Portal de Periódicos da CAPES

A Pain in the Neck: Thyroid Abscess

2013; Elsevier BV; Volume: 127; Issue: 3 Linguagem: Inglês

10.1016/j.amjmed.2013.09.036

1555-7162

Jennifer Brown, Hien Nguyen, Stuart H. Cohen,

Oropharyngeal Anatomy and Pathologies

A 43-year-old man presented with a 2-day history of fever and left neck swelling. Two years previously he was the recipient of a deceased-donor kidney transplant. He had experienced chronic renal allograft rejection and had chronic hepatitis C infection. His current medications included mycophenolate mofetil, prednisone, and tacrolimus. Upon examination, his left anterolateral neck was swollen, warm, and tender. Hematologic testing revealed a white blood cell count of 21.8 K/mm3 with a neutrophil count of 19.4 K/mm3. A computed tomography scan of the neck showed a 3-cm × 3-cm × 9-cm complex fluid collection in the left thyroid lobe that extended superiorly to the submandibular region, inferiorly to the clavicular head, and medially to the isthmus (Figure, A and B, arrows). The left carotid sheath was displaced laterally and a mild mass effect was evident on the trachea. Blood cultures and specimens of the thyroid fluid collection grew methicillin-susceptible Staphylococcus aureus. Thyroid abscesses are rare, comprising <1% of all thyroid diseases.1Al-Dajani N. Wootton S.H. Cervical lymphadenitis, suppurative parotitis, thyroiditis, and infected cysts.Infect Dis Clin North Am. 2007; 21: 523-541Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 2Paes J.E. Burman K.D. Cohen J. et al.Acute bacterial suppurative thyroiditis: a clinical review and expert opinion.Thyroid. 2010; 20: 247-255Crossref PubMed Scopus (136) Google Scholar Their scarcity is attributed to the gland's inherent protective factors, such as high iodine content, capsular encasement, and good lymphatic drainage.2Paes J.E. Burman K.D. Cohen J. et al.Acute bacterial suppurative thyroiditis: a clinical review and expert opinion.Thyroid. 2010; 20: 247-255Crossref PubMed Scopus (136) Google Scholar, 3Pearce E.N. Farwell A.P. Braverman L.E. Thyroiditis. N Engl J Med. 2003; 348: 2646-2655Crossref PubMed Scopus (759) Google Scholar Thyroid abscesses most often occur in patients who have preexisting disorders of the thyroid gland, such as nodules or cancer; anatomic defects, such as pyriformis sinus fistulae; or, like our patient, compromised immune systems.2Paes J.E. Burman K.D. Cohen J. et al.Acute bacterial suppurative thyroiditis: a clinical review and expert opinion.Thyroid. 2010; 20: 247-255Crossref PubMed Scopus (136) Google Scholar, 4Berger S.A. Zonszein J. Villamena P. Mittman N. Infectious diseases of the thyroid gland.Rev Infect Dis. 1983; 5: 108-122Crossref PubMed Scopus (196) Google Scholar, 5Miyauchi A. Matsuzuka F. Takai S. et al.Piriform sinus fistula. A route of infection in acute suppurative thyroiditis.Arch Surg. 1981; 116: 66-69Crossref PubMed Scopus (131) Google Scholar, 6Yolmo D. Madana J. Kalaiarasi R. et al.Retrospective case review of pyriform sinus fistulae of third branchial arch origin commonly presenting as acute suppurative thyroiditis in children.J Laryngol Otol. 2012; 126: 737-742Crossref PubMed Scopus (26) Google Scholar The abscesses may arise from hematogenous or lymphatic spread or by direct spread from infections in the neck or oropharynx. Rarely, they result from trauma or direct inoculation during invasive procedures, such as fine-needle aspiration of the gland or central venous line placement.7Nishihara E. Miyauchi A. Matsuzuka F. et al.Acute suppurative thyroiditis after fine-needle aspiration causing thyrotoxicosis.Thyroid. 2005; 15: 1183-1187Crossref PubMed Scopus (63) Google Scholar Complications of thyroid abscesses include tracheal or esophageal perforation, descending necrotizing mediastinitis, extension into the deep spaces of the neck, and death. The most common causative organism implicated in thyroid abscesses is S. aureus. Other organisms include anaerobes of the oropharyngeal area or Gram-negative aerobes.1Al-Dajani N. Wootton S.H. Cervical lymphadenitis, suppurative parotitis, thyroiditis, and infected cysts.Infect Dis Clin North Am. 2007; 21: 523-541Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 2Paes J.E. Burman K.D. Cohen J. et al.Acute bacterial suppurative thyroiditis: a clinical review and expert opinion.Thyroid. 2010; 20: 247-255Crossref PubMed Scopus (136) Google Scholar, 8Jeng L.B. Lin J.D. Chen M.F. Acute suppurative thyroiditis: a ten-year review in a Taiwanese hospital.Scand J Infect Dis. 1994; 26: 297-300Crossref PubMed Scopus (45) Google Scholar, 9Stavreas N.P. Amanatidou C.D. Hatzimanolis E.G. et al.Thyroid abscess due to a mixed anaerobic infection with Fusobacterium mortiferum.J Clin Microbiol. 2005; 43: 6202-6204Crossref PubMed Scopus (11) Google Scholar Treatment of thyroid abscesses includes drainage or partial or total thyroidectomy together with appropriate antimicrobial therapy.2Paes J.E. Burman K.D. Cohen J. et al.Acute bacterial suppurative thyroiditis: a clinical review and expert opinion.Thyroid. 2010; 20: 247-255Crossref PubMed Scopus (136) Google Scholar, 10Ilyin A. Zhelonkina N. Severskaya N. Romanko S. Nonsurgical management of thyroid abscess with sonographically guided fine needle aspiration.J Clin Ultrasound. 2007; 35: 333-337Crossref PubMed Scopus (35) Google Scholar If a pyriformis sinus tract is present, resection or obliteration of the tract is recommended.11Kim K.H. Sung M.W. Koh T.Y. et al.Pyriform sinus fistula: management with chemocauterization of the internal opening.Ann Otol Rhinol Laryngol. 2000; 109: 452-456Crossref PubMed Scopus (98) Google Scholar, 12Nicoucar K. Giger R. Pope Jr., H.G. Jaecklin T. Dulguerov P. Management of congenital fourth branchial arch anomalies: a review and analysis of published cases.J Pediatr Surg. 2009; 7: 432-439Google Scholar In this patient, the thyroid abscess resolved with percutaneous drainage and cefazolin therapy.