection because of its encapsulation, high iodide content, good blood supply, wide lymphatic drainage, and separation of the gland from other structures of the neck by fascial planes. Hendrick  reported that 24% of 117 reviewed patients with thyroiditis appeared with an acute form of the disease, and only 5% of them finally developed an abscess. Infectious thyroiditis may be either acute or chronic. Acute suppurative thyroiditis has also been associated with immunosuppression especially, human immunodeficiency virus.  Acute suppurative thyroiditis can lead to abscess formation, if left untreated, and is usually caused by Gram-positive or Gram-negative organisms. Staphylococcus aureus predominates but pneumococcal, Salmonella More Details, mycobacterial, parasitic, fungal, actinomycosis, and pneumocystis infections may also occur. ,, Mixed infections involving oropharyngeal flora and anaerobic bacteria can also occur.  Rarely, Lemierre's syndrome (post-anginal septicemia due to anaerobes) and infectious mononucleosis in adolescents have been reported with thyroid abscess. 
Thyroid abscesses have been observed more commonly in women than men, but there are reports demonstrating that the disease occurs in men and women in a 1:1 ratio.  Hazard et al. observed a more common occurrence in the women in the age range of 20-40 years.  Our patient was a female of 35-years-old. The age range may vary considerably; patients aged from 16 days to 79 years have been reported. Laboratory features include elevated Erythrocyte Sedimentation Rate and possibly an elevated white blood cells with a left shift. Radioactive-iodine scanning may be normal or show hypo-functional areas with decreased uptake or suppurative areas appearing as "cold"nodules. USG and CT scan may demonstrate the underlying configuration and extent of the abscess and potential local irregularities in thyroid anatomy. 
The management of a thyroid abscess is surgical, consisting of incision and drainage, combined with culture, and appropriate antibiotic therapy. Broad-spectrum antibiotic therapy covering aerobic, anaerobic, and oral flora should be started early after obtaining a specimen for microbiological studies. Complications such as destruction of the thyroid or parathyroid glands, internal jugular vein thrombophlebitis, local or hematological spread to other organs, sepsis, and even abscess rupture or fistula formation into the esophagus or trachea can follow thyroid abscess. 
This case exemplifies a rare lesion of thyroid abscess due to an unusual causative agent: MRSA.It also illustrates the need for high-index of suspicion in cases of fever of unknown origin and the relevance of excluding less common causes (such as Gram-negative bacilli like Klebsiella species) in the management of thyroid abscess.
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