Objective : Acute suppurative thyroiditis (AST) is a rare condition accounting for 0.1-0.7% of all thyroid diseases. The thyroid gland is uncommon location for infection due the anatomical encapsulation, high iodine content and the large vascular supply and lymphatic drainage. AST in adults is usually associated with a degree of immunodeficiency like HIV or ESRD on hemodialysis. We are presenting a rare case of AST causing thyroid storm.
A 58 year old male patient with ESRD on hemodialysis with no history of thyroid disease, who presented with fever vomiting and neck erythema, pain and swelling that progressed overnight. A right subclavian dialysis catheter was removed one week prior to presentation and was possibly infected. He was not in distress and his blood pressure was normal. Physical exam revealed skin erythema, tenderness and swelling in the anterior neck. His blood work up revealed leukocytosis of 19.9 x10 9 /L ( 4.5X11.0 x 10 9 )and lactic acidosis of 4.7 mmol/L ( 0.5-1 mmol/L) . Intravenous Zosyn and Vancomycin was initiated. Thyroid ultrasound showed severe edema of the entire thyroid gland and surrounding tissues suggesting severe acute thyroiditis with no fluid collection within the thyroid gland. TSH 1.93 mIU/L (0.4-5 mIU/L) and free T4 2.5 ng/dl (0.7-1.9 ng/dl). Blood cultures grew Methicillin Sensitive Staph Aureus(MSSA). Two days later, he developed acute change in mental status. Repeat thyroid function showed marked elevation in free T4 >6 ng/dl and suppressed TSH 0.11 mIU/L. He was diagnosed with Thyroid storm (TS) and was started on methimazole, stress-dose dexamethasone, B. blocker and Potassium iodine. Unfortunately he died after he developed Ventricular fibrillation and PEA arrest.
Methods : N/A
Results : N/A
Discussion : This patient with ESRD developed catheter infection with MSSA bacteremia and hematogenous spread of the bacterial infection to the thyroid gland without abscess formation. His neck symptoms developed and progressed acutely which explains the initial normal TSH level with elevated free T4 due to gland destruction. The acute change in mental status in the setting of thyrotoxicosis with precipitating acute infection led to the diagnosis of thyroid storm which was treated aggressively but unfortunately the patient died of cardiopulmonary arrest.
Acute Suppurative thyroiditis is a rare thyroid condition that is usually associated with normal thyroid function however AST with thyrotoxicosis has been reported. To our knowledge this is the first case of AST that caused decompensated thyrotoxicosis (TS). AST is treated with antibiotics and abscess drainage if present however prompt recognition of associated TS and aggressive therapy is crucial.
University of Missouri in Kansas City
I am a second year Endocrinology fellow at UMKC, interested in thyroid disease. I am submitting 2 interesting cases related to thyroid disorders.