Interesting and Challenging Thyroid Disorders
Case Studies, Discussion and Learning points
by
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MANAGEMENT OF GRAVES’ THYROTOXICOSIS IN A PATIENT WITH NECK ABSCESS ABSTRACT The simultaneous occurrence of acute sepsis from a neck abscess and new-onset symptomatic Graves’ thyrotoxicosis is uncommon and presents significant management challenges. This case highlights an individualised approach to treatment in such an acute scenario, emphasising the importance of careful perioperative planning. Clinicians must remain vigilant to the heightened risk of thyroid storm in patients undergoing surgical intervention in this context. Keywords: Graves’ thyrotoxicosis, neck abscess, thyroid storm, sepsis CASE PRESENTATION A woman in her forties was referred to the ENT team via the two-week-wait pathway with a one-week history of a painful, enlarging lump on the left side of her neck. She denied voice change or dysphagia but reported longstanding anxiety, occasional palpitations for more than six months, and unquantified weight loss over the preceding year. She also noted lighter-than-usual menstrual cycles for the past two months. Her past medical history was unremarkable, but she smoked approximately 10 cigarettes daily. On examination, she was febrile with a fluctuant, tender, erythematous mass in the left upper neck, measuring approximately 5 × 5 cm. There were no clinical signs of thyroid eye disease. Flexible nasoendoscopy demonstrated pooling of secretions. A neck ultrasound (figure 3.1) revealed suppurative lymphadenitis with evolving abscess formation (cystic changes), as well as diffuse thyroid enlargement with increased vascularity. Ultrasound-guided fine-needle aspiration yielded frank pus and thick echogenic fluid consistent with infection. She was admitted for intravenous antibiotics and urgent incision and drainage, as oral antibiotics had provided minimal improvement. Pre-operative ECG showed sinus tachycardia, prompting thyroid function tests (TFTs) alongside baseline bloods (table 3.1). This revealed an incidental finding of biochemical thyrotoxicosis (September 2021). The TSH receptor antibody (TRAb) result was not available. Table 3.1 Parameters 09/21 Normal range TSH <0.05 0.3-4.5="" mu/l="" ft4="" 49.9="" 10-22="" pmol/l="" ft3="" 32.9="" 3.1-6.8="" pmol/l="" tpo="" antibody="" 327="" 0-34="" kunits/l="" crp="" 58="" wbc="" 17.9="" question:="" what="" should="" be="" the="" immediate="" plan="" of="" action?="" 1.="" start="" carbimazole,="" lugol’s="" iodine="" and="" proceed="" with="" surgery="" immediately="" 2.="" start="" carbimazole,="" lugol’s="" iodine,="" colesevelam="" and="" proceed="" with="" surgery,="" but="" only="" after="" a="" few="" days="" 3.="" proceed="" with="" incision="" &="" drainage="" (i&d)="" and="" perform="" thyroidectomy="" at="" the="" same="" time="" 4.="" none="" of="" the="" above="" endocrine="" team="" recommendations="" the="" case="" was="" discussed="" with="" the="" endocrine="" team,="" who="" suspected="" graves’="" thyrotoxicosis="" given="" the="" markedly="" elevated="" ft3="" level="" and="" a="" ft4/ft3="" ratio=""><3.0. to="" minimise="" the="" risk="" of="" thyroid="" storm,="" they="" advised="" delaying="" incision="" and="" drainage="" for="" 2–3="" days="" to="" allow="" partial="" biochemical="" control.="" the="" following="" management="" plan="" was="" initiated:="" •="" carbimazole="" 40="" mg="" once="" daily="" •="" colesevelam="" 625="" mg="" twice="" daily="" (first="" dose="" given="" immediately),="" to="" bind="" thyroid="" hormones="" in="" the="" gut="" and="" reduce="" enterohepatic="" recycling="" •="" contrast-enhanced="" ct="" scan="" of="" the="" neck="" to="" aid="" surgical="" planning="" and,="" importantly,="" to="" provide="" a="" large="" iodine="" load,="" thereby="" inducing="" the="" wolff–chaikoff="" effect="" (1)="" the="" ct="" scan="" of="" the="" neck="" (figure="" 3.2)="" showed="" evidence="" of="" left="" cervical="" suppurative="" lymphadenitis="" with="" abscess="" formation.="" the="" arrow="" mark="" shows="" the="" large="" fluid="" collection="" of="" around="" 5.5="" cm.="" following="" implementation,="" thyroid="" function="" improved="" significantly="" (table="" 3.2),="" and="" the="" patient="" subsequently="" underwent="" safe="" surgical="" incision="" and="" drainage="" without="" complications.="" later="" the="" tsh="" receptor="" antibody="" returned="" markedly="" elevated="" at="" 40.9="" iu/l="" confirming="" severe="" graves’="" thyrotoxicosis.="" table="" 3.2="" parameters="" 09/09/21="" 15/09/21="" 28/09/21="" normal="" range="" tsh=""><0.05><0.05><0.05 0.3-4.5="" mu/l="" ft4="" 49.9="" 39.7="" 7.6="" 10-22="" pmol/l="" ft3="" 32.9="" 11.3="" 5.5="" 3.1-6.8="" pmol/l="" tpo="" antibody="" 327="" 0-34="" kunits/l="" trab="" 40.9=""><1.0 iu/l crp 58 wbc 17.9 further endocrine review it was considered likely that the patient had been suffering from undiagnosed graves’ disease for some time, which only came to light during her hospital admission with a neck abscess. she was discharged home once clinically stable, on carbimazole 40 mg once daily and a beta-blocker as required. at endocrine follow-up, she reported having experienced tremulousness for several months and marked weight loss, dropping from clothing size 18 to size 8 over the preceding year. on examination, she had a small diffuse goitre. discussion it is uncommon to encounter a patient who presents with sepsis and an acute neck abscess alongside a new diagnosis of thyrotoxicosis. the most important priority in such scenarios is to recognise the risk of thyroid storm and to implement strategies that reduce this risk. management options aim to: • inhibit thyroid hormone synthesis (e.g. antithyroid drugs such as carbimazole). • block thyroid hormone release (e.g. high-dose iodine to induce the wolff–chaikoff effect). • inhibit peripheral conversion of thyroxine (t4) to triiodothyronine (t3) (e.g. glucocorticoids). • interrupt enterohepatic circulation of thyroid hormones (e.g. bile acid sequestrants such as colesevelam). learning points • this case illustrates the importance of prompt and effective management of thyrotoxicosis in the acute setting when urgent surgical intervention is required. the key aim is to achieve rapid biochemical and clinical stabilisation prior to surgery. • treatment strategies in such circumstances may include: o high-dose carbimazole to inhibit thyroid hormone synthesis. o bile acid sequestrants (e.g. colesevelam, cholestyramine) to enhance faecal excretion of thyroid hormones via interruption of enterohepatic circulation. o high-dose glucocorticoids to provide haemodynamic stability and reduce peripheral conversion of t4 to t3. • lugol’s iodine (or potassium iodide) may be used to inhibit the release of pre-formed thyroid hormone. its therapeutic effect typically begins after 24–48 hours, but the benefit is transient due to the escape phenomenon; therefore, it should never be used as a stand-alone treatment and must be given only after antithyroid drugs have been initiatedalthough contrast-enhanced ct scanning is not routinely used as a therapeutic intervention in thyrotoxicosis, in this case it was employed after multidisciplinary team (mdt) discussion because of its dual diagnostic and therapeutic benefits. iu/l="" crp="" 58="" wbc="" 17.9="" further="" endocrine="" review="" it="" was="" considered="" likely="" that="" the="" patient="" had="" been="" suffering="" from="" undiagnosed="" graves’="" disease="" for="" some="" time,="" which="" only="" came="" to="" light="" during="" her="" hospital="" admission="" with="" a="" neck="" abscess.="" she="" was="" discharged="" home="" once="" clinically="" stable,="" on="" carbimazole="" 40="" mg="" once="" daily="" and="" a="" beta-blocker="" as="" required.="" at="" endocrine="" follow-up,="" she="" reported="" having="" experienced="" tremulousness="" for="" several="" months="" and="" marked="" weight="" loss,="" dropping="" from="" clothing="" size="" 18="" to="" size="" 8="" over="" the="" preceding="" year.="" on="" examination,="" she="" had="" a="" small="" diffuse="" goitre.="" discussion="" it="" is="" uncommon="" to="" encounter="" a="" patient="" who="" presents="" with="" sepsis="" and="" an="" acute="" neck="" abscess="" alongside="" a="" new="" diagnosis="" of="" thyrotoxicosis.="" the="" most="" important="" priority="" in="" such="" scenarios="" is="" to="" recognise="" the="" risk="" of="" thyroid="" storm="" and="" to="" implement="" strategies="" that="" reduce="" this="" risk.="" management="" options="" aim="" to:="" •="" inhibit="" thyroid="" hormone="" synthesis="" (e.g.="" antithyroid="" drugs="" such="" as="" carbimazole).="" •="" block="" thyroid="" hormone="" release="" (e.g.="" high-dose="" iodine="" to="" induce="" the="" wolff–chaikoff="" effect).="" •="" inhibit="" peripheral="" conversion="" of="" thyroxine="" (t4)="" to="" triiodothyronine="" (t3)="" (e.g.="" glucocorticoids).="" •="" interrupt="" enterohepatic="" circulation="" of="" thyroid="" hormones="" (e.g.="" bile="" acid="" sequestrants="" such="" as="" colesevelam).="" learning="" points="" •="" this="" case="" illustrates="" the="" importance="" of="" prompt="" and="" effective="" management="" of="" thyrotoxicosis="" in="" the="" acute="" setting="" when="" urgent="" surgical="" intervention="" is="" required.="" the="" key="" aim="" is="" to="" achieve="" rapid="" biochemical="" and="" clinical="" stabilisation="" prior="" to="" surgery.="" •="" treatment="" strategies="" in="" such="" circumstances="" may="" include:="" o="" high-dose="" carbimazole="" to="" inhibit="" thyroid="" hormone="" synthesis.="" o="" bile="" acid="" sequestrants="" (e.g.="" colesevelam,="" cholestyramine)="" to="" enhance="" faecal="" excretion="" of="" thyroid="" hormones="" via="" interruption="" of="" enterohepatic="" circulation.="" o="" high-dose="" glucocorticoids="" to="" provide="" haemodynamic="" stability="" and="" reduce="" peripheral="" conversion="" of="" t4="" to="" t3.="" •="" lugol’s="" iodine="" (or="" potassium="" iodide)="" may="" be="" used="" to="" inhibit="" the="" release="" of="" pre-formed="" thyroid="" hormone.="" its="" therapeutic="" effect="" typically="" begins="" after="" 24–48="" hours,="" but="" the="" benefit="" is="" transient="" due="" to="" the="" escape="" phenomenon;="" therefore,="" it="" should="" never="" be="" used="" as="" a="" stand-alone="" treatment="" and="" must="" be="" given="" only="" after="" antithyroid="" drugs="" have="" been="" initiatedalthough="" contrast-enhanced="" ct="" scanning="" is="" not="" routinely="" used="" as="" a="" therapeutic="" intervention="" in="" thyrotoxicosis,="" in="" this="" case="" it="" was="" employed="" after="" multidisciplinary="" team="" (mdt)="" discussion="" because="" of="" its="" dual="" diagnostic="" and="" therapeutic="">
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Book Details
About the Book
The idea for this book took shape during the final two years of my endocrinology specialty training, driven by a desire to share practical learning from real-world clinical experience. Thyroid disorders are common, yet their presentation and management can often be nuanced and challenging. This case series aims to reflect that clinical reality. The book brings together a collection of interesting and thought-provoking cases covering a broad spectrum of thyroid disorders. Most cases begin with a focused clinical question, followed by a structured case presentation, discussion, and—most importantly—clear key learning points to consolidate practical take-home messages. Having started this work as a senior specialty registrar and now practising as a Consultant in Diabetes and Endocrinology, two years into post, I have gained a deeper appreciation of the clinical questions that arise in everyday practice and the uncertainties clinicians often face. This perspective has shaped the way each case is presented and discussed, with an emphasis on pragmatic, evidence-based decision-making. This book is not intended to be exhaustive. The primary aim has been to keep the content concise and to the point, with emphasis on key learning points and meaningful discussion. It is hoped that this format will make the book particularly useful for specialty trainees, endocrine specialist nurses, and other healthcare professionals involved in the care of patients with thyroid disease. This book is dedicated to our mentors, teachers, trainees and patients The work has been undertaken entirely on a voluntary basis, without sponsorship, and any proceeds from the sale of this book will be donated to the British Thyroid Foundation.
About the Author
Lead Author: Mudassir Ali, FRCP - Consultant Physician and Endocrinologist in the Northumbria NHS Trust, UK, with dual CCT in Diabetes & Endocrinology and General Internal Medicine. Co-author: Irfan Khan, FRCP - Consultant Physician and Endocrinologist in the County Durham and Darlington NHS Trust, UK, with dual CCT in Diabetes & Endocrinology and General Internal Medicine.