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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 3  |  Issue : 3  |  Page : 180-183

Acute suppurative thyroiditis in pre-existing goiter in diabetic patients


1 Fellow Neurosurgery, Park Clinic, Kolkata, West Bengal, India
2 Department of Physiology, S.C.B Medical College, Cuttack, Odisha, India
3 Department of General Surgery, S.C.B Medical College, Cuttack, Odisha, India

Date of Web Publication13-Aug-2014

Correspondence Address:
Biswaranjan Nayak
Park Clinic, 4-Gorkey Terrace, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.138602

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  Abstract 

Background: Thyroid abscess is a rare clinical entity and infrequently encountered. We hereby present a review of 11 adult age group patients who presented to our hospital, which is a tertiary care referral center with thyroid abscess and the management being incision and drainage of abscess. Aims and Objective: In this paper, we have studied the association of acute suppurative thyroiditis (AST) with diabetes mellitus (DM), its early diagnosis and management. Materials and Methods: All the suspected AST cases were admitted to endocrine surgical unit of S.C.B Medical College and Hospital, Cuttack, India and studied prospectively. Thorough history taking and physical examination were done. All blood counts, serology and thyroid function were done. Plain radiograph, ultrasonography, computed tomography scan, magnetic resonance imaging of the neck were done as per the requirement. Indirect laryngoscopy was done as a routine procedure. Diagnostic aspiration was done in every case followed by incision and drainage. Results: We report our observations from the 11 cases of AST being managed in endocrine surgical unit. All the patients were of female sex and their age ranging from 27 to 65 years. Each of them had a pre-existing goiter of duration from 1 to 7 years. Staphylococcus aureus (nine cases) was the most common pathogen followed by Escherichia coli (two cases). Proper antibiotics as per culture sensitivity (cefuroxime, amikacin), control of diabetes with insulin, daily copious irrigation of the wound with normal saline healed all these abscesses. They were discharged from the hospital after full resolution of the infection and underwent thyroidectomy at a later date. Conclusion: Type-2 DM is rapidly emerging as a public health problem in South East Asia particularly in India leading to a wide variety of infectious complications in different anatomic locations. It is the single most important cause of AST in our population. Early recognition and prompt institution of surgical and endocrinological management by a multidisciplinary team is required and hence diabetic patients with pre-existing goiter should be recommended for planned thyroidectomy at an early date to reduce its complication. S. aureus is the most common pathogen followed by E. coli in our study group.

Keywords: Diabetes, diagnosis, management, suppuration, thyroid


How to cite this article:
Nayak B, Das RR, Mallik BN, Mohapatra KC. Acute suppurative thyroiditis in pre-existing goiter in diabetic patients. Int J Health Allied Sci 2014;3:180-3

How to cite this URL:
Nayak B, Das RR, Mallik BN, Mohapatra KC. Acute suppurative thyroiditis in pre-existing goiter in diabetic patients. Int J Health Allied Sci [serial online] 2014 [cited 2019 Sep 20];3:180-3. Available from: http://www.ijhas.in/text.asp?2014/3/3/180/138602


  Introduction Top


Acute suppurative thyroiditis (AST) is a pyogenic infection of thyroid gland, also known as infective thyroiditis, microbial inflammatory thyroiditis, pyrogenic thyroiditis and bacterial thyroiditis. AST is a rare clinical event [1] and an uncommon form of thyroiditis. [2] In the adult population, there may be multiple etiologies such as direct trauma from foreign bodies , extension from nearby anatomic structures such as thyroglossal fistula, fourth branchial arch fistula , fine needle aspiration or from an esophageal carcinoma . Rarely hematogenous spread from a distant site in intravenous drug abuser and immune compromised individual may be seen. Poor host resistance due to diabetes mellitus (DM), cancer, anemia, hypoprotenemia, chronic renal failure (CRF) and immunosuppression therapy contribute to thyroid abscess etiology. [1],[2] In children AST is associated with a persistent pyriform sinus fistula. Thyroid abscess represents only 0.1-0.7% of surgically treated thyroid pathologies. [3] The recently published Indian Council of Medical Research-India Diabetes national study reported that there are 62.4 million people with type 2 diabetes and 77 million people with prediabetes in India. These numbers are projected to increase to 101 million by the year 2030. [4] As these type-2 diabetics are living longer due to improved care infective complications are becoming common. One of such infective condition is the AST developing in a pre-existing goiter. Again the severity of infection is also very marked in patients with diabetes thereby necessitating early recognition and prompt institution of treatment and multidisciplinary team approach for management. Prognosis of the condition mainly depends upon the immune status of the patient and early surgical intervention. In this paper, we have tried to study the behavior of AST in association with DM.

Aim and objective

In this paper, we have studied the association of AST with DM, its early diagnosis and management.


  Materials and methods Top


All the suspected AST [Figure 1] cases were admitted to endocrine surgical unit of S.C.B Medical College and Hospital, Cuttack, India from June 1998 to June 2012 and studied prospectively. AST with associated DM were included in the study and AST due to other reasons such as organ transplant, immunosuppressive therapy, with associated malignancy and AIDS were excluded from the study. We have eleven patients in the study all the patients were female with age group ranging from 27 to 65 years with a history of type-2 diabetes of duration 1-7 years. Informed consent was obtained from each patient and the study protocol confirms to the ethical guidelines of the 1975 declaration of Helsinki. Thorough history taking and physical examination were done. Diabetic specific history, duration of diabetes and treatment (oral hypoglycemic agents/insulin) and so on , were recorded. History of any recent infection and diagnostic fine-needle aspiration cytology (FNAC) was also noted. All blood counts, serology and thyroid function were done. Plain radiograph, ultrasonography (USG) done in all the cases and computed tomography (CT) scan, magnetic resonance imaging of the neck were done for extensive cervical and retrosternal lesions [Figure 2] and [Figure 3]. CT scan shows diffuse swelling of the thyroid gland and perithyroid soft tissue. The affected thyroid gland shows a poorly defined margin, hypodensity. MR images show soft-tissue inflammation along the disease course, with intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images and on fat-suppressed T1-weighted images after IV administration of contrast. Indirect laryngoscopy was done as a routine procedure. Diagnostic aspiration was done in every case followed by incision and drainage under local or general anesthesia (LA/GA). An adequate length of incision given over the abscess, the cavity opened, and all the loculi braked with gentle maneuver and multiple abscess cavities along with their extensions drained using the same incision. Later regular dressing with copious amount of normal saline irrigation was done. Culture sensitive antibiotics were given, strict glycemic control done. The wound usually take 2-3 weeks for complete healing [Figure 4],[Figure 5] and [Figure 6]. Regular follow-up done as recurrence is not uncommon in these patients. Thyroidectomy was done after resolution of symptoms.
Figure 1: Patient showing thyroid abscess

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Figure 2: Ultrasonography showing thyroid abscess

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Figure 3: Computed tomography scan showing a suppurative lesion of thyroid

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Figure 4: Incision and drainage showing abscess cavity

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Figure 5: Postoperative (10th day)

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Figure 6: Postoperative (21st day)

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  Results Top


We report our observations from the 11 cases of AST being managed in endocrine surgical unit S.C.B Medical College and Hospital, Cuttack, India from June 1998 to June 2012. All the patients were of female sex and their age ranging from 27 to 65 years. Each of them had a pre-existing goiter of duration from 1 to 7 years. All of them presented for the first time. Most of the common presenting features were fever, chills and rigor, increase in the size of the thyroid with local rise of temperature and tenderness. Pressure symptoms like dysphagia was present in two patients which regressed after drainage and none of them had a distant primary focus of infection. Eight of them were known diabetic and three of them were detected to be diabetic for the first time. In four out of eight of known diabetic with AST the lesions were very large and multiloculated. In one patient, there was an extension to the other side and also retrosternally. All cases were managed in an endocrine surgical unit by a multidisciplinary team with adequate incision and drainage, breaking of all the loculae and extensions of the abscess. Staphylococcus aureus (nine cases) was the most common pathogen followed by  Escherichia More Details coli (two cases). Proper antibiotics as per culture sensitivity (cefuroxime, amikacin), control of diabetes with insulin, daily copious irrigation of the wound with normal saline healed all these abscesses. They were discharged from the hospital after full resolution of the infection and underwent thyroidectomy at a later date. No major postoperative complication was encountered in our patients.


  Discussion Top


Acute suppurative thyroiditis is a rare and an uncommon form of thyroiditis. The progression of the condition to thyroid abscess is equally unusual. [5] Both AST and thyroid abscess represent 0.1-0.7% of thyroid lesions and managed surgically. [3],[6] Thyroid abscess have been observed to be more usual in females than males [7] with a wide age range of 16 days-79 years. [8] In a study conducted over 14 years we found only 11 cases of AST associated with type-2 diabetes, which it shelf shows the rarity of the entity. In our study, all the patients were female which also shows the female preponderance of the disease and their age ranging from 27 to 65 years. Type-2 DM is rapidly emerging as a public health hazard in South East Asia including India with prevalence of 12.5%. It is the leading secondary immunodeficiency state in our population predisposing to several infectious complications of which thyroid abscess is one. In the adult population there may be multiple etiologies such as direct trauma from foreign bodies, extension from nearby anatomic structures such as thyroglossal fistula, fourth branchial arch fistula, fine-needle aspiration or from an esophageal carcinoma . Rarely, hematogenous spread from a distant site in intravenous drug abuser and immune compromised individual may be seen. Pre-existing thyroid pathology sets the ground for infection as it disrupts the local anatomy and barrier, thereby offers the least resistance to infection. Poor host resistance due to DM, cancer, anemia, hypoprotenemia, CRF and immunosuppression therapy contribute to thyroid abscess etiology. In children without any immunocompromised state AST is associated with a persistent pyriform sinus fistula. [8],[9],[10],[11] The most common clinical presentation are acute onset of pain and swelling. This is also similar in our series where all the patients presented with pain and swelling in the anterior neck. High index of suspicion for thyroid abscess in all cases of cervical suppurative lesions is mandatory for early detection and prompt institution of treatment. FNAC, diagnostic aspiration of pus, high resolution USG of neck along with a thorough history and physical examination clinches the diagnosis of thyroid abscess. Suspicion of underlying cancer (follicular/anaplastic) should be kept in mind. Incision and drainage (LA/GA), adequate antibiotic therapy based on conventional smears followed by definitive thyroid surgery for underlying pathology is essential to effect a cure. In our study S. aureus (nine cases) was the most common pathogen followed by E. coli (two cases). Proper antibiotics as per culture sensitivity (cefuroxime, amikacin) given after incision and drainage. Associated immuno-suppressed state needs to be evaluated and properly taken care of for the successful outcome. Untreated thyroid abscess may lead to several complications. L-thyroxine replacement therapy may be required in those with transient or prolonged hypothyroidism that can occur in individuals with severe, diffuse inflammation and necrosis of the gland. Local complications also include: vocal cord paralysis, abscess rupture or extension into adjacent sites and organs (anterior mediastinum, trachea, and esophagus), thrombosis of the internal jugular vein (Lemiere's syndrome), and extrinsic compression of the trachea. None of the above mentioned complications were seen in either of our patients. This could be due to timely presentation and their prompt and appropriate intervention.


  Conclusion Top


Type-2 DM is rapidly emerging as a public health problem in South East Asia particularly in India leading to a wide variety of infectious complications in different anatomic locations. Pre-existing goiter is at increased risk of developing suppurative thyroiditis/abscess in those patients. Therefore early recognition and prompt institution of surgical and endocrinological management by a multidisciplinary team is required and hence diabetic patients with pre-existing goiter should be recommended for planned thyroidectomy at an early date to reduce its complication.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

 
  References Top

1.Imai C, Kakihara T, Watanabe A, Ikarashi Y, Hotta H, Tanaka A, et al. Acute suppurative thyroiditis as a rare complication of aggressive chemotherapy in children with acute myelogeneous leukemia. Pediatr Hematol Oncol 2002;19:247-53.  Back to cited text no. 1
    
2.Tien KJ, Chen TC, Hsieh MC, Hsu SC, Hsiao JY, Shin SJ, et al. Acute suppurative thyroiditis with deep neck infection: a case report. Thyroid 2007;17:467-9.  Back to cited text no. 2
    
3.Lamani YP, Basarkod SI, Telkar SR, Goudar BV, Ambi U. Thyroid abscess in immuno compromised patient: A case report. J Clin Diagn Res 2012;6:106-7.  Back to cited text no. 3
    
4.Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R, et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study. Diabetologia 2011;54:3022-7.  Back to cited text no. 4
    
5.Rohondia OS, Koti RS, Majumdar PP, Vijaykumar T, Bapat RD. Thyroid abscess. J Postgrad Med 1995;41:52-4.  Back to cited text no. 5
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6.Schneider U, Birnbacher R, Schick S, Ponhold W, Schober E. Recurrent suppurative thyroiditis due to pyriform sinus fistula: A case report. Eur J Pediatr 1995;154:640-2.  Back to cited text no. 6
    
7.Nishihara E, Miyauchi A, Matsuzuka F, Sasaki I, Ohye H, Kubota S, et al. Acute suppurative thyroiditis after fine-needle aspiration causing thyrotoxicosis. Thyroid 2005;15:1183-7.  Back to cited text no. 7
    
8.Jacobs A, Gros DA, Gradon JD. Thyroid abscess due to Acinetobacter calcoaceticus: Case report and review of the causes of and current management strategies for thyroid abscesses. South Med J 2003;96:300-7.  Back to cited text no. 8
    
9.Miyauchi A, Matsuzuka F, Kuma K, Takai S. Piriform sinus fistula: an underlying abnormality common in patients with acute suppurative thyroiditis. World J Surg 1990;14:400-5.  Back to cited text no. 9
    
10.Rohn RD, Rubio T. Neck pain due to acute suppurative thyroiditis and thyroglossal duct abscess. J Adolesc Health Care 1980;1:155-8.  Back to cited text no. 10
[PUBMED]    
11.Lin KD, Lin JD, Huang MJ, Huang HS, Jeng LB, Ho YS. Acute suppurative thyroiditis and aggressive malignant thyroid tumors: Differences in clinical presentation. J Surg Oncol 1998;67:28-32.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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