Anterior Neck Pain Research Articles

A Rare Presentation of Acute Suppurative Thyroiditis.

A previously healthy 17-year-old female patient initially presented with symptoms of anterior neck pain. After multiple emergency department visits, she was found to have unilateral enlargement of her thyroid gland. Laboratory studies were consistent with hyperthyroidism. Symptoms were initially attributed to subacute thyroiditis, and she was discharged with steroids and propranolol. She presented again 1 week later with complaints of nausea, vomiting, abdominal pain, and shortness of breath. She was readmitted and developed sepsis with multiorgan system infection and Lemierre syndrome. Further imaging revealed acute suppurative thyroiditis as the likely source. Direct laryngoscopy and bronchoscopy revealed ulceration of the anterior esophageal wall, a fistulous tract to the thyroid, and copious purulent drainage. Esophageal biopsies with immunostaining established a diagnosis of herpes simplex virus esophagitis as the likely cause of esophageal perforation, fistula development, and acute suppurative thyroiditis.

5039 Chronic Painful Hashimoto's Thyroiditis

Abstract Disclosure: S. Ahmed: None. M. Vahidi Rad: None. S.A. Westphal: None. M.D. Whitaker: None. Introduction: Painful Hashimoto thyroiditis is a rare variant of Hashimoto thyroiditis that mostly affects women. Most cases are empirically treated as subacute thyroiditis with corticosteroids, levothyroxine, or nonsteroidal anti-inflammatory drugs. However, no medical treatment may provide sustained pain resolution, so optimal treatment remains unclear. We describe the case of a 40-year-old female with longstanding throbbing anterior neck discomfort that failed medical therapy and her symptoms completely resolved with total thyroidectomy. Case Report: A 40-year-old lady with anterior neck pain centered over the thyroid for more than 16 years, shortly after she delivered her last child. The pain is described as intense, it tends to wax and wane but there is a constant throbbing with occasional radiation to the angle of the jaw. Over the years the pain has gradually worsened and during its flares, the thyroid itself is very tender to the point where she experiences difficulty in swallowing and hoarseness of voice. Complicating the issue is her underlying diagnosis of fibromyalgia, as she tends to experience discomfort in many other areas of her body. However, the neck pain appears to be of a different character. No symptoms of hyper or hypothyroidism. The anterior neck pain has been difficult to alleviate, she has used chronic opioids for it which seems to have helped to some extent, in the past she was on prednisone for 1 month however this made no difference to it. On examination, the thyroid is tender and somewhat firm without lymphadenopathy. Thyroid levels have been consistently normal and the most recent of which was a TSH: 1.48, FT4: 1.4, FT3: 3.5 with negative TPO and thyroid stimulating antibodies. ESR and CRP were unremarkable. Thyroid ultrasound showed mildly heterogeneous parenchyma with no solid nodules or lymphadenopathy. Interestingly she had an elevated thyroid uptake in her scan dated April 1st 2022, 4 hour and 24-hour uptakes were abnormal at 23% and 49% respectively which can be seen with Hashimoto's. She underwent total thyroidectomy and her surgical pathology showed benign thyroid tissue with multiple foci of chronic lymphocytic thyroiditis and hyperplastic nodules. Her pain completely resolved after total thyroidectomy. Discussion: Painful Hashimoto thyroiditis is a rare diagnosis and optimal treatment remains unclear. The painful variant of Hashimoto's thyroiditis should be considered in the differential diagnosis of pain and tenderness of the thyroid which can be managed successfully by surgical treatment. Thyroidectomy not only can lead to alleviation of symptoms but also provides the definitive diagnosis. The risks of surgical intervention must be taken into consideration, especially because painful Hashimoto thyroiditis can be associated with a small fibrous gland; hence, the importance of access to highly skilled, experienced surgeons cannot be overemphasized. Presentation: 6/1/2024

Transient perivascular inflammation of the carotid artery (TIPIC) syndrome - a rare differential for anterior neck pain - Series of 3 cases and review of literature.

We report a series of 3 cases of transient perivascular inflammation of the carotid artery (TIPIC) syndrome in an otherwise healthy individual. We would also like to review this rare entity and compare it with other similar cases reported in the literature. Our first case was a young male with right-sided neck pain of 1-week duration with magnetic resonance imaging (MRI) showing right carotid perivascular inflammation which completely resolved after 2 weeks with anti-inflammatory drugs. In the second case, a young male presented with left-sided neck pain and odynophagia of 5 days duration with an MRI showing left carotid perivascular inflammation which completely resolved after 2 weeks with anti-inflammatory drugs. In the third case a young male presented with right-sided neck pain of 1-day duration with an MRI showing right common carotid perivascular inflammation near the bifurcation with complete resolution in pain but with residual wall thickening. We want to highlight the existence of this new entity by reporting these 3 case series with a brief review of the literature. The cause and pathogenesis of this rare entity remain unknown. It has been hypothesized to be autoimmune or viral-mediated inflammation which requires further understanding.

Descending necrotizing mediastinitis secondary to retropharyngeal abscess

We report a case of descending necrotizing mediastinitis (DNM) in a 68-year-old male who presented in acute respiratory distress accompanied with anterior cervical neck swelling and pain with swallowing. Contrast enhanced computed tomography (CECT) of the neck demonstrated a large, peripherally enhancing retropharyngeal fluid and air collection that appeared to communicate with a fluid and air collection within the mediastinum. CECT of the chest demonstrated punctate foci of air and fat stranding along the anterior and superior mediastinum. Radiological evidence and the presence of necrosis on surgical debridement of the retropharyngeal abscess established the diagnosis of DNM. This case emphasizes the role of computed tomography (CT) in the diagnosis of DNM and demonstrates the utility of chest imaging in a high-risk patient who presents with a retropharyngeal abscess.

SAT574 Thyroglossal Duct Papillary Thyroid Cancer With Normal Eutopic Thyroid Gland: A Management Dilemma

Abstract Disclosure: H. Belal: None. J.T. Batch: None. G.Y. Gandhi: None. Background: The incidence of thyroglossal duct cyst carcinomas is less than 1%, the majority being papillary thyroid cancer. One-third arise de novo from the thyroglossal duct. The rest are direct metastasis of eutopic papillary thyroid cancer. Management in the setting of a normal eutopic thyroid gland is challenging. Clinical Case: A 35-year-old female presented with transient right facial paresthesia. CT angiogram revealed an incidental 2.3 cm thyroglossal duct cyst with internal ectopic thyroidal tissue and micro-calcifications. She denied any compressive symptoms, radiation exposure, or family history of thyroid cancer and was euthyroid. Ultrasound noted a normal thyroid gland and complex solid-cystic mass measuring 2.3 x 2.0 x 1.5 cm superior to the isthmus. Satisfactory fine needle aspiration of the mass revealed benign-appearing epithelial cells, macrophage, and colloid-like material. Due to new anterior neck pain, a Sistrunk Procedure (SP) was performed. Pathology revealed a 1.2 cm papillary thyroid carcinoma, conventional type (confirmed by TTF-1 and thyroglobulin stains), arising within the thyroglossal duct cyst. Surgical margins were free of cancer, and there was no lymphovascular invasion. A thyroid ultrasound seven months after the procedure revealed heterogenous thyroid tissue, no thyroid nodules, and several small benign-appearing reniform-shaped cervical lymph nodes in zones 1 and 2. The patient was offered yearly thyroid ultrasound surveillance versus prophylactic thyroidectomy. She elected to proceed with thyroidectomy due to concerns about disease recurrence. Final pathology results revealed right lobe 2 mm papillary microcarcinoma limited to the thyroid. Conclusion: Fine needle aspiration of thyroglossal duct cysts can have a high false negative rate, as in our patient. There is currently no consensus on treatment of thyroid carcinomas arising from thyroglossal duct cysts. There are four possible surgical strategies: 1) SP alone 2) SP with concurrent thyroid lobectomy or pyramidal lobe resection 3) SP with total or near total thyroidectomy in all patients and 4) SP and selective addition of total or near total thyroidectomy in high-risk patients. The role of radio-iodine ablation and levothyroxine suppression after SP is also unclear. Management recommendations are Grade C, relying on case reports, case series, and expert opinion. Whether or not to proceed with total thyroidectomy, especially in the setting of a normal thyroid gland, remains highly controversial. Some experts even argue for an early aggressive surgical approach with SP, total thyroidectomy, and level I lymph node sampling in all patients to provide accurate staging and allow for the use of thyroglobulin and whole-body scintigraphy in surveillance. Multisite comparative data on the long-term outcomes of patients who receive early aggressive versus conservative management is needed. Presentation: Saturday, June 17, 2023

FRI461 Two-years Course Of Subacute Thyroiditis After COVID-19 Vaccination: A Case Report

Abstract Disclosure: S. Yoshida: None. COVID-19 has been reported to cause subacute thyroiditis. Furthermore, the literature includes cases of COVID-19 vaccine-related subacute thyroiditis, but few reports describe the long-term course of vaccine-induced subacute thyroiditis. Herein, we report the case of a 47-year-old woman with no medical history who developed subacute thyroiditis after mRNA COVID-19 vaccination and was followed up for 2 years. Her fever persisted after the second dose of the COVID-19 vaccine, and she became aware of left anterior neck pain 8 days later. There were no infectious disease symptoms or signs in the patient’s history or at a recent physical examination. All thyroid autoantibodies were negative. On ultrasound, the thyroid gland was diffusely enlarged, and internal echogenicity was diffusely hypoechoic, coarse, and color Doppler blood flow signals were decreased without confinement to the pain area. She was diagnosed with subacute thyroiditis with tender thyroid swelling, thyrotoxicosis, and an inflammatory reaction. It was suspected that there was a causal link between the onset of subacute thyroiditis and COVID-19 mRNA vaccination because it developed immediately after vaccination and there were no other obvious causes. She was started on prednisolone, and her symptoms improved rapidly, leading to hypothyroidism 1 month later. The swelling of the thyroid gland improved rapidly, and it became atrophic several months after the onset of subacute thyroiditis. She never received any additional vaccinations. Two years after the onset, there was no recurrence of subacute thyroiditis, thyroid atrophy persisted, and the patient required levothyroxine supplementation (100 µg/day). Subacute thyroiditis generally has a good prognosis and rarely leads to permanent hypothyroidism. Subacute thyroiditis due to vaccination may follow a different course than that due to typical viral infection, and we need to examine its long-term prognosis. Presentation: Friday, June 16, 2023

FRI563 Subacute Thyroiditis Is An Uncommon Cause Of Pyrexia Of Unknown Origin

Abstract Disclosure: N. Luke: None. D. Tay: None. Introduction: Subacute thyroiditis is a rare self-limiting inflammatory thyroid disorder often follows a viral infection. It is a diagnosis that is made clinically when patients present with typical features of anterior neck pain and thyrotoxic symptoms. We share our experience in unraveling a diagnostic challenge of a patient with an atypical presentation of subacute thyroiditis presenting with pyrexia of unknown origin during the Covid 19 pandemic. Clinical case: A 29 years old previously healthy Burmese domestic helper was admitted to a hospital in Singapore for persistent fever of 2 weeks duration associated with persistent sore throat. She had a brief 3 days duration of cough at the onset of fever with no other localizing infective symptoms. She had a booster dose of COVID 19 Moderna vaccination 6 months prior to her presentation with 2 preceding doses of Pfizer-BioNtech vaccine 12 months prior. She was empirically treated for acute pharyngitis with a course of intravenous antibiotics without improvement of her fever. Extensive workup for the fever was performed. A complete blood count showed monocytosis. Blood and urine cultures, urinalysis, COVID polymerase chain reaction (PCR), CMV, EBV, and HIV testing were negative. Respiratory multiplex PCR was negative for adenovirus, coronavirus, influenza, parainfluenza, respiratory syncytial virus, metapneumovirus, rhinovirus, chlamydia, mycoplasma, and Bordetella. CT of the thorax, abdomen, and pelvis was normal. She denied heat intolerance, weight loss, diarrhea, palpitations, or hand tremors. Clinical examination revealed mild anterior neck tenderness but no thyrotoxic features. There were no signs of Graves ophthalmopathy or pre-tibial myxoedema. Thyroid function tests were performed in view of persistent tachycardia which showed elevated free T4 at 51.6 pmol/L (12.7-20.3) with suppressed TSH <0.005 mIU/L (0.3-4.2). TSH receptor stimulating antibody levels (TRab) was elevated at 5.23IU/L (<1.76) and ESR was markedly elevated (115 mm/hr). Thyroid ultrasound showed homogeneous thyroid echotexture with no discrete suspicious nodules or abnormal vascularity. She was started on non-steroidal anti-inflammatory drug (Etoricoxib) with resolution of her fever and neck pain Clinical lesson: Clinicians should be aware that subacute thyroiditis can be a rare cause of pyrexia of unknown origin even in the absence of typical features. Presentation: Friday, June 16, 2023

Subacute Thyroiditis Developing Within 2 Days of Vaccination Against COVID-19 with BNT162b2 mRNA

A 32-year-old woman presented to the outpatient clinic with persistent fever, anterior neck pain, and palpitations over the past week which developed 2 days after she had received the first dose of the Pfizer/BioNTech SARS-CoV-2 mRNA vaccine. On examination, the patient’s heart rate was 140 beats per minute and the thyroid gland was tender on palpation. Laboratory studies showed a low serum TSH level with elevated free thyroxine. Thyroid ultrasound revealed low-echoic lesions compatible with the site of tenderness. The patient was diagnosed with subacute thyroiditis and treatment was initiated with acetaminophen and propranolol, which resulted in symptom resolution within 2 weeks. Clinicians should be aware that subacute thyroiditis may occur within a few days following COVID-19 vaccination, especially in patients with anterior cervical pain with no significant abnormal pharyngeal findings and/or severe palpitations, because differentiating them from early non-specific adverse reactions can be challenging.

A case of subacute thyroiditis after influenza vaccination.

A 40-year-old Japanese woman presented to the outpatient clinic with fever and palpitations 2 days after receiving the influenza vaccine (Influenza HA Vaccine 'KMB'®) following the second dose of coronavirus disease 2019 (COVID-19) vaccine (COVID-19 vaccine Moderna intramuscular injection®). At the first visit, the patient presented with a swollen thyroid gland with mild tenderness, and she was diagnosed with subacute thyroiditis (SAT) based on the presence of thyrotoxicosis (free T3: 5.42 pg/mL; free T4: 2.34 ng/dL; and thyroid-stimulating hormone (TSH): <0.01 μIU/mL), a high C-reactive protein level (5.77 mg/dL), a negative TSH receptor antibody, and characteristic ultrasound findings. The patient's human leukocyte antigen types were A2, A11, B35, B51, DR4, and DR1403. Prednisolone (15 mg/day) was given as an initial dose, after which the fever subsided, and the dose was tapered and discontinued after 6 weeks. The patient was thought to have developed SAT due to influenza vaccination. SAT after influenza vaccination may be overlooked. For patients with SAT, it is necessary to obtain information regarding their vaccination history. After influenza vaccination, subacute thyroiditis (SAT) may develop. If persistent fever, anterior neck pain, swelling, tenderness of the thyroid gland, and symptoms of thyrotoxicosis are observed immediately after vaccination for several viruses, including influenza, an examination to rule out the onset of SAT is recommended. Human leukocyte antigen type A2 (HLA-A2) and HLA-B35 may be linked to the development of SAT following influenza vaccination. The two doses of the coronavirus disease 2019 (COVID-19) vaccine given before the influenza vaccine may affect the onset of SAT.

Subacute Thyroiditis Developing Within 2 Days of Vaccination Against COVID-19 with BNT162b2 mRNA.

Cases of subacute thyroiditis after vaccination, including against COVID-19, have been increasingly reported.Subacute thyroiditis should be considered in patients with anterior cervical pain with no significant abnormal pharyngeal findings and/or severe palpitations after COVID-19 vaccination because these can be diagnostic clues.It is important to note that this condition can occur as early as a few days after vaccination, in order to avoid diagnostic pitfalls.

PSAT297 Subacute Thyroiditis Following COVID-19 Vaccination

Abstract Introduction Subacute thyroiditis (SAT) precipitated by COVID-19 infection has been documented in the literature. However, we are now seeing patients develop SAT following the COVID 19 vaccine. Vaccine-related SAT have been reported in the literature, such as in the SARS vaccine. There are now several COVID-19 vaccines being used with benefits on morbidity and mortality. The mechanism of action leading to SAT from the vaccine has not been deciphered, however there are some theories. Here we present a case of COVID-19 vaccine-related SAT. Case 42-year-old Caucasian gentleman with no past medical history, presented to the Endocrinology clinic with anterior neck pain around his thyroid area that started 3 days after his 2nd Pfizer COVID-19 vaccine. He described the pain as severe enough to wake him up from sleep. No weight loss, palpitation, heat intolerance or tremors. No prior exposure to stable iodine or radiation treatment. He takes no medications. He denies tobacco or alcohol use. Initial thyroid labs showed a T3 2.8 (2.5 - 4.4 pg/mL), T4 1.4 (0.61 - 1.44 ng/dL), TSH 1.4 (0.45 - 5.33 uIU/mL), TPO antibodies positive, thyroglobulin Ab undetectable, sedimentation rate of 42 (&amp;lt;30 mm/Hr). Ultrasound of the neck showed 1.7-centimeter TIRADS 4 nodules in the left lobe, and 0.9 cm on the right. The patient was noticing a discomfort in the right side of the neck. He was also having swallowing difficulties, low-grade fever, body ache, night sweats and unintentional weight loss. Though he initially presented with thyroid labs that were within the normal reference range, by the time he repeated them one month later, he was hyperthyroid. He was started on prednisone 20 mg and NSAID. At 2 weeks follow-up, his pain and swallowing difficulty have significantly improved. Over time, the patient's thyroid labs normalized and the pain in the neck subsided, repeat neck US 5 months later showed decreased nodule size. Steroids was stopped. Discussion The common side effects COVID-19 vaccines include pain in the injected site, skin reactions, flu-like symptoms, headache, fatigue and fever. SAT following viral vaccines has been reported previously. The association between SAT and COVID-19 vaccination has come to medical attention more recently due to widespread vaccinations. The mechanism for post-vaccination SAT remains unknown. However, adjuvants contained in vaccines may play a role in producing diverse autoimmune and inflammatory responses and the potential for cross-reactivity between the coronavirus spike protein target produced by the mRNA vaccine and healthy thyroid cells antigens. This case exemplifies the need to know about SAT and COVID 19 vaccine so that clinicians can advise patients to seek medical assistance if experiencing anterior neck pain, extended fever or palpitation so that they are treated properly and in a timely fashion. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Subacute Thyroiditis and the SARS-Cov-2: What Relationship?

Background: De Quervain's thyroiditis is an inflammatory thyroid disorder. The new coronavirus is incriminated as the causative agent. Aims: We describe two cases of subacute thyroiditis, the first is linked to covid-19 infection, and the second is secondary to the SARS-CoV-2 vaccine. Methods: A 48-year-old female, presented with severe anterior neck pain, and thyroid dysfunction; the thyroid ultrasound showed an enlarged gland, with external hypoechoic areas. The RT-PCR was positive, the patient was treated according to the protocol of covid-19. A 49-year-old female, consulted for intense neck pain, one month after receiving the first dose of vaccination (Astrazeneca); the cervical ultrasound showed an external hypoechoic areas. Results: In first case, neck pain and other signs disappeared in one week. In second case, neck pain disappeared within two weeks. Conclusion: Clinicians should be aware of the possibility of thyroiditis in patients infected with Sars-COV-2.

The bias in the nomenclature of large-vessel vasculitis.

Dear Editor, A 68-year-old man of Northern European ancestry presented with a 3-month history of constitutional symptoms to his general practitioner. The detection of a normochromic normocytic anaemia, an acute phase response and an elevated prostate-specific antigen prompted a referral to a rapid diagnostic service for cancer. A CT scan of the thorax, abdomen and pelvis did not detect any solid tumours but commented on thickened aorta. An urgent referral was made to the vasculitis clinic. In the interim he received a short course of prednisolone which had finished more than a week ago. On attendance in vasculitis clinic, he had no organ-specific symptoms. Constitutional symptoms included weight loss of >5 kg, drenching night sweats and fatigue. He reported feeling slightly better over the last few weeks. He did not have any risk factors for atherosclerosis. On direct questioning, he admitted to a mild frontal headache (which had been reported as being absent in the primary care referral letter), anterior neck pain and symmetrical shoulder pain. On examination, there were no nail changes or detectable lymphadenopathy. The radial pulses and blood pressure were difficult to elicit in both arms, but the extremities appeared well perfused. There were harsh bruits over both subclavian and axillary arteries. Carotid arteries did not exhibit bruits and were non-tender. There were no abnormalities in relation to the superficial temporal arteries.

Autoimmune and inflammatory thyroid diseases following vaccination with SARS-CoV-2 vaccines: from etiopathogenesis to clinical management.

Since the Covid-19 pandemic emerged in 2019, several adenoviral-vectored, mRNA-based and inactivated whole-virus vaccines have been developed. A massive vaccination campaign has been undertaken around the world, and an increasing number of SARS-CoV-2 vaccine-induced thyroid diseases have been described in the literature. Subacute thyroiditis has been reported in 52 patients, mean age 45.5 ± 1.8 years, mainly in women (n = 39). Graves’ disease is more frequent in women (n = 22) than in men (n = 10), mean age 46.2 ± 2.6 years, reported as new onset, recurrent or exacerbation of well-controlled hyperthyroidism. The mean time to symptoms onset is 9.0 ± 0.8 days in subacute thyroiditis, and 15.1 ± 2.6 days in Graves’ patients. Rare patients (n = 6) present silent or painless autoimmune thyroiditis. Thyroid function and autoimmune tests, inflammatory markers, thyroid echography with colour flow Doppler, radio-activity uptake on thyroid scan, medical treatment and follow-up are described and compared in patients with SARS-CoV-2 vaccine-induced thyroid diseases. The underlying pathogenic mechanisms of vaccine-induced thyroid diseases, molecular mimicry (various SARS-CoV-2 proteins sharing a genetic homology with a large heptapeptide human protein) or autoimmune/inflammatory syndrome induced by adjuvants (ASIA) are discussed in the context of predisposition or genetic susceptibility. The benefits of SARS-CoV-2 vaccination far outweigh the potential vaccine-induced adverse effects, but clinicians should be aware of possible autoimmune and inflammatory thyroid diseases, and can advise patients to seek medical assistance when experiencing anterior neck pain, fever or palpitations following SARS-CoV-2 vaccines. Further studies are warranted to investigate the etiopathogenesis and to clarify the factors which predispose patients to SARS-CoV-2 vaccine-induced thyroid diseases.

An Old Woman with Anterior Neck Pain

An 83-year-old woman with a history of diabetes mellitus presented to our emergency department with a sore throat. She recalled swallowing a fish bone 2 days prior to presentation, which was followed by progressive dysphagia and anterior neck pain. She was afebrile, and physical examinations were unremarkable. Blood test results revealed mild leukocytosis (10.2×103 cells/μL) and leftward shift (81%). A point-of-care neck ultrasound was performed (Figure 1 and Video).

Subacute thyroiditis associated with thyrotoxic periodic paralysis after COVID-19 vaccination: a case report.

SummaryWe report a 26-year-old Japanese man who visited our outpatient clinic presenting fever immediately after i.m. injection of the second dose of a coronavirus disease 2019 (COVID-19) vaccine (Moderna®). At the first visit, the patient had a fever of 37.7°C and a swollen thyroid gland with mild tenderness. He was diagnosed with subacute thyroiditis (SAT) based on the presence of thyrotoxicosis (free tri-iodothyronine, 32.3 pg/mL; free thyroxine, >7.77 ng/dL; and thyroid-stimulating hormone (TSH) < 0.01 μIU/mL), high C-reactive protein level (7.40 mg/dL), negative TSH receptor antibody, and characteristic ultrasound findings. His HLA types were A*02:01/24:02, B*15:11/35:01, Cw*03:03, DRB1*09:01/12:01, DQB1*03:03, and DPB1*05: 01/41:01. He was initially administered prednisolone 15 mg/day, following which the fever subsided. After 10 days, he developed limb weakness and could not walk. The serum potassium level decreased to 1.8 mEq/L, which confirmed the diagnosis of thyrotoxic periodic paralysis (TPP). Potassium supplementation was initiated. The muscle weakness gradually decreased. Prednisolone therapy was terminated 6 weeks after the first visit. His thyroid function returned to normal 5 months after the first visit, through a hypothyroid state. To our knowledge, this is the first reported case of TPP-associated SAT following COVID-19 vaccination. Persistent fever following vaccination should be suspected of SAT. Additionally, TPP may be associated with SAT in Asian male patients.Learning pointsFollowing coronavirus disease 2019 (COVID-19) vaccination, subacute thyroiditis may develop regardless of the vaccine type.If persistent fever, anterior neck pain, swelling and tenderness of thyroid gland, and symptoms of thyrotoxicosis are observed immediately after the COVID-19 vaccination, examination in consideration of the onset of subacute thyroiditis is recommended.HLA-B35 may be associated with the onset of subacute thyroiditis after the COVID-19 vaccination.Although rare, subacute thyroiditis can be associated with thyrotoxic periodic paralysis, especially in Asian men.Glucocorticoid therapy for subacute thyroiditis may induce thyrotoxic periodic paralysis through hypokalemia.

Medical Management of Septic Arthritis of the Sternoclavicular Joint With Extended-Spectrum Beta-Lactamase-Producing Escherichia coli: A Case Report

The sternoclavicular joint (SCJ) is an uncommon location for septic arthritis to occur in. Due to the rarity of the condition and the nonspecific symptoms, SCJ septic arthritis can be missed or mislabeled as osteoarthritis or muscle strain. Accurate history and physical examination is crucial for recognizing this condition. With the potential life-threatening complications that may ensue, SCJ septic arthritis has traditionally been managed surgically. This ranges from simple incision and drainage to resection of the joint. However, in cases where there is not enough fluid for incision and drainage, a trial of medical management with antibiotics can be attempted. We herein describe a case of a 58-year-old male who presented with nonspecific anterior chest wall and neck pain. Chest X-ray and ultrasound of the anterior chest wall was normal; however, magnetic resonance imaging (MRI) of the chest showed a small effusion without other complications. His blood cultures grew extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli, rendering this as his hematogenous source of septic arthritis. The ESBL was from a left-sided obstructing kidney stone that resulted in pyelonephritis, which was confirmed via computed tomography of the abdomen. His effusion was too minimal to drain; therefore, he was managed medically with intravenous (IV) antibiotics along with a left ureteral stent placement, and he had a full recovery. This case represents the ability for SCJ septic arthritis to be managed medically with IV antibiotics, especially when the diagnosis is caught early without complications. The role of MRI is indispensable for coming to the diagnosis, as it is capable of detecting complications that ultimately dictate management. Additionally, this case highlights the unique microorganism, ESBL-producing E. coli causing the SCJ septic arthritis, a finding that has been rarely reported in the literature as the majority of microorganisms that have been previously documented are either Staphylococcus aureus or Pseudomonas aeruginosa.

Tachycardiomyopathy Due To Hyperthyroidism: Case Report

Introduction High output heart failure (HF) is one of the complications of hyperthyroidism. Some patients may evolve with reduced ejection fraction HF (HFREF) due to tachycardiomyopathy. The most prevalent arrhythmias are atrial fibrillation and atrial flutter, which, when controlled, improve HF. Hypotheses: Tachycardiomyopathy resulting from hyperthyroidism. Methods Descriptive, qualitative, and documentary study of the “case report” type. Case report Male, 35 years old, with no previous comorbidities, sought emergency with signs of decompensated HF associated with palpitations, hyperthermia, sweating, anterior neck pain, and extremity tremors. Thyroid with increased volume resulting from multiple nodules, without murmurs; bilateral exophthalmos; propulsive ictus with two digital pulps, in the sixth left intercostal space, irregular heart rhythm, HR 140bpm, pathological jugular venous pressure, bilateral crackles up to middle third. Lower limbs with edema + 3 / + 4. EKG in high-response atrial fibrillation rhythm reversed during hospitalization with amiodarone. ECHO with severe global LV systolic dysfunction with Simpson's ejection fraction 12%. He was discharged from the hospital with carvedilol, furosemide, amiodarone, and oral anticoagulant, being referred to primary care. Doppler ultrasonography of the thyroid showing increased volume, lobulated contours with diffuse heterogeneous parenchyma of multinodular aspect, and increased vascularity. Laboratory tests confirmed hyperthyroidism (TSH 0.008 mU / L; T4L 2.22 ng / dL; TRAB 9.58 IU / L). Optimized treatment for HF (added enalapril and spironolactone), it evolved in NYHA I, with a new ECHO after 3 months showing mild LV dysfunction with 45% EF. In a joint follow-up with endocrinology, under treatment with Methimazole, awaiting thyroidectomy. Conclusion Hyperthyroidism increases metabolic demand and can lead to cardiovascular complications such as HF and atrial arrhythmias. This occurs by increasing blood volume, reducing systemic vascular resistance and reducing circulation time, triggering LV hypertrophy, and reducing myocardial contractile reserve. The hyperthyroidism with decompensated HF is a medical emergency with up to 30% mortality. It is a treatable entity, and its complications are potentially reversible. High output heart failure (HF) is one of the complications of hyperthyroidism. Some patients may evolve with reduced ejection fraction HF (HFREF) due to tachycardiomyopathy. The most prevalent arrhythmias are atrial fibrillation and atrial flutter, which, when controlled, improve HF. Hypotheses: Tachycardiomyopathy resulting from hyperthyroidism. Descriptive, qualitative, and documentary study of the “case report” type. Male, 35 years old, with no previous comorbidities, sought emergency with signs of decompensated HF associated with palpitations, hyperthermia, sweating, anterior neck pain, and extremity tremors. Thyroid with increased volume resulting from multiple nodules, without murmurs; bilateral exophthalmos; propulsive ictus with two digital pulps, in the sixth left intercostal space, irregular heart rhythm, HR 140bpm, pathological jugular venous pressure, bilateral crackles up to middle third. Lower limbs with edema + 3 / + 4. EKG in high-response atrial fibrillation rhythm reversed during hospitalization with amiodarone. ECHO with severe global LV systolic dysfunction with Simpson's ejection fraction 12%. He was discharged from the hospital with carvedilol, furosemide, amiodarone, and oral anticoagulant, being referred to primary care. Doppler ultrasonography of the thyroid showing increased volume, lobulated contours with diffuse heterogeneous parenchyma of multinodular aspect, and increased vascularity. Laboratory tests confirmed hyperthyroidism (TSH 0.008 mU / L; T4L 2.22 ng / dL; TRAB 9.58 IU / L). Optimized treatment for HF (added enalapril and spironolactone), it evolved in NYHA I, with a new ECHO after 3 months showing mild LV dysfunction with 45% EF. In a joint follow-up with endocrinology, under treatment with Methimazole, awaiting thyroidectomy. Hyperthyroidism increases metabolic demand and can lead to cardiovascular complications such as HF and atrial arrhythmias. This occurs by increasing blood volume, reducing systemic vascular resistance and reducing circulation time, triggering LV hypertrophy, and reducing myocardial contractile reserve. The hyperthyroidism with decompensated HF is a medical emergency with up to 30% mortality. It is a treatable entity, and its complications are potentially reversible.

Necrotizing fasciitis of the neck: A rare diagnostic emergency

A 76-year-old male, with no prior medical history, was referred to our hospital due to odynophagia and fever with 3 days, sudden worsening with dyspnea, drooling, edema and anterior neck pain. Physical examination revealed tachypnea, trismus, halitosis, bulging of the pharyngeal lateral walls and salivary stasis. No evidence of peritonsillar abscess or tonsil exudate was observed. Contrast-enhanced computed tomography (CT) of the neck revealed an organized collection involving both parapharyngeal and retropharyngeal with air bubbles and edema of the surrounding tissues (Figure 1). The patient was immediately admitted, started empiric broad-spectrum antibiotic therapy and submitted to an emergent surgical drainage. After securing the airway with tracheotomy, a trans-cervical drainage was performed. The drained pus had a grayish color and a foul smell. Necrotic tissue of fascia and sternocleidomastoid muscle were removed, as much as possible, without compromising vital structures. The cervical spaces were irrigated with a diluted solution of povidone-iodine and hydrogen peroxide. Penrose drains were placed and the skin was “loosely” approximated with minimal sutures. (Figure 2). Microbiology of the pus culture revealed the presence of Streptococcus constellatus, Eikenella corrodens, Prevotella buccae and Parvimonas micra.

Graves’ Disease Following Subacute Thyroiditis

Subacute thyroiditis is an inflammatory thyroid disease caused by viral infection. Graves’ disease is an autoimmune thyroid disease caused by thyrotropin (TSH) receptor antibody (TRAb). Graves’ disease following subacute thyroiditis is rare, and only a few cases have been reported. A 58-year-old woman presented with anterior neck pain and swallowing difficulty. Laboratory tests showed elevated FT4, low TSH, normal TRAb, and elevated erythrocyte sedimentation rate. Thyroid ultrasonography (US) revealed focal, ill-defined hypoechoic areas in both thyroid lobes. The patient was treated with corticosteroid, and symptoms subsided after 1 month. Three months later, she complained of tremor and palpitation. Thyroid function testing showed hyperthyroidism with the positive conversion of TRAb, indicating Graves’ disease. Doppler US showed increased vascular flow in both thyroid lobes. She started treatment for hyperthyroidism with methimazole.