Suppurative Thyroiditis

Aka: Suppurative Thyroiditis, Infectious Thyroiditis

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II. Definition

  1. Painful Thyroiditis associated with Non-Viral Infection

III. Epidemiology

  1. Rare form of Painful Thyroiditis

IV. Causes

  1. Gram Positive Bacteria (39%)
    1. Streptococcus Pneumoniae
    2. Streptococcus Pyogenes
    3. Staphylococcus auerus
  2. Gram Negative Bacteria (25%)
  3. Anaerobes (12%)
  4. Atypical Bacteria
    1. Pneumocystis jiroveci (AIDS)
    2. Nocardia
    3. Mycobacterium tuberculosis
  5. Non-Bacterial, non-Viral Infections
    1. Parasitic Infections
    2. Fungal infections
    3. Mycobacterial infections

V. Risk Factors

  1. Immunocompromised patients
  2. Elderly
  3. Pre-existing Thyroid disease in up to 50%
  4. Congenital defect
    1. Persistent thyroglossal duct
    2. Piriform sinus fistula

VI. Symptoms

  1. Acute unilateral Neck Pain and swelling
  2. Symptoms provoked by neck extension
  3. Focal neck structure compression
    1. Dysphagia
    2. Dysphonia
    3. Stridor

VII. Signs

  1. High fever
  2. Erythematous skin overlying Thyroid
  3. Thyroid swollen and tender to palpation (focal or diffusely)
  4. Cervical Lymphadenopathy

VIII. Labs

  1. Complete Blood Count
    1. Leukocytosis with band forms
  2. Blood Cultures
  3. Comprehensive Metabolic Panel
  4. Thyroid Function Tests (TSH, Free T4)
    1. Variable abnormalities or may be euthyroid
    2. Patients return to euthyroid state after infection resolves
    3. Thyroid autoantibodies (if obtained) are absent
  5. C-Reactive Protein (C-RP) or Erythrocyte Sedimentation Rate (ESR) increased

IX. Diagnosis

  1. Thyroid Fine Needle Aspirate (Thyroid FNA)
    1. Indicated for mass, abscess or fluid collection
    2. Ultrasound guided
    3. Send for Gram Stain and culture

X. Imaging

  1. First-Line
    1. CT Neck with contrast (consider including CT Chest)
  2. Alternative studies
    1. MRI Neck
    2. Lateral Neck Xray (may demonstrate soft tissue gas)

XI. Management

  1. Hospitalization
  2. ABC Management (airway management as needed)
  3. Surgery Consultation if abscess drainage required
  4. Intravenous Antibiotics to cover suspected organisms
    1. Piperacillin/Tazobactam (Zosyn) 3.375 g IV every 6 hours or 4.5 g IV every 8 hours OR
    2. Meropenem 1 g IV every 8 hours
    3. ADD Vancomycin if MRSA suspected
    4. MODIFY Antibiotic therapy based on Gram Stain and culture

XII. Complications

  1. Septic Shock
  2. Airway obstruction
  3. Thyroid abscess
    1. Consider for fluctuant swelling
  4. Vocal Cord Paralysis
  5. Transient Hypothyroidism
    1. Destructive Thyroiditis may result in chronic hypothryoidism

XIII. References

  1. (2021) Sanford Guide, accessed on IOS 12/17/2021
  2. Bindra (2006) Am Fam Physician 73:1769-76 [PubMed]
  3. Fukata (2002) Thyroid 12:175-8 [PubMed]
  4. Quintero (2021) Am Fam Physician 104(6): 609-17 [PubMed]
  5. Paes (2010) Thyroid 20(3): 247-55 +PMID: 20144025 [PubMed]
  6. Sweeney (2014) Am Fam Physician 90(6): 389-96 [PubMed]

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