Current Issue - 2006, Volume 1 Number 2 & 3

CASE REPORTS

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ACUTE SUPPURATIVE THYROIDITIS PRESENTING AS A PAINLESS THYROID SWELLING

Table 1. Laboratory investigations

Laboratory investigations

Outpatient

Inpatient Normal range

Haematology
Hb
WBC

Platelet
ESR


14.3
22.9 (neutrophils 84%)
188
65


13.8
17.0 (neutrophils 79.8%)
244
105


13-18 g/dL
4-11 x 103/mL
150-450 x
103/mL
<21 mm/hour

Urinalysis
Protein
Glucose
Blood
pH
S.G
Ketones


2+
Negative
1+
6.0
1.030
1+


4+
1+
1+
6.0
1.025
1+

 

Biochemistry
Sodium
Chloride
Urea
Creatinine
Total protein
Albumin
Globulin
Albumin/globulin ratio
Alkaline phosphatase
Total bilirubin
GGT
AST
ALT
HbA1c


131
94
3.5
71
87
45
42
1.1

139

56
328
62
142
-


131
93
4.9
97
79
34
45
0.8

135

52
318
23
119
5.3%


135-145 mmol/L
95-110 mmol/L
2.5-8.0 mmol/L
50-120 mmol/L
60-82 g/L
35-50 g/L
20-39 g/L
1.1-2.6

30-120 U/L

<17 mmol/L
15-85 U/L
15-37 U/L
30-65 U/L
-

Serology
Free thyroxine
Total T4
TSH
Thyroid microsomal antibody
Thyroglobubin antibody
HIV 1 & 2
HBs antigen
HBs antibody
Total HAV antibody (IgG & IgM)
Hepatitic C antibody
Dengue IgM
Dengue IgG


25
-
1.71

-

-
Non-reactive
-
-
-
-
-
-
-


-
14.29
0.44

8.6

90.3
-
Non-reactive
90.1
Non-reactive
Non-reactive
Negative
Negative
Negative


9.0-25.0 pmol/L
4.5-12.0 mg/dL
0.4-4.7 mIU/L

0-12 IU/mL

0-34 IU/mL
-
-
-
-
-
-
-
-

Figure 1. Spiral CT of neck. (A) Right thyroid mass, (B) trachea shifted to the left

Spiral CT of neck

DISCUSSION

Acute suppurative thyroiditis is an acute painful condition of the thyroid associated with bacterial, fungal, mycobacterial or parasitic infection. It presents typically with a tender swollen gland associated with fever, leucocytosis and a raised ESR. The cause of the condition can be due to haematogenous spread from a distant focus, spread via the lymphatics, rarely introduction of bacteria during a fine needle aspiration,3,4 direct inoculation at the time of thyroid surgery, spread via an infected thyroglossal duct and local spread through a piriform sinus fistula.4 It is believed that the majority of acute suppurative thyroiditis in children is due to spread via a left piriform sinus and they are prone to recurrent episodes of infection. Piriform sinus fistula refers to a persistent third or fourth branchial pouch which typically presents as a congenital sinus tract that originates from the piriform sinus.5 The sinus tract is usually diagnosed by barium study or direct endoscopic methods. Ultrasound, CT scan and MRI may aid in the diagnosis. During imaging the diagnosis can be aided by the so-called trumpet maneuver.6 FNAC remains the best single laboratory test in the evaluation of acute suppurative thyroiditis and will be diagnostic in most cases.2

 

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