A Rare case of neck swelling: Acute Suppurative thyroiditis with End-Stage Renal Disease. Cureus

The acute suppurative thyroiditis is rare and life-threatening endocrine crisis. The thyroid gland is rich in lymphatic drainage and vascularity, is a major source of iodine present in the tissues, produces hydrogen peroxide and is enclosed. Because of these factors it is not uncommon for thyroid glands to become infected. gland is extremely rare. The symptoms of acute suppurative thyroiditis is very similar to the subacute thyroiditis and a distinction is only possible through fine needle aspiration cytology (FNAC). But, separating these two conditions is vital since the treatment of the two disorders differs greatly. Treatment includes intravenous antibiotics, drainage of abscesses and, occasionally, surgery might be necessary. Here, we present a case of thyroid abscess caused by methicillin-resistant Staphylococcus aureus (MRSA), diagnosed using FNAC of the thyroid gland and blood culture.


The thyroid gland is inflamed and known as thyroiditis may be caused by a variety of reasons. Of those, acute suppurative thyroiditis while extremely rare, is that is associated with a high death rate if it is not treated. Its symptoms are similar to those of subacute thyroiditis that is a very common, self-remitting disorder. The acute suppurative thyroiditis is a mere 1 percent of thyroid diseases. We present the case of a male in his early twenties suffering from chronic kidney diseases (CKD) which was diagnosed as having acute thyroiditis suppurative.

Case Presentation

A 23-year old male, diagnosed with CKD stage 5 undergoing maintenance hemodialysis every two weeks and with a history marijuana consumption, but with no prior medical history of significance. The patient was admitted to the emergency department complaining of fever that were intermittent, low-grade and undocumented at first. It before progressing to high level that was accompanied by chills and rigors within the last 4 days. The patient was afflicted with neck swelling fifteen days back and it was gradually expanding in size. It was accompanied by moderate pain and difficulty swallowing, which was more common for liquids than solids. The swelling was not connected with discharge. He also reported the lower extremity swelling bilaterally as well as generalized myalgia for a week. He was suffering from chest pain that was non-radiating and retrosternal for 7 days . It was accompanied by palpitations as well as breathing problems when exercising.

At the time of examination, the pulse rate was 175/min that was irregularly uneven blood pressure was between 100 and 70 mmHg, the rate of breathing was 24 minutes 100% saturation with 12 liters oxygen, temperatures were 102oF. Glasgow Coma Scale (GCS) E4V4M6 the patient was distressed. Pallor and pitting pedal edema bilaterally were observed during a general exam. The respiratory system examination revealed bilateral basal edema Other system examinations were within normal boundaries. The local examination revealed a 10-x5cm lump on the left side of the neck which was causing deglutition and tenderness when palpating, but was it was not associated with discharge, redness or fluctuations.

A heart electrocardiogram showed atrial fibrillation. Diltiazem Bolus, followed by an infusion, was administered. Point-of-care ultrasound of the lungs (POCUS) revealed bilaterally grouping of B lines as well as small pleural shreds. There was no effusion of the pleura in the lung. The blood gas from the arterial system revealed severe metabolic acidosis . It had an acidity 7.12 7.12 as well as HCO 3 of 11.3 millimol/L. The patient was put with intravenous antibiotics (ceftriaxone and the clindamycin) as well as steroids. Hemodialysis performed on an urgent basis for anuria and extreme metabolic acidosis. He was later taken to an intensive treatment unit. The blood tests of the patient revealed leukocytosis, anemia as well as hyperbilirubinemia, thrombocytopenia as well as deranged thyroid and kidney function tests as described in Table 1.

Day-1 Day- 6 Day-10 Day-15 Day-18 Day-21 Reference Range
HB (g/dl) 7.2 8.5 9.4 9.6 10.1 10 12-15 (g/dl)
TLC (cells/mm3) 22.2 18.04 31.05 32.9 30.9 31.8 3.8-5.2(cells/mm3)
DLC (%) 81/8/5/0.15 83/7/7/0.5 86/4/7.6/0.3 93/2/2.1/1.1 92/2.5/4.6/0.3 91/2.6/5.6/0.4 40-70/20-40/2-8/1-6(%)
Platelets (thousand/mm3) 108 130 80 55 60 75 150-400 (thousand/mm3)
Total Bilirubin (mg/dL) 4.7 2.17 1.5 1.3 0.3-1.2 (mg/dL)
Direct Bilirubin (mg/dL) 3.09 1.4 0.8 0.7 0-0.2 (mg/dL)
SGOT (U/L) 50 22.7 29 35 0-35 (U/L)
SGPT (U/L) 53 15 9.1 22 0-35(U/L)
ALP(U/L) 900 799 879 769 30-120 (U/L)
GGT(U/L) 173 138 55 68 0-38(U/L)
S. Albumin (g/dL) 3.2 3.4 2.6 1.8 3.5-5.2 (g/dL)
TSH (mcIU/mL) 0.02 0.20 1.2 0.35-5.5 (mcIU/mL)
FT3(pg/mL) 6.33 4.2 2.04 2.3-4.2 (pg/mL)
FT4(ng/mL) 2.2 2.1 1.3 0.89-1.76 (ng/mL)
Urea (mg/mL) 188 121 98 78 65 55 17-43 (mg/mL)
Creatinine (mg/mL) 7.4 4.5 3.2 3.5 2.6 2.4 0.55-1.02 (mg/mL)
CRPH (mg/L) 173 180 168 179 Below 10 (mg/L)
Procalcitonin (ng/L) >75 68 >75 A little less that 0.1 (ng/L)
Anti TPO (U/mL) 42.7 More then 60 (U/mL)

The other investigations conducted are shown in Table 2.

Ultrasonogram of neck Edema diffuse in the muscle and subcutaneous tissues and thyroid gland that is enlarged. altering echo texture, which could be infective.
Ultrasound throughout the abdomen Bilateral renal parenchymal disorder with ascites.
Bilateral Lower Limb Doppler Normal
Transthoracic Echocardiography No abnormality in wall motions of the regional region Left Ventricular Ejection Fraction – 60 percent, and there is no vegetation
NCCT neck Thyroid gland that is small and weak with no significant laryngeal or tracheal compression.
HRCT Thorax Lungs with active infective disease, bilateral glass opacities in the ground
Thyroid FNAC Infiltrating acutely inflammatory cells densely (neutrophil) Cystic macrophages containing a small amount of histiocytes. areas of necrosis. ZN staining was negative.
Blood culture Methicillin-resistant Staphylococcus aureus.

The patient was initially started on Tab Propranolol, 60 mg every 6 hours and Tab Propylthiouracil 200 mg four times a day, Hydrocortisone 100 mg intravenously 8 hours per day. The antibiotic dosage was increased to intravenous vancomycin of 500 mg every two days, and meropenem 500 mg twice every day. The patient required oxygen with high flow to maintain saturation. As a result it was inconvenient to transport the patient to undergo thyroid scintigraphy, or for iodine-uptake study. A fine needle aspiration of the thyroid (FNAC) (FNAC) report identified an abscess in the thyroid (Figures 1 2 and 1) and the report on culture did not find any bacteria.


Ultrasound-guided aspiration for thyroid abscess was conducted and seropurulent pus was observed and thyroid drains were inserted and the patient improved in symptomatic ways. The diagnose of acute suppurative suppurative thyroiditis along with Lower respiratory tract infections (LRTI) that was sepsis severe on CKD was established. However, the patient was diagnosed with acute respiratory distress due to respiratory failure of type 1 and hypotension, for which he was intubatedand a noradrenaline injections were initiated. after which chest imaging revealed multiple constrictions with cavitations that could be indicative of pneumonia acquired in a hospital. Despite the best efforts the patient passed away to death on the 22nd day of admission.


The term thyroiditis is used to describe an inflammation in the thyroid gland. Thyroiditis is broadly classified into infectious Quervain’s, autoimmuneand Riedel’s, and other types [11. The thyroid gland has a lot of lymphatic drainage and vascularity. It contains a large amount of iodine within the tissue that produces hydrogen peroxide and is enclosed. Because of these an infection of the thyroid gland is extremely rare. The acute suppurative thyroiditis is an uncommon, life-threatening endocrine crisis. The incidence is reported as of 0.1%-0.7 percent and, if left not treated, it has the risk of death at about 12 percent [2,32 3. In contrast subacute thyroiditis can be an unremitting, spontaneously remitting disease that is more prevalent than acute thyroiditis suppurative. It can last from up to a few months and is more likely to be recurrent. It’s also known as de Quervain’s thyroiditis.

Many factors contribute to developing acute suppurative thyroiditis, of which immunosuppression is the most prevalent [66. However the pyriform sinus fistula as well as the fourth and third branchial arch anomalies are also significant in the case of children [7,8and. The clinical manifestations along with the laboratory findings and radiological signs for acute thyroiditis are very similar to the subacute thyroiditis features (Table 3.).

The main characteristics Acute Thyroiditis Subacute Thyroiditis
In the preceding upper respiratory Tract Infection More commonly Rarer
Fever More commonly Rarer
Thyrotoxicosis symptoms Rarer More frequent
Sore throat More frequent Rarer
Physical Exam
A painful thyroid swelling More frequent Not as common
Left side involvement More frequent Not as common
Thyroid tenderness that is migratory Rarer More commonly
The skin’s erythema can be atop it. More commonly Not as common
Laboratory Investigations
White blood cell counts are elevated. More frequent Not as common
Erythrocyte Sedimentation Rate > 30 mm/hr More commonly Not as common
Thyroid hormone levels that are abnormal (Elevated or decreased) Rarer More frequent
Transaminases, alkaline phosphatase and raised Rare More frequent
Radiological Investigations
ID 123I uptake is very low Common ~100%
A thyroid scan that is abnormal More frequent Rarer
Positive Gallium scan ~100% ~100%
18F-FDG-PET Positive Positive
A fistula in the barium swallow is seen. More commonly Not as common

Fine needle aspiration of the thyroid tissue is the most accurate diagnosis . It can be used to distinguish between these two conditions. When a patient is suffering from acute suppurative thyroiditis this FNAC aspirate is clear and shows the presence of fungi or bacteria and, in subacute thyroiditis the FNAC aspirate is a clear indication of lymphocytes and macrophages, along with some massive cells [99.

While these disorders closely resemble one another, specific characteristics of the clinical spectrum can be considered to be distinct elements. People suffering from chronic suppurative thyroiditis tend to be immune compromised, more ill, with chronic localized thyroid pain as well as an upper respiratory lymphadenopathy, and upper respiratory1. Thyrotoxic presentations are observed in just 8% to 12% of patients suffering from bacterial thyroiditis [33. We read a few recent studies regarding patients suffering from chronic suppurative thyroiditis. The most important studies have been presented in Table 4.

S. No Author (Published in the year) The present complaint Predisposing condition/Comorbidities Organism isolated Method and procedure Results
1. Hendricks et al. (2022) [10] Sore throat, fever, Odynophagia The accidental ingestion of bone of a fish Hemithyroidectomy, Antibiotics Survived
2. Siddiqui et al. (2021) [11] Dysphagia, Dyspnea, neck swelling and pain HIV, PTB, HTN Escherichia coli Antibiotics as well as drainage of abscess Survived
3. Cheung et al. (2021) [12] Atypical chest pain, palpitations and fever. Sore throat, Odynophagia IVDA T2DM HTN MRSA Antibiotics The cause of death was MI
4. Jariyawattanarat et al. (2021) [13] Swelling of the neck, fever, and an effervescent discharge Nodules of thyroid that have been present for a long time, iod deficiency Streptococcus sui Incisions and drainage, antibiotics Survived
5. Mishra et al. (2021) [14] The symptoms include pain, fever, and salivary drooling T2DM HTN, Hyperlipidemia, T2DM Bacteroides fragilis Antibiotics Survived
6. Siti Sanaa binti et al. (2021) [15] The neck is swelling and pain. anodynophagia Fever Mycobacterium tuberculosis Streptococcus anginosus as well as eikenella cordens Incision and drainage Hemithyroidectomy Survived
7. Akhanli et al. (2020) [16] Dysphagia, Fever, Neck swelling and pain, palpitation None Eikenella corrodens Antibiotics Survived
8. Win Htet et al. (2020) [17] Neck pain, fever Hand tremors HTN Hyperlipidemia, HTN Propionibacterium acnes Abscess aspiration or antibiotics Survived
9. Khoo et al. (2020) [18] The neck is swelling with pain. Odynophagia, Fever, Dysphagia or odynophagia, hoarseness of vocal quality, swelling of the neck, the sensation of pain T2DM HIV Salmonella enteritidis Abscess drainage by surgical procedureHemithyroidectomy Survived
10 AIYousef et al. (2020) [19] Neck pain, fever, dysphagia T2DM HTN, Hypothyroidism GERD Hyperlipidemia Salmonella enterica Multiple times percutaneous Aspiration Antibiotics Survived

It is vitally crucial as the treatment for each differs. When antibiotics without or with surgery are necessary in patients suffering from acute suppurative thyroiditis with subacute thyroiditis only require corticosteroids and analgesics. For emergency doctors, since outcomes of the FNAC are usually not available, it’s important that a low threshold is maintained to initiate antibiotics in patients who experience an aching thyroid, as untreated acute suppurative thyroiditis can be life-threatening. In the case of serious illnesses, antibiotics administered via parenteral route are recommended. The microscopic examination, the staining and the culture of a fine-needle aspirate can help identify the most effective treatment. Thionamides do not need to be used for people suffering from thyrotoxicosis caused by thyroiditis since there isn’t excess production of thyroid hormones; However, adjuvant drugs like beta-blockers and cholestyramine can be utilized to ease symptoms or quickly recover the euthyroid state. If a thyroid abscess has been discovered, aspiration or surgical drainage is recommended [2020. A surgical procedure that is open and completely, or nearly complete or hemithyroidectomy may be performed to ease tension sensations in the most extreme of situations, particularly in patients who fail to respond to the appropriate antibiotic treatment and drainage. In the end, surgery to remove the thyroid lobe damaged by injury could be necessary to treat the source of infection local to the area and inflammation in cases where systemic signs and symptoms don’t improve after the initial treatment [2121.

The patient we treated was male who was diagnosed as having CKD and who suffered from an ailly, painful neck swelling, along with signs of uremia and hyperthyroidism and was diagnosed with the bacterial thyroiditis suppurative. However, patients suffering from CKD have an altered immune response that encompasses both acquired and innate immunity [2223. Our patient was not on any anti-immune suppressant medications. Additionally, the clinical manifestation for our patient seemed more indicative of subacute thyroiditis in comparison to acute thyroiditis that is suppurative. Therefore, it was an uncommon case of acute thyroiditis suppurative.


A rare, but possibly fatal chronic suppurative thyroiditis must not be overlooked. Patients may be suffering from acute symptoms or experience a longer-term course based on the underlying condition. The symptoms are similar to those of subacute thyroiditis. It is a self-replicating illness. it is difficult to determine the exact cause at the time of an emergency. Thyroid abscess may cause a number of complications, such as thyroid storm as well as internal jugular vein embolism obstruction of the airway, tracheal or an esophageal perforation as well as necrotizing mediastinitis sepsis and even death. So, any patients who present to the emergency department with neck swellings that hurt must be treated with particular attention. The most accurate diagnosis can be made by fine needle aspiration from thyroid tissue. However ultrasound is the most commonly used test for diagnosing within the emergency department. Treatment choices include intravenous antibiotics, drainage of abscesses, and perhaps surgery.