Thyroid abscess: A rare case report and review of literature

Balram Sharma; Vijay Kumar Bhavi; Hardeva Ram Nehra; Anshul Kumar; Sanjay Saran; Sandeep Kumar Mathur

doi:10.4103/trp.trp_47_17

CASE REPORT

Year : 2018 | Volume : 15 | Issue : 1 | Page : 49-51

Thyroid abscess: A rare case report and review of literature

Balram Sharma, Vijay Kumar Bhavi, Hardeva Ram Nehra, Anshul Kumar, Sanjay Saran, Sandeep Kumar Mathur
Department of Endocrinology, SMS Medical College, SMS Medical College, Jaipur, Rajasthan, India

Date of Web Publication

23-Mar-2018

Correspondence Address:
Dr. Balram Sharma
SMS Medical College, JLN Road, Jaipur - 302 015, Rajasthan
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/trp.trp_47_17

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 2022 May 21];15:49-51. Available from: https://www.thetrp.net/text.asp?2018/15/1/49/228380

Introduction

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 3^rd or 4^th 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

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)

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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

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

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Discussion

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

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.

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