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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 37-39

Acute suppurative thyroiditis: An unusual complication


1 Department of General Surgery, R G Kar Medical College, Kolkata, West Bengal, India
2 Department of Pediatric Surgery, R G Kar Medical College, Kolkata, West Bengal, India
3 Department of Pediatric Medicine, R G Kar Medical College, Kolkata, West Bengal, India

Date of Submission28-May-2021
Date of Acceptance19-Oct-2021
Date of Web Publication03-Nov-2021

Correspondence Address:
Dr. Pankaj Kumar Halder
Saroda Pally, Baruipur, Kolkata - 700 144, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/trp.trp_7_21

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  Abstract 


Acute thyroiditis is rare and usually subsides with medical therapy. An abscess arising due to it is even rarer. Sometimes, surgical drainage is required to control ongoing infection and sepsis. We report a case of a 4-year-old girl who had acute suppurative thyroiditis. The swelling was not resolving after 9 days of administering intravenous antibiotics and eventually compressing the esophagus and trachea which was relieved leading to a speedy recovery on emergency surgical drainage.

Keywords: Cauterization, children, endoscopy, suppuration, surgery, thyroiditis


How to cite this article:
Das D, Chakraborty P, Ganguly M, Halder PK. Acute suppurative thyroiditis: An unusual complication. Thyroid Res Pract 2021;18:37-9

How to cite this URL:
Das D, Chakraborty P, Ganguly M, Halder PK. Acute suppurative thyroiditis: An unusual complication. Thyroid Res Pract [serial online] 2021 [cited 2021 Dec 9];18:37-9. Available from: https://www.thetrp.net/text.asp?2021/18/1/37/329889




  Introduction Top


Acute suppurative thyroiditis (AST) accounts for 1%–7% of all thyroid diseases. It occurs due to direct extension from acute bacterial pharyngitis, the persistence of pyriform sinus fistula (PSF), recent invasive procedure on the thyroid gland, or foreign-body impaction in the pharynx or esophagus. The condition usually subsides with medical therapy. Inappropriate/delayed treatment can be life-threatening and may result in higher mortality (12%). Endoscopic chemical cauterization of the internal opening of PSF is a safe and effective technique.[1] Surgical drainage of the abscess is seldom required. We report a case of a 4-year-old girl who had AST which did not respond to medical therapy. We had to perform surgical drainage of the thyroid abscess to control the ongoing infective process.


  Case Report Top


A 4-year-old girl, weighing 10 kg, presented with right-sided painful neck swelling for 15 days duration, which was increasing in size. There was accompanying fever, dysphagia, and difficulty with breathing for the same duration. She had no history suggestive of any pit or depression or swelling at the same site earlier. There was no history of active pulmonary tuberculosis/contact, any foreign-body ingestion, previous infection, or recent immunization. The girl was febrile, irritable, and had tachypnea and limitation in movement of the neck. Adjacent anterior cervical lymph nodes were enlarged and tender. Local examination revealed a soft, smooth, tender mass, 3 cm × 1.5 cm, on the right side of the anterior aspect of the neck which moved with deglutition and tongue protrusion. However, it was not attached to the surrounding structure. Her hemoglobin was 9.6 g/dL with high white blood cell count (20,200/mm3) with neutrophil predominance (81%). HIV was nonreactive and antithyroid peroxidase antibody was <28.0, (<or 60 Negative). Thyroid-stimulating hormone (TSH) was 0.4 and free T4 was 1.4 mIU/L. The reference value of TSH is between 0.4 and 3.8 micro IU/ml, and free T4 is between 0.8 and 2 ng/dL, (chemiluminescence immunoassay technique). The thyroid ultrasonography revealed a solid cystic lesion, 3 cm × 2.5 cm sized, arising from the right lobe of the thyroid. The neck X-ray did not reveal any foreign body or any definite evidence of a patent airway. Thus, an assessment of AST was made and she was placed on intravenous antibiotic in the form of amoxicillin + clavulanic acid and linezolid. Computed tomography (CT) of the neck showed an indistinct soft tissue density area on the right cervical region, overlapping the ipsilateral strap muscles, pushing the right lobe of thyroid inward and inseparable from the right lobe of thyroid at places. On day 6th, further assessment by fine-needle aspiration cytology revealed acute suppurative lesion (abscess) following which the antibiotics were stepped up to meropenem and vancomycin. Unfortunately, the swelling characters worsen more prominent and hyperemic. Finally, we embarked on surgical drainage of the abscess on the 9th day and drained about 6 ml of frank pus [Figure 1]. Culture sensitivity of the pus, however, revealed no growth. The child's condition was improved significantly thereafter, and she was able to eat unhindered. We discharged her on the 3rd postoperative day and she is now doing well.
Figure 1: Computed tomography and perioperative pictures of acute suppurative thyroiditis in a 4-year-old girl

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  Discussion Top


The thyroid gland is well known to resist infections because of:

  1. A rich blood supply and lymphatic drainage
  2. High glandular content of iodine which can be bactericidal
  3. Separation of the gland by facial planes from other nearby vital structures of the neck, and
  4. Generation of hydrogen peroxide inside the gland which helps in the synthesis of thyroid hormone.[2]


A persistent PSF or third and fourth bronchial pouch can lead to recurrent thyroiditis in children. It also occurs due to direct extension from acute bacterial pharyngitis or following an invasive procedure on the thyroid gland or foreign-body impaction in pharynx/esophagus, and in  Brucellosis More Details.[3] Commonly isolated organisms are Staphylococcus aureus, Streptococcus, pneumococcus,  Salmonella More Details, Klebsiella, and Mycobacterium tuberculosis; anaerobes such as Actinomycetes, Peptostreptococcus, and Propionibacterium; or fungi such as Coccidioides immitis and Aspergillus, especially in immune compromised.[4]

AST mostly (92%) occurs in the first decade of life and has no sex predilection. Clinical features include fever, sore throat, tenderness, anterior midline swelling in the neck (usually left site), dermal erythema, dysphasia, hoarseness, and limitation of head movements.[5] Tachycardia, leucocytosis, and increased erythrocyte sedimentation rate are common with typically normal thyroid function tests. Destruction of the thyroid gland due to bacterial invasion can cause thyroid hormone release, and thus might cause symptomatic thyroiditis.[6]

Ultrasonography helps to differentiate intra or extra thyroid abscesses and also solid from cystic structures as well as adjacent thyroid nodules. The telescopic hypopharyngoscopy is considered for the identification of the internal opening of PSF.[7]

Treatment can vary according to the needs, as most have been successfully treated by intravenous antibiotics. Some require surgical drainage in conjugation with the removal of the fistulous tract. CT-guided percutaneous catheter drainage may be an effective and safe alternative in many cases.[8] Endoscopic chemical cauterization of internal opening is also effective and safe technique with low morbidity and a high potential for cure.[9] Rarely, it may rupture into the trachea or esophagus. It also may give rise to thyroid gland destruction leading to a variable degree of hypothyroidism.

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
    
2.
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. 2
    
3.
Nicoucar K, Giger R, Pope HG Jr, Jaecklin T, Dulguerov P. Management of congenital fourth branchial arch anomalies: A review and analysis of published cases. J Pediatr Surg 2009;44:1432-9.  Back to cited text no. 3
    
4.
Cawich SO, Hassranah D, Naraynsingh V. Idiopathic thyroid abscess. Int J Surg Case Rep 2014;5:484-6.  Back to cited text no. 4
    
5.
De Sousa RF, Amonkar D, Mervyn C. Thyroid abscess with cutaneous fistula: Case report and review of the literature. Thyroid Sci 2008;3:1-4.  Back to cited text no. 5
    
6.
Mali VP, Prabhakaran K. Recurrent acute thyroid swellings because of pyriform sinus fistula. J Pediatr Surg 2008;43:e27-30.  Back to cited text no. 6
    
7.
Tien KJ, Chen TC, Hsieh MC, Hsu SC, Hsiao JY, Shin SJ, et al. Acute suppurative thyroiditis with deep neck infection: A case report. Thyroid 2007;17:467-9.  Back to cited text no. 7
    
8.
Akdemir Z, Karaman E, Akdeniz H, Alptekin C, Arslan H. Giant thyroid abscess related to postpartum Brucella infection. Case Rep Infect Dis 2015;2015:646209.  Back to cited text no. 8
    
9.
Liu Y, Yu S, Ren X, Qiao Y, Sun G. Klebsiella pneumoniae thyroid abscess complicated with esophagitis in a woman with newly diagnosed diabetes mellitus: A case report. J Diabetes Investig 2016;7:127-9.  Back to cited text no. 9
    


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