Acute suppurative thyroiditis

Case contributed by Pedro Aguado Linares

Presentation

Pain, firmness, tenderness, redness and swelling in the anterior aspect of the neck. Sudden fever, difficulty swallowing and difficulty moving the neck. Neutrophilic leukocytosis with high CRP. Negative Serology for CMV, EBV and Parvovirus. Negative blood and catheter cultures. Good response to intravenous antibiotics.

Patient Data

Age: 2 years
Gender: Male

Thyroid ultrasound

ultrasound

There is an ovoid picture with a heterogeneous intern ecostructure. It lenghts approximately 3 x 2.7 cm. We think that it is placed in the left thyroid lobe, due to it seems to be continued by the isthmus. The carotid arthery and the yugular vein are being displaced by it but they remain permeables. By using Doppler-color mode, there is an increased vascularity in the surrounding area. This picture can correspond to a collection in a proper clinic context.

There are lymph nodules which present a non-specific-reactive aspect in both of the posterior cervical chains.

Cervical Spine MRI

mri

There is a rise of the size of the left thyroid lobe with a heterogeneous signal which restrings the diffusion. It is located in the anterior cervical region at the C5-C7 level, next to the vascular structures. It has a 3 cm approximately maximum diameter. This picture can correspond to the mentioned inflammatory collection that has been previously described.

There are lymph nodules which present a non-specific-reactive aspect in both of the posterior cervical chains.

No other structural invasion is visible.
 

Tc-99m thyroid scintigraphy

Nuclear medicine

The thryoid´s situation is normal. It shows an asymmetric uptake between both lobes. There is a right thyroid lobe with a normal morphology and an homogeneus/regular uptake, whereas the left thyroid lobe has a cold area which includes the upper two thirds. This is probably in relation to the inflammatory thyroid collection, described in the morphological tests (ECO/MRI)

 

Neck contrast-enhanced CT

ct

An inflammatory collection with approximate measurements of 31 x 15 x 10 mm seems to originate in the upper pole of the left thyroid lobe and extends anteriorly to the soft tissues, prethyroid and left sternocleidomastoid muscles, and cranially through the paralaryngeal space to the level of the valleculae. At a posterior level, it extends until contacting the pharynx without visualizing retropharyngeal collections or mediastinal extension.

There is a deviation of the air lumen to the right without a significant decrease in its caliber.

Multiple laterocervical lymph node conglomerates (internal jugular, accessory spinal, and submandibular chains).

Left sublingual hyperdense image of 1 cm, which could correspond to ectopic thyroid tissue without clinical significance in the current study

Case Discussion

The thyroid is normally very resistant to infection. Due to a relatively high amount of iodine in the tissue, as well as high vascularity and lymphatic drainage to the region, it is difficult for pathogens to infect the thyroid tissue. Despite all this, a persistent fistula from the piriform sinus may make the left lobe of the thyroid susceptible to infection and abscess formation.

AIT is most often caused by a bacterial infection but can also be caused by a fungal or parasitic infection, most commonly in an immunocompromised host.

We decided to practise a barium esophagram in our case eventually, in order to demonstrate this abnormality. However we could not conclude anything because of the procedure´s difficulty and the lack of help of our patient. The upper GI series were normal till the duodenum but the clinical suspicion was high.

Another way to diagnose this pathology may be using a fibroendoscopy. 

Finally, our patient underwent surgery and with the use of direct endoscopy the suspected fistula was founded in the left piriform sinus and it was treated with cauterization.

 

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