Current Issue - 2006, Volume 1 Number 2 & 3

CASE REPORTS

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ACUTE SUPPURATIVE THYROIDITIS PRESENTING AS A PAINLESS THYROID SWELLING

Microbiological agents involved in acute bacterial thyroiditis typically include the Staphylococci, Streptoccoci and the Enterobacteria.7 On rare occasions the fungi were involved, although in this immunocompromised era more of these cases had been reported.8-11 Parasitic infection of the thyroid is indeed a curiosity and a true rarity. A variety of clinical pattern of community-acquired Klebsiella pneumoniae septicemia had been described,12 , however those associated with acute suppurative thyroiditis were distinctly rare.13

Life threatening complications include tracheal compression due to enlarging mass, vocal cord paralysis,14  and abscesses spreading into the retropharyngeal space and mediastinum15. A transient phase of hyperthyroidism due to outpouring of thyroid hormone in conjunction with massive destruction of the tissues associated with the abscess had been described.16

The clinical presentation of the case was rather unusual as the thyroid was not tender. The thyroid is normally tender in acute thyroiditis and exquisitely tender in subacute granulomatous thyroiditis (De Quervain thyroiditis). A non-tender thyroid swelling would suggest a nodular disease or Hashimoto’s thyroiditis. The non-tender nature of the thyroid in this case may be due deep-seated site of infection and that it was not confined but was spreading into the deeper planes. A high index of suspicion is necessary when the presentation is atypical. FNAC will clinch the diagnosis, as in this case. FNA biopsy was also useful to rule out malignancy and other infections like tuberculous thyroiditis.17-19 The treatment of acute suppurative thyroiditis usually involved the administration of antibiotics. It is only occasionally that surgical drainage of the abscess will be required when conservative treatment failed. The source of the infection was indeterminate in this case, but the respiratory tree and the urinary tract were prime suspects.

CONCLUSION

We like to highlight the fact that if one encounters a patient with an enlarging neck mass, whether tender or not, associated with fever, leukocytosis and raised ESR, one should consider the diagnosis of acute suppurative thyroiditis

 

REFERENCES

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  6. Wang HK, Tiu CM, Chon YH, et al. Imaging studies of pyriform sinus fistula. Paediatr Radiol. 2003;33(5):328-33 [PubMed]
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  8. Ayala AR, Bassaria S, Roberts KE, et al. Aspergillus thyroiditis. Postgrad Med J. 2001;77(907):336 [PubMed]
  9. Vandjme A, Pageaux GP, Bismuth M, et al. Nocardiosis revealed by thyroid abscess in a liver-kidney transplant recipient. Transpl Int. 2001;14(3):202-4 [PubMed]
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WEBSITES, GUIDELINES AND MORE: THYROID

American Thyroid Association
http://www.thyroid.org/professionals/publications/guidelines.html
Published five peer guidelines for the diagnosis and management of thyroid disease.

Guidelines from British Thyroid Association
http://www.british-thyroid-association.org/guidelines.htm
Use of thyroid function tests [2002] [PDF] (565Kb)
Management of thyroid cancer in adults [2002]. Full guideline [PDF] (910Kb); For primary care physician [PDF] (46Kb)

Thyroid Disease Manager http://www.thyroidmanager.org/
This website offers an “up-to-date analysis of thyrotoxicosis, hypothyroidism, thyroid nodules and cancer, thyroiditis, and all aspects of human thyroid disease and thyroid physiology.” A textbook [HTML] is available for free download.

Systematic Reviews
Abraham P, Avenell A, Watson WA, et al. Antithyroid drug regimen for treating Graves' hyperthyroidism. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003420. DOI: 10.1002/14651858.CD003420.pub3
Bottomline: “Lower doses of anti-thyroid drugs may be just as effective for people with Graves' hyperthyroidism, but with fewer adverse effects.” [HTML]

Abraham P, Avenell A, Park CM, et al. A systematic review of drug therapy for Graves' hyperthyroidism. Eur J Endocrinol. 2005;153(4):489-98
Bottomline: “The titration regimen appeared as effective as the Block-Replace regimen, and was associated with fewer adverse effects.” [HTML]

Castro MR, Caraballo PJ, Morris JC. Effectiveness of thyroid hormone suppressive therapy in benign solitary thyroid nodules: a meta-analysis. J Clin Endocrinol Metab. 2002;87(9):4154-9
Bottomline: “Suppressive thyroid hormone therapy for longer than 6 months is associated with a trend toward a reduction of more than 50% in volume of benign thyroid nodules, without achieving statistical significance.” [HTML]

Editor’s note: the information provided here is extracted from the website “as is”; please evaluate the validity before application.

 

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