The Gathering Storm: A Case of Fever and Neck Pain

1University of California, San Francisco, San Francisco, CA

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 242

Case Presentation:

A 47‐year‐old man with a history of ul‐cerative colitis (UC) was admitted for malaise, fever, and neck pain. On arrival he was ill‐appearing, febrile (39.2°C), hypotensive (80/63 mm Hg), and tachycardic (163 bpm) with an exam notable for tender thyromegaly. Of note, the patient had been recently hospitalized for UC‐related hemorrhagic proctitis, during which he had had a peripherally inserted central catheter placed and removed prior to discharge. Initial management focused on volume resuscitation, initiation of broad‐spectrum antibiotics, and urgent evaluation for sources of infection. Neck CT showed an enlarged heterogeneous thyroid, which in this context was most consistent with acute suppurative thyroiditis. Thyroid‐stimulating hormone (TSH) was 0.08 mIU/L (0.4–4 mIU/L), and free T4 was 47 pmol/L (9–24 pmol/L). Blood cultures grew methicillin‐resistant Staphylococcus aureus. Because of concern for an embolic source of the thyroid infection, an echocardiogram was done, which revealed vegetations on the aortic valve and papillary muscle. His recent central line was a key risk factor for endovascular infection. On hospital day 3 he developed new altered mental status and hypertension. Repeat free T4 was above the assay maximum. His presentation was now most consistent with thyrotoxic crisis, which resolved after treatment with corticosteroids and propranolol. Although he improved clinically, a thyroid ultrasound done for persistent leukocytosis showed an abscess. This was successfully managed with percutaneous drainage and did not require surgical intervention. The patient ultimately developed hypothyroidism requiring oral replacement therapy, but he recovered well and was discharged to a skilled nursing facility for reconditioning.

Discussion:

Acute suppurative thyroiditis is a bacterial infection of thyroid tissue, most commonly caused by Staphylococcus aureus. Although it more often occurs in children with congenital connections between the thyroid and the oropharynx, it is also recognized as an uncommon complication of bacteremia. Inflammation causes release of preformed thyroid hormone in a TSH‐independent manner, and in rare cases this leads to thyrotoxic crisis. Because the hormone is preformed, thyroid suppressive‐medications are unnecessary. Although traditionally treated with surgical de‐bridement, recent case series demonstrated that conservative management with antibiotics and percutaneous drainage can be successful. Hypothyroidism is a common late complication.

Conclusions:

Acute suppurative thyroiditis is a rare complication of bacteremia and can cause thyro‐toxicosis. Although surgical debridement was previously thought to be essential, increasing experience reveals that conservative management can be successful in select cases.

Disclosures:

K. Bischoff ‐ none; S. Berkowitz ‐ none; S. Rennke ‐ none; N. Sehgal ‐ none

To cite this abstract:

Bischoff K, Berkowitz S, Rennke S, Sehgal N. The Gathering Storm: A Case of Fever and Neck Pain. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 242. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/the-gathering-storm-a-case-of-fever-and-neck-pain/. Accessed July 19, 2019.

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