Hypertension Secondary to Thyrotoxicosis Caused by Acute Suppurative Thyroiditis

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 449-497-Thyroid Neoplasia & Case Reports
Clinical
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-472
Rajan Senguttuvan*, Miranda Marguerite Broadney and Priti Gupta Patel
University of Arizona, Tucson, AZ
BACKGROUND:The prevalence of childhood hypertension in the United States approaches 5% of which 70% is secondary to an identifiable cause. However, hypertension caused by thyrotoxicosis secondary to Acute Suppurative Thyroiditis (AST) is extremely rare. AST most commonly is associated with a pyriform sinus fistula. Most cases of AST are caused by aerobic bacteria; however, anerobic bacteria are increasingly recognized as a cause of AST. Normally, AST does not lead to thyroid dysfunction.

CLINICAL CASE:A previously healthy 3 year old male presented with 5 days of fever, sore throat and progressive neck swelling to a community hospital. He was presumed to have Group A streptococcal infection and started on antibiotics. As he acutely worsened with complaints of a choking sensation and severe pain in his neck, his mother promptly presented to the ER. Vital Signs in the ER demonstrated a temperature 36 °C, blood pressure 140/103 mmHg and heart rate 170 bpm. The neck exam demonstrated marked erythema of the anterior lower neck with an exquisitely tender indurated area, 5-6 cm in diameter which extended laterally to the left. His CBC showed a leucocyte count of 36,000 with 93 % segmented neutrophils, elevated platelet count at 421,000 and elevated CRP of 36. A neck CT scan with contrast identified an infrahyoid multiloculate 4x3x5 cm left neck abscess. ENT was consulted and incision and drainage was performed. Post operatively in the PICU, he continued to have tachycardia and hypertension requiring propranolol initially and then IV Hydralazine. Labs studies revealed TSH 0.01 uIU /ml (0.27 to 4.20) and FT4 4.36 ng/dl (0.93 to 1.70). The TSI, TSH receptor, thyroglobulin receptor and TPO antibodies were negative.  He continued to receive IV clindamycin for his neck abscess and culture of the abscess demonstrated mixed oral flora suggesting AST as the cause for thyrotoxicosis. His thyroid function studies normalized on the 5th day of hospitalization without antithyroid drugs. At 4 months post hospitalization TSH and FT4 were reported to be normal by PCP.  

DISCUSSION:  AST is a relatively rare diagnosis in children. Historically, patients with AST remain euthyroid. In contrast, this case presentation supports previously published case reports demonstrating thyrotoxicosis as a result of AST with resulting hypertension and tachycardia. Given these findings, clinicians must keep a high level of suspicion for prompt recognition and management of AST related thyrotoxicosis.

Nothing to Disclose: RS, MMB, PGP

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