Acute infectious thyroiditis

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Acute infectious thyroiditis
Other namessuppurative thyroiditis
Specialty Endocrinology   OOjs UI icon edit-ltr-progressive.svg

Acute infectious thyroiditis (AIT) also known as suppurative thyroiditis, microbial inflammatory thyroiditis, pyrogenic thyroiditis and bacterial thyroiditis. [1] [2] [3]

Contents

The thyroid is normally very resistant to infection. Due to a relatively high amount of iodine in the tissue, as well as high vascularity and lymphatic drainage to the region, it is difficult for pathogens to infect the thyroid tissue. Despite all this, a persistent fistula from the piriform sinus may make the left lobe of the thyroid susceptible to infection and abscess formation. [1] AIT is most often caused by a bacterial infection but can also be caused by a fungal or parasitic infection, most commonly in an immunocompromised host.

Signs and symptoms

In most cases AIT is characterized by onset of pain, firmness, tenderness, redness or swelling in the anterior aspect of the neck. [4] Patients will also present with a sudden fever, difficulty swallowing and difficulty controlling the voice. [5] Symptoms may be present from 1 to 180 days, with most symptoms lasting an average of about 18 days. The main issue associated with the diagnosis of AIT is differentiating it from other more commonly seen forms of thyroid conditions. [4] Pain, fever and swelling are often much more severe and continue to get worse in people who have AIT compared to those with other thyroid conditions. [1]

Causes

Despite the thyroid gland being extremely resistant to infection, it is still susceptible to infection by various bacteria. [6] The cause can be almost any bacterium. Staphylococcus aureus , Streptococcus pyogenes , Staphylococcus epidermidis , and Streptococcus pneumoniae in descending order are the organisms most commonly isolated from acute thyroiditis cases in children. Other aerobic organisms are Klebsiella sp, Haemophilus influenza , Streptococcus viridans , Eikenella corrodens , Enterobacteriaceae , [4] and salmonella sp. [7] Occurrences of AIT are most common in patients with prior thyroid disease such as Hashimoto's thyroiditis or thyroid cancer. The most common cause of infection in children is a congenital abnormality such as pyriform sinus fistula. [5] In most cases, the infection originates in the piriform sinus and spreads to the thyroid via the fistula. [8] In many reported cases of AIT the infection occurs following an upper respiratory tract infection. One study found that of the reported cases of AIT, 66% occurred after an acute illness involving the upper respiratory tract. [6] Although the rates of infection are still very low, cases of AIT have been on the rise in recent years due to the higher occurrence of immune-compromised patients.[ citation needed ] Other causes of AIT are commonly due to contamination from an outside source and are included below.

Diagnosis

Patients who are suspected of having AIT often undergo tests to detect for elevated levels of white blood cells as well as an ultrasound to reveal unilobular swelling. [1] [4] Depending on the age and immune status of the patient more invasive procedures may be performed such as fine needle aspiration of the neck mass to facilitate a diagnosis. [4] In cases where the infection is thought to be associated with a sinus fistula it is often necessary to confirm the presence of the fistula through surgery or laryngoscopic examination. [6] While invasive procedures can often tell definitively whether or not a fistula is present, new studies are working on the use of computed tomography as a useful method to visualize and detect the presence of a sinus fistula. [6]

Diagnostic tests

Subtypes of thyroiditis

SubtypesCauses
Hashimoto's thyroiditis, Chronic lymphocytic thyroiditis, [3] Chronic autoimmune thyroiditis, Lymphadenoid goiter [5] Autoimmune [3]
Subacute lymphocytic thyroiditis, Postpartum thyroiditis, Sporadic painless thyroiditis, [3] Silent sporadic thyroiditis [5] Autoimmune [3]
Acute infectious thyroiditis, Microbial inflammatory thyroiditis, Suppurative thyroiditis, [3] Pyrogenic thyroiditis, Bacterial thyroiditis [5] Cause: Bacterial, Parasitic, Fungal [3]
de Quervain's thyroiditis, Subacute granulomatous thyroiditis, [3] Giant-cell thyroiditis, Pseudogranulomatous thyroiditis, Painful subacute thyroiditis, [5] Viral [3]
Riedel's thyroiditis, Riedel's struma, Invasive fibrous thyroiditisUnknown [3]

Treatment

Treatment of AIT involves antibiotic treatment. Based on the offending organism found on microscopic examination of the stained fine needle aspirate, the appropriate antibiotic treatment is determined. In the case of a severe infection, systemic antibiotics are necessary. [2] Empirical broad spectrum antimicrobial treatment provides preliminary coverage for a variety of bacteria, including S. aureus and S. pyogenes. [4] Antimicrobial options include penicillinase-resistant penicillins (ex: cloxacillin, dicloxacillin) or a combination of a penicillin and a beta-lactamase inhibitor. [4] However, in patients with a penicillin allergy, clindamycin or a macrolide can be prescribed. [4] The majority of anaerobic organisms involved with AIT are susceptible to penicillin. Certain Gram-negative bacilli (ex: Prevotella , Fusobacteriota , and Porphyromonas ) are exhibiting an increased resistance based on the production of beta-lactamase. [4] Patients who have undergone recent penicillin therapy have demonstrated an increase in beta-lactamase-producing (anaerobic and aerobic) bacteria. Clindamycin, or a combination of metronidazole and a macrolide, or a penicillin combined with a beta-lactamase inhibitor is recommended in these cases. [4] Fungal thyroiditis can be treated with amphotericin B and fluconazole. [2] Early treatment of AIT prevents further complications. However, if antibiotic treatment does not manage the infection, surgical drainage is required. Symptoms or indications requiring drainage include continued fever, high white blood cell count, and continuing signs of localized inflammation. [4] The draining procedure is also based on clinical examination or ultrasound/CT scan results that indicate an abscess or gas formation. [4] Another treatment of AIT involves surgically removing the fistula. This treatment is often the option recommended for children. [2] However, in cases of an antibiotic resistant infection or necrotic tissue, a lobectomy is recommended. [4] If diagnosis and/or treatment is delayed, the disease could prove fatal. [5]

Epidemiology

Acute infectious thyroiditis is very rare, with it only accounting for about 0.1–0.7% of all thyroiditis. Large hospitals tend to only see two cases of AIT annually. [2] For the few cases of AIT that are seen the statistics seem to show a pattern. AIT is found in children and young adults between the ages of 20 and 40. The occurrence of the disease in people between 20 and 40 is only about 8% with the other 92% being in children. Men and women are each just as likely to get the disease. [5] If left untreated, there is a 12% mortality rate. [2]

Related Research Articles

Abscess Localized collection of pus that has built up within the tissue of the body

An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends beyond the swelling. Carbuncles and boils are types of abscess that often involve hair follicles, with carbuncles being larger.

Lemierres syndrome Medical condition

Lemierre's syndrome refers to infectious thrombophlebitis of the internal jugular vein. It most often develops as a complication of a bacterial sore throat infection in young, otherwise healthy adults. The thrombophlebitis is a serious condition and may lead to further systemic complications such as bacteria in the blood or septic emboli.

Pharyngitis Medical condition

Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse voice. Symptoms usually last 3–5 days. Complications can include sinusitis and acute otitis media. Pharyngitis is a type of upper respiratory tract infection.

Infective endocarditis Medical condition

Infective endocarditis is an infection of the inner surface of the heart, usually the valves. Signs and symptoms may include fever, small areas of bleeding into the skin, heart murmur, feeling tired, and low red blood cell count. Complications may include backward blood flow in the heart, heart failure – the heart struggling to pump a sufficient amount of blood to meet the body's needs, abnormal electrical conduction in the heart, stroke, and kidney failure.

Osteomyelitis Medical condition

Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the feet, spine, and hips are most commonly involved in adults.

Cellulitis Bacterial infection of the skin

Cellulitis is a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of the area of redness are generally not sharp and the skin may be swollen. While the redness often turns white when pressure is applied, this is not always the case. The area of infection is usually painful. Lymphatic vessels may occasionally be involved, and the person may have a fever and feel tired.

Tonsillitis Inflammation of the tonsils

Tonsillitis is inflammation of the tonsils in the upper part of the throat. Tonsillitis is a type of pharyngitis that typically comes on fast. Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and large lymph nodes around the neck. Complications include peritonsillar abscess.

Peritonsillar abscess Pus behind the tonsil due to an infection

Peritonsillar abscess (PTA), also known as quinsy, is an accumulation of pus due to an infection behind the tonsil. Symptoms include fever, throat pain, trouble opening the mouth, and a change to the voice. Pain is usually worse on one side. Complications may include blockage of the airway or aspiration pneumonitis.

Mastoiditis Middle ear disease

Mastoiditis is the result of an infection that extends to the air cells of the skull behind the ear. Specifically, it is an inflammation of the mucosal lining of the mastoid antrum and mastoid air cell system inside the mastoid process. The mastoid process is the portion of the temporal bone of the skull that is behind the ear. The mastoid process contains open, air-containing spaces. Mastoiditis is usually caused by untreated acute otitis media and used to be a leading cause of child mortality. With the development of antibiotics, however, mastoiditis has become quite rare in developed countries where surgical treatment is now much less frequent and more conservative, unlike former times.

Ludwigs angina Medical condition

Ludwig's angina is a type of severe cellulitis involving the floor of the mouth and is often caused by bacterial sources. Early in the infection, floor of the mouth raises due to swelling, leading to difficulty swallowing saliva. As a result, patients may present with difficulty speaking and drooling. As the condition worsens, the airway may be compromised and hardening of the spaces on both sides of the tongue may develop. Overall, this condition has a rapid onset over a few hours.

Subacute bacterial endocarditis Medical condition

Subacute bacterial endocarditis, abbreviated SBE, is a type of endocarditis. Subacute bacterial endocarditis can be considered a form of type III hypersensitivity.

Ampicillin/sulbactam is a fixed-dose combination medication of the common penicillin-derived antibiotic ampicillin and sulbactam, an inhibitor of bacterial beta-lactamase. Two different forms of the drug exist. The first, developed in 1987 and marketed in the United States under the brand name Unasyn, generic only outside the United States, is an intravenous antibiotic. The second, an oral form called sultamicillin, is marketed under the brand name Ampictam outside the United States. And generic only in the United States, ampicillin/sulbactam is used to treat infections caused by bacteria resistant to beta-lactam antibiotics. Sulbactam blocks the enzyme which breaks down ampicillin and thereby allows ampicillin to attack and kill the bacteria.

Sultamicillin

Sultamicillin, sold under the brand name Unasyn among others, is an oral form of the penicillin antibiotic combination ampicillin/sulbactam. It is used for the treatment of bacterial infections of the upper and lower respiratory tract, the kidneys and urinary tract, skin and soft tissues, among other organs. It contains esterified ampicillin and sulbactam.

Cavernous sinus thrombosis Medical condition

Cavernous sinus thrombosis (CST) is the formation of a blood clot within the cavernous sinus, a cavity at the base of the brain which drains deoxygenated blood from the brain back to the heart. This is a rare disorder and can be of two types–septic cavernous thrombosis and aseptic cavernous thrombosis. Most commonly the form is of septic cavernous sinus thrombosis. The cause is usually from a spreading infection in the nose, sinuses, ears, or teeth. Staphylococcus aureus and Streptococcus are often the associated bacteria.

Orbital cellulitis Inflammation of eye tissues

Orbital cellulitis is inflammation of eye tissues behind the orbital septum. It is most commonly caused by an acute spread of infection into the eye socket from either the adjacent sinuses or through the blood. It may also occur after trauma. When it affects the rear of the eye, it is known as retro-orbital cellulitis.

Dental abscess Medical condition

A dental abscess is a localized collection of pus associated with a tooth. The most common type of dental abscess is a periapical abscess, and the second most common is a periodontal abscess. In a periapical abscess, usually the origin is a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth. This can be caused by tooth decay, broken teeth or extensive periodontal disease. A failed root canal treatment may also create a similar abscess.

A pneumococcal infection is an infection caused by the bacterium Streptococcus pneumoniae, which is also called the pneumococcus. S. pneumoniae is a common member of the bacterial flora colonizing the nose and throat of 5–10% of healthy adults and 20–40% of healthy children. However, it is also a cause of significant disease, being a leading cause of pneumonia, bacterial meningitis, and sepsis. The World Health Organization estimates that in 2005 pneumococcal infections were responsible for the death of 1.6 million children worldwide.

Anaerobic infections are caused by anaerobic bacteria. Obligately anaerobic bacteria do not grow on solid media in room air ; facultatively anaerobic bacteria can grow in the presence or absence of air. Microaerophilic bacteria do not grow at all aerobically or grow poorly, but grow better under 10% carbon dioxide or anaerobically. Anaerobic bacteria can be divided into strict anaerobes that can not grow in the presence of more than 0.5% oxygen and moderate anaerobic bacteria that are able of growing between 2 and 8% oxygen. Anaerobic bacteria usually do not possess catalase, but some can generate superoxide dismutase which protects them from oxygen.

Osteomyelitis of the jaws is osteomyelitis which occurs in the bones of the jaws. Historically, osteomyelitis of the jaws was a common complication of odontogenic infection. Before the antibiotic era, it was frequently a fatal condition.

There are many circumstances during dental treatment where antibiotics are prescribed by dentists to prevent further infection. The most common antibiotic prescribed by dental practitioners is penicillin in the form of amoxicillin, however many patients are hypersensitive to this particular antibiotic. Therefore, in the cases of allergies, erythromycin is used instead.

References

  1. 1 2 3 4 5 Melmed, Shlomo, Kenneth S. Polonsky, and P. R. Larsen. thyroiditis vs subacute thyroiditis diagnosis criteria [ permanent dead link ] "Acute InfectiousThyroiditis." Willams Textbook of Endocrinology. By Henry M. Kronenberg. 11th ed. Philadelphia: Elsevier, 2008. 945-47.
  2. 1 2 3 4 5 6 Lazarus, John, and James Hennessey. "Archived copy". Archived from the original on 2012-04-29. Retrieved 2012-04-20.{{cite web}}: CS1 maint: archived copy as title (link) "Acute and Subacute, and Reidel’s Thyroiditis." Ed. Leslie J. De Groot. The Thyroid And Its Diseases. 6th ed. New York: Elsevier, 1996.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 Slatosky, D.O., J; Shipton, B; Wahba, H (Feb 15, 2000). "Thyroiditis: differential diagnosis and management". American Family Physician. 61 (4): 1047–52, 1054. PMID   10706157 . Retrieved 24 August 2012.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Brook, I. (2002). "Microbiology and management of acute suppurative thyroiditis in children." International Journal of Pediatric Otorhinolaryngology, 67, 447-451.
  5. 1 2 3 4 5 6 7 8 Pearce, Elizabeth M.D., Alan P. Farwell M.D. and Lewis E. Braverman M.D. "Thyroiditis." The New England Journal of Medicine. 2003 June 26;348:2646-2655.
  6. 1 2 3 4 Park, Sun W., Moon H. Han, Myung H. Sung, In O. Kim, Kwang H. Kim, Kee H. Chang, and Man C. Han. "Neck Infection Associated with Pyriform Sinus Fistula: Imaging Findings." American Journal of Neuroradiology Am J Neuroradiol 21 (2000): 817-22.
  7. ↑ 3) Lazarus, John, and James Hennessey. "Acute and Subacute, and Reidel’s Thyroiditis." Ed. Leslie J. De Groot. The Thyroid And Its Diseases. 6th ed. New York: Elsevier, 1996
  8. ↑ Yamada, H., Fujita, K., Tokuriki, T., & Ishida, R. (2002). "Nine cases of piriform sinus fistula with acute suppurative thyroiditis." Elsevier, 29, 361-365.
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