MON-340 - Acute Bacterial Thyroiditis in A Patient with Multinodular Goiter

Background: Acute bacterial (suppurative) thyroiditis is a rare but potentially life-threatening condition. Predisposing factors include immunosuppression, diabetes mellitus, and underlying structural thyroid disease such as multinodular goiter, which may disrupt normal tissue architecture and immune defense.

Case Presentation: A 52-year-old woman with type 2 diabetes mellitus, class III obesity, and a three-year history of multinodular goiter presented with three days of progressively worsening anterior neck pain, acute enlargement of her goiter, dysphagia, and fever. She denied dyspnea or voice changes, and there were no clinical features suggestive of thyrotoxicosis.
Laboratory evaluation revealed an elevated white blood cell count: 13,600/mm³ (3,700–10,500), normal thyroid function: TSH 2.98 μIU/mL (0.27–4.20), free T4 1.1 ng/dL (0.8–1.8), total T3 1.1 ng/mL (0.8–2.0), and an elevated C-reactive protein: 6.3 mg/dL ( < 0.5).
Contrast-enhanced CT of the neck demonstrated marked thyroid enlargement with multiple nodules, the largest measuring 5.5 cm, along with bilateral cervical lymphadenopathy. There was rightward tracheal deviation without airway compromise, and no discrete fluid collection was identified. Blood cultures were obtained, and empiric broad-spectrum antibiotics vancomycin and piperacillin–tazobactam were initiated, along with anti-inflammatory and analgesic therapy. The patient experienced rapid clinical improvement in neck pain and swelling. Fine-needle aspiration of the thyroid revealed benign nodules without features of granulomatous thyroiditis. Antibiotic therapy was narrowed to amoxicillin–clavulanate at discharge.

Discussion: Acute bacterial thyroiditis typically presents with acute neck pain, swelling, and fever, with thyrotoxicosis occurring variably. In this patient, diabetes mellitus and multinodular goiter likely increased susceptibility to infection. Despite negative blood cultures and the absence of a drainable abscess on imaging, the elevated inflammatory markers, lymphadenopathy, and prompt response to antibiotics supported the diagnosis. Early recognition is essential given the risk of airway compromise and systemic infection.

Conclusion: Clinicians should maintain a high index of suspicion for acute bacterial thyroiditis in patients with structural thyroid disease who present with acute-onset neck pain, rapid goiter enlargement, and systemic symptoms, even in the absence of an abscess on imaging. Prompt antimicrobial therapy can prevent serious complications.
Reference: Lafontaine N, Learoyd D, Farrell S, Wong R. Suppurative thyroiditis: Systematic review and clinical guidance. Clin Endocrinol (Oxf). 2021; 95: 253–264.

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