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Introduction Thyroid storm is a life-threatening endocrinological emergency. It creates a hypermetabolic state caused by excessive release of thyroid hormones, causing adrenergic hyperactivity following a precipitant(s). An uncommon precipitant of thyroid storm is a thyroid abscess. Clinical Case A 48-year-old man with a PMHx of COPD on home oxygen, OSA, HTN, left thyroid lobe nodule and recent treatment for community-acquired pneumonia the prior week presented to the ED with complaints of right neck pain and swelling of 5 days duration. Patient had associated diarrhea, fever, nausea, vomiting and palpitations. VS: Temp 101.9 F, BP 164/120, RR 20 and HR 160. Physical examination revealed a right non-mobile tender neck mass, rales on the lower lobe of the left lung, and drenching sweats. CT of the neck showed a prominent soft tissue mass on the right side of the neck with irregular margins abutting the right thyroid lobe, suggesting possible abscess. A subsequent thyroid US revealed a large heterogeneous nonvascular right thyroid mass measuring approximately 12×7×7 cm. Initial labs: TSH < 0. 005 mU/L (normal range 0.45-5. 0 mU/L), FT4 2.54 mU/L (normal range 0.9 to 2.3 mU/L); TSHrAB, TSI and TPO were negative. Thyroid storm was diagnosed using the Burch Wartofsky score (45 points). He was treated with propythiouracil, hydrocortisone, propranolol and antibiotics. FT4 normalized after 2 days on admission at which time he was taken for surgical drainage of his right thyroid abscess. 80 cc of pus was aspirated and cultured with isolation of Klebsiella Pneumoniae. Blood cultures also revealed K. Pneumoniae. Repeat Thyroid US showed resolution of abscess. Patient remained in hospital for ongoing treatment of his pneumonia. Clinical Lesson: Acute suppurative thyroiditis (AST) is a rare, life-threatening infection of the thyroid gland. Thyroid gland is rich in iodine, blood supply and lymphatics with a thick capsule which is relatively resistant to infection from neighboring sites. AST is more common in women and affects the left lobe of thyroid. Our patient is a man and his thyroid abscess was on the right lobe. The most common route of infection in AST is a congenital pyriform sinus fistula which was ruled out in our patient with direct laryngoscopy. Common presenting symptoms include fever, neck pain, and dysphagia. Pathogens commonly found to cause AST include Streptococcus and Staphylococcus. Our patient presents as an interesting case of AST from K. Pneumoniae with hematogenous spread that precipitated a thyroid storm. Thyroid storm incidence is noted to be Presentation: No date and time listed |
