Suppurative thyroiditis in children and adolescents
- Itzhak Brook, MD, MSc
Itzhak Brook, MD, MSc
- Adjunct Professor, Department of Pediatrics
- Georgetown University School of Medicine
- Section Editors
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
- Mitchell Geffner, MD
Mitchell Geffner, MD
- Section Editor — Pediatric Endocrinology
- Professor of Pediatrics
- Keck School of Medicine, University of Southern California
Suppurative thyroiditis (ST) is caused by an infection of the thyroid gland (usually bacterial), and is rare, but potentially life-threatening [1-3]. The disease is far less common than other inflammatory conditions of the thyroid gland, including subacute granulomatous thyroiditis (which results from a viral infection of the gland) and chronic thyroiditis (which is usually autoimmune in nature). The signs and symptoms of ST may mimic these and other noninfectious inflammatory conditions. Recognition of the clinical and bacteriological features of ST is essential for prompt management.
The primary treatment for ST is antimicrobial therapy, directed against the likely bacterial pathogens. Although most cases of ST are caused by aerobic bacteria, anaerobic bacteria are increasingly recognized as a cause of ST, and this has led to revision of treatment protocols for this condition. Rarely, mycobacteria, fungi, or other nonbacterial pathogens may cause a subacute form of suppurative thyroiditis.
The pathogenesis, diagnosis, and treatment of acute suppurative thyroiditis in children are discussed here; subacute forms of suppurative thyroiditis are discussed briefly. The diagnosis and treatment of other inflammatory conditions of the thyroid gland, including subacute granulomatous thyroiditis and chronic thyroiditis, are discussed separately. (See "Clinical manifestations and diagnosis of hyperthyroidism in children and adolescents", section on 'Differential diagnosis of thyrotoxicosis' and "Overview of thyroiditis", section on 'Subacute thyroiditis' and "Acquired hypothyroidism in childhood and adolescence", section on 'Chronic autoimmune (Hashimoto’s) thyroiditis'.)
The thyroid gland is relatively resistant to infections . The rarity of thyroid infection has been explained by the high concentration of iodine within the gland, ample supply of blood and lymphatics, and the anatomical isolation of the gland from other neck structures. This isolation is due to the capsule around the thyroid gland and the lack of direct communication with neighboring structures. All of these features make the thyroid gland relatively resistant to infection by direct extension from contiguous sites [1,2].
Pyriform sinus fistula — In children, a fistula from the pyriform sinus associated with a third or fourth branchial arch anomaly  is a common route through which bacteria infect the thyroid gland (image 1) [5-7]. This type of fistula extends from the pharynx to the thyroid capsule and is almost always left-sided; the anomaly is particularly likely to be found in children with recurrent or left-sided ST. For a child with a pyriform sinus fistula presenting with a first episode of suppurative thyroiditis, the risk of recurrent thyroiditis has not been established, but appears to be high [5,6,8,9].
- Shah SS, Baum SG. Diagnosis and Management of Infectious Thyroiditis. Curr Infect Dis Rep 2000; 2:147.
- Paes JE, Burman KD, Cohen J, et al. Acute bacterial suppurative thyroiditis: a clinical review and expert opinion. Thyroid 2010; 20:247.
- Wongphyat O, Mahachoklertwattana P, Molagool S, Poomthavorn P. Acute suppurative thyroiditis in young children. J Paediatr Child Health 2012; 48:E116.
- Nishiyama RH. Overview of surgical pathology of the thyroid gland. World J Surg 2000; 24:898.
- Yolmo D, Madana J, Kalaiarasi R, et al. Retrospective case review of pyriform sinus fistulae of third branchial arch origin commonly presenting as acute suppurative thyroiditis in children. J Laryngol Otol 2012; 126:737.
- Rich EJ, Mendelman PM. Acute suppurative thyroiditis in pediatric patients. Pediatr Infect Dis J 1987; 6:936.
- Sai Prasad TR, Chong CL, Mani A, et al. Acute suppurative thyroiditis in children secondary to pyriform sinus fistula. Pediatr Surg Int 2007; 23:779.
- Pereira KD, Davies JN. Piriform sinus tracts in children. Arch Otolaryngol Head Neck Surg 2006; 132:1119.
- Taphey M, Pornkul R. Acute suppurative thyroiditis due to pyriform sinus fistula: a case report. J Med Assoc Thai 2010; 93:388.
- Bussman YC, Wong ML, Bell MJ, Santiago JV. Suppurative thyroiditis with gas formation due to mixed anaerobic infection. J Pediatr 1977; 90:321.
- Madana J, Yolmo D, Gopalakrishnan S, Saxena SK. Complete congenital third branchial fistula with left-sided, recurrent, suppurative thyroiditis. J Laryngol Otol 2010; 124:1025.
- Gaafar H, El-Garem F. Acute thyroiditis with gas formation. J Laryngol Otol 1975; 89:323.
- Brook I. Microbiology and management of acute suppurative thyroiditis in children. Int J Pediatr Otorhinolaryngol 2003; 67:447.
- Higbee D. Acute thyroiditis in relation to deep infections of the neck. Ann Otol Rhinol Laryngol 1943; 52:620.
- Yung BC, Loke TK, Fan WC, Chan JC. Acute suppurative thyroiditis due to foreign body-induced retropharyngeal abscess presented as thyrotoxicosis. Clin Nucl Med 2000; 25:249.
- Yu EH, Ko WC, Chuang YC, Wu TJ. Suppurative Acinetobacter baumanii thyroiditis with bacteremic pneumonia: case report and review. Clin Infect Dis 1998; 27:1286.
- Golshan MM, McHenry CR, de Vente J, et al. Acute suppurative thyroiditis and necrosis of the thyroid gland: a rare endocrine manifestation of acquired immunodeficiency syndrome. Surgery 1997; 121:593.
- Robazzi TC, Alves C, Mendonça M. Acute suppurative thyroiditis as the initial presentation of juvenile systemic lupus erythematosus. J Pediatr Endocrinol Metab 2009; 22:379.
- Jeng LB, Lin JD, Chen MF. Acute suppurative thyroiditis: a ten-year review in a Taiwanese hospital. Scand J Infect Dis 1994; 26:297.
- Lindsay LM, Mead CI. Tuberculosis of the thyroid gland with report of a case in a child aged three. Canad Med Assoc J 1934; 30:373.
- Chi H, Lee YJ, Chiu NC, et al. Acute suppurative thyroiditis in children. Pediatr Infect Dis J 2002; 21:384.
- Brook I. Role of methicillin-resistant Staphylococcus aureus in head and neck infections. J Laryngol Otol 2009; 123:1301.
- Adeyemo A, Adeosun A, Adedapo K. Unusual cause of thyroid abscess. Afr Health Sci 2010; 10:101.
- Sayyahfar S, Nasiri SJ. First report of a thyroid abscess in the pediatric age group caused by Arcanobacterium haemolyticum. J Infect Chemother 2012; 18:584.
- Maraj A, Kiss A, Luvhengo TE. Salmonella thyroiditis: a case report and review of the literature. S Afr J Surg 2013; 51:149.
- Yoshino Y, Inamo Y, Fuchigami T, et al. A pediatric patient with acute suppurative thyroiditis caused by Eikenella corrodens. J Infect Chemother 2010; 16:353.
- Abe K, Taguchi T, Okuno A, et al. Recurrent acute suppurative thyroiditis. Am J Dis Child 1978; 132:990.
- Brook I. Emergence and persistence of beta-lactamase-producing bacteria in the oropharynx following penicillin treatment. Arch Otolaryngol Head Neck Surg 1988; 114:667.
- Appelbaum PC, Cohen IT. Thyroid abscess associated with Eikenella corrodens in a 7-year-old child. Clin Pediatr (Phila) 1982; 21:241.
- N'gattia KV, Kacouchia NB, Vroh BT, Kouassi-Ndjeundo J. Suppurative thyroiditis and HIV infection. Eur Ann Otorhinolaryngol Head Neck Dis 2015; 132:371.
- Ataca P, Atilla E, Saracoglu P, et al. Aspergillus Thyroiditis after Allogeneic Hematopoietic Stem Cell Transplantation. Case Rep Hematol 2015; 2015:537187.
- Aamir S, Rizvi AA. Visual vignette. Suppurative thyroiditis due to Nocardia asteroides. Endocr Pract 2012; 18:426.
- Teckie G, Bhana SA, Tsitsi JM, Shires R. Thyrotoxicosis followed by Hypothyroidism due to Suppurative Thyroiditis Caused by Nocardia brasiliensis in a Patient with Advanced Acquired Immunodeficiency Syndrome. Eur Thyroid J 2014; 3:65.
- Spitzer M, Alexanian S, Farwell AP. Thyrotoxicosis with post-treatment hypothyroidism in a patient with acute suppurative thyroiditis due to porphyromonas. Thyroid 2012; 22:97.
- Guttler R, Singer PA, Axline SG, et al. Pneumocystis carinii thyroiditis. Report of three cases and review of the literature. Arch Intern Med 1993; 153:393.
- Slatosky J, Shipton B, Wahba H. Thyroiditis: differential diagnosis and management. Am Fam Physician 2000; 61:1047.
- Crisafulli G, Wasniewska M, Ascenti G, et al. Acute suppurative thyroiditis disclosing diagnosis of thyroid cancer in a boy. J Endocrinol Invest 2008; 31:1137.
- Spitzer RD, Chan JC, Marks JB, et al. Case report: hypothyroidism due to pneumocystis carinii thyroiditis in a patient with acquired immunodeficiency syndrome. Am J Med Sci 1991; 302:98.
- Battan R, Mariuz P, Raviglione MC, et al. Pneumocystis carinii infection of the thyroid in a hypothyroid patient with AIDS: diagnosis by fine needle aspiration biopsy. J Clin Endocrinol Metab 1991; 72:724.
- Masuoka H, Miyauchi A, Tomoda C, et al. Imaging studies in sixty patients with acute suppurative thyroiditis. Thyroid 2011; 21:1075.
- Naik KS, Bury RF. Imaging the thyroid. Clin Radiol 1998; 53:630.
- Chang YW, Hong HS, Choi DL. Sonography of the pediatric thyroid: a pictorial essay. J Clin Ultrasound 2009; 37:149.
- McCarty M, Coker R, Claydon E. Case report: disseminated Pneumocystis carinii infection in a patient with the acquired immune deficiency syndrome causing thyroid gland calcification and hypothyroidism. Clin Radiol 1992; 45:209.
- Miyauchi A, Matsuzuka F, Kuma K, Takai S. Piriform sinus fistula: an underlying abnormality common in patients with acute suppurative thyroiditis. World J Surg 1990; 14:400.
- Jordan JA, Graves JE, Manning SC, et al. Endoscopic cauterization for treatment of fourth branchial cleft sinuses. Arch Otolaryngol Head Neck Surg 1998; 124:1021.
- Park NH, Park HJ, Park CS, et al. The emerging echogenic tract sign of pyriform sinus fistula: an early indicator in the recovery stage of acute suppurative thyroiditis. AJNR Am J Neuroradiol 2011; 32:E44.
- Parida PK, Gopalakrishnan S, Saxena SK. Pediatric recurrent acute suppurative thyroiditis of third branchial arch origin--our experience in 17 cases. Int J Pediatr Otorhinolaryngol 2014; 78:1953.
- Mou JW, Chan KW, Wong YS, et al. Recurrent deep neck abscess and piriform sinus tract: a 15-year review on the diagnosis and management. J Pediatr Surg 2014; 49:1264.
- Lu Y, Zhang J, Liang X, et al. Efficacy of fine-needle aspiration cytology for a thyroid abscess in children: Two case reports. Exp Ther Med 2015; 9:860.
- Smith SL, Pereira KD. Suppurative thyroiditis in children: a management algorithm. Pediatr Emerg Care 2008; 24:764.
- Miyauchi A, Inoue H, Tomoda C, Amino N. Evaluation of chemocauterization treatment for obliteration of pyriform sinus fistula as a route of infection causing acute suppurative thyroiditis. Thyroid 2009; 19:789.
- Madana J, Yolmo D, Gopalakrishnan S, Saxena SK. Cervical infection secondary to pyriform sinus fistula of branchial origin. Congenit Anom (Kyoto) 2009; 49:276.
- Pereira O, Prasad DS, Bal AM, et al. Fatal descending necrotizing mediastinitis secondary to acute suppurative thyroiditis developing in an apparently healthy woman. Thyroid 2010; 20:571.
- Lough DR, Ramadan HH, Aronoff SC. Acute suppurative thyroiditis in children. Otolaryngol Head Neck Surg 1996; 114:462.
- Sultany GL, Kahaleh MB. Acute rheumatic fever after thyroid abscess in an adult. South Med J 1983; 76:810.