Hyperthyroidism Associated with Acute Suppurative Thyroiditis C. H. Walsh, C. Dnnne
Department of Medicine, South Infirmary, Victoria Hospital, Cork. Summary Acute suppurative thyroiditis is a rare condition with potentially serious complications 1. It has been suggested that hyperthyroidism may be a feature in occasional cases but this has been poorly documented. W e describe a patient in whom acute suppurative thyroiditis caused transient hyperthyroidism. of the thyroid gland reported in the literature between 1900 and 19802. The disorder occurred most commonly in patients with a preceding history of thyroid disease, and in a number of cases followed an upper respiratory tract infection, or pharyngitis. The most common symptom was anterior neck pain but dyspnoea, and dysphonia also occurred. The typical findings included a warm tender swelling in the anterior neck of a patient who was usually febrile. A neutrophil leucocytosis was frequent and bacteriological examination of thyroid tissue or aspirated pus usually disclosed organisms which were most frequently found to be staphylococci or streptococci. Berger stated that in 12 of the 153 cases reviewed by him at least one test suggested hyperthyroidism2. However the data available is limited and the relative insensitivity of many of the tests used makes precise evaluation of thyroid function impossible, and would not, in our present state of understanding of thyroid function tests confirm hyperthyroidism. The literature has also been confused by misquotations or misinterpretation of results 3, and some authors have referred to cases which, while clearly hyperthyroid, are examples of forms of thyroiditis which arc nonsuppurativer Thus we feel that hyperthyroidism has not previously been convincingly demonstrated in a patient with acute suppurative thyroiditis. The elevated serum thyroxine and suppressed thyroid stimulating hormone level noted in our patient, together with the markedly reduced I TM uptake and increased plasma iodide suggest that hyperthyroidism resulted from thyroid tissue destruction such as is found in subacute thyroiditis (de Quervains thyroiditis). The condition is transient as indicated by the return to normal of thyroid hormone values and subsequently radioactive iodine uptake by the thyroid gland. We are grateful to Mr. T. O'Sullivan FRCS lor referring this patient.
Case Hi.~[ory A 4 2 year old male was referred from another hospital because of respiratory distress associated with painful swelling of the front of his neck. For a week previously he had complained of a sore throat and increasing neck discomfort. On admission his temperature was 37.8~ and heart rate 84 per minute, regular. He was in obvious respiratory distress and the front of his neck was diffusely swollen, warm and tender. Initial investigations showed a neutrophil leucocytosis (24x109/1), the erythrocyte sedimentation rate (Westergren Method) was 75 mm in the first hour, and liver function tests were elevated. Because of continuing respiratory distress a tracheostomy was performed during which tissue was obtained for pathological examination. This revealed thyroid tissue with severe suppurative inflammation. Numerous gram positive cocci were seen and identified as staphylococcus aureus. His condition deteriorated, he developed a supraventricular taehycardia and in addition persistent hyperglycaemia with blood sugar values varying from 20-25 mmols/ 1. At this time his total serum thyroxine was 186 mmol/ 1 (normal 50-130 mmol/1) and thyroid stimulating hormone was 0.03 miu/l (normal 0.6-4.4 miu/l). He was treated with intravenous fluids, antibiotics, digoxin, and insulin infusion. Because of his history of heavy smoking betablockers were withheld. His arrhythmia settled, and over the ensuing days his condition improved progressively. Normoglycaemia was subsequently maintained by dietary measures alone. Four weeks after admission his total serum thyroxine was 72 mmol/l and thyroid function tests remained normal. Radioactive iodine uptake studies are shown in the accompanying table. Comment The scant reference to acute suppurati,ve thyroiditis in major endocrine text books is testimony to the rarity of the condition. Berger reviewed 153 cases of bacterial infection
References I. Ingbar,S. H, The thyroid gland, in: Wilson, J. D., Foster. D. W., eds. WilliamsText Bookof Endocrinology,7th ed. W. B. Saundcrs Company 1985: 682-815. 2. Berger, S. A., 7xms/.eth,J., Villamena,P., Mittman, N. infectious diseases of the thyroid gland. Medicine 1983: 5, 108-122. 3. Lambert, M. J., Johns, M. E., Meutzer, R. Acute suppurative thyroiditis. Annals of Surgery 1980: 46, 461-463. 4. Hagan,A. D., Goffinel,J., Davis,J.W. Acutestreptococcalthyroiditis. JAMA 1967: 202, 282-283. 5. Perloff,W. H. Thyrotoxicosisfollowingacute thyroiditis.A report of 5 cases. 1956: 16, 542-546.
TABLE I TM uptake (%) 4 weeks and 24 weeks after presentation 4 weeks 4 hours 24 hours 48 hours 48 hour plasma iodide
2.2 2.2 2.7 0.58
24 weeks 13.3 28.4 31.1 0.0 137
Department of Medicine, South Infirmary, Victoria Hospital, Cork. Summary Acute suppurative thyroiditis is a rare condition with potentially serious complications 1. It has been suggested that hyperthyroidism may be a feature in occasional cases but this has been poorly documented. W e describe a patient in whom acute suppurative thyroiditis caused transient hyperthyroidism. of the thyroid gland reported in the literature between 1900 and 19802. The disorder occurred most commonly in patients with a preceding history of thyroid disease, and in a number of cases followed an upper respiratory tract infection, or pharyngitis. The most common symptom was anterior neck pain but dyspnoea, and dysphonia also occurred. The typical findings included a warm tender swelling in the anterior neck of a patient who was usually febrile. A neutrophil leucocytosis was frequent and bacteriological examination of thyroid tissue or aspirated pus usually disclosed organisms which were most frequently found to be staphylococci or streptococci. Berger stated that in 12 of the 153 cases reviewed by him at least one test suggested hyperthyroidism2. However the data available is limited and the relative insensitivity of many of the tests used makes precise evaluation of thyroid function impossible, and would not, in our present state of understanding of thyroid function tests confirm hyperthyroidism. The literature has also been confused by misquotations or misinterpretation of results 3, and some authors have referred to cases which, while clearly hyperthyroid, are examples of forms of thyroiditis which arc nonsuppurativer Thus we feel that hyperthyroidism has not previously been convincingly demonstrated in a patient with acute suppurative thyroiditis. The elevated serum thyroxine and suppressed thyroid stimulating hormone level noted in our patient, together with the markedly reduced I TM uptake and increased plasma iodide suggest that hyperthyroidism resulted from thyroid tissue destruction such as is found in subacute thyroiditis (de Quervains thyroiditis). The condition is transient as indicated by the return to normal of thyroid hormone values and subsequently radioactive iodine uptake by the thyroid gland. We are grateful to Mr. T. O'Sullivan FRCS lor referring this patient.
Case Hi.~[ory A 4 2 year old male was referred from another hospital because of respiratory distress associated with painful swelling of the front of his neck. For a week previously he had complained of a sore throat and increasing neck discomfort. On admission his temperature was 37.8~ and heart rate 84 per minute, regular. He was in obvious respiratory distress and the front of his neck was diffusely swollen, warm and tender. Initial investigations showed a neutrophil leucocytosis (24x109/1), the erythrocyte sedimentation rate (Westergren Method) was 75 mm in the first hour, and liver function tests were elevated. Because of continuing respiratory distress a tracheostomy was performed during which tissue was obtained for pathological examination. This revealed thyroid tissue with severe suppurative inflammation. Numerous gram positive cocci were seen and identified as staphylococcus aureus. His condition deteriorated, he developed a supraventricular taehycardia and in addition persistent hyperglycaemia with blood sugar values varying from 20-25 mmols/ 1. At this time his total serum thyroxine was 186 mmol/ 1 (normal 50-130 mmol/1) and thyroid stimulating hormone was 0.03 miu/l (normal 0.6-4.4 miu/l). He was treated with intravenous fluids, antibiotics, digoxin, and insulin infusion. Because of his history of heavy smoking betablockers were withheld. His arrhythmia settled, and over the ensuing days his condition improved progressively. Normoglycaemia was subsequently maintained by dietary measures alone. Four weeks after admission his total serum thyroxine was 72 mmol/l and thyroid function tests remained normal. Radioactive iodine uptake studies are shown in the accompanying table. Comment The scant reference to acute suppurati,ve thyroiditis in major endocrine text books is testimony to the rarity of the condition. Berger reviewed 153 cases of bacterial infection
References I. Ingbar,S. H, The thyroid gland, in: Wilson, J. D., Foster. D. W., eds. WilliamsText Bookof Endocrinology,7th ed. W. B. Saundcrs Company 1985: 682-815. 2. Berger, S. A., 7xms/.eth,J., Villamena,P., Mittman, N. infectious diseases of the thyroid gland. Medicine 1983: 5, 108-122. 3. Lambert, M. J., Johns, M. E., Meutzer, R. Acute suppurative thyroiditis. Annals of Surgery 1980: 46, 461-463. 4. Hagan,A. D., Goffinel,J., Davis,J.W. Acutestreptococcalthyroiditis. JAMA 1967: 202, 282-283. 5. Perloff,W. H. Thyrotoxicosisfollowingacute thyroiditis.A report of 5 cases. 1956: 16, 542-546.
TABLE I TM uptake (%) 4 weeks and 24 weeks after presentation 4 weeks 4 hours 24 hours 48 hours 48 hour plasma iodide
2.2 2.2 2.7 0.58
24 weeks 13.3 28.4 31.1 0.0 137
