THYROTOXICOSIS DUE TO ACUTE SUPPURATIVE THYROIDITIS IN A POSTPARTUM WOMAN

Size: px

Start display at page:

Download "THYROTOXICOSIS DUE TO ACUTE SUPPURATIVE THYROIDITIS IN A POSTPARTUM WOMAN"

Lynne Hamilton
6 years ago
Views:

1 Case Report THYROTOXICOSIS DUE TO ACUTE SUPPURATIVE THYROIDITIS IN A POSTPARTUM WOMAN Leslee N. Matheny, MD; Shichun Bao, MD, PhD ABSTRACT Objective: Postpartum thyroiditis is usually painless, is typically accompanied by thyrotoxicosis, and has an autoimmune pathogenesis. Here we present a case of acute suppurative thyroiditis with thyrotoxicosis in a postpartum woman. Methods: The following is a case report with a review of the literature. Results: A 24-year-old female, 5 months postpartum, presented with neck pain, palpitations, and fevers for 2 weeks. One month prior to presentation, she was treated with amoxicillin and prednisone for strep throat, with persistent symptoms. Blood pressure was 141/86 mm Hg and heart rate was 135 beats per minute. Examination revealed thyromegaly with a palpable, tender left thyroid nodule. Labs revealed low thyroid stimulating hormone (0.13 µiu/ml), elevated free thyroxine (2.04 ng/dl), and leukocytosis. Thyroid antibodies were normal. Thyroid ultrasound revealed a 3.4-cm complex nodule found to be hypofunctioning on a technetium pertechnetate scan. Computerized tomography of her neck showed an exophytic mass in the left lobe and an adjacent 1.1-cm abscess. She underwent fine needle aspiration of both lesions; each site grew Streptococcus constellatus. She was treated with Submitted for publication November 22, 2015 Accepted for publication February 10, 2016 From the Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee. Address correspondence to Dr. Leslee N. Matheny, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, st Avenue South, Nashville, TN leslee.a.nissing@vanderbilt.edu. DOI: /EP CR To purchase reprints of this article, please visit: vancomycin and piperacillin-tazobactam while inpatient and was discharged on Augmentin. At a 5-week follow-up, her thyroid function tests had normalized. Conclusion: Acute suppurative thyroiditis is a rare entity, with only two cases reported in the postpartum setting. It is known to be more common in immunocompromised individuals, though it is unclear if postpartum status is also a risk factor. Abscess formation is common, which can be due to direct or hematogenous spread. It must be recognized and treated quickly. (AACE Clinical Case Rep. 2017;3:e26-e30) Abbreviations: CT = computerized tomography; FNA = fine needle aspiration; 99m Tc = technetium INTRODUCTION Thyrotoxicosis due to thyroiditis is a relatively common entity, especially in the postpartum population. Postpartum thyroiditis is typically painless, occurs within the first few months after delivery, and is of an autoimmune pathogenesis with lymphocytic inflammation of the thyroid. It is usually transient, with varying degrees of self-limiting thyrotoxicosis, and is estimated to occur in up to 10% of women in the United States (1). Cases due to thyroidal infection are much less prevalent. Here, we present a case of acute suppurative thyroiditis in the setting of an adjacent soft tissue neck abscess in a postpartum woman. CASE REPORT A 5-month postpartum (gravida 1, para 1) 24-year-old female presented to the emergency department with severe throat and unilateral neck pain, palpitations, and intermittent fevers for 2 weeks. Of note, she had undergone e26 AACE CLINICAL CASE REPORTS Vol 3 No. 1 Winter 2017

2 Acute Suppurative Thyroiditis, AACE Clinical Case Rep. 2017;3(No. 1) e27 a dental procedure on her left mandibular teeth 2 months prior. One month after that, she was also diagnosed with strep throat and treated with 10 days of amoxicillin. Her sore throat improved somewhat, but worsened again within days of completing the antibiotic, now with extension to the left side of the neck. She was then given prednisone 30 mg daily, presumably as an anti-inflammatory, for the 10 days leading up to her presentation. She noted heat intolerance and a slight hand tremor. No significant changes were reported in her bowel habits, skin, hair, or weight; nor were eye symptoms present. She was still nursing her child, and had not resumed regular menses. On presentation, she was borderline hypertensive with a blood pressure of 141/86 mm Hg, tachycardic with a heart rate of 135 beats per minute, and had a high-normal respiratory rate of 18 breaths per minute. Neck exam revealed bilateral enlarged submandibular lymph nodes, significant, asymmetric thyromegaly with a palpable, tender left-sided nodule, and erythema of the skin overlying the gland. She had a fine peripheral hand tremor and normal deep tendon reflexes. Labs revealed a low thyroid stimulating hormone level of 0.13 µiu/ml (normal range: 0.3 to 5.0 µiu/ml) and an elevated free thyroxine of 2.04 ng/dl (normal range: 0.5 to 1.2 ng/dl). Serum thyroglobulin and white blood cell counts were also significantly elevated to 588 ng/ml (normal range: 1.9 to 42.7 ng/ml) and 17,000 cells/ µl (normal range: 3,900 to 10,700 cells/µl), respectively. Thyroid stimulating immunoglobulin, antithyroid peroxidase, and antithyroglobulin antibodies were not elevated. Thyroid ultrasound revealed a cm, partly ill-defined, isoechoic complex nodule encompassing the majority of the left lobe (Fig. 1). This corresponded to a hypofunctioning area on a subsequent technetium ( 99m Tc) pertechnetate thyroid scan (Fig. 2). Multiple bilateral cervical lymph nodes were seen, with morphologic sonographic appearance of the inflammatory type. Computerized tomography (CT) of her neck showed a large, mixed solid and cystic, exophytic-like mass emanating from the left thyroid lobe. Also seen was an adjacent 1.1-cm rimenhancing fluid collection anterior and superior to the left thyroid lobe, considered to represent abscess or necrosis (Fig. 3). The airway was widely patent. She then underwent fine needle aspiration (FNA) of both lesions. The aspirate from the thyroid nodule consisted of numerous neutrophils, several histiocytes, follicular cells, and colloid; most consistent with a benign thyroid nodule involved by abscess. The blood tinged, yellowish-brown aspirate from the adjacent neck soft tissue lesion was also consistent with abscess. Bacterial cultures from each site were positive for Streptococcus constellatus. She was also seen in consultation by the otolaryngology team, who elected to defer more invasive surgical intervention pending response to antibiotics. Shortly after performing the FNA, she was treated with intravenous vancomycin and piperacillin-tazobactam for 4 days while inpatient. She was ultimately discharged on Augmentin for 14 days, as well as atenolol for heart rate control. At follow-up 5 weeks later, her thyroid function tests had normalized, her leukocytosis had resolved, and she was doing well clinically. A plan was made for repeat thyroid ultrasound and thyroid function testing in 6 to 12 months, but the patient moved out of state and was lost to follow-up. Fig. 1. Thyroid ultrasound showing a 3.4-cm left complex nodule.

3 e28 Acute Suppurative Thyroiditis, AACE Clinical Case Rep. 2017;3(No. 1) Fig. 2. Pertechnetate scan showing large, hypofunctioning nodule occupying the left thyroid lobe. Fig. 3. Computerized tomography of the neck demonstrating thyroid lesion (arrow).

4 Acute Suppurative Thyroiditis, AACE Clinical Case Rep. 2017;3(No. 1) e29 DISCUSSION Acute suppurative thyroiditis is a rare but potentially life-threatening condition that encompasses only 0.1 to 0.7% of all thyroid disease. It may result in up to 12% or higher mortality if left untreated (2). It affects men and women equally, with the most susceptible age group being younger adults that are years of age (1). Its rarity is in part due to the rich blood supply and lymphatic drainage of the gland, the high iodine content (which may be bactericidal), and the protective capsule which physically separates it from other neck structures and potential pathogens (3-5). When thyroidal infections do occur, they typically affect individuals with congenital abnormalities such as piriform sinus fistula, those who are immunocompromised, elderly, or debilitated, or those with pre-existing thyroid disease such as thyroid cancer, Hashimoto s thyroiditis, or multinodular goiter (1). Thyroidal infections may also occur in the setting of neck trauma, retro- and parapharyngeal abscesses or other deep neck infections, or as a complication of FNA biopsy of the thyroid (3). Our patient had a pre-existing, but previously undiagnosed nodular goiter. The preceding dental procedure and/or strep throat infection could have been the initial source leading to thyroidal infection. To our knowledge, there are currently only 2 other cases reported in the literature of acute suppurative thyroiditis occurring in the postpartum period. One was due to a large thyroid abscess in the setting of disseminated Brucella infection, and the other was suspected to be due to an embolic lesion, superimposed on previously undiagnosed papillary thyroid cancer, in the setting of a caesarian section wound infection (6,7). Acute infections are most often due to bacteria, with Staphylococcus aureus and Streptococcus pyogenes being the most common pathogens seen in adults. Other species of bacteria which have been reported include Streptococcus pneumoniae, and members of other genera including Salmonella, Klebsiella, Pasturella, and Eikenella (4). Fungal, mycobacterial, and parasitic organisms have also been reported; however, these infections tend to be more chronic and are much more common in immunocompromised patients (1). Our patient had a S. constellatus infection. Patients with acute suppurative thyroiditis usually present with acute onset neck pain, fever, and tender thyromegaly. Fluctuance and cervical lymphadenopathy may also be present. It is often preceded by an upper respiratory tract infection (5) which, in patients with piriform sinus fistulas, may induce inflammation of the tract and allow bacteria easier access to the gland. As such, late fall and spring are the most common times of year for thyroidal infections (3). Thyroid function typically remains normal, though either destructive hypothyroidism or thyrotoxicosis may occur. When thyrotoxicosis does occur, it is typically self-limiting, resolving within 2 to 3 months, as was seen in our case. Inflammatory markers and thyroglobulin levels are often elevated in thyrotoxicosis; however, these are nonspecific tests and are thought to be generally unhelpful in making a diagnosis (2,3). Our patient had a significantly elevated thyroglobulin and leukocytosis. Empiric antibiotics should be started rapidly, as suppurative thyroiditis is a potentially fatal condition. Initial therapy could include a penicillinase-resistant penicillin and beta-lactamase inhibitor, in addition to vancomycin if methicillin-resistant S. aureus is suspected (2). Experts also advocate close attention to the patient s airway and early imaging of the neck and/or chest with CT. CT is often chosen over ultrasound in the acutely ill patient as it provides a more comprehensive view of the neck and upper mediastinum, which helps in the assessment of extrathyroidal involvement (2). Once the patient is stabilized, ultrasound with FNA and biopsy is often the next best step (3). Gram stain and culture from the aspirate may help identify the particular organism involved and tailor antibiotic therapy, as well as help differentiate between subacute thyroiditis and acute suppurative thyroiditis if the diagnosis is still in question. Our patient had a widely patent airway and was clinically stable, thus it was decided to pursue imaging studies and FNA first to confirm the diagnosis prior to starting antibiotic therapy. Radionuclide imaging with 123 I or 99m Tc pertechnetate thyroid scans are unlikely to be helpful for definitive diagnosis as other conditions, such as acute focal infection, inflammation, and thyroid malignancy, are also associated with focally decreased uptake (2). Urgent surgical drainage or thyroidectomy may be needed in cases of airway compromise, clinical deterioration, or persistent abscess. Resection may also be necessary if a significant amount of infarcted thyroid tissue is present, or if there is suspicion of thyroid malignancy. This should ideally occur electively after the acute inflammatory process has resolved to better ensure complete resection of the tissue in question (2). In those patients with piriform sinus fistulas, surgical resection or nonsurgical obliteration of the fistula reduces the chance of recurrent infection (2). In others, there has been a recent trend towards less invasive management, such as FNA with drainage as opposed to an open surgical procedure, when possible (4). Our patient responded well to FNA and antibiotic therapy alone. It is unclear how to best follow these patients in the long-term. Serial thyroid function testing should be performed, especially in those who develop hypo- or hyperthyroidism during their disease course. In some patients, the destruction of the gland may be sufficiently severe that permanent hypothyroidism results (4). CONCLUSION Acute suppurative thyroiditis is a rare entity, especially in the postpartum setting. Only two cases have been previously reported. It occurs more commonly in indi-

5 e30 Acute Suppurative Thyroiditis, AACE Clinical Case Rep. 2017;3(No. 1) viduals who are immunocompromised or who have preexisting thyroid disease. Pregnancy and the postpartum state are not currently considered risk factors for development, though further study is needed. Abscess formation is common, which can be due to direct spread in the setting of a congenital abnormality or hematogenous spread from infection elsewhere in the body. It is a potentially fatal condition which must be recognized and treated quickly. It is unclear how to best approach these patients, and there is a current trend toward less invasive management. More investigation is needed to determine the best diagnostic approach, duration of antibiotics, and if/when to consider surgical intervention. DISCLOSURE The authors have no multiplicity of interest to disclose. REFERENCES 1. Pearce EN, Farwell AP, Braverman LE. Thyroiditis. N Engl J Med. 2003;348: Paes JE, Burman KD, Cohen J, et al. Acute bacterial suppurative thyroiditis: a clinical review and expert opinion. Thyroid. 2010;20: Farwell, AP. Sporadic Painless, Painful Subacute and Acute Infectious Thyroiditis. In: Braverman LE, Cooper DS, eds. Werner and Ingbar s The Thyroid: A Fundamental and Clinical Text. 10 th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013: Shrestha RT, Hennessey JV. Chapter 19. Acute and Subacute, and Riedel s Thyroiditis. In: De Groot LJ, ed. Thyroid Manager ( South Dartmouth, MA: Endocrine Education Inc; Szego PL, Levy RP. Recurrent acute suppurative thyroiditis. Can Med Assoc J. 1970;103: Akdemir Z, Karaman E, Akdeniz H, Alptekin C, Arslan H. Giant thyroid abscess related to postpartum Brucella infection. Case Rep Infect Dis. 2015;2015: George MM, Goswamy J, Penney SE. Embolic suppurative thyroiditis with concurrent carcinoma in pregnancy: lessons in management through a case report. Thyroid Res. 2015;8:3.

Hyperthyroidism Diagnosis and Treatment. April Janet A. Schlechte, M.D.

Hyperthyroidism Diagnosis and Treatment Family Practice Refresher Course April 2015 Janet A. Schlechte, M.D. Disclosure of Financial Relationships Janet A. Schlechte, M.D. has no relationships with any