Thyroid Abscess: Challenges in Diagnosis and Management

Inflammatory and Infectious Disorders in Endocrine Pathology

A variety of inflammatory conditions may directly involve the endocrine glands, leading to endocrine dysfunction that can cause severe consequences on patients' health, if left untreated. Inflammation of the endocrine system may be caused by either infectious agents or other mechanisms, including autoimmune and other immune-mediated processes. Not infrequently, inflammatory and infectious diseases may appear as tumor-like lesions of endocrine organs and simulate neoplastic processes. These diseases may be clinically under-recognized and not infrequently the diagnosis is suggested on pathological samples. Thus, the pathologist should be aware of the basic principles of their pathogenesis, as well as of their morphological features, clinicopathological correlates, and differential diagnosis. Interestingly, several systemic inflammatory conditions show a peculiar tropism to the endocrine system as a whole. In turn, organ-specific inflammatory disorders are observed in endocrine glands. This review will focus on the morphological aspects and clinicopathological features of infectious diseases, autoimmune disorders, drug-induced inflammatory reactions, IgG4-related disease, and other inflammatory disorders involving the endocrine system. A mixed entity-based and organ-based approach will be used, with the aim to provide the practicing pathologist with a comprehensive and practical guide to the diagnosis of infectious and inflammatory disorders of the endocrine system.

A case report of acute suppurative thyroiditis caused by Clostridium perfringens

A 42-year-old woman inadvertently discovered a neck mass, which caused pain. Initially, she was treated with antibiotics at a local clinic; however, this treatment did not alleviate the symptoms. She visited the authors' outpatient clinic for further treatment and underwent thyroid ultrasonography, which revealed a mixed echo nodule. On day 4 after admission, surgery was performed to remove the diseased thyroid tissue and levofloxacin (0.4 g/day) was infused. Bacterial culture confirmed infection with Clostridium perfringens. Subsequently, the treatment was switched to ceftriaxone sodium (2 g/day) according to the results of the drug sensitivity test. Following treatment, the patient recovered fully and was discharged. She was then followed up with after discharge. Ultrasonography, laboratory testing and clinical manifestations did not indicate obvious abnormalities.

Thyroid Abscess: A Case Series and Literature Review

OBJECTIVE

In this retrospective case series, we chronicle six patients presenting with acute suppurative thyroiditis (AST) with progression to thyroid abscess in a single institution.

METHODS

Patients ranged in age from 16 to 74 years of age. The most common presenting symptoms were progressive unilateral neck pain, swelling, and odynophagia. Other symptoms included hoarseness and systemic signs of infection. Diagnosis of thyroid abscess was made with a CT scan of the neck, fine needle aspiration, and/or incision and drainage (I&D).

RESULTS

Management included antibiotic therapy, I&D, and thyroidectomy. All patients were successfully treated except for one who developed mediastinitis and died.

CONCLUSION

A complete literature review was performed to determine etiologies, common findings, and management of similar cases.

Clinical Analysis of Acute Suppurative Thyroiditis in 18 Children

Objective

To summarize our clinical experience with the diagnosis and treatment of children with acute suppurative thyroiditis (AST).

Methods

We retrospectively reviewed the clinical data of 18 children with AST treated at our hospital between January 2009 and May 2022.

Results

There were 8 boys and 10 girls, aged 7.8 ± 3.8 years at admission. The main clinical manifestations were fever (88.9%), neck pain (100%), and neck mass (100%). Blood and pus cultures were performed in 9 and 15 patients, respectively. All blood cultures were negative, while positive pus cultures were noted in eight cases (six Streptococcus spp., one Staphylococcus spp., and one Streptococcus spp. and Staphylococcus spp. mixed infection). Additionally, all patients received antibiotic treatment: three received antibiotics alone, seven received antibiotics and ultrasound (US)-guided needle aspiration, seven received antibiotics as well as surgical incision and drainage, and one received antibiotics, US-guided needle aspiration in addition to surgical incision and drainage. Consequently, the average length of hospital stay in patients who received antibiotics and US-guided needle aspiration was 9.1±2.9 days compared to 14.0±2.0 days in patients in the antibiotics alone group and 13.0 ± 2.2 days in patients in the antibiotics and surgical incision and drainage group. Follow-up was conducted in 15 of the 18 patients. Three patients relapsed, and the prognosis of the other patients was good.

Conclusion

AST has atypical clinical symptoms at the early stage. Regular monitoring of the thyroid gland using ultrasonography is strongly advised in unsure cases. Antibiotics combined with US-guided aspiration is a safe, effective, and minimally invasive treatment for AST in children and can reduce hospital stay. However, surgery may be necessary, particularly in the presence of complications. It is strongly recommended that patients with recurrence be examined for anatomical abnormalities and undergo radical treatment.

Actinomycotic Abscess of Thyroid Gland in a 3-Year-Old Child

Actinomycosis is an atypical cause of infection in the head and neck area, especially in children. A rare incidence of actinomycosis, its nonspecific clinical signs that mimic other pathological conditions, as well as a complicated identification of microorganism lead to diagnostic delays in clinical practice. Besides an accurate diagnosis, it is of an utmost importance to pinpoint relevant predisposing factors, which might result in the infection. We present a clinical case of actinomycotic infection of the thyroid gland in the pediatric patient at our department.

Spontaneous thyroid abscesses without underlying malignancy: a differential diagnosis for recent onset or rapidly growing thyroid masses

Thyroid abscess is a rare cause of neck swelling in patients. The rich iodine environment, good vasculature and protective capsule make bacterial growth suboptimal. We present two cases of thyroid abscess without underlying thyroid cancer in immunocompromised patients presenting to a thyroid unit. The demographics, clinical details, investigation, management and outcomes of two patients with thyroid abscess were reviewed. Two octogenarian women were referred with neck lumps originating in the thyroid gland. Ultrasound demonstrated fluid collection in the thyroid, aspiration of which demonstrated Escherichia coli. The patients had underlying diabetes mellitus and raised inflammatory markers at presentation. Both were treated with antibiotics and follow-up demonstrated complete resolution of infection with no underlying thyroid neoplasm. Thyroid abscesses are an important differential diagnosis in rapidly growing thyroid masses due to the potential for rapid deterioration, especially in patients with conditions or medications causing immunosuppression. Urgent admission should be considered to facilitate prompt intervention and rapid recovery.

Salmonella thyroid abscess-two case reports

Acute suppurative thyroiditis account for <1% of thyroid diseases and is uncommon because of the gland's encapsulation, iodine-rich environment, good vascular supply and extensive lymphatic drainage. It has been reported in patients with underlying goiters, thyroid cancers and in immuno-compromised patients. The usual causative organisms are Staphylococci spp. and Streptococci spp. Rarer organisms include Klebsiella spp. and Salmonella spp. Due to its rarity (as there have been only 28 cases of Salmonella thyroid abscess being reported in the literature till 2020), only case reports are available to guide management. We report two cases of thyroid abscess due to Salmonella enteritidis in our institution that may herald the re-emergence of this uncommon infection of the thyroid gland and to raise awareness for all clinicians. Both patients presented with neck swelling, dysphagia and sepsis. Surgical intervention was warranted in both patients due to the severity of the disease and failed medical therapy. Recovery was uneventful following adequate surgical intervention and antibiotic therapy according to the culture and sensitivity report of the pathogen. This case report highlights that both patients were immunocompromised, and they contracted Salmonella thyroid abscess without any gastrointestinal involvement. Thus, a high index of suspicion for Salmonella thyroid abscess in immunocompromised patients can expedite the diagnosis and appropriate management can be commenced such as antibiotic therapy, percutaneous aspiration and surgical drainage in the event of failed medical therapy.

A pain in the neck: Salmonella spp. as an unusual cause of a thyroid abscess. A case report and review of the literature

Background

Thyroid gland infections are rare. Their incidence is estimated to be less than 1% in immunocompromised hosts. Most common pathogens isolated are Gram positive aerobic cocci. Infections with Gram negative facultative aerobes such as Salmonella are rare.

Case presentation

A 55-year-old female with type II diabetes mellitus and a history of a colloid right thyroid lobe nodule presented with neck pain and fever. She was found to have a thyroid abscess 2 weeks following a non-specific diarrheal illness. A needle aspiration for symptomatic and diagnostic purposes was performed. Cultures grew Salmonella enterica serotype Heidelberg. She was treated with a 12-week course of oral antibiotics and serial aspiration.

Conclusion

A thyroid abscess is a rare occurrence; however, a high index of suspicion is required to make the diagnosis. The management is directed at minimizing morbidity. The mainstay treatment is medical, but surgery is sometimes necessary to achieve adequate source control, particularly when complications arise.

Acute spontaneous suppurative thyroiditis caused by Eikenella corrodens presented with thyrotoxicosis

Acute suppurative thyroiditis is a very rare and life-threatening endocrine emergency. Thyrotoxicosis is a rare condition accompanying acute suppurative thyroiditis. While the majority of the cases in the literature are caused by different reasons, spontaneous development is very rare. We present a patient with acute suppurative thyroiditis who presented to our clinic with thyrotoxic findings, and we compared the case to the literature. A 31-year-old male patient was admitted to our clinic with a complaint of progressive neck pain, swelling and redness on midline neck, fever, and palpitations. On physical examination, swelling, redness and tenderness were detected on the neck region that was consistent with the thyroid location. He presented with tremor on the hands, tachycardia and agitation. Thyroid function tests were compatible with thyrotoxicosis, but there were findings supporting the presence of infection in biochemistry tests. On his radiological evaluations, a heterogeneous lesion divided with small septs was observed, with consolidation areas in the left thyroid lobe. In fine needle aspiration biopsy, 2mL of purulent fluid could be aspirated due to the presence of small, separated consolidation areas. He initiated on antibiotic therapy, propranolol, steroid and symptomatic treatment. Eikenella corrodens was detected on the culture antibiogram. Antibiotic therapy was continued for 14 days due to less symptoms and better biochemical values. After treatment, the patient had normal thyroid function, had relief of fever and redness of the neck, and was followed-up. It should be kept in mind that acute suppurative thyroiditis may develop spontaneously with the findings of thyrotoxicosis, with no risk factors.

Concurrent Methicillin-Resistant Staphylococcus aureus Septicemia and Thyroid Abscess in a Young Male with Dengue

BACKGROUND

Dengue fever is an arthropod-borne viral infection with a very high incidence rate in Southeast Asia. Most patients present with self-limiting febrile illness, while some patients may develop complications like acute kidney injury, acute liver failure, myocarditis or Guillain- Barre syndrome. The coexistence of Dengue and MRSA (Methicillin-resistant Staphylococcus aureus ) is rarely reported in the literature.

CASE

A 28-year-old male is presented with high-grade fever, polyserositis and thrombocytopenia. The patient was treated symptomatically for dengue infection. During the course of hospitalization, patient developed neck swelling (thyroid abscess) and left forearm abscess. MRSA was isolated from blood culture and pus, and successfully treated with iv antibiotics (Vancomycin).

CONCLUSION

High anticipation and vigilance are required to detect concurrent bacteremia in dengue patients. Early recognition of warning signs with readily antibiotic therapy is important to prevent mortality and morbidity in these patients. Our report also highlights the MRSA as a rare cause of thyroid abscess, with only 5 cases reported in the literature so far.

CT of the Neck: Image Analysis and Reporting in the Emergency Setting

Interpreting findings seen at CT of the neck is challenging owing to the complex and nuanced anatomy of the neck, which contains multiple organ systems in a relatively small area. In the emergency department setting, CT is performed to investigate acute infectious or inflammatory symptoms and chronic processes. With few exceptions, neck CT should be performed with intravenous contrast material, which accentuates abnormally enhancing phlegmonous and neoplastic tissues and can be used to delineate any abscesses or necrotic areas. As part of the evaluation, the vascular structures and aerodigestive tract must be scrutinized, particularly for patency. Furthermore, although the patient may present because of symptoms that suggest non-life-threatening conditions involving structures such as the teeth or salivary glands, there may be serious implications for other areas, such as the orbits, brain, and spinal cord, that also may be revealed at the examination. With a focus on the emergency setting, the authors propose using an approach to interpreting neck CT findings whereby 12 areas are systematically evaluated and reported on: the cutaneous and subcutaneous soft tissues, aerodigestive tract and adjacent soft tissues, teeth and periodontal tissues, thyroid gland, salivary glands, lymph nodes, vascular structures, bony airspaces, cervical spine, orbits and imaged brain, lung apices, and superior mediastinum. The use of a systematic approach to interpreting neck CT findings is essential for identifying all salient findings, recognizing and synthesizing the implications of these findings to formulate the correct diagnosis, and reporting the findings and impressions in a complete, clear, and logical manner.Online supplemental material is available for this article.^©RSNA, 2019.

Salmonella Thyroid Abscess Treated by Serial Aspiration: Case Report and Literature Review

Thyroid abscesses are the most rare conditions of the thyroid gland but it could be potentially life threatening. Most patients are immunocompromised or has an underlying chronic thyroid disorder. We report a case of a 58 year-old lady with underlying uncontrolled diabetes mellitus and a long standing uninvestigated goiter who presented with lethargy, a new anterior neck swelling with dysphagia and change of voice. Ultrasound and computed tomography were performed and showed collection with multiple air pockets in the right thyroid lobule extending to the anterior mediastinum. She was started on intravenous antibiotics and underwent serial bedside aspiration. Her symptoms improved and complete resolution was achieved after serial aspirations and antibiotics.

First case report of thyroid abscess caused by Helicobacter cinaedi presenting with thyroid storm

Background

Helicobacter cinaedi is a microaerobic Gram-negative spiral-shaped bacterium that causes enteritis, cellulitis, and bacteremia in both immunocompromised and immunocompetent patients. While there have been increasing numbers of reported H. cinaedi infections recently, there has been no thyroid abscess case caused by H. cinaedi presenting with thyroid storm.

Case presentation

A 50-year-old Japanese man presented with a 9-day history of high fever associated with palpitations, dry cough, and chronic diarrhea. The patient had a history of Basedow’s disease that had been treated with thiamazole in the past. During the current episode, the patient was diagnosed with thyroid storm and treated accordingly. The blood culture taken on admission was positive for H. cinaedi. This finding was confirmed by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOFMS). A systemic computed tomography (CT) scan revealed a thyroid abscess as the site of infection and cause of the bacteremia. The 16S rRNA gene sequencing identified the pathogen of thyroid abscess as H. cinaedi. Clinical symptoms and laboratory data normalized on admission day 7 after treatment with both effective antibiotics and antithyroid drugs.

Conclusions

The case study described a patient with a history of Basedow’s disease that presented with a thyroid abscess caused by H. cinaedi with symptoms similar to those of thyroid storm. While this bacterium has been implicated in other infections, we believe this is the first time the bacteria has been documented to have caused a thyroid abscess.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3808-7) contains supplementary material, which is available to authorized users.