MON-463 Thyroid Abscess Due to Intravenous Drug Use: A Rare Cause of Thyroid Storm

Abstract

Objective: Our objective is to discuss the clinical presentation, diagnosis and management of thyroid storm due to thyroid abscess. Methods: We report a case of thyroid abscess due to intravenous drug use (IVDU) resulting in thyroid storm. Results: A 28 year old female with history of IVDU and no known thyroid disease presented with neck pain and fever after injecting heroin into her neck 10 days prior. CT Neck showed an early bilateral thyroid abscess 3.0 cm on the left and 2.0 cm on the right, with heterogeneous enhancement in the rest of the thyroid concerning for thyroiditis. TSH 0.4 m[iU]/L (0.34–5.60 m[iU]/L). She was started on antibiotics but left AMA. She returned 9 days later with worsening neck swelling and pain. CT neck showed a multiloculated, bilateral thyroid abscess 8.6 cm on the left and 5.3 cm on the right. She suffered a cardiac arrest, was intubated, and resuscitated with defibrillation and epinephrine. WBC 25.9 K/mm3, ANC 9.8 K/mm3, TSH <0.01 m[iU]/L (0.34–5.60 m[iU]/L), fT4 4.25 ng/dL (0.89–1.76 ng/dL), T3 96.0 ng/dL (70–204 ng/dL), TSI <89 (<140%). Burch-Wartofsky score was 60. She was treated with propylthiouracil (PTU) and hydrocortisone. She developed transaminitis post-arrest due to shock liver, AST 2881 U/L (15–37 U/L), ALT 981 U/L (16–61 U/L) and PTU was discontinued. Two days later TSH <0.005 m[iU]/L (0.4–4.5 m[iU]/L), fT4 3.06 ng/dL (0.89–1.76 ng/dL), T3 62.0 ng/dL(60.0–181.0 ng/dL). Neck ultrasound showed enlarged, heterogeneous thyroid with numerous loculated fluid collections. Incision and drainage (I&D) drained 100 cc of pus and drains were left in situ. Cultures grew MRSA. Patient was treated with vancomycin, clindamycin, and metronidazole. Following I&D, thyroid function improved to normal and eventual hypothyroidism by postoperative day 8, fT4 0.59 ng/dL, T3 32.1 ng/dL, TSH 1.2 m[iU]/L. She was initiated on levothyroxine 50 mcg daily with follow up testing for possible resolution of thyroiditis-induced hypothyroidism. Discussion: Thyroid abscess causing acute suppurative thyroiditis presenting as thyroid storm is rarely seen1. There are no reported cases of thyroid storm occurring as a complication of IVDU. Acute suppurative thyroiditis has been reported following MSSA bacteremia from a forearm abscess due to IVDU, TSH 0.02U/mL, fT4 3.89ng/dL, fT3 of 5.1pg/mL2. Presentation was consistent with thyrotoxicosis but not thyroid storm2. It is important to consider thyroid abscess as a rare cause of thyroid storm, in patients with risk factors such as IVDU. Management with antithyroid drugs (ATD), steroids, antibiotics, and I&D produced successful outcomes in this patient after cardiac arrest. Conclusion: Thyroid abscess resulting in thyroiditis can be a rare cause of thyroid storm that resolves following I&D. Successful management includes use of antibiotics, steroids, and ATD for thyroid infection, thyroid inflammation and thyroid hormone levels.