Acute Suppurative Thyroiditis in an Intravenous Drug User with a Preexisting Goiter

Abstract

Acute suppurative thyroiditis (AST) is an uncommon, potentially life-threatening cause of a rapidly enlarging neck mass. It may present similarly to subacute thyroiditis, a relatively benign and self-limiting condition. We report a case of AST in an adult intravenous (IV) drug user with a preexisting goiter who presented with a left forearm abscess that grew methicillin-sensitive Staphylococcus aureus. In this particular case, clinical suspicion for AST was high. As a result, early IV antibiotic therapy was initiated, and this led to rapid clinical improvement furthermore preventing airway compromise. To our knowledge, this is the first case of AST in the literature resulting from likely hematogenous spread in the setting of IV drug use and a preexisting goiter. Overall, this case highlights the importance of assessing risk factors for AST in patients whose presentations may seem more typical of subacute thyroiditis. Such an approach will lead to timely diagnosis and treatment to avoid potentially devastating consequences.

Thyroid Abscess After Injection of Heroin into the Neck Complicated by Thyroid Storm

“…Only a few cases of thyroid abscess following IVDU have been reported (6,16,17). In a previous report, a patient developed thyroid abscess following bacteremia due to a left forearm abscess from IVDU (7).…”

“…In a previous report, a patient developed thyroid abscess following bacteremia due to a left forearm abscess from IVDU (7). She had a preexisting multinodular goiter but no thyrotoxicosis at baseline (6). It has been postulated that patients with preexisting multinodular goiter may have an impaired antioxidant defense mechanism which increases risk of thyroid infection (6).…”

“…She had a preexisting multinodular goiter but no thyrotoxicosis at baseline (6). It has been postulated that patients with preexisting multinodular goiter may have an impaired antioxidant defense mechanism which increases risk of thyroid infection (6). After developing thyroid abscess, that patient became only mildly thyrotoxic with TSH at 0.02 U/mL, free T4 at 3.89 ng/dL, and free T3 at 5.1 pg/mL (6).…”

“…Thyroid abscess can be lifethreatening, making it crucial to identify cases early (2,5). The mortality rate for acute suppurative thyroiditis can be >12% without appropriate treatment (6).…”

“…The thyroid is considered resistant to infection due to its dense vascularity, lymphatic drainage, thyroid capsule, high iodine content, and presence of hydrogen peroxide as a substrate for thyroid hormone synthesis (2,7). Thus, thyroid abscess usually occurs in the presence of risk factors such as an immunocompromised state or congenital abnormalities of thyroid development (6,7). However, despite multiple protective mechanisms, direct puncture of the normal thyroid gland in a healthy individual can lead to acute suppurative thyroiditis and thyroid abscess (2).…”