Case Report: Disseminated Burkholderia pseudomallei with Acute Suppurative Thyroiditis and Abscess Formation

Abstract

Melioidosis has a highly variable presentation. Almost any organ can be involved, although an antemortem diagnosis of acute suppurative thyroiditis (AST) has not, to our knowledge, been previously described. A 68-year-old Australian male with poorly controlled type 2 diabetes mellitus presented with fever, odynophagia, and thyroid function tests consistent with hyperthyroidism. Imaging demonstrated a lung abscess and an enlarged thyroid gland with three nodules. Blood cultures and fine-needle aspiration of the thyroid nodules grew Burkholderia pseudomallei. He received intravenous ceftazidime and concurrent oral trimethoprim/sulfamethoxazole (TMP/SMX) for 4 weeks followed by high-dose oral TMP/SMX for a further 3 months and made a complete recovery. Acute suppurative thyroiditis is an uncommon cause of hyperthyroidism and thyroid aspirates are not commonly sent for bacterial culture. The case highlights the need to consider AST in patients presenting with a hyperthyroid state and disseminated infection. It also demonstrates that in a case of disseminated melioidosis any symptom may be a clue to underlying metastatic infection.

Figure 1.

Computed tomography revealed (A) a 21 × 18 × 28 mm irregular left upper lobe pulmonary lesion, and (B) bilateral perinephric stranding with a 12-mm exophytic lesion of the right kidney (arrow).

Figure 2.

Imaging of the thyroid gland. Initial ultrasound demonstrated (A) a 30 × 22 × 21 mm nodular lesion in the left lobe, and two smaller lesions in the right. (B) Nuclear thyroid scan at 4 weeks reveals diffusely increased uptake, more prominent on the right. The arrow marked SSN identifies the suprasternal notch. (C) Ultrasound at 6 weeks shows improvement of the left lobe lesion. This figure appears in color at www.ajtmh.org.

Figure 3.

(A) Thyroid-stimulating hormone and (B) thyroxine levels over time demonstrating acute hyperthyroid state, subsequent hypothyroid phase, and eventual normalization.