Surgical Decision-Making in Thyroiditis: A Review Article.

Thyroiditis is a common thyroid disorder worldwide. Its commonest variant is Hashimoto's thyroiditis (HT). The usual presenting symptom is hypothyroidism at the time of diagnosis. Most patients are asymptomatic. A few cases may experience more obvious symptoms. The standard treatment is medical, and surgery is rarely indicated. This review aims to shed light on the most relevant articles discussing surgery in thyroiditis and compare them. The author included 16 relevant articles focused on the surgical management of thyroiditis. Of the studies, 10 were designed as retrospective reviews, four as prospective studies, and two as systematic reviews. The included studies aimed to focus on certain objectives. Three of them discussed indications of surgical intervention in cases of thyroiditis. Five covered postoperative complications. Six looked at the thyroid cancer association with thyroiditis. Two explored the impact of thyroiditis on surgery. Five discussed the postoperative improvement of symptoms and the effect on the quality of life. All the studies listed in this review engaged cases of HT except two. This review concentrates on conceptualizing and organizing the parameters in the minds of surgeons who manage cases of thyroiditis to enable them to decide whether to operate or not. These factors are indications of surgery, improvement of local compressor symptoms post thyroidectomy like dysphasia and shortness of breath, risk of thyroid cancer, intraoperative difficulty, and postoperative complications. Different variants of thyroiditis cases are treated medically, and surgery is rarely indicated. The surgeons should consider the mentioned factors affecting their decision to operate on this special entity. Thus, each case should be individualized in deciding whether to operate or not by assessing the benefit-risk ratio.

Acute suppurative thyroiditis with Graves disease - A very rare association.

Acute suppurative thyroiditis is an uncommon disorder caused by a bacterial infection, usually presenting with normal thyroid function. It is a serious condition that requires a prompt diagnosis and treatment with antibiotics and supportive measures. A 62 years-old female presented with a painful cervical induration and odynophagia a week after a fish bone had been removed from her pharynx. She was febrile, and tachycardic and, on physical examination, a painful thyroid mass was detected. High inflammatory parameters and thyrotoxicosis were confirmed: thyroid stimulating hormone (TSH) < 0.01 mIU/L (normal range [NR] 0.27-4.2); free thyroxine (FT4) 3.86 ng/dL (NR 0.9-1.7) and anti-TSH receptor antibodies (TRABs) 5.3 U/L (NR < 1.5). Thyroid scintigraphy showed a diffuse uptake of the thyroid parenchyma suggesting Graves disease. Cervical ultrasonography revealed an abscess of the left thyroid lobe of 36 × 36 mm and fine needle aspiration biopsy (FNAB) with partial drainage was performed. Staphylococcus aureus and Streptococcus viridans were isolated, and directed antibiotic therapy was started. Clinical improvement was observed as well as a decrease of inflammatory parameters and the patient was discharged after 9 days of hospitalization. Eighteen days after discharge, thiamazole was initiated due to persistent thyrotoxicosis. Complete resolution of the abscess was documented within 6 months and the patient became euthyroid under thiamazole one year after initial presentation. To our knowledge, this is the third case reporting an association between acute thyroiditis and Graves disease. Furthermore, this is the first case detailing the simultaneous diagnosis of acute suppurative thyroiditis caused by a foreign body and Graves disease.

Acute suppurative thyroiditis with Graves disease - A very rare association

SUMMARY Acute suppurative thyroiditis is an uncommon disorder caused by a bacterial infection, usually presenting with normal thyroid function. It is a serious condition that requires a prompt diagnosis and treatment with antibiotics and supportive measures. A 62 years-old female presented with a painful cervical induration and odynophagia a week after a fish bone had been removed from her pharynx. She was febrile, and tachycardic and, on physical examination, a painful thyroid mass was detected. High inflammatory parameters and thyrotoxicosis were confirmed: thyroid stimulating hormone (TSH) < 0.01 mIU/L (normal range [NR] 0.27-4.2); free thyroxine (FT4) 3.86 ng/dL (NR 0.9-1.7) and anti-TSH receptor antibodies (TRABs) 5.3 U/L (NR < 1.5). Thyroid scintigraphy showed a diffuse uptake of the thyroid parenchyma suggesting Graves disease. Cervical ultrasonography revealed an abscess of the left thyroid lobe of 36 × 36 mm and fine needle aspiration biopsy (FNAB) with partial drainage was performed. Staphylococcus aureus and Streptococcus viridans were isolated, and directed antibiotic therapy was started. Clinical improvement was observed as well as a decrease of inflammatory parameters and the patient was discharged after 9 days of hospitalization. Eighteen days after discharge, thiamazole was initiated due to persistent thyrotoxicosis. Complete resolution of the abscess was documented within 6 months and the patient became euthyroid under thiamazole one year after initial presentation. To our knowledge, this is the third case reporting an association between acute thyroiditis and Graves disease. Furthermore, this is the first case detailing the simultaneous diagnosis of acute suppurative thyroiditis caused by a foreign body and Graves disease.

Sub-Acute Thyroiditis presenting as pyrexia of unknown origin: A rare case with literature review.

Pyrexia of unknown origin (PUO) is a challenging entity in medical practice from a diagnostic point of view. Sub-Acute Thyroiditis (SAT), that is an inflammatory condition of thyroid, self-limiting and easily treatable, is a very rare cause for PUO with a few published cases and unfortunately not considered in routine for the differential diagnosis (DD) of PUO. Usually, it presents with mild thyrotoxicosis signs and symptoms, painful goiter, and rarely with cervical Lymph adenopathy. Thyroid antibodies might be negative, but inflammatory markers are usually raised. Anti-inflammatory drugs (NSAID) and steroids are a simple but very effective treatment. We present our experience for diagnosing and treating a female patient presenting with PUO. She was diagnosed as a case of sub-acute Thyroiditis on nuclear thyroid scan, High resolution ultrasound (HR-USG) of Thyroid and radioimmunoassay (RIA) for thyroid hormones and thyroid antibodies. The Patient was successfully treated with NSAIDs and steroids. The consent of the patient was taken to publish her case.

Asymptomatic thyroiditis presenting as pyrexia of unknown origin: a case report.

BACKGROUND: Pyrexia of unknown origin is a difficult and challenging problem for the physician. Endocrine disorders, such as subacute thyroiditis, rarely present with pyrexia of unknown origin. Subacute thyroiditis can have a broad spectrum of clinical presentations including fever and biochemical thyrotoxicosis without overt signs or symptoms. CASE PRESENTATION: A previously healthy 42-year-old Sri Lankan Sinhalese man was extensively investigated for a prolonged fever of 3 weeks with high inflammatory markers. He had mild tenderness over his neck with cervical lymphadenopathy with no thyrotoxic symptoms or signs. An ultrasound scan revealed an enlarged thyroid with increased vascularity and he had suppressed thyroid-stimulating hormone with elevated free thyroxine and free triiodothyronine hormone levels. Fine-needle aspiration cytology confirmed thyroiditis. He responded well to low-dose steroids. CONCLUSION: Subacute thyroiditis should be considered in the diagnostic workup of pyrexia of unknown origin even in the absence of overt toxic symptoms of thyroid hormone excess.

Painful Hashimoto's thyroiditis: myth or reality?

Neck pain is a common complain, being in most cases due to non-thyroidal causes. However, a minority of patients suffer from painful thyroid diseases. Among them, sub-acute thyroiditis (SAT) is the most frequent one. Rare thyroid-related causes of neck pain include hemorrhage within a thyroid nodule as well as Riedel's thyroiditis and suppurative thyroiditis. In the last 30 years, a few cases of a painful variant of Hashimoto's thyroiditis (HT) have been described. Biochemical, ultrasound, and histologic features were clearly suggestive for HT in all of the published cases and definitely ruled out the diagnosis of SAT. While sound descriptions of painful HT are present in the literature, it is important to emphasize that only 20 cases were reported from the year 2000 until now. The condition, however, is clinically relevant because neck pain was reported to be refractory both to steroids and to other analgesic drugs, being thyroidectomy the only effective treatment for pain relief in these patients. This short review analyzes currently available data supporting a role for HT as a rare cause of neck pain.

Acute suppurative thyroiditis following fine-needle aspiration biopsy in an immunocompetent patient.

The thyroid gland is remarkably resistant to infectious agents owing to several protective mechanisms. Acute suppurative thyroiditis after fine-needle aspiration (FNA) in an immunocompetent patient is very rare. We report the case of a 50-year-old immunocompetent male patient who presented with painful cervical swelling, fever, and chills after an FNA of the thyroid. His physical and laboratory examination suggested an acute suppurative thyroiditis. Repeat FNA results were consistent with thyroid abscess. Physicians should be aware of the probability of acute bacterial thyroiditis after FNA.

Tiroiditis granulomatosa de De Quervain: diagnóstico por citología con aspiración por aguja fina / De Quervain's granulomatous thyroiditis: diagnosis by cytology with thin needle

La tiroiditis de De Quervain, también nombrada como tiroiditis subaguda o tiroiditis de células gigantes, frecuentemente es precedida por un cuadro infeccioso del tracto respiratorio superior. Su diagnóstico es eminentemente clínico; pero el uso de la citología por aspiración con aguja fina de tiroides, confirma o niega el planteamiento clínico según las características citológicas. Fue empleada esta técnica en 6 pacientes con clínica y ultrasonido diferentes y por la necesidad de realizar un correcto diagnóstico diferencial con otras formas de hipertiroidismo con peor pronóstico evolutivo. La citología por aspiración con aguja fina mostró en estos casos ser un arma eficaz para ello, por lo que se decidió realizar esta presentación.

De Quervain's thyroiditis, also called sub-acute thyroiditis or thyroiditis of giant cells, is frequently preceded by an infectious picture of the high respiratory tract. Its diagnosis is eminently clinical; but the usage of the cytology by aspiration of the thyroid with thin needle, confirm or denied the clinical conclusions according to the cytological characteristics. This technique was used in six patients with different clinical and ultrasound results, because of the necessity of arriving to a correct differential diagnosis with other forms of hyperthyroidism with worse evolvable diagnosis. The cytology by aspiration with thin needle in these cases showed to be an efficacious weapon for that, so we decided to prepare this presentation.

Significant role of serum CRP in differentiating inflammatory from non-inflammatory causes of thyrotoxicosis.

BACKGROUND: C-reactive protein (CRP), which is a marker of inflammation, has not been widely studied in inflammatory thyroid disorders particularly in sub-acute thyroiditis (SAT). AIM: This study was aimed to find the significance of CRP level rise in patients with SAT and compare that to the rise in erythrocyte sedimentation rate (ESR), a gold standard laboratory parameter in establishing the diagnosis of SAT. MATERIALS AND METHODS: Serum CRP levels were measured at initial presentation in 28 subjects with SAT(12 male, 16 female, age (Mean +SD) 37.96 ±8.5 years),and 19 patients with Graves' disease (2 male, 17 female, age [Mean +SD] 36.8 ±16.5 years) as controls. Erythrocyte sedimentation rate (ESR) was measured in all 28 patients with SAT by Westergrens' method. Either Tc(99) nucleotide thyroid scan or high resolution ultrasonography (HR-USG) was performed to differentiate SAT from Graves' disease.Fine needle aspiration cytology (FNAC) of thyroid was performed selected patients. RESULTS: Serum CRP level was high in 61% of SAT patients but in none of the Graves'patients. Mean (SEM) (90%CI) serum CRP level (mg/L) was also significantly higher (P <0.0004) in the SAT group [27.55 (5.76) (15.72-39.38)], than in the Graves' group [4.09 (0.12) (3.81-4.36)]. The sensitivity of serum CRP was 73.33%, specificity 53.85%, positive predictive value (PPV) 64.71%, and negative predictive value (NPV) 63.64% as compared to the sensitivity (53.57%), specificity (15.38%), PPV (57.69 %), and NPV (13.33%) of ESR. CONCLUSION: There is significantly higher rise in serum CRP level in patients with SAT is compared to patients with Graves' disease. It correlates well with the rise in ESR. Such findings of this pilot study highlight the scope of using serum CRP as a diagnostic marker of SAT specially in situations when it may be confused with Graves' disease, another common cause of thyrotoxicosis. It is logical to carry out studies to find a particular cut-off for serum CRP which can serve as an objective parameter for grading the inflammation in patients with SAT.

Tiroiditis aguda piógen: revisión del tema a propósito de un caso / Acute pyogenic thyroiditis: case report and review

La tiroiditis aguda piógena o supurada es considerada una entidad rara y se caracteriza por signos inflamatorios y colección purulenta a nivel tiroideo. Se presenta el caso de una niña de 9 años, vista en el Hospital de Apoyo Juli, en el departamento de Puno, que presentó bocio doloroso, disfagia, fiebre y leves signos de hiperfunción tiroidea. La ecografía mostró una colección en el lóbulo derecho y en la punción tiroidea se obtuvo material purulento. El tratamiento se realizó con ceftriaxona, 50 mg/kg/d, clindamicina, 30 mg/kg/d y drenaje quirúrgico. La evolución de la paciente fue satisfactoria.

Acute suppurative thyroiditis is currently considered a rare entity and it is characterized by inflammatory signs and a collection of pus in the thyroid. We report a 9 years-old girl that was seen at Hospital de Apoyo Juli in the department of Puno, in which a tender goiter with dysphagia, fever and light signs of thyroid hyperfunction were present. Ultrasonogra-phy showed right lobule collection and the punction revealed purulent material. Treatment was done with cephtriaxone 50 mg/kg/d and clindamycin 30 mg/kg/d, besides of surgical drainage. The patient evolution was satisfactory.

Forma atípica de tireoidite supurativa aguda em paciente pediátrico: relato de caso / Atypical form of acute suppurative thyroiditis in pediatric patient: case report

A tireoidite aguda é uma doença rara. Na infância associa-se principalmente a anormalidades congênitas com acometimento do lobo esquerdo. Na ausência de tireoidopatia preexistente, a função tireoidiana geralmente está normal. Relatamos um caso de uma menina, 6 anos de idade, com tumoração associada a sinais flogísticos na região cervical anterior há 15 dias acompanhada de leucocitose com desvio à esquerda, VSH e TSH elevados. Não havia história prévia de tireoidopatia. A ultra-sonografia da região cervical foi sugestiva de abscesso tireoidiano. Realizou-se antibioticoterapia e drenagem cirúrgica com boa resposta, porém posteriormente a paciente evoluiu com hipotireoidismo clínico. O esofagograma não detectou fístula do seio piriforme e a ultra-sonografia controle revelou heterogeneidade do parênquima, levantando-se a possibilidade de tireoidite de Hashimoto. A importância do caso deve-se à sua apresentação incomum: ausência de anormalidades congênitas, acometimento difuso da tireóide, alteração da função tireoidiana e provável tireoidite de Hashimoto como fator predisponente da tireoidite aguda.

Acute thyroiditis is an unusual disease. In pediatric patients it is usually associated with congenital abnormalities towards the unilateral envelopment of the left thyroid lobe. In general, in the absence of preexisting thyroid disease, the thyroid function is most often normal. It is here described a case of a six-year-old girl who had presented a mass with flogistic signs in the anterior neck region for fifteen days, together with leukocytosis and increased levels of VSH and TSH. There was no evidence of previous thyroid disease and the cervical ultrasonography suggested thyroid abscess. Intravenous antibiotic and surgical dranaige were done with a good response, however, the patient developed clinical hypothyroidism aftherwards . Barium swallow did not demonstrate pyriform sinus fistula and the follow-up ultrasonography revealed heterogeneous internal texture suggesting Hashimoto's Thyroiditis. The relevance of this case is due to its unusual findings: the absence of congenital abnormalities, bilateral envelopment of thyroid lobes, hypothyroidism and a probable Hashimoto's Thyroiditis as a predisposing factor for acute thyroiditis.

A Case of Acute Perithyroiditis with Transient Thyrotoxicosis in Childhood / 대한내분비학회지

Acute thyroiditis is a rare disease because of the sufficient supply of blood vessels and lymphatics in thyroid tissue, the high concentration of iodide in the thyroid tissue and the nearly completely isolated structure of the thyroid gland from the surrounding tissue via its capsule. The most common route of infection is from a pyriform sinus fistula and then the inflammation spreads from the sinus to the perithyroidal space. Computed tomography (CT) and magnetic resonance imaging (MRI) can show a low echogenic mass encircling thyroid gland and swelling of the perithyroidal tissue in acute suppurative thyroiditis. We experienced a case of acute perithyroiditis with thyrotoxicosis that developed in a 13-year old boy and he was diagnosed by the CT findings. The patient had complained of a low graded fever and neck swelling. The laboratory diagnosis and clinical course was like that of subacute thyroiditis, but the CT finding showed a show low echogenic mass encircling the thyroid glands and swelling of the perithyroidal tissue. Therefore, we diagnosed this patient with acute perithyroiditis. After treatment with antibiotics, he displayed clinical improvement and was discharged.

Tiroiditis aguda producida por Haemophilus influenza en un lactante menor

Objetivo: Presentar el caso poco frecuente de un lactante mayor con una tiroiditis aguda causada por un microorganismo inusual como es el Haemophilus influenzae. Métodos: Se resume la historia clínica, se dan los resultados de exámenes de laboratorio y ecografía, así como el manejo realizado. Se hace una revisión de la literatura. Resultados: Se trata de lactante mayor masculino de 17 meses de edad quien se presentó con fiebre, afectación del estado general y tumoración dolorosa fluctuante en región anterior del cuello, con signos de flogosis, sin adenomegalias laterocervicales. La hematología reportó lecocitosis (17.000 x mm³) con neutrofilia marcada (segmentados 88%, linfocitos 7% y monocitos 3%) y elevación de la eritrosedimentación globular (VSG de 48 mm). Función tiroidea conservada. En la ecografía tiroidea se observó lóbulo tiroideo izquierdo aumentado de tamaño con imagen hipoecogénica (colección semilíquida - absceso) y se diagnosticó una tiroiditis aguda supurativa. Se realizó drenaje quirúrgico, cultivo y antibiograma y se indicó antibióticoterapia a base de oxacilina, considerando los microorganismos mas frecuentemente hallados en esta patología. El paciente presentó una evolución desfavorable por lo que, de acuerdo a cultivo y antibiograma, que demostró crecimiento de Haemophilus influenzae, se indicó ceftriaxona con buena respuesta. Se descartó la presencia de defectos anatómicos predisponentes de la enfermedad. Conclusión: La tiroiditis aguda es una patología que se puede presentar en niños de corta edad y además puede ser producida por microorganismos distintos a los descritos comúnmente en la literatura. Se debe iniciar terapia con antibióticos de amplio espectro, mientras se espera el resultado del cultivo y antibiograma de la secreción para precisar el agente etiológico y los antibióticos específicos. Se debe descartar la presencia de anomalías congénitas predisponentes en todos los casos, así como su corrección quirúrgica, para evitar residuos.

Objective: To report an uncommon case of an infant with acute thyroiditis caused by an inusual microorganism as Haemophilus influenzae. Methods: Data from clinical history, laboratory tests, ultrasonographic findings and management performed are summarized. The literature is reviewed. Results: A 17 months old male infant with fever, poor general conditions and a tender cystic mass in the neck region, without regional lymphadenopathies, was admitted. Leukocytosis with marked shift to the left (neutrophilous 88%, lymphocytes 7% and monocytes 3%) and elevated sedimentation rate (VSG: 48 mm) was found. Thyroid function studies were normal. Ultrasonography showed an abscess in the left thyroid lobe, and a acute suppurative thyroiditis was diagnosed. Surgical drainage and culture of the neck mass content was performed. Therapy with oxacilin was initiated, according to the most common organisms found in this pathology, but the evolution was not satisfactory. Haemophylus influenzae was identified in the culture and the antimicrobial was changed for ceftriaxone, showing better response. Underlying anatomic defects of the disease were excluded. Conclusion: Acute suppurative thyroiditis could occur in infants. It could be caused for unusual organisms. A broad spectrum antibiotic should be given before the organism is identified. The appropiate antimicrobial therapy is determined by the specific microorganism isolated. In order to prevent recurrence, anatomic congenital anomalies should be investigated and corrected, in all the cases.

A Case of Acute Suppurative Thyroiditis Caused by Pyriform Sinus Fistula with Thyrotoxicosis / 대한내분비학회지

This is the first case report about acute suppurative thyroiditis with thyrotoxicosis and pyriform sinus in Korea. A female patient, who was previously healthy, visited our hospital for the treatment of common cold symptoms and neck pain which developed 2 weeks before the visit. The condition of the patient did not improve through the use of antipyretics and even worsened. The patient was admitted to the hospital and was diagnosed with acute suppurative thyroiditis. The culture result of the drained fluid revealed group D Streptococcus. The patients condition was improved after using antibiotics and drainage. After recovery from acute thyroiditis, esophagography was performed and the pyriform sinus was found to be obliterated by chemical cauterization. It is very important yet difficult to differentiate acute thyroiditis with thyrotoxicosis from subacute thyroiditis. In this study, we discussed the differential diagnosis between acute thyroiditis and subacute thyroiditis with a review of literature.