Endocrine Abstracts

Case History: We present a case of a 24 year old music teacher and who attended our medical assessment unit. The gentleman described a twelve day history of neck pain, malaise, and odynophagia having received treatment one month previously for a PVL positive Staphylococcus aureus (PVLSA) lip abscess for which he did not complete eradication therapy. He described associated difficulty swallowing, rigors, vomiting and weight loss. On examination he had a tender, hot goitre and was septic.

Investigations: Chest radiograph showed changes consistent with pneumonia and empirical treatment as per local guidelines was commenced. He was notably thyrotoxic with a raised T4 level of 27, total T3 of 2.2 and partly suppressed TSH of 0.03. Suppurative thyroiditis was suspected and a neck CT revealed a large retropharyngeal collection and evidence of thyroid abscesses throughout the gland.

Results and treatment: The patient was transferred urgently to ENT and received further treatment for sepsis-associated coagulopathy. He underwent drainage of the collection and thyroid abscess formation and was monitored in the ICU. Cultures from the drained pus returned positive for PVLSA and anti-microbial treatment was optimised with senior microbiology input. A viral throat swab also returned positive for Influenza A and Oseltamivir was added. Thyrotoxicosis initially worsened with a T4 level greater than maximal assay detection. He continued to receive supportive management on the advice of the Endocrine team and T4 level began to down-trend five days post-operatively. Thyroid receptor and peroxidase antibodies returned negative.

Conclusion and Point for discussion: To conclude, a PVLSA infection progressed to an acute suppurative thyroiditis and retropharyngeal abscess. This occurred in the context of an associated pneumonia and Influenza-A. Further discussion of PVLSA infection, predisposing factors and differential diagnoses or underlying sequelae is prompted. This case highlights the considerations for the on-call Endocrinologist when faced with a rare and potentially fatal presentation of acute suppurative thyroiditis.