Acute suppurative thyroiditis (AST) is frequently caused by anatomic abnormalities, including branchial cleft cysts. Patients with AST are typically euthyroid, but thyrotoxicosis may occur. Thyroid antibodies are usually not present in AST. Our objective is to describe a teenage male who presented with concomitant suppurative thyroiditis and Graves disease (GD).
Case Report COINCIDENT SUPPURATIVE THYROIDITIS AND GRAVES DISEASE IN A PATIENT WITH INFECTED BRANCHIAL CLEFT CYST Ugen Lhamu, MD1,2; Ari J Wassner, MD3,4; Lisa Swartz Topor, MD, MMS1,2 ABSTRACT Objective: Acute suppurative thyroiditis (AST) is frequently caused by anatomic abnormalities, including branchial cleft cysts Patients with AST are typically euthyroid, but thyrotoxicosis may occur Thyroid antibodies are usually not present in AST Our objective is to describe a teenage male who presented with concomitant suppurative thyroiditis and Graves disease (GD) Methods: We report a case of an infected left branchial cleft cyst with AST and concurrent GD in an adolescent male Thyroid function tests and thyroid imaging were used for diagnostic evaluation, and the patient was managed with antibiotics, analgesia, and surgery Results: A 17-year-old male with a history of an infected left fourth branchial cleft cyst presented with recurrence of neck pain, odynophagia, and fever Serum labs showed thyrotoxicosis and elevated thyroid antibodies and inflammatory markers Magnetic resonance imaging showed an abscess adjacent to the left thyroid lobe Symptoms resolved after antibiotic therapy, but laboratory tests showed persistent subclinical thyrotoxicosis Four months later, he underwent excision of the branchial cleft Submitted for publication May 19, 2019 Accepted for publication July 17, 2019 From the 1Division of Pediatric Endocrinology, Hasbro Children’s Hospital, Providence, Rhode Island, 2Warren Alpert Medical School of Brown University, Providence, Rhode Island, 3Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts, and 4Harvard Medical School, Boston, Massachusetts Address correspondence to Dr Lisa Swartz Topor, 111 Plain Street, Providence, RI 02903 E-mail: lisa_swartz_topor@brown.edu DOI:10.4158/ACCR-2019-0236 To purchase reprints of this article, please visit: www.aace.com/reprints Copyright © 2019 AACE Copyright © 2019 AACE cyst and left thyroid lobe Two months after surgery, evaluation showed overt thyrotoxicosis with laboratory tests confirming GD Methimazole was initiated and thyroid function subsequently normalized Conclusion: This patient manifested a rare coincidence of AST due to a branchial cleft cyst and autoimmune thyroid disease Further studies are needed to determine if there is any relationship between AST and development of thyroid autoimmunity Assessment of thyroid autoimmunity may be considered in patients with prior or recurrent AST (AACE Clinical Case Rep 2019;5:e365-e368) Abbreviations: AST = acute suppurative thyroiditis; GD = Graves disease; T3 = triiodothyronine; T4 = thyroxine; TBII = thyroid-binding inhibitory immunoglobulin; TSH = thyroid-stimulating hormone; TSI = thyroid-stimulating immunoglobulin INTRODUCTION Acute suppurative thyroiditis (AST) is usually caused by bacterial infection and typically presents with anterior neck swelling, pain, and fever (1) Thyroid function usually remains normal, but AST can lead to transient thyrotoxicosis due to destruction of thyroid follicles and release of preformed thyroid hormones Most patients with AST have complete resolution with antibiotics, but mortality may occur if treatment is delayed (1) Patients with AST should be evaluated for anatomic causes, including branchial anomalies, which may predispose them to infection In the pediatric population, branchial anomalies occur due to abnormal development of any of the branchial structures (2,3) The most common branchial anomaly (95%) is a second branchial cleft cyst, whereas a pyriform sinus fistula is the most common anomaly found during evalua- AACE CLINICAL CASE REPORTS Vol No November/December 2019 e365 e366 Suppurative Thyroiditis and GD, AACE Clinical Case Rep 2019;5(No 6) tion after AST (4,5) Fourth branchial cleft cysts are rare (6) Here we report case of a male adolescent with recurrent infection of a fourth left branchial cleft cyst and AST as well as concurrent Graves disease (GD) CASE REPORT A 17-year-old male presented to his primary care provider with day of neck pain, neck stiffness, and odynophagia He had no tremor, palpitations, weight loss, or increased frequency of bowel movements Family history included autoimmune thyroid disease in grandparents Four years prior, he had presented with similar symptoms and was diagnosed with an infected left fourth branchial cleft cyst based upon computed tomography imaging of the neck The infection was successfully treated with intravenous antibiotics, and he was euthyroid throughout this initial episode During his second presentation, a neck ultrasound showed a heterogenous and hyperemic thyroid gland suggestive of thyroiditis, as well as an infiltrating, heterogeneously hypoechoic structure in the lower pole of the thyroid gland Laboratory tests showed a white blood cell count of 13.5 × 109 cells/L (reference range is 3.5 to 11 × 109 cells/L) with 76% segmented neutrophils, erythrocyte sedimentation rate of 56 mm/hour (reference range is to 15 mm/hour), and C-reactive protein of 153 mg/mL (reference range is