A 14 year old girl presented with a two week history of painful throat and ears after having been previously treated with a course of antibiotics. She also complained of neck swelling and on further questioning admitted to increasing sweating and weight loss.
On examination she had pyrexia of 38.9 °C and a tachycardia. A postural tremor was elicited and an enlarged, smooth, tender goitre. Initial laboratory investigations were fT4 56.2 and TSH 0.03, WCC 12.8, CRP118, monospot ve and anti TPO antibody titre 0. She was diagnosed as a viral thyroiditis and commenced on propranolol and analgesia for symptomatic relief.
Two days later, she represented to hospital with worsening of her thyroid swelling and pain. She now had difficulty swallowing saliva and was again pyrexic. On examination, the left lobe of the thyroid had increased in size with an obvious red patch. It was hot to the touch and very tender (fT4 44.6, TSH <0.02). An ultrasound of neck showed an abscess in the left lobe of the thyroid and retrothyroid space. On aspiration 30 mls of purulent fluid was removed with symptomatic relief. This grew streptococcus constellatus on culture.
A diagnosis of acute pyogenic thyroiditis was made. This was thought to be due to a fistula from the left piriform sinus. Intravenous antibiotics were commenced and the fistula was excised and remaining abscess drained. The elevated serum thyroid hormones levels resolved over several weeks and the girl is now clinically euthyroid.
Pyogenic thyroiditis is a rare and potentially life threatening cause of thyroid swelling. This case is unusual due to the thyrotoxicosis at presentation - as literature would suggest these patients are euthyroid. There are, however, isolated case reports with some patients presenting with thyrotoxicosis. It highlights the need for vigilance and further assessment of non resolving thyroid pain.