Bombay Hospital Journal, Vol. 54, No. 2, 2012

Thyroid Abscess Due to Staphylococcus Epidermidis

K. Shanmuga Priya*, G. Prabhu*, N. Sindhumathi*, M. V. Reddy**, M. # ##Chandrasekaran , K. Jagadeesan

*Post Graduate Student, **Practicing Rural Surgeon, # ##Endocrine Surgeon, Surgeon, Chairman and

Director, K. J. Hospital Research and Postgraduate

Centre, Chennai - 600084.

Abstract

Acute suppurative thyroiditis - infection of the thyroid gland is uncommon

constituting only 0.1-0.7% of the surgical thyroid pathologies. Many such cases have

been reviewed and reported on. Here we review a male patient with history of

hypothyroidism for two years now presenting with abscess in thyroid.

Introduction

hyroid abscess is a rare entity. It Tusually occurs in patients with a pre

existing thyroid pathology. The organisms

commonly associated with thyroid abscess

are staph aureus, streptococcus etc. We

present a case of thyroid abscess in a 41

year old male due to staphylococcus

epidermidis.

Case Report

A 41 year old male patient came with complaints

of swelling in front of neck for 2 years. It gradually

increased in size and he had difficulty in swallowing,

pain and fever for 4 days. He had history suggestive of

hypothyroidism and was under treatment with

150 µg thyroxine. He is a known epileptic for past 15

years on regular treatment with eptoin,

carbamazepine and sodium valproate. On

examination patient was febrile with a single swelling

over the front of neck of about 12 x 6 cm, prominent

on right side, moves with deglutition. The plane of

swelling was deep to deep fascia. On palpation it was

warm and tender. Surface was smooth with no

nodularity. Lower border was visible. Blood

investigations showed an Hb of 13 g% with total

WBC-9, 100/ cu.mm with a rise in polymorphs to

77%, ESR 42 mm at ½ hr and 128 mm at one hour.

Renal and liver function parameters were normal.

Urine culture sensitivity showed the presence of

E.coli. T3 - 64ng/dl [60-200ng/dl], T4 -

10.10µg/dl[4.5 - 12 µg/dl], TSH - 0.15µIU/ml [0.30-

5.5 µIU/ml]. HIV testing showed him to be negative.

X-ray AP and lateral view of neck showed a soft

tissue swelling on the right side over thyroid and

displacing trachea to left. USG showed a cystic mass

with homogenous echo pattern of 8.0 x 4.8 x 2.0 cm

(Fig. 1)

Bilateral submandibular nodes enlarged with normal

appearing left lobe and isthmus. Thyroidectomy was

planned but difficulty was encountered while

introducing endotracheal tube due to shift of trachea

with reduced lumen. Under local anaesthesia

incision and drainage was done. 300 ml of

seropurulent fluid was obtained and sent for

microbiological examination. It showed gram positive

cocci which on culture were staphylococcus

epidermidis susceptible to norfloxacin, cephazolin

and tetracycline. The swelling reduced in size

Fig. 1: USG showing a cystic mass with homogenous echo pattern

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Bombay Hospital Journal, Vol. 54, No. 2, 2012

following the procedure. Surgery was postponed and

in the meantime the patient was put on antibiotics

and thyroxine. Soft tissue X-ray neck taken after a

few days showed a dramatic reduction of soft tissue

on the right side of neck. Surgery was planned under

GA. Through a skin crease collar incision the thyroid

gland was exposed. It showed a mass in right lobe.

Classical right hemithyroidectomy was done and the

specimen sent for HPE. It showed thyroid follicles of

varying sizes filled with colloid and a cyst containing

haemorrhage (Fig. 2 and 3) with thickened cyst wall

due to fibrosis along with cholesterol clefts. No

evidence of malignancy seen.

Discussion

Thyroid abscess or acute suppurative

thyroiditis (AST) is uncommon. It is an

acute inflammatory condition due to

infection of thyroid gland. The most

common organisms are staphylococcus

and streptococcus. However rarely

o r g a n i s m s l i k e A c i n e t o b a c t e r

c a l c o a c e t i c u s , F u s o b a c t e r i u m

morteiferum., Salmonella, Eikennella

corrodens, Nocardia has been implicated.

Mycobacteria, Rhodococcus equi,

Anaerobes are common pathogens in HIV

patients.

Thyroid gland has inherent resistance

to infections owing to its high iodine

content, tough capsule, good blood supply

and lymphatic drainage, anatomic

isolation. The common predisposing

factors are pre existing thyroid pathologies

like a cyst or nodule, congenital pyriform

sinus fistula, following Fine needle

aspiration cytology (FNAC), direct trauma,

immuno compromised state. It can also

occur following a respiratory or urinary

tract infection and rarely through

haematogenous spread.

AST is a painful condition and should

be differentiated from other painful

conditions of thyroid like de quervain

thyroiditis, rapidly progressive carcinoma

and haemorrhage into a cyst.

AST presents with fever, pain,

dysphagia and tachycardia. AST may

present as pulsatile swelling. But it may

sometimes follow an insidious course like

the index case with minimal signs and

symptoms of inflammation. Two cases of

vocal cord paralysis have been reported.

FNAC can be done to determine the type of

organism and its antibiotic susceptibility.

Untreated thyroid abscess may go in

for complications like jugular vein

Fig. 2 Cut section of thyroid gland showing thyroid follicle with abscess cavity and areas of haemorrhage

Fig. 3: Histopathology section showing colloid filled follicles with cholesterol cleft

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thrombosis, sepsis, rupture, destruction

of thyroid and parathyroid glands and

formation of sinus or fistula. Abscess in

long standing goitre is an acute

emergency.

Different modalities of treatment have

been tried with varying results.

Ultrasonographic drainage or incision and

drainage followed by treatment with

susceptible antibiotics or surgical removal

of the abscess cavity along with part of

gland can be done.

Conclusion

We are reporting this in view of the

rarity of the case. The anaesthetic problem

where the intubation became critical. The

draining of the abscess of about 300 ml of

seropurulent material relieved the

obstruction of the airway, thereafter

intubation was made possible. It is noted

within a short period of 24 hours, the fluid

reaccumulated to the tune of about

100 ml. surgical resection was challenging

because of the adhesions around the

surrounding tissues. Extreme degree of

care was taken to save the neurological

structures and parathyroid. Post operative

period was uneventful. Patient's voice and

vocal cord functions remain normal. In

such situation where intubation become

difficult, on the spot tapping and

intubation or tracheostomy could be

attempted.

References

1. Rohondia O S, Koti R S, Majumdar P P,

Vijaykumar T, Bapat R D, Thyroid abscess. J

Postgrad Med. 1995;41:52-54.

2. Nishihara E, Miyauchi A, Matsuzuka F, Sasaki I,

Ohye H, Kubota S, Fukata S, Amino N,Kuma K.

Acute suppurative thyroiditis after fine-needle

aspiration causing thyrotoxicosis. Thyroid.

2005;15:1183-1187.

3. Nikolaos P. Stavreas, Constantina D.

Amanatidou, Emmanuel G. Hatzimanolis et al.

Thyroid Abscess Due to a Mixed Anaerobic

Infection with Fusobacteriummortiferum.

4. Menegaux, F., G. Biro, C. Schatz, and J. P.

Chigot. Thyroid abscess. Apropos of 5 cases,

Ann. Med. Interne (Paris). 1991;142:99-102.

5. Schneider, U, R. Birnbacher, S. Schick, W.

Ponhold, and E. Schober. Recurrent

suppurative thyroiditis due to pyriform sinus

fistula: Eur. J. Pediatr 1995;154:640-642

6. Jacobs A, Gros DC, Gradon JD. Thyroid Abscess

Due to Acinetobacter calcoaceticus: Case Report

and Review of the Causes of and Current

Management Strategies for Thyroid Abscesses

Southern Medical Associat ion. 2003

Mar;96(3):300-307.

7. Thyroid abscess caused by Eikenella corrodens.

Cheng AF, Man DW, French GL. Department of

Microbiology, Chinese University of Hong Kong.

8. Gram-negative thyroid abscess resulting from

fine-needle aspiration in animmunosuppressed

patient Wang. Yu-Chun | Yeh, Ta-Sen | Lin,

Jen-Der Clinical Infectious Diseases [CLIN.

INFECT. DIS]. 1997; Vol. 25, No.3, pp. 745-746.,

Sep.

9. Barton, Gary M. Shoup, William B. Bennett,

William G. Williams, James B. Vesely, David L.

Combined Escherichia Coli and Staphylococcus

Aureus Thyroid Abscess in an Asymptomatic

Man.

Antiretroviral Therapy in TB and HIV Coinfection

In this study from Cambodia, giving antiretrovirals 2 weeks after the start of TB therapy was superior to therapy begun at 8 weeks, with a decrease in mortality.

N ENGL J MED 2011; 1470365;16;

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