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Case Report:  Thyroid Abscess in a Longstanding Multinodular Goiter
 
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Thyroid Abscess Associated with a Longstanding Multinodular Goiter
A Case Report


Authors:  *Dr. D. Paramhans,  ** Dr. Batra Ankur, ***Dr. Raj K Mathur
* Principal investigator, ** Literature Review, ***Case Analysis

Institution: Department of Surgery, M.G.M. Medical College, Indore, MP, India.

Corresponding Author: 

Paramhans D. -M.B.B.S, M.S, F.A.I.S, Department of Surgery, M.G.M. Medical College, Indore, MP, India. dparamhans@gmail.com

Abstract:

OBJECTIVE  The authors report a rare case of thyroid abscess associated with a longstanding multinodular goiter.

METHODS  Case reports and a review of the world literature concerning thyroid abscess are presented.

RESULTS  Thyroid abscess is a rare disease entity, accounting for only 0.1% of surgical pathologies of the thyroid gland.  Being more common in children than adults, thyroid gland infections are rare due to its isolated anatomical location, fibrous capsule, rich blood supply, generous lymphatic drainage and high content of iodine.  When such an infection does occur, an underlying anomaly of the thyroid gland should be suspected.  Pre-existing thyroid disease may predispose to suppurative thyroiditis with more than two-thirds of cases found in women.

CONCLUSION  Acute suppurative thyroiditis is not a common complication in multinodular goiter.  Source of infection may be from surrounding sepsis or anatomic abnormality such as pyriform sinus.  The management must include complete excision of suppurated tissues along with underlying thyroid pathology.

 
Introduction:

Acute suppurative thyroiditis is an uncommon condition, the majority of which were reported in children with predisposing factors such as pyriform fistulas or thyroglossal duct anomalies.1  Pre-existing thyroid disease is also a known predisposing factor in adults, including longstanding thyroid goiter and thyroid malignancies.2  Diabetes mellitus and immunosuppression may also precipitate thyroiditis.3  Organisms commonly responsible for bacterial thyroiditis are those that colonize the skin and oropharynx.  Staphylococcus aureus is the most common organism cultured from thyroid abscesses.4  Fulminate cases may lead to septicemia, osteomyelitis or septic thrombophlebitis.  Early biopsy and cultures are needed for prompt antimicrobial therapy.  Surgical drainage is required for a large abscess.5  We report a case of 50-year-old female with multinodular goiter, who presented with acute suppurative thyroiditis with impending abscess. 

Case Report:

Preoperative Appearance of a Thyroid AbscessA 50-year-old female presented with swelling in the anterior neck for 20 years.  She had a history of palpitations and was easily fatigued.  The swelling had slowly increased in size (Fig 1).  The patient developed hoarseness of voice and difficulty in swallowing over the past month.  The patient had normal vocal cord function with mild edema which produced the hoarseness.  Skin discoloration and pain were present for one month prior to initial presentation.  She had no history of dyspnea, respiratory tract infection or contact with tuberculosis.

Figure 1:  Thyroid Abscess in a Multinodular Goiter

On examination, she was of thin build and well oriented.  Her thyroid gland was enlarged to a dimension of 12 by 10 cm.  It had a 2 by 2 cm mass with overlying indurated skin with irregular margins.  The left side of the lobe was predominantly enlarged, tender and cystic, anteriorly.  No engorged veins or lymphadenopathy were identified.  Deglutition was painful.  Her sleeping pulse rate was 80 per min and she was euthyroid.  Soft tissue neck x-ray showed tracheal compression by a homogenous soft tissues density pushing the trachea to the right.  The retropharyngeal space was normal.  Ultrasound examination of the thyroid showed a multinodular goiter with a cystic lesion near the surface.  The largest nodule measured 8 by 8 by 6.5 cm.  There were no calcifications in the abscess cavity wall.  Indirect laryngoscopy was normal with no evidence of pyriform sinus or cord abnormalities.   Needle aspiration yielded brown pus.

Broad spectrum antibiotics were given and she was scheduled for surgery.   A transverse elliptical incision was created which included the infected skin over the goiter [Fig. 2].  The superficial nodule of the multinodular goiter had a cystic cavity filled with pus.  It was excised and a hemithyroidectomy was performed [Fig-3].  She had an uneventful recovery.  The culture of the pus yielded Staphylococcus aureus, sensitive to Piperacilin.  Histopathology of abscess wall revealed dense fibrous tissue and necrosis with inflammatory cells.  The other nodules were compatible with a benign nodular goiter.  At one month follow up, she was not hoarse and had a minimal scar.  Patient did not require thyroxin or calcium supplement.

Operative Removal of Thyroid Abscess - Initial Approach Operative Removal of a Thyroid Abscess
Figure 2:  Elliptical incision Encircling the Abscess Cavity. Figure 3:  Multiple Thyroid Nodules with Superficial Suppuration.

Discussion

Thyroid abscess is a rare disease entity, accounting for only 0.1% of surgical pathologies of the thyroid gland.4  Thyroid abscess may follow apparent subacute thyroiditis or acute suppurative thyroiditis.6  Being more common in children than adults, they are associated with a wide range of clinical symptoms.  Since 1950, Schweitzer and Olson noted that only 39 cases of thyroid abscess have been reported in the medical literature.  Out of the 39 cases of abscess, 16 were in children.4  Acute suppurative thyroiditis due to infection from pyriform sinus fistula has been reported in 15 patients by Takai, et al., in 1976.  The parenchyma of the thyroid gland or perithyroid soft tissue may harbor the fistulous tract originating from the pyriform sinus.  These infections occur due to the accumulation of contaminated secretions in the pharynx , usually after upper respiratory tract infections.3,5,6  They respond well to fistulectomy, drainage and antibiotics..

Thyroid gland infection is rare due to its isolated anatomical location, fibrous capsule, rich blood supply, generous lymphatic drainage and high content of iodine.  Thus, the thyroid gland is extremely resistant to acute bacterial infections, and when such an infection does occur, an underlying anomaly of the thyroid gland should be suspected.8,9  Immunocompromised patients are prone to get infections from remote sources.  Concomitant tubercular and cryptococcal as well as gram negative infections have been reported forming thyroid abscesses.10,11  The route of infection may be via hematogenous or lymphatic seeding or may occur directly from the oropharynx, contagious cervical tissue, esophagitis, foreign bodies or patent thyroglossal duct fistula.12  Pre-existing thyroid disease may predispose to suppurative thyroiditis with more than two-thirds of cases found in women.13,14  A high incidence of thyroid abscess, 10.7% over 10 years (9 of 84 cases), has been reported by Nmadu, Ameh and Sabo to develop in multinodular goiters in Zaria, Nigeria.7

Various pathogens have been isolated on culture examinations.  The most common organisms are Staphylococcus aureus, Streptococcus species and anaerobes.15  Escherichia coli and Bacteroids fragilis may originate from perineal infections.16  Duraker, et al., have reported salmonella to cause vocal cord paralysis in a patient presenting with stridor and thyroid abscess.17  However, mycobacteria and fungi have also been documented.18,19  Rarely, Lemierre’s syndrome (post anginal septicemia due to anaerobes) and infectious mononucleosis in adolescents have been reported with thyroid abscess.20

The management of acute suppurative thyroiditis consists of intravenous antibiotics and incision and drainage of the abscess.  It is best to excise the abscess cavity without rupture.  If it is ruptured during surgery, it could result in spread of the infection or possibly produce a sinus or external fistula.  In our case report, because of a longstanding multinodular goiter, a hemithyroidectomy was performed.  The suppurative skin and perithyroidal tissue was included in the excised specimen.  The skin was closed primarily which produced minimal scaring.  The patient’s mild postoperative dysphagia and hoarseness rapidly resolved.

Conclusion

Acute suppurative thyroiditis is not a common complication in multinodular goiter.  The source of infection in our patient was not known.  Thyroid abscesses may be from surrounding sepsis or anatomic abnormality or spread from a distant site.  Bacteria may spread via a hematogenous route and can produce positive blood cultures.  The management may include complete excision of the suppurated tissues along with underlying thyroid pathology.

Summary:

• We report a rare case of thyroid abscess associated with a longstanding multinodular goiter.
• A 50-year-old female had swelling in the front of the neck for 20 years.
• Her thyroid gland was enlarged to a dimension of 12x10 cm. It had a 2 by 2 cm mass with overlying indurated skin with irregular margins.
• On investigation she was euthyroid.
• USG thyroid showed multinodular goiter with a cystic lesion near the surface.
• A transverse elliptical incision was created including the infected skin over the goiter.  The superficial nodule of the multinodular goiter had a cystic cavity filled with pus.  It was excised and a hemithyroidectomy was performed.
• She had an uneventful recovery.

 
References:

1. Mali VP, Prabhakaran K.  Recurrent acute thyroid swellings because of pyriform sinus fistula.  J Pediatr Surg. 2008 Apr;43(4):e27-30.  View Abstract

2. Sai Prasad TR, Chong CL, Mani A, Chui CH, Tan CE, Tee WS, Jacobsen AS.  Acute suppurative thyroiditis in children secondary to pyriform sinus fistula.  Pediatr Surg Int. 2007 Aug;23(8):779-83. Epub 2007 May 30.   View Abstract

3. Rohondia OS, Koti RS, Majumdar PP, Vijaykumar T, Bapat RD.  Thyroid abscess.  J Postgrad Med. 1995 Apr-Jun;41(2):52-4.  View Abstract

4. Schweitzer VG, Olson NR.  Thyroid abscess.  Otolaryngol Head Neck Surg. 1981 Mar-Apr;89(2):226-9.  View Abstract

5. Tien KJ, Chen TC, Hsieh MC, Hsu SC, Hsiao JY, Shin SJ, Hsin SC. Acute suppurative thyroiditis with deep neck infection: a case report. Thyroid. 2007 May;17(5):467-9.  View Abstract

6. Ogale SB, Tuteja VG, Chakravarty N. Acute suppurative thyroiditis with thyroid abscess. Indian Pediatr. 2002 Dec;39(12):1156-8.  View Abstract

7. Ameh EA, Sabo SY, Nmadu PT. The risk of infective thyroiditis in nodular goitres. East Afr Med J.  1998 Jul;75(7):425-7.  View Abstract

8. Herndon MD, Christie DB, Ayoub MM, Duggan AD. Thyroid abscess: case report and review of the literature.   Am Surg. 2007 Jul;73(7):725-8.  View Abstract

9. De Sousa RF, Amonkar D, Mervyn C, Thyroid Abscess with Cutaneous Fistula: Case Report and Review of the Literature.  Thyroid Science, 2008 Nov;3(11):CR1-4.   View Article

10. Wang YC, Yeh TS, Lin JD. Gram-negative thyroid abscess resulting from fine-needle aspiration in an immunosuppressed patient. Clin Infect Dis. 1997 Sep;25(3):745-6.   View Abstract

11. Kiertiburanakul S, Sungkanuparph S, Malathum K, Pracharktam R. Concomitant tuberculous and cryptococcal thyroid abscess in a human immunodeficiency virus-infected patient. Scand J Infect Dis. 2003;35(1):68-70.  View Abstract

12. Sicilia V, Mezitis S. A case of acute suppurative thyroiditis complicated by thyrotoxicosis. J Endocrinol Invest. 2006 Dec;29(11):997-1000.  View Abstract

13. Lavini C, Natali P, Magni G, Valli R, Morandi U. Thyroid abscess associated with a substernal goiter. Case report. J Cardiovasc Surg (Torino). 2003 Apr;44(2):271-3.  View Abstract

14. Houghton DJ, Gray HW, MacKenzie K. The tender neck: thyroiditis or thyroid abscess? Clin Endocrinol (Oxf). 1998 Apr;48(4):521-4.  View Abstract

15. Sun JH, Chang HY, Chen KW, Lin KD, Lin JD, Hsueh C. Anaerobic thyroid abscess from a thyroid cyst after fine-needle aspiration. Head Neck. 2002 Jan;24(1):84-6.  View Abstract

16. Fraisse TC, Ferreira E, Lechiche C, Le Moing V, Reynes J. [Article in French] [Escherichia coli thyroid abscess associated with multinodular goitre] Rev Med Interne. 2006 Mar;27(3):258-60. Epub 2005 Nov 22.  View Abstract

17.  Duraker N, Ağaç E, Ozpaçaci T. Thyroid abscess caused by Salmonella typhi leading to vocal cord paralysis. Eur J Surg. 2000 Dec;166(12):971-3.  View Abstract

18. Kang M, Ojili V, Khandelwal N, Bhansali A. Tuberculous abscess of the thyroid gland: a report of two cases. J Clin Ultrasound. 2006 Jun;34(5):254-7.  View Abstract

19. Cevera JJ, Butehorn HF 3rd, Shapiro J, Setzen G. Actinomycosis abscess of the thyroid gland. Laryngoscope. 2003 Dec;113(12):2108-11.  View Abstract

20.  Kara E, Sakarya A, Keleş C, Borand H, Pekindil G, Göktan C. Case of Lemierre's syndrome presenting with thyroid abscess. Eur J Clin Microbiol Infect Dis. 2004 Jul;23(7):570-2. Epub 2004 Jun 26.  View Abstract

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