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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 8  |  Issue : 1  |  Page : 52-54

Tuberculosis of the thyroid gland


1 Department of Respiratory Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Pulmonary Medicine, All Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Web Publication2-Feb-2017

Correspondence Address:
Ved Prakash
Department of Respiratory Medicine, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-9727.199364

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  Abstract 

Thyroid tuberculosis is a very rare condition despite an overall increase in the extrapulmonary forms of tuberculosis. Tuberculous infection spreads to the thyroid by lymphogenous/hematogenous route or directly from adjacent organs. Thyroid tuberculosis does not have any specific symptom. Fine needle aspiration is the mainstay of diagnosis. Antituberculous therapy and surgical removal of affected parts of the thyroid gland are the most common methods of treatment of thyroid tuberculosis. We present a case of a 37-year-old male who presented with a swelling in the neck and was diagnosed as tubercular thyroiditis on cytopathological examination.

Keywords: Extrapulmonary, thyroid, tuberculosis


How to cite this article:
Verma AK, Mishra M, Prakash V, Kant S, Singh H P, Kapoor N. Tuberculosis of the thyroid gland. Muller J Med Sci Res 2017;8:52-4

How to cite this URL:
Verma AK, Mishra M, Prakash V, Kant S, Singh H P, Kapoor N. Tuberculosis of the thyroid gland. Muller J Med Sci Res [serial online] 2017 [cited 2020 Dec 3];8:52-4. Available from: https://www.mjmsr.net/text.asp?2017/8/1/52/199364


  Introduction Top


Tuberculosis of the thyroid gland is very rare even in countries with a high prevalence of tuberculosis. The supposed reasons for this are the bactericidal attributes of the thyroid colloid, extensive vascularization, and high levels of iodine in the gland. Thyroid involvement can be symptom-free as seen in generalized miliary spread or may present as a diffuse or localized swelling of the gland. It can also present as thyroid abscess in pulmonary tuberculosis patients.


  Case Report Top


A 37-year-old male came to our outpatient department with chief complaints of swelling on the right side of neck for 1 month. It developed slowly and did not show signs of compression. Swelling was about 2 cm × 2 cm in size, present on the right anterior side of the neck at the level of cricoid cartilage.

An ultrasound inspection of the neck revealed a bulky thyroid, mainly the right lobe, with heterogenous appearance. Cervical lymph nodes of level 2, 3, 4 on the right side and level 2 on the left side were also enlarged. Thyroid profile was suggestive of hyperthyroidism with raised level of T3 and T4 and decreased level of thyroid-stimulating hormone.

Fine needle aspiration of the neck swelling revealed benign follicular cells in small clusters along with well-formed epithelioid granulomas comprising epithelioid cells, histiocytes, lymphocytes, and giant cells in a background of scant colloid, [Figure 1] and [Figure 2] suggestive of granulomatous thyroiditis – tubercular pathology. However, acid-fast bacilli (AFB) were not visualized in the specimen examined. A biopsy was planned but not done as the fine needle aspiration cytology report was suggestive of and clinically correlated with tuberculosis and also because the patient did not give consent.
Figure 1: Granulomatous thyroiditis

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Figure 2: Granulomatous thyroiditis suggestive tubercular pathology

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Chest X-ray was normal. Mantoux test was suggestive of tuberculosis with 15 mm induration. A final diagnosis of tubercular thyroiditis with tubercular lymphadenitis was made and the patient was treated with isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months, followed by isoniazid and rifampicin for 4 months as per the Revised National Tuberculosis Control Programme protocol. Clinical signs of regression of the swelling and improvement in thyroid profile started to occur toward the end of intensive phase of treatment and were completely normal by the end of therapy. However, serial ultrasounds were not done in follow-up.


  Discussion Top


Thyroid tuberculosis is rare, with an incidence of <0.4% based on histological analysis of resected thyroid specimens.[1] Frequently, it is unsuspected because of its rare occurrence; furthermore, it is manifested with a wide array of nonspecific symptoms such as high temperature, weight loss, malaise, night time sweating, or it can even be asymptomatic.

Most frequently, the patients are middle-aged women.[2] Although dysphagia, dyspnea, and more rarely dysphonia are the main symptoms of the disease, the patient may be asymptomatic.[3] The most frequent clinical presentation is a solitary thyroid nodule that may present a cystic component.[2],[4],[5] The patients are usually euthyroid, but cases of hypothyroidism and hyperthyroidism are described.[6]

It is observed that certain tissues are relatively resistant to tuberculous infection -so tubercles in heart, striated muscle, thyroid and pancreas are rarely seen.[7] The ability of thyroid to resist infection is attributed to a number of factors – prosperous lymphatic and vascular supply, well-developed capsule and high iodine content of the gland,[8] colloid possessing bactericidal action, destruction of tubercle bacilli due to increased physiological activity of phagocytes in hyperthyroidism, and possible antitubercular role of thyroid hormones.[9]

Tuberculosis may involve thyroid gland in two main forms. One of them is miliary spread to thyroid gland as a part of generalized dissemination. Alternatively, focal caseous tuberculosis of thyroid may occur, presenting as localized swelling mimicking carcinoma or as cold abscess.[10],[11],[12],[13]

Spread of the disease to the thyroid occurs by hematogenous or lymphogenous route or directly from larynx or tubercular cervical lymphadenitis.[1] Four morphological variations of thyroid tuberculosis are distinguished: (1) Multiple tubercles in case of military tuberculosis, (2) solitary and sometimes merging tubercles, (3) foci of caseation necrosis or cold abscesses, and (4) cicatrized tubercular foci.

Tuberculosis of the thyroid gland is diagnosed on the basis of cytological or histological examination and identification of AFB. Histological demonstration of epithelioid cell granulomas with peripheral lymphocytic cuffing, Langhans giant cells, and central caseation necrosis proves the diagnosis. Ultrasonographic and computed tomography (CT) findings can help in this matter as well: Heterogeneous hypoechoic mass is seen on ultrasonogram and peripheral-enhancing low-density abscess with regional lymphadenopathy is demonstrated on CT scan.

The following prerequisite conditions present for diagnosis of thyroid tuberculosis were described in early 1939: (1) Demonstration of AFB within thyroid, (2) a necrotic or abscessed gland, and (3) demonstration of tuberculous focus outside. Histological and bacteriological confirmation is adequate and fulfillment of the third criterion is not essential.

Tuberculosis is difficult to distinguish from other inflammations of the thyroid gland as well as from its carcinoma mainly because the regional lymphatic nodes are infiltrated as well. It is particularly vital to distinguish thyroid tuberculosis from thyroid cancer in an attempt to avoid unnecessary surgery. It is very important to differentiate tuberculosis from other granulomatous diseases such as De Quervain's thyroiditis and sarcoidosis. Corticosteroids are used for treatment of these disorders which could worsen the illness of patients with tuberculosis of the thyroid gland. In this case, sarcoidosis was excluded based on the absence of multisystem involvement (presentation only in the form of neck swelling), positive Mantoux test, normal chest X-ray, and cytology report favoring tuberculosis.

The treatment of tuberculosis of the thyroid gland is not much different from the treatment of other forms of tuberculosis. At least 6 months of therapy is required using two or three of the following drugs – rifampicin, isoniazid, pyrazinamide, and ethambutol. Surgical treatment is required, along with the earlier described therapy, when the affected thyroid gland causes mechanical obstruction, when there is a suspected combined malignant process or if hyperthyroidism is present which is unaffected by medical treatment. When surgical treatment has to be undertaken in addition to antituberculous therapy, one must keep in mind possible complications such as local relapse of disease, slow wound recovery, fistula formation, and the occurrence of tuberculous abscess.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
  References Top

1.
Al-Mulhim AA, Zakaria HM, Abdel Hadi MS, Al-Mulhim FA, Al-Tamimi DM, Wosornu L. Thyroid tuberculosis mimicking carcinoma: Report of two cases. Surg Today 2002;32:1064-7.  Back to cited text no. 1
    
2.
Abdulsalam F, Abdulaziz S, Mallik A. Primary tuberculosis of the thyroid gland. Kuwait Med J 2005;37:116-8.  Back to cited text no. 2
    
3.
Khan EM, Haque I, Pandey R, Mishra SK, Sharma AK. Tuberculosis of the thyroid gland: A clinicopathological profile of four cases and review of the literature. Aust N Z J Surg 1993;63:807-10.  Back to cited text no. 3
    
4.
Das DK, Pant CS, Chachra KL, Gupta AK. Fine needle aspiration cytology diagnosis of tuberculous thyroiditis. A report of eight cases. Acta Cytol 1992;36:517-22.  Back to cited text no. 4
    
5.
Surer I, Ozturk H, Cetinkursun S. Unusual presentation of tuberculosis reactivation in childhood: An anterior neck mass. J Pediatr Surg 2000;35:1263-5.  Back to cited text no. 5
    
6.
Nieuwland Y, Tan KY, Elte JW. Miliary tuberculosis presenting with thyrotoxicosis. Postgrad Med J 1992;68:677-9.  Back to cited text no. 6
    
7.
Pandit AA, Joshi AS, Ogale SB, Sheode JH. Tuberculosis of thyroid gland. Indian J Tuberc 1997;44:205-7.  Back to cited text no. 7
    
8.
Mpikashe P, Sathekge MM, Mokgoro NP, Ogunbanjo GA. Tuberculosis of the thyroid gland: A case report: Case study. S Afr Fam Pract 2004;46:19-20.  Back to cited text no. 8
    
9.
Gupta KB, Gupta R, Varma M. Tuberculosis of the thyroid gland. Pulmonary 2008;9:65-8.  Back to cited text no. 9
    
10.
Muzaffar TH, Alkahtani NM. Overview of thyroid tuberculosis. Middle East J Inter Med 2008;1:27-8. Available from: http://me-jim.com/NewArchives/MEJIM_Vol1_Iss3.pdf. [Last accessed on 2016 Feb 25].  Back to cited text no. 10
    
11.
Parmar H, Hashmi M, Rajput A, Patankar T, Castillo M. Acute tuberculous abscess of the thyroid gland. Australas Radiol 2002;46:186-8.  Back to cited text no. 11
    
12.
Unnikrishnan AG, Koshy GR, Rajaratnam S, Seshadri MS, Sarada V. Suppurative neck abscess due to tuberculous thyroiditis. J Assoc Physicians India 2002;50:610-1.  Back to cited text no. 12
    
13.
Bahadur P, Bhatnagar BN, Aurora AL, Seetharaman ML. Tuberculous abscess of thyroid gland. Indian J Tuberc 1983;30:33-5.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]



 

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