The sonographic diagnosis of diffuse thyroid disease has received scant attention in the ultrasound literature. Several authors have described the ultrasound appearance of various diffuse thyroid diseases, such as subacute thyroiditis,' Hashimoto's t h y r~i d i t i s ,~,~ and acute thyroiditi~.~ Our case report describes the sonographic features of acute suppurative thyroiditis. Correlative radionuclide images are included. CASE REPORTThe patient was a 28-yr-old woman who had recently arrived in this country from Jamaica. She was well until 5 yr prior to admission to our hospital, when she was diagnosed as having systemic lupus erythematosus (SLE) after presenting with arthralgia and arthritis. Renal biopsy done at that time revealed basement membrane thickening. She has subsequently suffered from various complications of SLE, as well as from steroid-induced cataracts, hypertension with one episode of pulmonary edema, nephrotic syndrome, and herpes zoster. Medications have included prednisone (up to 40 mg/day), Lasix, digoxin, and Inderal.On present admission, the patient complained of a sore throat with temperatures of up to 103°F. Laboratory tests at that time demonstrated an elevated white blood cell count with a left shift, an erythrocyte sedimentation rate of 103, and a urinalysis revealing red blood cell casts. An infection-induced lupus flare was deduced, for which she was treated with high-dose prednisone. During her hospital stay, she developed rapid swelling of the neck, with the right side greater than 222the left. Nuclear medicine 99mT~ pertechnetate thyroid scan revealed an ill-defined 3 X 3-cm cold nodule in the right lobe (Fig. 1). Ultrasound examination of the thyroid revealed a diffusely enlarged, somewhat irregular gland with decreased echogenicity, but no focal abnormality was demonstrated (Fig. 2). Triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) were normal 5 days following plasmapheresis treatment for SLE and a diagnosis of viral thyroiditis was made, which was treated successfully with salicylates. One week after discharge, the patient returned with an acute exacerbation of neck swelling associated with tenderness and an elevated temperature. Repeat nuclear medicine scans and an ultrasound examination of the thyroid were performed (Figs. 3, 4).The patient was taken to the operating room, where 300 cc of purulent material was aspirated from the swelling in the neck. Cultures revealed alpha streptococcus, sensitive to penicillin, and the patient was treated with 6 million units/day. The patient responded well and was subsequently discharged to complete the antibiotic therapy. DISCUSSIONThyroid sonography has been found to be a reliable tool for evaluating the hypo-or nonfunctioning thyroid nodule and for differentiating cystic and solid masses of the thyroid gland.2,4 However, the role of ultrasound in diffuse thyroid disease is less well appreciated. The common entities of subacute thyroiditis and Hashimoto's thyroiditis are usually easily differentiated and man...
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