The Journal of Emergency Medicine, Vol. 49, No. 3, pp. 335–337, 2015 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.04.023
Visual Diagnosis in Emergency Medicine
AN UNUSUAL CASE OF DYSPHAGIA Daniel Lasoff, MD and Gabriel Wardi, MD Department of Emergency Medicine, University of California, San Diego, California Reprint Address: Daniel Lasoff, MD, Department of Emergency Medicine, University of California, 200 W. Arbor Drive, San Diego, CA
systems was otherwise unremarkable. A bedside sonogram demonstrated a complex fluid-filled cystic mass and is demonstrated in Figure 2. A formal ultrasound revealed a single heterogeneous solitary nodule of the thyroid with increased peripheral vascularity, which was concerning for a malignant nodule. Needle aspiration was performed by an otolaryngologist and approximately 8 cm3 of frank pus was aspirated from the nodule and sent for aerobic, anaerobic, acid fast, and fungal culture, as well as cytology. Laboratory tests revealed a white blood cell count of 6.8 1000/mm3, and a thyroid-stimulating hormone value of 0.97 mIU/mL. She noted immediate improvement after aspiration and was discharged on a course of clindamycin and head and neck surgery follow-up. Her aerobic cultures grew Streptococcus milleri, while her acid fast bacilli and fungal cultures were negative. She was found to have no underlying congenital abnormalities during her follow-up, which included a barium swallow and an ultrasound that demonstrated complete resolution of her thyroid abscess, as show in Figure 3.
CASE REPORT A previously healthy 38-year-old female pregnant at 6 weeks (first pregnancy) presented to our emergency department (ED) for the second time in 5 days with a chief complaint of a sore throat. Her medical history was significant only for the pregnancy and, besides prenatal vitamins, she did not take any other medications. During her initial visit, she stated she had pain on swallowing, which was located anterior and just left of midline around her thyroid. Her vital signs were unremarkable and her examination revealed a well-developed female without any obvious pharyngitis, uvular deviation, or swelling of the neck. She did exhibit minimal tenderness to the left side of her thyroid gland. No masses or asymmetry were noted on palpation while she swallowed. There were no bruits or erythematous regions noted near the thyroid. On her second visit, she described a progressively worsening pain in the same region, along with an increased fullness on the left side of her neck. She also noted that her voice sounded muffled. She denied any fever, chills, weight changes, cough or trauma to the region. Her vital signs at this visit were temperature of 97.4 F, heart rate of 76 beats/min, and blood pressure of 126/76 mm Hg. Her examination revealed a patent airway with tenderness on the left side of her neck, and a mobile mass that moved with swallowing was noted just lateral to her thyroid, as depicted in Figure 1. Her review of
DISCUSSION Acute infectious thyroiditis, also referred to as acute suppurative thyroiditis, is a rare clinical entity. The most common complication is the development of a thyroid abscess. There have been just over 300 cases reported in the adult literature, and > 100 in the pediatric population (1). This is likely a combination of under-reporting, but is also
RECEIVED: 5 March 2015; ACCEPTED: 16 April 2015 335
336
Figure 1. Patient’s physical exam demonstrating asymmetric swelling of her neck.
due to the thyroid’s inherent resistance to infection. It has a dual blood supply, consisting of the superior thyroid and inferior thyroid arteries, a robust lymphatic drainage system, and a strong fibrous capsule that separates it from the remainder of the neck, all of which serve to prevent infectious infiltration. Early canine studies, in an attempt to model the disease, showed that direct inoculation of the superior thyroid artery with Staphylococcal and Strepto-
Figure 2. Patient’s ultrasound of thyroid with arrow directed at the heterogeneous hypoechoic mass within her thyroid.
D. Lasoff and G. Wardi
Figure 3. Patient’s repeat ultrasound at follow-up demonstrating normal architecture of her thyroid. The arrow is directed at the area of her resolved abscess.
coccal species had a very low proportion of disease that developed (2). In addition, high concentrations of iodine within the gland have intrinsic antiseptic properties. Approximately 90% of patients have pain to the anterior neck, fever, and tenderness (1). For uncertain reasons, the left aspect of the thyroid is more likely to develop infection. Less common are hoarseness, chills, dysphagia, and radiation to the ear or the posterior neck; case reports exist of patients with vocal cord paralysis and pulsatile masses (3,4). As in this case, patients typically acknowledge a preceding upper respiratory infection, pharyngitis, or acute otitis media (5). Emergency physicians should recall that acute atraumatic pain in this region has a broad differential diagnosis, including bacterial and fungal etiologies, amiodarone thyroiditis, and radiation thyroiditis (after 131I therapy) (6). Attention should be given to more common etiologies of pain in this region, including viral thyroiditis (subacute or de Quervains), which has a more indolent presentation; pharyngitis; hemorrhagic cysts; infarction of a thyroid nodule; and malignancy. Painful subacute thyroiditis is the most common cause of a painful thyroid, and occurs in approximately 5% of patients with thyroid disease (7). As the thyroid is well fortified against infectious agents, patients who develop an abscess tend to fall into three categories: those with underlying thyroid disease, those with congenital defects, and those who are immunocompromised (6). Approximately two-thirds of women and half of men with thyroid infections have pre-existing disease, usually Hashimoto thyroiditis, goiter, or carcinoma (8). Pediatric patients who develop a thyroid abscess have a fistula originating from the hypopharygneal region, typically the piriform sinus, which allows bacteria to infiltrate the thyroid (9). A minority of patients present with infected embryonic cysts from
An Unusual Case of Dysphagia
the thyroglossal duct and the third and fourth brachial pouches (10). Infectious agents typically enter the thyroid via these anatomic abnormalities, but can also enter from direct trauma, with reports of fine-needle aspiration and foreign-body trauma to the region, including fish bones lodged in the esophagus (11). Reports of hematogenous spread also exist, usually in the setting of a prior thyroid disease, from urinary tract infections and even a pilonidal cyst (2). The majority of causes are bacterial, but parasitic, mycobacterial, fungal, and syphilitic pathogens have been reported, especially in those who are immunocompromised (12). The most common bacterial causes are either Staphylococcal or Streptococcal species, as seen with the growth of S. milleri in this particular case (13). Patients with suppurative thyroiditis and abscess generally have normal thyroid function tests, although they may present with either elevated or decreased thyroid function studies (6). Other common laboratory abnormalities include leukocytosis and elevated erythrocyte sedimentation rate. Ultrasound is the imaging modality of choice, especially in the ED, as it can quickly detect an abscess and evaluate for other conditions. A barium swallow can help to evaluate for fistulas (14). Management revolves around broad-spectrum antibiotics and drainage of the abscess, generally by a specialist. Some abscesses are complex and may require operative intervention. Complications of untreated suppurative thyroiditis with resultant abscess can be devastating to the patient, and include destruction of the thyroid and the parathyroid glands, internal jugular vein thrombophlebitis, spread to other organs, and the creation of new fistulae (2). CONCLUSIONS Thyroid abscesses are a rare clinical entity that can be easily missed, especially in the early phase of their
337
development. Bedside ultrasound is a quick and simple diagnostic test that can help emergency physicians rapidly diagnose or exclude the possibility of this condition. Prompt identification and proper consultation with an otolaryngologist or surgeon are recommended in cases concerning for a thyroid abscess. REFERENCES 1. Farwell AP. Infectious thyroiditis. In: Braverman LE, Utiger RD, eds. Werner & Ingbar’s the thyroid: a fundamental and clinical text. 8th edn. Philadelphia: Lippincott Williams & Wilkins; 2000: 1044–50. 2. Herndon MD, Christie DB, Ayoub MM, Duggan AD. Thyroid abscess: case report and review of the literature. Am Surg 2007;73: 725–8. 3. Baker SR, van Merwyk AJ, Sing A. Abscess of the thyroid gland presenting as a pulsatile mass. Med J Aust 1985;143:253–4. 4. Boyd CM, Esclamado RM, Telian SA. Impaired vocal cord mobility in the setting of acute suppurative thyroiditis. Head Neck 1997;19: 235–7. 5. Jacobs A, David-Alexandre C, Gradon J. 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. 6. Pearce EN, Farwell AP, Braverman LE. Thyroiditis. N Engl J Med 2003;348:2646–55. 7. Greene JN. Subacute thyroiditis. Am J Med 1971;51:97–108. 8. Thyroiditis. In: Turner H, Wass J, eds. Oxford textbook of endocrinology and diabetes. 2nd edn. Oxford, UK: Oxford University Press; 2011. 9. Mali VP, Prabhakaran K. Recurrent acute thyroid swellings because of pyriform sinus fistula. J Pediatr Surg 2008;43:e27–30. 10. Liberman M, Kay S, Emil S, et al. Ten years of experience with third and fourth branchial remnants. J Pediatr Surg 2002;37:685–90. 11. Chen C, Peng JP. Esophageal fish bone migration induced thyroid abscess: case report and review of the literature. Am J Otolaryngol 2011;32:253–5. 12. Danahey DG, Kelly DR, Forrest LA. HIV-related Pneumocystis carinii thyroiditis: a unique case and literature review. Otolaryngol Head Neck Surg 1996;114:158–61. 13. Yu EH, Ko WC, Chuang YC, et al. Suppurative Acinetobacter baumanii thyroiditis with bacteremic pneumonia: case report and review. Clin Infect Dis 1998;27(5):1286–90. 14. Masuoka H, Miyauchi A, Tomoda C, et al. Imaging studies in sixty patients with acute suppurative thyroiditis. Thyroid 2011; 21:1075–80.
http://dx.doi.org/10.1016/j.jemermed.2015.04.023
Visual Diagnosis in Emergency Medicine
AN UNUSUAL CASE OF DYSPHAGIA Daniel Lasoff, MD and Gabriel Wardi, MD Department of Emergency Medicine, University of California, San Diego, California Reprint Address: Daniel Lasoff, MD, Department of Emergency Medicine, University of California, 200 W. Arbor Drive, San Diego, CA
systems was otherwise unremarkable. A bedside sonogram demonstrated a complex fluid-filled cystic mass and is demonstrated in Figure 2. A formal ultrasound revealed a single heterogeneous solitary nodule of the thyroid with increased peripheral vascularity, which was concerning for a malignant nodule. Needle aspiration was performed by an otolaryngologist and approximately 8 cm3 of frank pus was aspirated from the nodule and sent for aerobic, anaerobic, acid fast, and fungal culture, as well as cytology. Laboratory tests revealed a white blood cell count of 6.8 1000/mm3, and a thyroid-stimulating hormone value of 0.97 mIU/mL. She noted immediate improvement after aspiration and was discharged on a course of clindamycin and head and neck surgery follow-up. Her aerobic cultures grew Streptococcus milleri, while her acid fast bacilli and fungal cultures were negative. She was found to have no underlying congenital abnormalities during her follow-up, which included a barium swallow and an ultrasound that demonstrated complete resolution of her thyroid abscess, as show in Figure 3.
CASE REPORT A previously healthy 38-year-old female pregnant at 6 weeks (first pregnancy) presented to our emergency department (ED) for the second time in 5 days with a chief complaint of a sore throat. Her medical history was significant only for the pregnancy and, besides prenatal vitamins, she did not take any other medications. During her initial visit, she stated she had pain on swallowing, which was located anterior and just left of midline around her thyroid. Her vital signs were unremarkable and her examination revealed a well-developed female without any obvious pharyngitis, uvular deviation, or swelling of the neck. She did exhibit minimal tenderness to the left side of her thyroid gland. No masses or asymmetry were noted on palpation while she swallowed. There were no bruits or erythematous regions noted near the thyroid. On her second visit, she described a progressively worsening pain in the same region, along with an increased fullness on the left side of her neck. She also noted that her voice sounded muffled. She denied any fever, chills, weight changes, cough or trauma to the region. Her vital signs at this visit were temperature of 97.4 F, heart rate of 76 beats/min, and blood pressure of 126/76 mm Hg. Her examination revealed a patent airway with tenderness on the left side of her neck, and a mobile mass that moved with swallowing was noted just lateral to her thyroid, as depicted in Figure 1. Her review of
DISCUSSION Acute infectious thyroiditis, also referred to as acute suppurative thyroiditis, is a rare clinical entity. The most common complication is the development of a thyroid abscess. There have been just over 300 cases reported in the adult literature, and > 100 in the pediatric population (1). This is likely a combination of under-reporting, but is also
RECEIVED: 5 March 2015; ACCEPTED: 16 April 2015 335
336
Figure 1. Patient’s physical exam demonstrating asymmetric swelling of her neck.
due to the thyroid’s inherent resistance to infection. It has a dual blood supply, consisting of the superior thyroid and inferior thyroid arteries, a robust lymphatic drainage system, and a strong fibrous capsule that separates it from the remainder of the neck, all of which serve to prevent infectious infiltration. Early canine studies, in an attempt to model the disease, showed that direct inoculation of the superior thyroid artery with Staphylococcal and Strepto-
Figure 2. Patient’s ultrasound of thyroid with arrow directed at the heterogeneous hypoechoic mass within her thyroid.
D. Lasoff and G. Wardi
Figure 3. Patient’s repeat ultrasound at follow-up demonstrating normal architecture of her thyroid. The arrow is directed at the area of her resolved abscess.
coccal species had a very low proportion of disease that developed (2). In addition, high concentrations of iodine within the gland have intrinsic antiseptic properties. Approximately 90% of patients have pain to the anterior neck, fever, and tenderness (1). For uncertain reasons, the left aspect of the thyroid is more likely to develop infection. Less common are hoarseness, chills, dysphagia, and radiation to the ear or the posterior neck; case reports exist of patients with vocal cord paralysis and pulsatile masses (3,4). As in this case, patients typically acknowledge a preceding upper respiratory infection, pharyngitis, or acute otitis media (5). Emergency physicians should recall that acute atraumatic pain in this region has a broad differential diagnosis, including bacterial and fungal etiologies, amiodarone thyroiditis, and radiation thyroiditis (after 131I therapy) (6). Attention should be given to more common etiologies of pain in this region, including viral thyroiditis (subacute or de Quervains), which has a more indolent presentation; pharyngitis; hemorrhagic cysts; infarction of a thyroid nodule; and malignancy. Painful subacute thyroiditis is the most common cause of a painful thyroid, and occurs in approximately 5% of patients with thyroid disease (7). As the thyroid is well fortified against infectious agents, patients who develop an abscess tend to fall into three categories: those with underlying thyroid disease, those with congenital defects, and those who are immunocompromised (6). Approximately two-thirds of women and half of men with thyroid infections have pre-existing disease, usually Hashimoto thyroiditis, goiter, or carcinoma (8). Pediatric patients who develop a thyroid abscess have a fistula originating from the hypopharygneal region, typically the piriform sinus, which allows bacteria to infiltrate the thyroid (9). A minority of patients present with infected embryonic cysts from
An Unusual Case of Dysphagia
the thyroglossal duct and the third and fourth brachial pouches (10). Infectious agents typically enter the thyroid via these anatomic abnormalities, but can also enter from direct trauma, with reports of fine-needle aspiration and foreign-body trauma to the region, including fish bones lodged in the esophagus (11). Reports of hematogenous spread also exist, usually in the setting of a prior thyroid disease, from urinary tract infections and even a pilonidal cyst (2). The majority of causes are bacterial, but parasitic, mycobacterial, fungal, and syphilitic pathogens have been reported, especially in those who are immunocompromised (12). The most common bacterial causes are either Staphylococcal or Streptococcal species, as seen with the growth of S. milleri in this particular case (13). Patients with suppurative thyroiditis and abscess generally have normal thyroid function tests, although they may present with either elevated or decreased thyroid function studies (6). Other common laboratory abnormalities include leukocytosis and elevated erythrocyte sedimentation rate. Ultrasound is the imaging modality of choice, especially in the ED, as it can quickly detect an abscess and evaluate for other conditions. A barium swallow can help to evaluate for fistulas (14). Management revolves around broad-spectrum antibiotics and drainage of the abscess, generally by a specialist. Some abscesses are complex and may require operative intervention. Complications of untreated suppurative thyroiditis with resultant abscess can be devastating to the patient, and include destruction of the thyroid and the parathyroid glands, internal jugular vein thrombophlebitis, spread to other organs, and the creation of new fistulae (2). CONCLUSIONS Thyroid abscesses are a rare clinical entity that can be easily missed, especially in the early phase of their
337
development. Bedside ultrasound is a quick and simple diagnostic test that can help emergency physicians rapidly diagnose or exclude the possibility of this condition. Prompt identification and proper consultation with an otolaryngologist or surgeon are recommended in cases concerning for a thyroid abscess. REFERENCES 1. Farwell AP. Infectious thyroiditis. In: Braverman LE, Utiger RD, eds. Werner & Ingbar’s the thyroid: a fundamental and clinical text. 8th edn. Philadelphia: Lippincott Williams & Wilkins; 2000: 1044–50. 2. Herndon MD, Christie DB, Ayoub MM, Duggan AD. Thyroid abscess: case report and review of the literature. Am Surg 2007;73: 725–8. 3. Baker SR, van Merwyk AJ, Sing A. Abscess of the thyroid gland presenting as a pulsatile mass. Med J Aust 1985;143:253–4. 4. Boyd CM, Esclamado RM, Telian SA. Impaired vocal cord mobility in the setting of acute suppurative thyroiditis. Head Neck 1997;19: 235–7. 5. Jacobs A, David-Alexandre C, Gradon J. 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. 6. Pearce EN, Farwell AP, Braverman LE. Thyroiditis. N Engl J Med 2003;348:2646–55. 7. Greene JN. Subacute thyroiditis. Am J Med 1971;51:97–108. 8. Thyroiditis. In: Turner H, Wass J, eds. Oxford textbook of endocrinology and diabetes. 2nd edn. Oxford, UK: Oxford University Press; 2011. 9. Mali VP, Prabhakaran K. Recurrent acute thyroid swellings because of pyriform sinus fistula. J Pediatr Surg 2008;43:e27–30. 10. Liberman M, Kay S, Emil S, et al. Ten years of experience with third and fourth branchial remnants. J Pediatr Surg 2002;37:685–90. 11. Chen C, Peng JP. Esophageal fish bone migration induced thyroid abscess: case report and review of the literature. Am J Otolaryngol 2011;32:253–5. 12. Danahey DG, Kelly DR, Forrest LA. HIV-related Pneumocystis carinii thyroiditis: a unique case and literature review. Otolaryngol Head Neck Surg 1996;114:158–61. 13. Yu EH, Ko WC, Chuang YC, et al. Suppurative Acinetobacter baumanii thyroiditis with bacteremic pneumonia: case report and review. Clin Infect Dis 1998;27(5):1286–90. 14. Masuoka H, Miyauchi A, Tomoda C, et al. Imaging studies in sixty patients with acute suppurative thyroiditis. Thyroid 2011; 21:1075–80.
