A Case of Acute Suppurative Thyroiditis with Thyrotoxicosis in an Elderly Patient
A 70-year-old female.\nFever and systemic debilitation.\nThe patient was transferred to our hospital due to the finding of thyrotoxicosis during an in-patient stay at another hospital where she was being treated for a 2-week fever and systemic debilitation.\nThe patient had hypertension and had taken antihypertensive medication for 20 years.\nThere was nothing specific.\nThe patient was quite alert, but showed signs of acute illness. Her blood pressure measured 120/80 mm Hg, pulse rate was 110 bpm, respiratory rate was 20 times per minutes and axillary temperature was 38.4℃. Based on examinations of her head and neck, a lump was detected and palpitation of the lump was accompanied by local heatness and minor tenderness. The lump was fixated and soft. There was no finding of tenderness of the paranasal sinus or pharyngolaryngeal flare, tonsillar hypertrophy, or enlargements of lymph node.\nThe blood assay revealed that white blood cell (WBC) count was 13,500/mm3 (neutrophils, 80.9%), hemoglobin was 9.3 g/dL, and platelet was 456,000/µL. The erythrocyte sedimentation rate (ESR) increased to 151 mm/hr, and C-reactive protein increased to 24.7 mg/dL. The endocrinology report showed that T3 was 228.0 ng/dL (normal range, 80 to 200), free T4 (FT4) was >7.77 ng/dL (normal range, 0.93 to 1.7), thyroid stimulating hormone (TSH) was 0.02 µIU/mL (normal range, 0.27 to 4.2), and thyroglobulin was >5,000 ng/mL (normal range, 1.4 to 78). Antimicrosome antibody (Ab), antithyroglobulin Ab, and thyroid stimulating Ab were in the normal ranges. Serum calcitonin was in the normal range of less than 1.0 pg/mL, and the HIV Ab test was negative.\nThe 99mTc thyroid scan showed that the radioactive isotope intake of the thyroid was reduced and irregular ().\nThe margin of the right side of the thyroid was unclear and a multilobulated lump with poor contrast was observed. Multiple lymph nodes were observed from the IV, V, and VI areas of the right side of the neck ().\nNeck sonography revealed that there were no abnormal structures found in the homogeneous image of the left lobe of the thyroid, but in the right lobe, there was a mass that was about 4.5×2.5×4.6 cm in size with heterogeneous echogenicity (). Using fine needle aspiration biopsy, we obtained chocolate-colored abscess fluid that was chocolate in color (), and a cytopathogenic test revealed no atypical cells or malignant cells, but many neutrophil cells and histiocytes were observed.\nImmediately, we commenced with treatment by administration of amoxicillin/clavulanate 1 g/200 mg three times a day and prescribed 40 mg propranolol four times a day for relieving the symptoms of thyrotoxicosis. No microbes were identified from the culture test of aspirated samples from blood or thyroid gland. Hyperpyrexia gradually disappeared within 3 days after administration of antibiotics, but the feeling of local fever, neck swelling and tenderness continued for up to 10 days after administration of antibiotics. We performed a thyroid lobectomy and found that the abscess was accompanied by fibrosis in the right lobe of the thyroid. The pathological findings revealed inflammation accompanied by necrotic tissue and abscess.\nAfter the surgery, the patient showed symptomatic recovery from neck pain and swelling, and was discharged from the hospital. We performed outpatient follow-up with esophagography and neck computed tomography (CT) and we could not find any anatomical defect such as fistula. A thyroid function test in the outpatient department at 2 months after surgery revealed that FT4 was 1.02 ng/dL and TSH was 2.40 µIU/mL, indicating that thyroid function had been restored to normal.