Acute Suppurative Thyroiditis Secondary to Escherichia coli Infection

Infections of the thyroid gland are rare. Its innate resistance to infections can be attributed to its unique anatomical features and rich blood supply. High clinical suspicion is required as a delay in diagnosis can lead to significant morbidity and mortality. Major pathogens include the Gram-positive Staphylococcus aureus and Streptococcus species; however, Gram-negative organisms have been found especially in immunocompromised hosts. We present a rare case of acute suppurative thyroiditis (AST) secondary to Escherichia coli (E. coli) infection in a woman known to be infected with human immunodeficiency virus (HIV).

Outcomes of endoscopic chemo- and laser-cauterizations and open fistulectomy for pyriform sinus fistula

Background Acute suppurative thyroiditis through the congenital pyriform sinus fistula (PSF) often recurs if the fistula is not resected. Although endoscopic chemo-cauterization (ECC) to obliterate the orifice of the fistula is less invasive than open fistulectomy, it may require repeated treatments. We recently adopted an endoscopic diode laser-cauterization (ELC) system with the intention of improving treatment outcomes in PSF. Here, we describe ELC and compare the outcomes of these three modalities. Methods We evaluated 83 patients with PSF who underwent treatment between 2007 and 2018 at Kuma Hospital, a tertiary thyroid treatment hospital. ECC and ELC were implemented in 2007 and 2015, respectively. Patients who were ineligible for the endoscopic procedures underwent open fistulectomy. Barium swallow studies and computed tomography scan under a trumpet maneuver were performed after treatment to evaluate obliteration or removal of the fistula. Results In total, 70 of the 81 (86%) patients who underwent barium swallow studies after the first treatment achieved obliteration or removal of the fistula. The success rates for open fistulectomy, ECC, and ELC were 100% (9/9), 83% (49/59), and 100% (13/13), respectively. ECC and ELC had significantly shorter operative times and lower blood loss than open fistulectomy. Insufficient opening of the mouth was the major reason for converting endoscopic procedures to open fistulectomy. Conclusions ELC may yield superior outcomes and is therefore the optimal treatment modality for PSF. However, it is still associated with certain limitations. Thus, treatment selection remains dependent on the shape and size of the PSF and the mouth opening of the individual patient.

A Rapidly Enlarging Thyroid Nodule- Aspergillus Abscess

Introduction: Acute suppurative thyroiditis is a rare thyroid disorder with high mortality often due to bacterial or fungal infection. Here we present a case of a rapidly enlarging thyroid nodule in the setting of disseminated aspergillosis. Case: A 31 year old female with lupus on immunosuppressants first presented with weakness to the emergency department with workup finding multiple pulmonary, intracranial and vertebral lesions and a left thyroid nodule. On thyroid ultrasound the nodule was solid, hypoechoic, 1.5x2.3x2.7cm with irregular margins and no echogenic foci. Thyroid function tests: Total T3 52ng/dL (80-210ng/dL), Free T4 2.26ng/dL (0.6-1.12ng/dL), TSH 0.015µIU/mL (0.45-4.12µIU/mL). The patient was started on voriconazole for disseminated aspergillosis with plan for outpatient thyroid workup. However with further brain lesion growth, the patient was readmitted with incidental finding of thyroid nodule developing into a multiloculated, septated, fluid filled 5x2.9x4cm lesion after 3 months. Fine needle aspiration of the thyroid lesion resulted in negative bacterial and fungal cultures, no malignant cells, positive fungal elements consistent with aspergillus on cytology. The patient was continued on antifungal therapy (switched to cresemba due to voriconazole side effects) with thyroid lesion regression to 2.4x0.6x1.3cm at 6 months and 1.8x1.1x1.6cm at 12 months. Her thyroid function test normalized ~ 1 month after initial set of labs and the patient remained clinically euthyroid throughout her course. Discussion: Thyroid infections are limited due to the thyroid’s high iodine content, capsular encasement and rich vascularity. Acute suppurative thyroiditis (AST) due to aspergillus is a rare finding that can present solo or as a part of disseminated infection especially in immunocompromised individuals. Early presentation is often asymptomatic with possible thyroid function test abnormalities that self resolve in a couple weeks. Occasionally patients present with obstructive symptoms or findings of thyroid storm. Diagnosis is done through fine needle aspiration or autopsy, with treatment options including surgery, antifungals or both. Due to the high mortality of fungal AST, with improved outcomes with early diagnosis, it is important to consider AST as a part of the differential diagnosis in immunocompromised patients with systemic illness.