Subacute thyroiditis in children: patient report and review of the literature

Subacute thyroiditis is extremely rare during childhood. We treated a 10 year-old prepubertal girl who presented with typical clinical features of subacute thyroiditis. Considering this case and previous reports in children, we characterized the clinical features of this disorder as it occurs in childhood. In contrast to the predominance of subacute thyroiditis in adults, the incidence of subacute thyroiditis is lower than that of acute suppurative thyroiditis in children. This may cause difficulty with differential diagnosis, particularly when leukocytosis is present or the lesion is localized to the left lobe. Ultrasonography can be helpful in differentiation.     

Atypical presentation of subacute thyroiditis.

Subacute thyroiditis is extremely rare during the first decade of life. We describe a case of subacute thyroiditis in a 2 year old child whose initial clinical, sonographic, and radioisotopic features were indistinguishable from acute suppurative thyroiditis. The diagnosis was established by a raised antibody titre against adenovirus and typical increased thyroid function tests.     

Graves disease presenting as painful thyroiditis

Hyperthyroidism associated with subacute (painful, viral) thyroiditis is well-recognized as a clinical entity; the thyroid gland in Graves disease is minimally, if ever, tender and painful. We describe a 10-year-old girl with hyperthyroidism whose initial clinical presentation was predominantly a painful, tender goiter. Graves disease was established by high uptake of ¹³¹I with a diffuse pattern of distribution of radioactivity on scan and the presence of thyroid-stimulating antibody. Thyrotropin-binding inhibiting IgG and antibody to thyroid microsomal antigen were both positive. She responded well to treatment with propylthiouracil and had spontaneous regression of her thyroid pain. The cause of the severe pain and tenderness remains speculative.Abbreviations PTU propylthiouracil - TSAb thyroid-stimulating antibody This work was supported by the U.S. Public Health Service Grant DK-31391     

Acute suppurative thyroiditis as a rare complication of aggressive chemotherapy in children with acute myelogeneous leukemia

Acute suppurative thyroiditis (AST) is quite rare, even in immunocompromised patients. The authors describe 2 cases of AST during aggressive chemotherapy for acute myelogeneous leukemia (AML). They were treated with aggressive combination chemotherapy and achieved complete remission. After several courses of chemotherapy, they developed fever and pain in the region of the thyroid gland. Laboratory tests showed hyperthyroidism and elevated levels of thyroglobulin and C-reactive protein. Ultrasonography revealed hypoechoic areas in the thyroid gland. A diagnosis of AST was made. Bacterial infections were suspected because they were successfully treated with antibiotics. After a month, the patients' thyroid function and thyroglobulin levels returned to normal without a period of transient hypothyroidism. A pyriformsinus fistula was not demonstrated. The results suggest that neutropenia and preceding cellulitis around the thyroid gland, which might be subsequent to oral mucosal damage induced by anticancer drugs, may play a role in the development of AST. AST should be considered a potential complication of aggressive chemotherapy for leukemia.     

Acute suppurative thyroiditis in young children

We report two children with acute suppurative thyroiditis (AST). They presented with typical features of AST, which include fever, painful goiter and biochemical euthyroidism. An anatomical defect predisposed to thyroid infection, pyriform sinus fistula, was identified in one patient. Both patients responded well to surgical pus drainage and antibiotic treatment. Anatomical defects must be sought in all children with AST to perform specific surgical treatment and prevent recurrent infection.     

Actinomycotic suppurative thyroiditis in a child

AIM: To present a rare case of actinomycotic suppurative thyroiditis in an infant with provision of the etiology, pathogenesis, clinical findings and treatment of this rare disease. DESIGN: A report of an 18-month-old female infant who presented with fever, erythema, induration and tenderness of the neck. The patient had the diagnosis of acute suppurative thyroiditis after a series of laboratory evaluation. RESULT: She was treated successfully with surgical debridement and intravenous penicillin G. CONCLUSION: Although rare, Actinomyces spp. should be considered in the etiology of acute suppurative thyroiditis. Because of its fastidious nature the probability of positive culture is low, thus, the microbiology laboratory should be called in advance to make preparations before culture and transport.     

Eikenella corrodens as a cause of thyroid abscess

Acute suppurative thyroiditis in children is rarely reported. It is generally associated with upper respiratory tract infections and is manifest as an acute febrile illness with swelling of the thyroid gland. Diagnosis is established by aspiration of the affected area, and cultures for both aerobic and anaerobic bacteria should be carried out. Therapy is based on drainage of the abscess and treatment with specific antimicrobial drugs, as determined by culture results. We describe a 3 1/2-year-old girl with a thyroid abscess from whom Eikenella corrodens, in addition to mixed flora, was recovered. No disturbance in thyroid function was observed. We review the pathogenesis of acute bacterial infections of the thyroid gland and the literature regarding the specific cause of these infections.     

Recurrent suppurative thyroiditis due to pyriform sinus fistula: a case report

Acute suppurative thyroiditis is a rare disease, particularly in childhood. We present a case with recurrent acute suppurative thyroiditis due to a pyriform sinus fistula originating from the fourth branchial pouch. The typical symptoms of a piriform sinus fistula are recurrent left-sided pain and swelling of the neck with signs of acute bacterial inflammation. Diagnosis should be made by high resolution ultrasound, barium meal studies and endoscopic examination. During acute exacerbations treatment with antibiotics is indicated, but permanent cure can only be attained by complete fistulectomy.     

Congenital piriformo-thyroid fistula as a cause of recurrent suppurative thyroiditis

A previously healthy five year old boy presented with suppurative, febrile thyroiditis of the left lobe with pronounced general and local signs of inflammation, normal thyroid function and lack of thyroid antibodies. Intravenous antibiotic therapy improved the condition quickly. Six and nine months later however recurrent left lobe thyroiditis occurred. Endoscopic examination showed an internal fistula from the left piriform sinus to the left thyroidal lobe which was cut out. The case report confirms previous communications, that recurrent suppurative thyroiditis is nearly always caused by a piriform sinus fistula, probably a fourth pharyngeal pouch remnant which can be cured surgically.     

Acute suppurative thyroiditis in children.

Ten cases of acute suppurative thyroiditis were studied. All patients remained euthyroid clinically during the course of this disease and during the follow-up. Of seven cases in which bacterial cultures were performed, an aerobic bacterium alone was isolated in one patient and anaerobic bacteria alone in four patients. Mixed aerobic and anaerobic microorganisms were recovered from one patient and cultures were negative in one case. Plasma TSH, T4, T3, and PBI levels were normal except in one case. The 131I uptake values were normal in six of seven cases. Plasma TSH response to TRH stimulation was normal in four of five cases. Antibodies against thyroglobulin and thyroid microsome were negative in four of six cases. These findings suggest that anaerobic bacteria may play an important role in the pathogenic process of acute suppurative thyroiditis and that the pituitary-thyroid functions are not impaired.     

Thyroid disease in the pediatric patient: emphasizing imaging with sonography

Thyroid disease does occur in the pediatric patient, and imaging plays an important role in its evaluation. A review is presented of normal development of the thyroid gland, the technique and indications for thyroid sonography, and key imaging features of congenital thyroid disorders (ectopic or absent thyroid, infantile goiter, thyroglossal duct remnants), benign thyroid masses (follicular adenoma, degenerative nodules, colloid and thyroid cysts), malignant masses (follicular, papillary and medullary carcinoma) and diffuse thyroid disease (acute bacterial thyroiditis, Hashimoto's thyroiditis, Grave's disease).     

Thyroiditis in children. Personal observations

Enlargement of the thyroid gland, local tenderness and thyroid function disorder are common symptoms of thyroiditis. Hashimoto's thyroiditis (chronic lymphocytic thyroiditis) is the most common form of thyroiditis in children. This disease is a frequent cause of acquired hypothyroidism. Hashimoto's thyroiditis (HT) is characterised by infiltration of the thyroid gland by lymphocytes, gradual destruction of the gland and production of various thyroid autoantibodies, mainly antimicrosomal (ATM) and antithyroglobulin antibodies (ATGL). 54 children (45 girls and 9 boys) aged from 11 to 18 with confirmed or suspected HT were observed. The clinical diagnosis of HT was confirmed by fine needle aspiration biopsy (FNAB) in 27 patients. In one case HT was histologicaly confirmed after thyroid surgery. FNAB was not carried out in 19 patients and in 7 cases FNAB was thyroiditis negative. All patients were positive for ATM and/or ATGL. Initially 24 patients were euthyroid. Hypothyroidism was recognized in 8 children, subclinical hypothyroidism in 11 children. One patient was hyper- thyroid. 51 patients were treated with l-thyroxin. Ultrasonography revealed variable thyroid abnormality in all patients: hyperplasia in 38 patients, multinodular goiter or solitary nodule in 15 patients. 8 children suffered from associated disease: 5 patients from allergy, 1 patient from trombocytopenia, 1 from alopecia areata, 1 from secondary amenorrhea. Follow up examination of children with HT must be continued due to the risk of hypothyroidism or neoplastic disease of thyroid.     

Sonography of multinodular thyroid gland in children and adolescents.

Multinodular disease of the thyroid gland is uncommon in children and adolescents, and has received little attention in the recent literature. This article reviews the clinical, sonographic, and pathologic findings in 16 children with multinodular disease of the thyroid gland, and draws attention to the high incidence of other associated clinical findings. This condition was associated with a triad including renal and digital anomalies in three patients, with McCune-Albright syndrome in two patients, with Hashimoto's thyroiditis in three patients, and with thyroid carcinoma in four patients. Three of five patients with a history of previous radiation therapy had thyroid carcinoma. Sonography is a proven valuable imaging modality for the study of thyroid disease in children and has contributed to our understanding of multinodular disease of the thyroid gland in this age group.     

Acute suppurative thyroiditis in children

BACKGROUND: Acute suppurative thyroiditis in children is rare and is often related to a pyriform sinus fistula or thyroglossal duct remnant, especially when it is recurrent. METHODS: From January, 1985, through December, 2000, 15 children with acute suppurative thyroiditis were treated. Their clinical, laboratory and radiologic findings were reviewed and analyzed. RESULTS: There were 8 girls and 7 boys, with a mean age at diagnosis of 6.1+/-2.9 years (range, 1.5 to 9.8). A thyroid mass was present on the left in 13 and on the right in 2 (P < 0.05). Fever, neck pain and swelling were the most common symptoms and signs. Seven patients (46.7%) had recurrent disease. Needle aspiration for Gram stain and bacterial cultures were done, and pathogenic organisms were identified on culture in 8 patients but were found only on Gram stain in 2 patients. In one-half of the patients with positive cultures, mixed pathogens were found. The most common organisms isolated were streptococcal species (50%). Barium esophagography was performed in all patients, and 5 (33.3%) had a pyriform sinus fistula on the left. Only 1 of the recurrent patients had a fistula. Thyroid scans were performed in 13 patients, of whom 12 (92.3%) had decreased radioactive uptake. Thyroid function tests were normal in all 15. CONCLUSIONS: Acute suppurative thyroiditis is usually caused by oropharyngeal flora, resulting in mixed pathogens on culture. Broad spectrum antibiotics should be given once cultures have been obtained. Imaging studies might be helpful in the diagnosis of acute suppurative thyroiditis.     

Acute thyroiditis caused by Eikenella corrodens and abnormality of the left pyriform sinus

A case of suppurative thyroiditis is reported. The initial course was insidious and mimicked De Quervain subacute thyroiditis. The abscess was surgically drained. It contained numerous Eikenella corrodens bacilli. Fibroscopy of pharyngo-laryngeal region showed that the left pyriform sinus was abnormal. Surgical removal of a fistula of the fourth branchial pouch was performed in order to prevent recurrence of the thyroiditis.     

Typical and Atypical Subacute Thyroiditis in Twin Girls

Twin girls with subacute thyroiditis are described. Twin A showed typical features of the disease. Twin B showed a goiter with normal radioiodine uptake and mild thyrotoxi-cosis and the histological findings on needle biopsy specimens were indicative of simple goiter. However, their clinical courses during the observation period were quite similar and were characterized by an initial thyrotoxic phase followed by a rapid decrease of T₄ levels and gradual recovery to a stable euthyroid state. The diagnostic problem in differentiation between simple goiter and subacute thyroiditis in Twin B was resolved by the above clinical course. Subacute thyroiditis is rare in children, however, exclusion of this disease should be made only after careful observation of the clinical course. (Acta Paediatr Jpn 23(2): 139–142 1981)     

Autoimmune thyroiditis in children and adolescents: clinical and laboratory findings in 34 patients

Autoimmune thyroiditis (AT) is the most common cause of nonendemic thyromegaly and acquired hypothyroidism in childhood and adolescence. Outgoing from an increasing number of newly diagnosed patients during the last years we performed a retrospective analysis including 34 patients treated between 1989 and 1998. Clinical data, laboratory and sonographical findings are described. Cases were ascertained by palpable thyroid enlargement or clinical signs of thyroid dysfunction and positive autoantibodies against thyroid tissue. Frequency of AT diagnosis has threefold increased since 1995 in our department. Age at diagnosis was 5.4 to 16.3 years (median 11.3). Palpable thyromegaly was present in 29 (85%) of our patients. Three patients had myxedema without goiter. Symptoms had been present for a period between 6 weeks and 7.5 years: median in all patients 6 months, median in hypothyroid patients 9 months. At time of diagnosis 15 patients suffered from hypothyroidism, 3 from hyperthyroidism and 7 patients showed normal levels of thyroid hormones. In 9 patients we found an isolated elevation of thyrotropin. 12 patients were prepubertal (Tanner I), 15 patients were pubertal (Tanner II-IV). 5 patients showed a dissociation of pubertal maturation. Ultrasound of thyroid gland showed an inhomogeneous and hypoechoic pattern in 32 patients. 30 patients were treated with thyroxine. Patients with persistent hyperthyroidism were treated with carbimazol. During the follow-up period enlargement of the thyroid gland decreased in one third of the patients. Thyromegaly caused by autoimmune thyroiditis gets an increasing importance. The high degree of obviously hypothyroid patients at the time of diagnosis reflects a delay of diagnosis. Early recognition and treatment of the disease should be achieved for a preventive care of hypothyroidism.     

Non-Hodgkin's lymphoma in childhood presenting as thyroid enlargement

The authors report a case of a 10-year-old girl with early involvement of the thyroid gland by non-Hodgkin's lymphoma, an uncommon site of presentation of childhood lymphomas. In pediatrics, thyroid enlargement is more often caused by lymphocytic thyroiditis. The good response to therapy, in spite of the advanced stage of the disease, is noted.     

Clinical and microbiological analysis of six children with acute suppurative parotitis

Six children including two neonates with acute suppurative parotitis are described. They presented typical symptoms and signs of fever (4/6) and swelling (6/6), tenderness (6/6), erythema (4/6) and local warmness (4/6) of the parotid gland affected. Leucocytosis and an elevated erythrocyte sedimentation rate and serum amylase level may be seen. The presence of purulent discharge from the Stensen duct when the parotid gland is externally compressed is pathognomonic of the disease, and the microbiological diagnosis can be made by culture of the pus. Microbiologically, this series highlights the polymicrobic nature and importance of Streptococcus viridans in paediatric suppurative parotitis, indicating, therefore, that the causative bacteria entered the gland from the oral cavity. Our data also suggest that initial antibiotic therapy for such patients should provide adequate coverage for streptococci and staphylococci as well as for anaerobic bacteria.     

Conservative strategies in treating thyroid diseases in children

In the Federal Republic of Germany disorders of the thyroid gland are among the most common chronic diseases of childhood and adolescence. In Munich 30% of schoolchildren, in G?ttingen 16% of children 6 to 16 years of age have goiters. Iodine deficiency is the most important etiological reason for the development of euthyroid goiter, which is encountered in more than 80% of children and adolescents suffering from thyroid disorders. Lymphocytic chronic thyroiditis (Hashimoto) causes goiters which may be eu-, hypo- but also hyperthyroid. Thyrotoxicosis (M. Basedow, Grave's Disease) in childhood occurs mainly in pubertal girls. The frequency of congenital hypothyroidism in West Germany is 1:3,800 neonates. The postnatally acquired hypothyroidism in childhood is as rare as hyperthyroidism caused by toxic thyroid adenoma. 27% of nodular goiters in childhood are due to Thyroid carcinoma. The diagnostic procedure of evaluation of thyroid disorders in childhood includes family and past personal history, palpatory findings, ultrasonography and the determination of TSH and thyroid hormone plasma concentrations. The aims of conservative management of thyroid diseases during childhood and adolescence are 1st normalisation of size of the thyroid gland, 2nd achievement and maintenance of euthyroid function.(ABSTRACT TRUNCATED AT 250 WORDS)