Acute suppurative thyroiditis (AST) is a rare inflammatory disease. The rarity of this disease can be attributed to several factors. The thyroid is well encapsulated, which may hinder the transmission of infection from surrounding tissue to the thyroid. In addition, a rich blood supply and lymphatic drainage within the thyroid may be protective against bacterial infection. Furthermore, high iodine levels within the thyroid gland may create an environment that is unfavorable to bacterial growth.1 Reports of AST are uncommon in patients who have hematological malignancy. Only 9 cases have been reported in the literature.2,3
A 27-year-old man presented to our hospital with symptoms of general weakness and fatigue. His blood test results were positive for anemia (hemoglobin level, 2.9 g/dL). A bone marrow biopsy specimen showed cellularity values of 0% to 10%, a range that is considered hypocellular for the patient's age; erythropoiesis, granulopoiesis, and megakaryocyte production were decreased. Aplastic anemia was diagnosed, and the patient was treated with a consecutive 5-day regimen of antithymoglobulin (ATG). At the start of chemotherapy, the absolute neutrophil count (ANC) was 1534/mL
Five days after the administration of ATG (day 1), sudden fever and sore throat developed. The patient's temperature was 39.9C (103.8F). Blood pressure was 110/70 mm Hg, with a pulse rate of 96 beats per minute. Symptoms of influenza were absent, but the patient complained of a sore throat and right-sided neck pain. No skin change or discoloration of the neck area was observed; however, swelling and tenderness of the neck developed.
The ANC was 252/mL. Athyroid function test revealed high free thyroxine levels (2.37 ng/dL; normal, 0.70 to 1.80 ng/dL), depressed thyroid- stimulating hormone levels (0.12 mIU/L; normal, 0.4 to 4.1 mIU/L), and normal total triiodothyronine levels (91 ng/dL; normal, 87 to 184 ng/dL). A blood culture was performed, and piperacillin and tobramycin were administered empirically.
Radiological examination revealed cystic lesions of the thyroid gland with decreased enhancement; a thyroid abscess was therefore suspected (day 3; Figure 1). No pyriform sinus fistula (PSF) was detected by laryngoscopy or CT. Because the blood culture grew methicillin-sensitive Staphylococcus aureus (MSSA), cefazolin was added to the therapeutic regimen. Despite this antibiotic therapy and ultrasonography-guided aspiration (day 6; Figures 2 and 3), the patient's condition did not improve. Surgery was performed to manage the thyroid abscess (day 8).
- Braverman LE, Utiger RD, eds. Werner & Ingbar’s The Thyroid, A Fundamental and Clinical
- Text. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:541-547. Dai MS, Chang H, Peng MY, et al. Suppurative salmonella thyroiditis in a patient with chroniclymphocytic leukemia. Ann Hematol. 2003;82: 646-648.
- Imai C, Kakihara T, Watanabe A, et al. Acute suppurative thyroiditis as a rare complicationof aggressive chemotherapy in children with acute myelogeneous leukemia. Pediatr Hemato Oncol. 2002;19:247-253.
- Hazard JB. Thyroiditis: a review. Am J Clin Pathol. 1955;25:289-298.
- Berger SA, Zonszein J, Villamena P, et al. Infectious diseases of the thyroid gland. Rev InfectDis. 1983;5:108-122.
- Marsh JC, Ball SE, Darbyshire P, Mittman N. Guidelines for the diagnosis and managementof acquired aplastic anaemia. Br J Haematol. 2003;123:782-801.
- Gafter-Gvili A, Fraser A, Paul M, Leibovici L.Meta-analysis: antibiotic prophylaxis reducesmortality in neutropenic patients. Ann Intern Med. 2005;142(12, pt 1):979-995.
- Liberati A, D’Amico R, Pifferi S, et al. Antibiotic prophylaxis to prevent nosocomial infectionsin patients in intensive care units: evidence that struggle to convince practising clinicians. InternEmerg Med. 2006;1:160-162.
- Gafter-Gvili A, Fraser A, Paul M, et al. Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy. Cochrane Database Syst Rev. 2005; (19):CD004386.
- Lo N, Cullen M. Antibiotic prophylaxis in chemotherapy-induced neutropenia: time to reconsider. Hematol Oncol. 2006;24:120-125.
- Bernard PJ, Som PM, Urken ML, et al. The CT findings of acute thyroiditis and acute suppurativethyroiditis. Otolaryngol Head Neck Surg. 1988;99:489-493.
- Miyauchi A, Matsuzuka F, Kuma K, Takai S.Piriform sinus fistula: an underlying abnormality common in patients with acute suppurative thyroiditis. World J Surg. 1990;14:400-405.
- Moskowitz C, Dutcher JP, Wiernik PH. Associationof thyroid disease with acute leukemia.Am J Hematol. 1992;39:102-107
- Toubert ME, Socié G, Gluckman E, et al. Shortand long-term follow-up of thyroid dysfunctionafter allogeneic bone marrow transplantation without the use of preparative total body irradiation. Br J Haematol. 1997;98:453-457.