E. coli mediated Acute Suppurative Thyroiditis with Thyroid abscess in a patient with Urosepsis: Case report

doi:10.21203/rs.3.rs-4469842/v1

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E. coli mediated Acute Suppurative Thyroiditis with Thyroid abscess in a patient with Urosepsis: Case report

https://doi.org/10.21203/rs.3.rs-4469842/v1

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Introduction: Thyroid abscesses are rare modalities of infectious pathology of the thyroid gland. The thyroid is highly resistant to infection due to high iodine content, capsule, and rich vascularity. Acute suppurative thyroiditis represents less than 1% of thyroid diseases, but if present, could potentially lead to a life-threatening endocrine emergency.

Case Presentation: A 62 year-old elderly diabetic lady presented with complaints of sudden onset anterior neck swelling and difficulty in swallowing for a week. She had a history of Urinary Tract Infection leading to Acute Kidney Injury and Urosepsis twenty days back, which was managed conservatively by antibiotics. Bacteraemia from the urosepsis spread to thyroid gland leading to Acute Suppurative Thyroiditis and thyroid abscess. Patient developed acute onset painful enlargement of thyroid gland. Incision and drainage of the neck abscess was done along with left thyroid lobectomy and tracheostomy. She developed left vocal cord paresis postoperatively, but the hoarseness improved after three months. Regular dressing and parenteral antibiotics against E. coli resulted in complete wound healing in two weeks.

Conclusion: We found an association of urinary tract infection with thyroid abscess which was confirmed by E.coli positivity in thyroid abscess pus culture report and previous urine culture reports. In cases of acute suppurative thyroiditis with thyroid abscess, the primary source of infection should be searched and meticulously treated because in majority of cases it occurs due to bacteriological spread from a distant site in the body.

Acute suppurative thyroiditis

thyroid abscess

thyroid lobectomy

urosepsis

The thyroid gland is resistant to infection because of its high vascularity, intact capsule, and rich iodine content. An infection in thyroid should be diagnosed with a high index of suspicion, and the primary source of infection is usually located at a different site, which should be meticulously identified. Thyroid abscess presents with an acute onset and rapidly enlarging anterior neck swelling in a febrile patient. There is associated neck tenderness on palpation. Such patients require hospitalisation, parenteral antibiotics and surgical drainage of the abscess under general anaesthesia. Here, the authors present a unique case of urosepsis mediated thyroid abscess due to hematogenous spread of E. coli bacteria.

A 62 year old female presented with history of swelling in front of neck for 8 years and had experienced sudden increase in size of the neck swelling since 20 days. She also complained of fever and odynophagia for one week. Patient had history of admission in a private hospital around 20 days back for uncontrolled type 2 diabetes mellitus with Urinary Tract Infection (UTI), urosepsis with Acute Kidney Injury (AKI) where she was managed conservatively. Patient had been a known case of type 2 Diabetes Mellitus for ten years on irregular medication.

Physical examination revealed diffuse enlargement of the thyroid gland along with tenderness on palpation. There was a 6x6 cm, single midline neck swelling with erythematous bulging points over the swelling (Fig I-A). Trachea was deviated to the right side. Laboratory investigations were significant for leucocytosis, raised neutrophils and peripheral blood smear showed microcytic hypochromic anaemia (Hb -7.5). HbA1c was 9.2 suggestive of uncontrolled diabetes mellitus. Her thyroid function tests were within normal limits. Initial ultrasonography of the neck showed nodules in the left lower thyroid and isthmus with hypo-echoeic collection in left lobe. CECT scan of the neck showed an enlarged left thyroid lobe with a heterogeneous abscess cavity measuring 4.5 cm x 4 cm, which caused a mass effect on the trachea deviating it to the right side and compression of left Internal Jugular vein was noted (Fig I-B,C).

Incision and drainage was done for this patient under general anaesthesia. A liberal horizontal incision was made 2 finger breadth above suprasternal notch and flap was elevated superiorly and inferiorly(Fig II-A,B). Left lobe of thyroid was seen grossly enlarged, adhered to the surrounding structure. Thyroid tissue was seen engulfing left internal jugular vein. Aspiration was done with wide bore needle. Around 150ml of frank pus was drained (Fig II-C). Adjacent necrosed thyroid tissue was excised and abscess cavity was thoroughly cleaned by saline irrigation (Fig II-D,E). A prophylactic tracheostomy was done in view of possible vocal cord palsy which can develop postoperatively(Fig II-F). Pus culture showed growth of Escherichia coli. Strict glycaemic control and meticulous endocrine work up was done. Histopathology report was suggestive of Thyroid abscess. No evidence of granuloma and malignancy was noted. She was discharged after seven days of parenteral antibiotics. Patient developed ipsilateral vocal cord palsy in the immediate postoperative period which gradually improved over next three months. She was decannulated after one month and had a stable postoperative recovery.

The thyroid gland is relatively resistant to development of infections essentially due to its anatomical and physiological properties. Even among immunocompromised individuals, acute suppurative thyroiditis is a rare disease with incidence being less than 1% of all thyroid diseases. [1]. Thyroid abscess cases are more common in females and majority cases are under the age of 40 years. Amongst children, congenital anomalies like pyriform sinus fistula and 3rd or 4th branchial pouch have increased predisposition to develop AST. In adult patients, pre-existing thyroid lesions like Hashimotos thyroiditis or thyroid malignancy have higher chances to develop AST though idiopathic thyroid abscess cases have been reported in literature [2].

It is usually caused by hematogenous spread or direct inoculation by a pathogenic organism. Microbiological examination reveals Staphylococcus aureus and Streptococcus in most of the cases, occasionally some gram negative organisms and fungi (Coccidioides immitis, Aspergillus, and Actinomyces ) have been reported [3]. Salmonella and E coli are extremely rare causes of thyroid abscesses [4]. In our case, the patient had developed urosepsis, wherein E.coli mediated UTI in the urethra and bladder ascended to the kidneys and then entered the bloodstream causing bacteraemia. Hematogenous spread of the organism resulted in seeding of E. coli bacteria in the thyroid gland leading to acute suppurative thyroiditis and thyroid abscess. The Gram-negative E.coli in thyroid abscess is very unusual and extensive literature search revealed few cases [5, 6, 7, 8]. In our patient, we found an association of urinary tract infection with thyroid abscess which was confirmed by E.coli positivity in thyroid abscess pus culture report and previous urine culture reports.

This case report highlights that a midline neck abscess presenting as an acute onset painful swelling should be dealt as an absolute medical and surgical emergency. Our patient complained of odynophagia, sudden increase in the pre-existing neck swelling with erythematous changes of the overlying skin. Common clinical manifestations include pyrexia, sore throat, dysphagia, odynophagia, and a painful neck mass similar to how our case presented. Thyroid abscess can progress to deadly complications like necrotising mediastinitis, deep neck space abscess, tracheal or esophageal perforation [9]. Rarely, thyroid abscess patients have landed in thyroid storm due to upsurge of thyroid hormones at the time of acute bacterial infection [10]. Hence, it is imperative that these cases are posted under general anaesthesia for surgical intervention with adequate anaesthetic and surgical preparedness.

A biopsy is always conclusive and helpful to rule out malignancy which is an important differential in an elderly patient. Treatment usually involves parenteral antibiotic therapy along with surgical incision and drainage. Our case posed a challenge with major part of the left lobe undergoing necrosis and abscess cavity involving almost entire lobe. Abscess drainage and debridement may result in thyroid lobectomy and recurrent laryngeal nerve may lie exposed in the operative field. Meticulous dissection as in thyroid surgeries should be implemented during thyroid abscess drainage. Parenteral antibiotics and regular dressing of the neck wound along with optimisation of the immunocompromised state is the treatment of choice in such cases.

Acute suppurative Thyroiditis with thyroid lobe abscess caused by sepsis induced Escherichia coli spread secondary to Urinary Tract Infection is a rare clinical scenario in Otolaryngology department. Clinically, the huge thyroid mass caused gross tracheal deviation to contralateral side posed an impending airway emergency. Huge size of abscess cavity and involvement of entire left lobe had exposed the recurrent laryngeal nerve of the left side. The primary source of infection should be searched and meticulously treated because in majority of cases it occurs due to bacteriological spread from a distant site in the body.

Acknowledgements: We would like to show our gratitude to the patient and his family for giving their approval towards publication of this case report. We acknowledge the support of Medical Record Section, Department of ENT & Head neck surgery and Department of Anaesthesia of our institute.

Funding: There was no source of funding for this study.

Conflicts of interest/Competing interests: All authors declare that there were no conflict of interests and no competing interests for publication of this case report.

Ethics approval: Ethical approval was obtained from the Ethical Committee of the institute for conducting the study for this case report.

Consent to participate: Informed and written consent was obtained from the patient regarding participation in the study.

Written Consent for publication: Informed and written consent was obtained from the individual participant for publication of the case report.

Availability of data and material: All data generated during this study are included in this case report. The relevant data regarding the case (including clinical photographs) can be made available if needed for further clarification.

Code availability: Not applicable

Authors' contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by SC, RMJ, AG. The first draft of the manuscript was written by SC and all authors commented on all the versions of the manuscript. All authors read and approved the final manuscript.

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E. coli mediated Acute Suppurative Thyroiditis with Thyroid abscess in a patient with Urosepsis: Case report

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