Coincident Suppurative Thyroiditis and Graves Disease in a Patient with Infected Branchial Cleft CYST

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 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.

Acute suppurative thyroiditis with Graves disease – A very rare association

“…The symptoms and signs reported by our patient illustrate the typical presentation of acute thyroiditis. Most patients with AST present with fever, neck pain and swelling and elevated acute phase reactants (6). AST is associated with an elevation of erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) levels, as showed in our case (8).…”

“…However, there have been few cases reporting thyrotoxicosis in this setting (1,3,8). Thyrotoxicosis is usually transient and results from inflam mation and destruction of the gland, with release of preformed thyroid hormones into circulation, in the absence of elevated thyroid antibodies (6,8). However, in this case AST was characterized by excessive discharge of thyroid hormone and elevated TRABs levels, confirming a concomitant GD.…”

“…Later, in 2019 Lhamu and cols. described a case of a young man with an infected left fourth branchial cleft cyst and GD (6). Here we report the third case associating both conditions.…”

“…Despite its rarity, AST is a serious condition with a mortality rate of 3.7%-9% and a timely diagnosis is crucial (4). The mainstay treatment is broad-spectrum antibiotics and drainage is sometimes needed (2,6). However, the treatment course can be long and surgical resolution is required in cases of relapse despite medical treatment (4).…”

Case report: Fourth branchial cleft cyst: a case of acute suppurative thyroiditis

“…In this report, we describe the case of a healthy child with an anterior neck mass causing airway compression and thyroiditis, resulting from an infected fourth branchial cleft cyst that communicated with the superior left lobe of the thyroid. This association is not uncommon, according to the available literature (4)(5)(6)(7). However, due to the infrequent occurrence of these congenital malformations, they may not always be recognizable in clinical practice.…”