An Unusual Case of a Thyroid Abscess
Joseph E. Rondon
North Broward Preparatory School
Robert Reid, MD
Pediatric Infectious Disease, Joe DiMaggio Children's Hospital, Hollywood, FL
Abstract
Infection of the thyroid gland is uncommon and microbial etiologies are not well-defined. We describe a case of a thyroid abscess secondary to Streptococcus intermedius and features suggestive of Actinomyces coinfection on a patient upon return from a summer camp in Pennsylvania.
Introduction
Infection of the thyroid gland is uncommon and microbial etiologies are not well-defined. We describe a case of a thyroid abscess secondary to Streptococcus intermedius and features suggestive of Actinomyces coinfection on a patient upon return from a summer camp in Pennsylvania. While at the camp, he participated in numerous outdoor activities, including swimming in the local lakes. [1]
Case Presentation
A 15-year-old male with no past medical history was at a summer camp in Pennsylvania. Part of the activities at the camp involved swimming in lakes and activities in mud. Four days after returning home he experienced non-radiating, sharp, and constant left neck pain. He became febrile with a temperature of 39.4°C; reported chills, sweats, extreme sore throat, odynophagia, and fatigue. He denied dyspnea or drooling and continued to eat despite the pain. He became febrile with a temperature of 39.4°C; reported chills, sweats, extreme sore throat, odynophagia, and fatigue. He denied dyspnea or drooling and continued to eat despite the pain.
Around seven days later, the 15-year-old male presented to the emergency department with progressive symptoms. Workup revealed elevated inflammatory markers: white blood cell count: 15.2 x 103 ( 11.4% neutrophils), C-reactive protein 4.93 mg/dLand erythrocyte sedimentation rate (ESR):15mm/hr. The thyroid panel revealed mildly suppressed thyroid stimulating hormones (TSH): 0.278 with normal free T3 and T4. A computed tomography scan (CT) of the neck revealed an enlarged left thyroid lobe containing a nonspecific 3.1cm x 2.5cm x 2.1cm hypodense lesion, deviating from the trachea. Ultrasound of the thyroid revealed a complex collection in the left lobe of the thyroid concerning for abscess; differential diagnoses include adenoma with internal hemorrhage or necrotic tumor [2-4]. Those findings were concerning for acute suppurative bacterial thyroiditis and the patient was started on intravenous clindamycin therapy. [1]
The next day the patient underwent ultrasound-guided thyroid fine needle biopsy with successful aspiration of approximately 10 mL of purulent fluid. The abscess cavity was completely drained and copiously irrigated. The pathology report was consistent with fibrinopurulent exudate and there was a concern of some granules suggestive of actinomycosis. The culture predominantly grew Streptococcus intermedius susceptible to penicillin and clindamycin. Fungal culture was negative. Final surgical pathology did not reveal any malignant cells and consisted of fibrinopurulent exudate with focal bacterial forms with features suggestive of actinomycosis. AFB and GMS staining were negative for acid-fast or fungal elements. [2, 5, 6, 7]
Discussion
The culture predominantly grew Streptococcus intermedius susceptible to penicillin and clindamycin. Fungal culture was negative. Final surgical pathology did not reveal any malignant cells and consisted of fibrinopurulent exudate with focal bacterial forms with features suggestive of actinomycosis. AFB and GMS staining were negative for acid-fast or fungal elements. [2, 5, 6]
The patient was evaluated and followed up by an otolaryngologist who performed a laryngoscopy that was essentially normal; he also had a normal esophagram, excluding the probability of a branchial cleft anomaly.
Conclusions
Literature on the microbiologic etiology of infected human thyroid gland is scarce. We report a case of thyroid abscess secondary to Streptococcus intermedius and features suggestive of Actinomyces coinfection.
The patient was discharged on oral amoxicillin-clavulanate. Follow-up ultrasound of soft tissue at 20 and 30 days showed significant improvement but persistent surrounding inflammatory and phlegmonous changes. He completed 5 weeks of antibiotic therapy with complete resolution of symptoms and no recurrence seen at 1-year follow-up. This report could inform clinicians of less commonly known thyroid gland infection proposed treatment.
Figure A: Coronal view of CT scan of the neck showing a lesion located in the left thyroid lobe containing a non-specific 3.1 cm hypodense lesion.
Figure B: Ultrasound of the thyroid revealed a complex collection in the left lobe.
