Embolic suppurative thyroiditis with concurrent carcinoma in pregnancy: lessons in management through a case report

Abstract

Background: The thyroid undergoes a variety of physiological changes during pregnancy. The relatively low iodine levels seen in pregnancy have been implicated in thyroid growth during this time. Management of thyroid cancer in pregnancy is not immediately apparent. Furthermore, acute suppurative thyroiditis is rare and this is attributed to the glands innate immunity. We thoroughly review the evidence regarding management of thyroid abscess and thyroid malignancy during pregnancy and illustrate it via an extremely rare case of an embolic thyroid abscess highlighting an underlying carcinoma in a pregnant woman.

Case: A 29-year old female was found to have a thyroid mass during an antenatal assessment. Following a wound infection from Caesarian section she developed a rapidly progressive thyroid abscess. Incision and drainage of the abscess, and subsequent histology revealed papillary carcinoma. She subsequently underwent both total thyroidectomy with level 6 dissection and radio-iodine ablation post-natally.

Conclusion: The literature is inconsistent regarding pregnancy as a risk factor for thyroid cancer, but overall it has been suggested as equally or slightly more frequent than in the non-pregnant population. Thyroid mass investigation should be as for the non-pregnant population. In the first trimester any endocrine surgery is associated with miscarriage, whereas these risks are reduced in second trimester. Importantly, there is no survival benefit in undergoing papillary carcinoma surgery in the third trimester versus early post partum and the risks of premature labour may outweigh any benefit gained by operating early. Most importantly, acute suppurative thyroiditis is rare entity and clinicians should have a low threshold for suspicion of underlying malignancy in these patients. This is especially true in the pregnant population who may be especially susceptible whilst undergoing hypertrophic thyroid changes.

Keywords: Abscess; Carcinoma; Embolic; Pregnancy; Suppurative; Thyroiditis.

Figure 1

CT with contrast axial slice through neck. CT image demonstrating a large fluid collection arising from left thyroid mass, suggestive of an abscess. Noted compression and deviation of adjacent organs.

Figure 2

CT with contrast axial slice through neck. A more superior CT neck slice demonstrating a resolving abscess and concurrent left thyroid soft tissue mass, now confirmed as a papillary thyroid carcinoma.