[A toddler with a rare complication of scarlet fever]

BACKGROUND

Haemolytic group A streptococci (GAS) are the most common bacterial cause of infection in the Netherlands. These bacteria can cause many different non-invasive infections, including scarlet fever.

CASE DESCRIPTION

A two-year-old girl presented with fever, tachycardia, exanthema and swelling in the neck. On suspicion of scarlet fever with neck phlegmon we treated her with antibiotics and supportive therapy. Blood and throat cultures revealed growth of haemolytic GAS. Lab tests revealed mild hyperthyroidism and neck ultrasound revealed an inhomogeneous appearance of the thyroid. We diagnosed her with 'infectious thyroiditis', a rare complication of infection with haemolytic GAS. A fistula from the pyriform sinus could not be demonstrated.

CONCLUSION

Although GAS infections are common, complications such as thyroiditis are rare. When a paediatric patient is diagnosed with infectious thyroiditis, a fistula from the pyriform sinus should be considered. Patients with such a congenital malformation have an increased risk of recurrent infectious thyroiditis and thyroid abscess formation.

Acute suppurative thyroiditis following fine-needle aspiration biopsy in an immunocompetent patient

The thyroid gland is remarkably resistant to infectious agents owing to several protective mechanisms. Acute suppurative thyroiditis after fine-needle aspiration (FNA) in an immunocompetent patient is very rare. We report the case of a 50-year-old immunocompetent male patient who presented with painful cervical swelling, fever, and chills after an FNA of the thyroid. His physical and laboratory examination suggested an acute suppurative thyroiditis. Repeat FNA results were consistent with thyroid abscess. Physicians should be aware of the probability of acute bacterial thyroiditis after FNA.

[A case of brucellosis complicated with endocarditis, pyelonephritis, sacroileitis and thyroiditis]

Brucellosis which is a endemic in Turkey, is a systemic infection which can affect any organ or system in the body. Since signs and symptoms of brucellosis resemble many other diseases, misdiagnosis and related increase in morbidity rate, are common. In this report, a case of brucellosis complicated with endocarditis, pyelonephritis, sacroileitis and thyroiditis, was presented. The case was a 32-years-old female patient in whom the diagnosis of brucellosis was delayed by 12 months since it was not taken into consideration during the clinical follow-up of the patient in various clinical centers. The patient was admitted to our center with the complaints of fever, headache, back pain, night sweats, fatigue, loss of appetite, weight loss, dysuria and polyuria. The patient had a history of consumption of raw milk and dairy products. Positive Brucella tube agglutination test (1/1280) and isolation of Brucella spp. in blood cultures led to the diagnosis of brucellosis. Sacroileitis was diagnosed upon pain on right hip joint movements, pain and restriction at the same joint in FABER test. The detection of vegetation during echocardiography, cardiac murmur during physical examination and the determination of increased ESR and CRP levels led to the diagnosis of endocarditis. Abdominal ultrasonography and urinalysis results (hematuria, proteinuria and pyuria) revealed pyelonephritis and increased free T3 and T4, decreased TSH and positive anti-thyroid autoantibodies (anti-TG, anti-TPO) revealed thyroiditis. Treatment was started with combination of rifampisin (1 x 600 mg/day) and doxycycline (2 x 100 mg/day). After the diagnosis of endocarditis, trimethoprim-sulfamethoxazole (3 x 960 mg/day) and streptomycin (1 x 1 g/day) were added to the treatment. Valve replacement surgery was planned, however, the patient didn't accept surgical intervention and antimicrobial treatment continued with streptomycin for 21 days and other antibiotics for six months. The patient exhibited significant improvement after the medical treatment. Although sacroileitis is a frequent complication of brucellosis, endocarditis, thyroiditis and pyelonephritis are among the rare complications. In cases of brucellosis with multiorgan involvement including endocarditis, successful results may be achieved by aggressive antimicrobial treatment. In endemic areas, brucellosis should always be taken into consideration in patients with fever of unknown origin and multisystem involvement.

[Pain in the throat due to acute suppurative thyroiditis caused by Salmonella]

A 53-year-old woman presented with fever accompanied by chills and an extremely painful swelling of her right thyroid lobe. She was initially diagnosed as having subacute thyroiditis, but after 14 days her disease appeared to be caused by a destructive suppurative thyroiditis due to Salmonella group C. A pre-existing hyperplastic nodule in the right thyroid lobe was the predisposing factor. Antibiotics were given for several weeks and surgical drainage was performed. Finally a hemithyroidectomy was done to eliminate the predisposing factor.

Acute blastomycosis thyroiditis

Acute thyroiditis is very unusual, and fungal thyroiditis is even more rare. Cervical blastomycosis, on one occasion masquerading as a thyroid mass, has been reported. Here we report the first case of acute blastomycosis infection of the thyroid documented by biopsy and imaging studies. The patient was a 23-year-old woodcutter with no history or features of overt immunodeficiency. The initial response to Itraconazole therapy was satisfactory.

Thyroid tuberculosis mimicking carcinoma: report of two cases

Among 527 patients with thyroid disease who underwent surgery at our hospital during a 20-year period, 2 (0.4%) had tuberculous thyroiditis mimicking carcinoma. The first patient was a 44-year-old man with a solitary thyroid nodule and the second was a 24-year old man with a thyroid abscess. The unexpected diagnosis was made postoperatively and was based on histological findings in both patients. No primary focus was found elsewhere in either patient, and both responded to antituberculous chemotherapy. Although the diagnosis is usually based on examination of resected specimens, recent reports indicate that find-needle aspiration cytology is a cost-effective technique of diagnosing thyroid tuberculosis. A review of 35 cases reported in the English literature is also discussed.

Acute suppurative thyroiditis in children

BACKGROUND

Acute suppurative thyroiditis in children is rare and is often related to a pyriform sinus fistula or thyroglossal duct remnant, especially when it is recurrent.

METHODS

From January, 1985, through December, 2000, 15 children with acute suppurative thyroiditis were treated. Their clinical, laboratory and radiologic findings were reviewed and analyzed.

RESULTS

There were 8 girls and 7 boys, with a mean age at diagnosis of 6.1+/-2.9 years (range, 1.5 to 9.8). A thyroid mass was present on the left in 13 and on the right in 2 (P < 0.05). Fever, neck pain and swelling were the most common symptoms and signs. Seven patients (46.7%) had recurrent disease. Needle aspiration for Gram stain and bacterial cultures were done, and pathogenic organisms were identified on culture in 8 patients but were found only on Gram stain in 2 patients. In one-half of the patients with positive cultures, mixed pathogens were found. The most common organisms isolated were streptococcal species (50%). Barium esophagography was performed in all patients, and 5 (33.3%) had a pyriform sinus fistula on the left. Only 1 of the recurrent patients had a fistula. Thyroid scans were performed in 13 patients, of whom 12 (92.3%) had decreased radioactive uptake. Thyroid function tests were normal in all 15.

CONCLUSIONS

Acute suppurative thyroiditis is usually caused by oropharyngeal flora, resulting in mixed pathogens on culture. Broad spectrum antibiotics should be given once cultures have been obtained. Imaging studies might be helpful in the diagnosis of acute suppurative thyroiditis.

Sonographic findings of tuberculous thyroiditis in a patient with Behçet's syndrome

We report a case of tuberculous thyroiditis in a woman with Behçet's syndrome. The initial physical examination in May 1998 revealed multiple soft, nontender, mobile lymph nodes, each measuring less than 1 cm, in the left lower internal jugular chain. Sonography performed in February 2000 showed multiple small (< 1 cm), oval lymph nodes, each with an intact fatty hilum, in the left lower internal jugular chain; the thyroid gland appeared normal. Follow-up sonography 6 months later showed multifocal, heterogeneous, hypoechoic lesions with ill-defined margins in both lobes of the thyroid and several small, oval lymph nodes, each with an intact fatty hilum, in the left lower internal jugular chain. Fine-needle aspiration was performed on the largest thyroid lesion, and cytologic analysis of the aspirate revealed a small number of epithelioid histiocytes in a necrotic background, which was suggestive of tuberculosis. Follow-up sonography after 3 months of antituberculosis chemotherapy showed that the thyroid lesions had resolved.

Brucella infection of the thyroid gland

Three cases of Brucella infection of the thyroid gland are reported. All three were female, and two were from rural areas in Tehran Province. All presented with fever, chills, and painful swelling in the neck, had positive wright and 2-mercaptoethanol test; and had normal thyroid function. Cultures of FNA materials grew Brucella in all cases. They were cured following antibiotic treatment.

Salmonella brandenburg: a novel cause of acute suppurative thyroiditis

A patient with suppurative thyroiditis due to infection with Salmonella brandenburg is reported. Localization of the infection occurred to a pre-existing thyroid nodule after Salmonella bacteremia. S. brandenburg was isolated in pure culture from the fluid obtained by needle aspiration of the suppurated thyroid nodule. Surgical drainage followed by subtotal thyroidectomy was required to cure the disease. No evidence of pyriform sinus fistula was found. Suppurative thyroiditis due to Salmonella ubiquitous serotypes is an extremely rare condition, and infection to the thyroid produced by S. brandenburg is reported now for the first time. Indeed, the isolation rate of S. brandenburg from all human sources is low, and this microorganism is an uncommon agent of bacteremia.

Thyroiditis. Differentiation of acute suppurative and subacute. Case report and review of the literature

Acute suppurative thyroiditis is rarely seen during childhood. The classic clinical features of this illness (fever, neck pain, and a swollen, tender mass over the thyroid gland) can differentiate acute thyroiditis from the more common subacute thyroiditis. In less typical cases, however, this distinction can be difficult. An adolescent male presented with a swollen, tender thyroid gland. Atypical laboratory findings and the lack of fever and toxicity delayed the diagnosis and treatment of acute suppurative thyroiditis. A review of the pediatric literature summarizes clinical and diagnostic features valuable in the differential between acute suppurative thyroiditis and subacute thyroiditis in childhood. The important contribution of fistulae between the piriform sinus and thyroid gland to the pathogenesis and acute suppurative thyroiditis is emphasized. Such a fistula should be sought in every patient in whom this entity is diagnosed.