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Case Reports Indian Pediatrics 2002; 39:1156-1158 |
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Acute Suppurative Thyroiditis with Thyroid Abscess |
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S.B. Ogale
Acute suppurative thyroiditis (AST) is a rare condition in children(1). Progression to abscess formation is even more uncommon. Only 60 cases were reported in pediatric patients till 1997, 18 of whom had recurrent episodes of this disease(2,3). Two pediatric cases were reported after that, which makes it 62 to the best of our knowledge(3,4). Case Report An eight year old male child presented with fever, painful swelling in the neck, throat pain and dysphagia of 5-6 days duration. There was history of cough and cold, 10-12 days before. Examination revealed a tender, warm, diffuse, midline swelling in the thyroid region more prominent on left side, with erythema of the overlying skin. The swelling moved with deglutition. Associated findings included tachycardia, restriction of neck movements to the left and tender enlargement of left jugulodigastric group of lymph nodes. Initial investigation showed a white blood cell count of 14.4 × 103/µL with 78% neutrophils. ESR was 54 mm in first hour. Ultrasonography of neck revealed enlargment of the thyroid gland, the right and left lobe being 2.4 × 1.4 × 1.2 cm and 3 × 2.4 × 1.7 cm respectively. Left lobe showed decreased echogenicity. Associated pretracheal and cervical lymphadenopathy was documented. The thyroid function tests were normal. Barium esophagogram did not show any abnormality including pyriform sinus fistula. HIV test was negative. The diagnosis of acute suppurative thyroiditis was made and parenteral ampicillin-cloxacillin was started. However fever persisted and the swelling localized, became soft and fluctuant over the period of next 4-5 days. Surgical drainage yielded about 30 mL of thick greenish yellow pus. Bacterial as well as fungal cultures were sterile, perhaps because of prior antibiotic therapy. Smear for AFB was negative. Fever subsided 2 days after the surgical drainage which was done after one week of hospitalization. Radionucleide studies (Tc99) done one week after the surgical drainage still revealed a cold area superomedially over the left lobe. The child improved completely thereafter and was normal one month after the discharge. Discussion Acute suppurative thyroiditis is very uncommon in children though other types e.g. subacute and Hashimoto’s thyroiditis are relatively common. Occasional neonatal cases also have been reported(5). Thyroid gland is inherently resistant to the bacterial infection. Protective mechanisms include (i) rich blood supply and lymphatic drainage, (ii) high glandular content of iodine which can be bactericidal and (iii) separation of the gland from other structures of the neck by fascial planes(6). Clinical features include fever, sore throat, anterior midline tender swelling in the neck, dermal erythema, dysphagia, hoarse voice and limitation of head movements(4,7). Tenderness suggests an inflammatory process or hemorrhage into the gland(8). Though fluctuation was present in our case, it may not be apparent because of the edema and induration of the surrounding tissues. Preceding history of a respiratory infection may be present. Left lobe is more involved than the right(3). Tachycardia along with leucocytosis is common. T3, T4, TSH are typically normal but thyroglobulin levels may be high(9). Radionucleide scan may be normal or show a cold nodule in the area of abscess formation. Barium oesophagogram should be done after infective process subsides to look for pyriform sinus fistula(10). Ultrasound adequately demonstrates intra or extrathyroid abscesses and solid or mixed lesions of the thyroid as well as adjacent inflammatory nodes(11). Our patient satisfied most of the criteria of acute suppurative thyroiditis with thyroid abscess. Organisms identified in pediatric acute suppurative thyroiditis are a part of normal oropharyngeal flora. Indigenous flora in upper respiratory tract spreads via a communicating fistula to the perithyroid space and thyroid gland(2). Hence predisposition to acute suppurative thyroiditis may be due to presence of the embryologic remnant of third or fourth pharyngeal pouch, i.e. left pyriform sinus fistula(2,10). Hemolytic streptococci, Staphylococcus aureus and pneumococci are the most commonly involved pathogens, however other organisms including anerobic and gram negative bacteria are also responsible(2,4,9). Treatment includes parenteral antibiotics and surgical drainage(3). If the abscess is not drained, it may dissect into the neck or extend to the chest. Rupture of the abscess into the trachea or esophagus may occur. Thrombophlebitis of internal jugular vein has also been reported. In case of pyriform sinus fistula, excision of fistulous tract is advised to prevent recurrences(4). Acknowledgements The authors are grateful to Dr. R.D. Khare, and Dr. S.F. Irani, K.J. Somaiya Medical College for permitting to publish this article. Contributors: SBO, VGT and NC were involved in the diagnosis and management of the patient and preparation of the manuscript. Funding: None. Competing interests: None stated.
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