Malaysian Family Physicians - Acute suppurative thyroiditis

CASE REPORTS

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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