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Suppurative thyroiditis in a pregnant patient
Otolaryngology Case Reports 8 (2018) 12–13
Contents lists available at ScienceDirect
Otolaryngology Case Reports journal homepage: www.elsevier.com/locate/xocr
Suppurative thyroiditis in a pregnant patient ∗
T
Bennett Jun Sheng Ong , Andy Jian Kai Chua, Song Tar Toh Department of Otolaryngology, Singapore General Hospital, Singapore
A R T I C LE I N FO
A B S T R A C T
Keywords: Suppurative thyroiditis Thyroid abscess Pregnancy
Acute suppurative thyroiditis is rare, and its occurrence in pregnancy is thought to be related to high circulating levels of human chorionic gonadotropin that cross-bind to TSH receptors. The subsequent dysregulation of normal thyroid processes could increase its susceptibility to infection. We describe a 33 year old pregnant woman who presented in her second trimester with acute suppurative thyroiditis, which was confirmed on ultrasound and MRI. She underwent successful surgical drainage after failed attempts at aspiration of the abscess. Suppurative thyroiditis is an uncommon disease. In pregnancy, the need to consider maternal and fetal safety creates additional challenges in diagnosis and management.
Introduction Acute suppurative thyroiditis is a rare condition with a incidence of 0.1–0.7% amongst all thyroid diseases [1]. The thyroid gland is generally thought to be resistant to infections due to a variety of reasons, including its encapsulation, rich vascular supply, and high intraglandular iodine concentration [2]. However, in pregnancy, the thyroid undergoes a variety of physiological changes in pregnancy owing to high circulating levels of human chorionic gonadotropin that cross bind to TSH receptors, inducing hypertrophy and hyperplasia. The subsequent dysregulation of the normal thyroid processes via hypertrophy could potentially alter the susceptibility of thyroid gland to infection. In this report, we describe a case in which we highlight the challenges of diagnosing suppurative thyroiditis in a pregnant patient, as well as management considerations for such patients. Case presentation A 33 year old female presented with painful swelling over the left neck for 1 week. She was G4P2 and 25 weeks pregnant at the time of presentation. She also complained of dysphagia with a one day history of fever, with a temperature of 39° celsius. 2 weeks prior to presentation, she had symptoms suggestive of an upper respiratory tract infection, including purulent rhinorrhea, sore throat, and cough. She had been making a good recovery, until the left neck swelling began. Physical examination revealed a warm and tender left neck swelling which moved with swallowing. There was no palpable cervical lymphadenopathy and the patient was clinically euthyroid. The initial thyroid function test was suggestive of subclinical
∗
hypothyroidism, with low thyroid stimulating hormone (TSH - 0.360 MU/L) and normal thyroxine (fT4 - 9.5 PMOL/L) and triiodothyronine f (T3 - 4.1 PMOL/L) levels. Her inflammatory markers were raised with a total white cell count of 12.0 × 109/L and CRP of 141 mg/L. An ultrasound of the thyroid was performed initially which showed a heterogeneous lesion involving almost the entire left thyroid lobe with reactive changes in the overlying soft tissue and possible internal foci of gas. In order to further evaluate the lesion, magnetic resonance imaging (MRI) was selected instead of a CT to avoid exposure to ionising radiation in this pregnant patient. This demonstrated a heterogeneous fluid filled lesion replacing the left thyroid lobe with prominent surrounding inflammatory change, consistent with an abscess (see Fig. 1). A cystic tumour was the less likely differential. The trachea was noted to be displaced to the right side. At this point, the working diagnosis was acute suppurative thyroiditis with abscess. The patient was started on intravenous co-amoxiclav empirically. An attempt was made at ultrasound guided fine needle aspiration (US FNA) but no purulent fluid was obtained. The patient remained unwell despite 48 hours of intravenous antibiotics, and a decision was made to proceed with open incision and drainage of the thyroid abscess under general anesthesia. Intra-operatively, she was placed in the left lateral tilt position to relieve inferior vena cava compression from the gravid uterus, allowing sufficient venous return. A standard midline approach was taken with a transverse skin crease incision and separation of strap muscles in the midline. These were dissected off the surface of the thyroid gland on the left. Pus was encountered lateral to the left thyroid lobe, which tracked into an intraglandular abscess. The abscess was drained and flushed copiously. A drain was inserted into the cavity and this was packed with
Corresponding author. Department of Otolaryngology (ENT), Singapore General Hospital, Outram Road, 169608, Singapore. E-mail address: [email protected] (B.J.S. Ong).
https://doi.org/10.1016/j.xocr.2018.07.006 Received 21 April 2018; Accepted 17 July 2018 Available online 19 July 2018 2468-5488/ © 2018 Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Otolaryngology Case Reports 8 (2018) 12–13
B.J.S. Ong et al.
directed antibiotics, and has proved successful in a few reported cases [13]. Some have reported intra-lesional antibiotics in the same setting with good results [13]. In our patient, we elected to attempt US-FNA in the hope of avoiding general anesthesia. However, this was unsuccessful, and in view of minimal clinical improvement, we had to proceed with surgical drainage, which proved to be definitive. Conclusion A less invasive procedure, such as ultrasound guided aspiration, is a reasonable first-line treatment for suppurative thyroiditis during pregnancy. If this is unsuccessful, surgical intervention may be required, bearing in mind the risks to the mother and the fetus. Further studies to evaluate the efficacy of intralesional antibiotics may be useful, especially with its potential benefits in the treatment of pregnant or other high risk patients.
Fig. 1. T2 sequence of the patient's MRI that shows a heterogeneous fluid filled lesion with a hyperintense wall that has replaced the left thyroid lobe, along with prominent surrounding inflammatory changes.
Consent ribbon gauze. Cultures of the pus grew pan-sensitive Streptococcus anginosus, and she subsequently completed a 2-week course of intravenous penicillin. The abscess wall was sent for histological analysis, with no malignancy found. The wound was dressed and flushed regularly post-operatively. This was serially lightened, and the drain withdrawn. Secondary suture was performed 2 weeks post-incision and drainage. She was discharged well and subsequently delivered without any complications.
Informed consent was taken from this patient and approved by the hospital ethics committee. Disclosure statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of interest
Discussion
None.
Acute suppurative thyroiditis is a rare condition, with a reported incidence of 0.1–0.7% [1]. The gland is generally resistant to infection due to its encapsulation, rich vascularity, and high iodine concentration [2]. They seem to be more common in females and on the left side [3]. Causative organisms include pyogenic bacteria (most commonly by Gram-positive aerobes such as Staphylococcus aureus and Streptococcus species), fungal, parasitic, or tuberculous organisms [4–8]. Immunosuppression is a risk factor [9]. These infections are thought to primarily spread to the thyroid gland hematogenously from a separate source, although direct extension from an adjacent deep neck infection and penetrating foreign bodies are other reported causes of thyroid abscesses [10]. The incidence of suppurative thyroiditis in pregnancy and its association has not been reported in the literature. One existing case report describes the occurrence of embolic suppurative thyroiditis with concurrent carcinoma which developed postpartum due to an infected cesarean section wound [11]. A number of imaging modalities may be useful in assisting with the diagnosis. An ultrasound of the thyroid gland is a useful first-line investigation especially in our patient as it provides information on location, nature, and contents of the lesion without exposing her and her foetus to ionising radiation. If further evaluation is required, computed tomography (CT) may be useful in characterising the lesion and may hint at a fistulous tract, which may be fibrous, or contain gas [12]. In our patient, we selected MRI as it highlighted the inflammatory changes suggestive of abscess formation, distinguishing it from a neoplastic lesion or just a colloid nodule on a background of subacute thyroiditis [4]. It also demonstrated the relationship of critical surrounding structures without radiation risk. In a patient with an external skin opening, a fistulogram may demonstrate the tract; otherwise, a watersoluble contrast study may also help to delineate the fistula [13]. Once the diagnosis is clinched, the primary consideration for management is source control while minimising harm to the patient and foetus. Intravenous antibiotics should be started and the patient closely monitored for signs of deterioration. Ultrasound guided needle aspiration may serve to reduce bacterial load and provide samples for culture-
Acknowledgements All listed authors contributed to the concept, design, writing and proofreading of this article. References [1] Al-Dajani N, Wootton SH. Cervical lymphadenitis, suppurative parotitis, thyroiditis, and infected cysts. Infect Dis Clin 2007;21:523–41. viii. [2] Brook I. Microbiology and management of acute suppurative thyroiditis in children. Int J Pediatr Otorhinolaryngol 2003;67:447–51. [3] Jacobs A, Gros DA, Gradon JD. Thyroid abscess due to Acinetobacter calcoaceticus: case report and review of the causes of and current management strategies for thyroid abscesses. South Med J 2003;96:300–7. [4] Paes JE, Burman KD, Cohen J, Franklyn J, McHenry CR, Shoham S, et al. Acute bacterial suppurative thyroiditis: a clinical review and expert opinion. Thyroid 2010;20(3):247–55. [5] Fernandez JF, Anaissie EJ, Vassilopoulou-Sellin R, Samaan NA. Acute fungal thyroiditis in a patient with acute myelogenous leukaemia. J Intern Med 1991;230:539–41. [6] Akbulut S1, Demircan F, Sogutcu N. Hydatid cyst disease of the thyroid gland: report of two cases. Int Surg 2015;100(4):643–7. [7] Ghosh A, Saha S, Bhattacharya B, Chattopadhay S. Primary tuberculosis of thyroid gland: a rare case report. Am J Otolaryngol 2007;28:267–70. [8] Terzidis K, Tourli P, Kiapekou E, Alevizaki M. Thyroid tuberculosis. Hormones (Basel) 2007;6:75–9. [9] Golshan MM, McHenry CR, de Vente J, Kalajyian RC, Hsu RM, Tomashefski JF. Acute suppurative thyroiditis and necrosis of the thyroid gland: a rare endocrine manifestation of acquired immunodeficiency syndrome. Surgery 1997;121:593–6. [10] Yung BC, Loke TK, Fan WC, Chan JC. Acute suppurative thyroiditis due to foreign body-induced retropharyngeal abscess presented as thyrotoxicosis. Clin Nucl Med 2000;25:249–52. [11] George MM, Goswamy J, Penney SE1. Embolic suppurative thyroiditis with concurrent carcinoma in pregnancy: lessons in management through a case report. Thyroid Res 2015;8:3. [12] Kawanaka M, Sugimoto Y, Suehiro M, Fukuchi M. Thyroid imaging in a typical case of acute suppurative thyroiditis with abscess formation due to infection from a persistent thyroglossal duct. Ann Nucl Med 1994;8:159–62. [13] Ilyin A, Zhelonkina N, Severskaya N, Romanko S. Nonsurgical management of thyroid abscess with sonographically guided fine needle aspiration. J Clin Ultrasound 2007;35:333–7.
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Contents lists available at ScienceDirect
Otolaryngology Case Reports journal homepage: www.elsevier.com/locate/xocr
Suppurative thyroiditis in a pregnant patient ∗
T
Bennett Jun Sheng Ong , Andy Jian Kai Chua, Song Tar Toh Department of Otolaryngology, Singapore General Hospital, Singapore
A R T I C LE I N FO
A B S T R A C T
Keywords: Suppurative thyroiditis Thyroid abscess Pregnancy
Acute suppurative thyroiditis is rare, and its occurrence in pregnancy is thought to be related to high circulating levels of human chorionic gonadotropin that cross-bind to TSH receptors. The subsequent dysregulation of normal thyroid processes could increase its susceptibility to infection. We describe a 33 year old pregnant woman who presented in her second trimester with acute suppurative thyroiditis, which was confirmed on ultrasound and MRI. She underwent successful surgical drainage after failed attempts at aspiration of the abscess. Suppurative thyroiditis is an uncommon disease. In pregnancy, the need to consider maternal and fetal safety creates additional challenges in diagnosis and management.
Introduction Acute suppurative thyroiditis is a rare condition with a incidence of 0.1–0.7% amongst all thyroid diseases [1]. The thyroid gland is generally thought to be resistant to infections due to a variety of reasons, including its encapsulation, rich vascular supply, and high intraglandular iodine concentration [2]. However, in pregnancy, the thyroid undergoes a variety of physiological changes in pregnancy owing to high circulating levels of human chorionic gonadotropin that cross bind to TSH receptors, inducing hypertrophy and hyperplasia. The subsequent dysregulation of the normal thyroid processes via hypertrophy could potentially alter the susceptibility of thyroid gland to infection. In this report, we describe a case in which we highlight the challenges of diagnosing suppurative thyroiditis in a pregnant patient, as well as management considerations for such patients. Case presentation A 33 year old female presented with painful swelling over the left neck for 1 week. She was G4P2 and 25 weeks pregnant at the time of presentation. She also complained of dysphagia with a one day history of fever, with a temperature of 39° celsius. 2 weeks prior to presentation, she had symptoms suggestive of an upper respiratory tract infection, including purulent rhinorrhea, sore throat, and cough. She had been making a good recovery, until the left neck swelling began. Physical examination revealed a warm and tender left neck swelling which moved with swallowing. There was no palpable cervical lymphadenopathy and the patient was clinically euthyroid. The initial thyroid function test was suggestive of subclinical
∗
hypothyroidism, with low thyroid stimulating hormone (TSH - 0.360 MU/L) and normal thyroxine (fT4 - 9.5 PMOL/L) and triiodothyronine f (T3 - 4.1 PMOL/L) levels. Her inflammatory markers were raised with a total white cell count of 12.0 × 109/L and CRP of 141 mg/L. An ultrasound of the thyroid was performed initially which showed a heterogeneous lesion involving almost the entire left thyroid lobe with reactive changes in the overlying soft tissue and possible internal foci of gas. In order to further evaluate the lesion, magnetic resonance imaging (MRI) was selected instead of a CT to avoid exposure to ionising radiation in this pregnant patient. This demonstrated a heterogeneous fluid filled lesion replacing the left thyroid lobe with prominent surrounding inflammatory change, consistent with an abscess (see Fig. 1). A cystic tumour was the less likely differential. The trachea was noted to be displaced to the right side. At this point, the working diagnosis was acute suppurative thyroiditis with abscess. The patient was started on intravenous co-amoxiclav empirically. An attempt was made at ultrasound guided fine needle aspiration (US FNA) but no purulent fluid was obtained. The patient remained unwell despite 48 hours of intravenous antibiotics, and a decision was made to proceed with open incision and drainage of the thyroid abscess under general anesthesia. Intra-operatively, she was placed in the left lateral tilt position to relieve inferior vena cava compression from the gravid uterus, allowing sufficient venous return. A standard midline approach was taken with a transverse skin crease incision and separation of strap muscles in the midline. These were dissected off the surface of the thyroid gland on the left. Pus was encountered lateral to the left thyroid lobe, which tracked into an intraglandular abscess. The abscess was drained and flushed copiously. A drain was inserted into the cavity and this was packed with
Corresponding author. Department of Otolaryngology (ENT), Singapore General Hospital, Outram Road, 169608, Singapore. E-mail address: [email protected] (B.J.S. Ong).
https://doi.org/10.1016/j.xocr.2018.07.006 Received 21 April 2018; Accepted 17 July 2018 Available online 19 July 2018 2468-5488/ © 2018 Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Otolaryngology Case Reports 8 (2018) 12–13
B.J.S. Ong et al.
directed antibiotics, and has proved successful in a few reported cases [13]. Some have reported intra-lesional antibiotics in the same setting with good results [13]. In our patient, we elected to attempt US-FNA in the hope of avoiding general anesthesia. However, this was unsuccessful, and in view of minimal clinical improvement, we had to proceed with surgical drainage, which proved to be definitive. Conclusion A less invasive procedure, such as ultrasound guided aspiration, is a reasonable first-line treatment for suppurative thyroiditis during pregnancy. If this is unsuccessful, surgical intervention may be required, bearing in mind the risks to the mother and the fetus. Further studies to evaluate the efficacy of intralesional antibiotics may be useful, especially with its potential benefits in the treatment of pregnant or other high risk patients.
Fig. 1. T2 sequence of the patient's MRI that shows a heterogeneous fluid filled lesion with a hyperintense wall that has replaced the left thyroid lobe, along with prominent surrounding inflammatory changes.
Consent ribbon gauze. Cultures of the pus grew pan-sensitive Streptococcus anginosus, and she subsequently completed a 2-week course of intravenous penicillin. The abscess wall was sent for histological analysis, with no malignancy found. The wound was dressed and flushed regularly post-operatively. This was serially lightened, and the drain withdrawn. Secondary suture was performed 2 weeks post-incision and drainage. She was discharged well and subsequently delivered without any complications.
Informed consent was taken from this patient and approved by the hospital ethics committee. Disclosure statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of interest
Discussion
None.
Acute suppurative thyroiditis is a rare condition, with a reported incidence of 0.1–0.7% [1]. The gland is generally resistant to infection due to its encapsulation, rich vascularity, and high iodine concentration [2]. They seem to be more common in females and on the left side [3]. Causative organisms include pyogenic bacteria (most commonly by Gram-positive aerobes such as Staphylococcus aureus and Streptococcus species), fungal, parasitic, or tuberculous organisms [4–8]. Immunosuppression is a risk factor [9]. These infections are thought to primarily spread to the thyroid gland hematogenously from a separate source, although direct extension from an adjacent deep neck infection and penetrating foreign bodies are other reported causes of thyroid abscesses [10]. The incidence of suppurative thyroiditis in pregnancy and its association has not been reported in the literature. One existing case report describes the occurrence of embolic suppurative thyroiditis with concurrent carcinoma which developed postpartum due to an infected cesarean section wound [11]. A number of imaging modalities may be useful in assisting with the diagnosis. An ultrasound of the thyroid gland is a useful first-line investigation especially in our patient as it provides information on location, nature, and contents of the lesion without exposing her and her foetus to ionising radiation. If further evaluation is required, computed tomography (CT) may be useful in characterising the lesion and may hint at a fistulous tract, which may be fibrous, or contain gas [12]. In our patient, we selected MRI as it highlighted the inflammatory changes suggestive of abscess formation, distinguishing it from a neoplastic lesion or just a colloid nodule on a background of subacute thyroiditis [4]. It also demonstrated the relationship of critical surrounding structures without radiation risk. In a patient with an external skin opening, a fistulogram may demonstrate the tract; otherwise, a watersoluble contrast study may also help to delineate the fistula [13]. Once the diagnosis is clinched, the primary consideration for management is source control while minimising harm to the patient and foetus. Intravenous antibiotics should be started and the patient closely monitored for signs of deterioration. Ultrasound guided needle aspiration may serve to reduce bacterial load and provide samples for culture-
Acknowledgements All listed authors contributed to the concept, design, writing and proofreading of this article. References [1] Al-Dajani N, Wootton SH. Cervical lymphadenitis, suppurative parotitis, thyroiditis, and infected cysts. Infect Dis Clin 2007;21:523–41. viii. [2] Brook I. Microbiology and management of acute suppurative thyroiditis in children. Int J Pediatr Otorhinolaryngol 2003;67:447–51. [3] Jacobs A, Gros DA, Gradon JD. Thyroid abscess due to Acinetobacter calcoaceticus: case report and review of the causes of and current management strategies for thyroid abscesses. South Med J 2003;96:300–7. [4] Paes JE, Burman KD, Cohen J, Franklyn J, McHenry CR, Shoham S, et al. Acute bacterial suppurative thyroiditis: a clinical review and expert opinion. Thyroid 2010;20(3):247–55. [5] Fernandez JF, Anaissie EJ, Vassilopoulou-Sellin R, Samaan NA. Acute fungal thyroiditis in a patient with acute myelogenous leukaemia. J Intern Med 1991;230:539–41. [6] Akbulut S1, Demircan F, Sogutcu N. Hydatid cyst disease of the thyroid gland: report of two cases. Int Surg 2015;100(4):643–7. [7] Ghosh A, Saha S, Bhattacharya B, Chattopadhay S. Primary tuberculosis of thyroid gland: a rare case report. Am J Otolaryngol 2007;28:267–70. [8] Terzidis K, Tourli P, Kiapekou E, Alevizaki M. Thyroid tuberculosis. Hormones (Basel) 2007;6:75–9. [9] Golshan MM, McHenry CR, de Vente J, Kalajyian RC, Hsu RM, Tomashefski JF. Acute suppurative thyroiditis and necrosis of the thyroid gland: a rare endocrine manifestation of acquired immunodeficiency syndrome. Surgery 1997;121:593–6. [10] Yung BC, Loke TK, Fan WC, Chan JC. Acute suppurative thyroiditis due to foreign body-induced retropharyngeal abscess presented as thyrotoxicosis. Clin Nucl Med 2000;25:249–52. [11] George MM, Goswamy J, Penney SE1. Embolic suppurative thyroiditis with concurrent carcinoma in pregnancy: lessons in management through a case report. Thyroid Res 2015;8:3. [12] Kawanaka M, Sugimoto Y, Suehiro M, Fukuchi M. Thyroid imaging in a typical case of acute suppurative thyroiditis with abscess formation due to infection from a persistent thyroglossal duct. Ann Nucl Med 1994;8:159–62. [13] Ilyin A, Zhelonkina N, Severskaya N, Romanko S. Nonsurgical management of thyroid abscess with sonographically guided fine needle aspiration. J Clin Ultrasound 2007;35:333–7.
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