MON-485 Thyroid Abscess in a Healthy 22-Year Old Female

Background: Thyroid abscess is a rare pathology, exhibiting an incidence of less than 1% of all thyroid diseases. The thyroid is highly resilient against infections. Those who do experience thyroid abscesses are commonly immunocompromised. We illustrate a case of a thyroid abscess in a young, healthy patient. Clinical Case: A previously healthy 22-year-old woman presented to the emergency department complaining of a sore throat, fever, nausea, and body aches. On exam, the patient was febrile, but had no obvious cervical lymphadenopathy, masses, or oropharyngeal lesions/growths. Initial labs showed leukocytosis to 13.5 k/ul with left-shift. The patient was diagnosed with acute pharyngitis, and was discharged on oral steroids and antibiotics for an incidental urinary tract infection. After some improvement, the patient returned to the ED 14 days later with a worsening odynophagia, dysphagia, and hematemesis. The patient was afebrile, but had neck swelling and possible thyromegaly. Lab results showed leukocytosis to 17.3 k/ul, and CT of the neck identified a 3.1cm x 3.3cm x 4.4c heterogeneous cystic/solid mass that nearly completely replaced the normal right thyroid lobe parenchyma and extended to the isthmus. Right-sided lymphadenopathy was also present. Initial evaluation suggested thyroid carcinoma. The patient was re-initiated on steroids due previous improvement, and was referred to a tertiary academic medical center for biopsy and further evaluation. 2 days later, the patient returned to the ED for worsening symptoms. However, she was discharged to home with no further management. At her endocrine surgery consultation visit, the patient reported worsening pain, inability to move her neck, inability to eat or drink, inability to lie flat, and new-onset sialorrhea and voice changes. A bedside ultrasound was performed with findings suggestive of an abscess. An in-office fine-needle aspiration produced purulent fluid, which relieved some of the patient’s compressive symptoms. Cytology showed inflammatory cells (mostly neutrophils) and numerous bacteria. The patient was emergently taken to the operating room for neck exploration, hemithyroidectomy, and incision/drainage of a suspected thyroid abscess. A drain was placed and removed POD 2 after minimal output. The patient was discharged on oral antibiotics. 1-week post-operatively, the patient returned to the ED due to reaccumulation of the abscess. This was successfully treated with IR placement of a drain. The drain was removed 2-weeks post-operatively, and the patient is doing well. Conclusion: Thyroid abscesses are rare but possible in young and immune-competent patients. While the imaging findings can point towards a more common diagnosis, such as thyroid carcinoma, avoiding anchoring bias is important. Imaging data should be considered in the context of the clinical picture to avoid the possibility of misdiagnosis.