The boy was previously healthy and had no prior thyroid disease, neck surgery or recurrent infections. Before admission, he had experienced six days of high fever, reaching 39°C, with pain radiating from his throat to the left ear. Odynophagia began on the second day, followed by hoarseness, neck stiffness and pain during neck movement. He had no stridor, drooling, respiratory distress or clinical features of hyperthyroidism. On admission, his temperature was 38.7°C, heart rate was 117 beats per minute, blood pressure was 113/73 mmHg, respiratory rate was 24 breaths per minute and oxygen saturation was 99% on room air. Examination found pharyngeal erythema, deviation of the uvula to the right, mild thyroid tenderness and painful restriction of neck movement, but no visible swelling, fluctuance or clinical thyrotoxicosis.

Laboratory findings indicated acute inflammation and biochemical thyroid dysfunction. The white blood cell count was 10.8 × 10⁹/L with neutrophil predominance, C-reactive protein was 15.67 mg/dL against a reference range of 0.10–0.50 mg/dL, and procalcitonin was 0.24 ng/mL against a reference range of 0.02–0.10 ng/mL. Thyroid-stimulating hormone was suppressed at 0.02 µIU/mL, while free T3 was elevated at 7.48 pg/mL and free T4 at 2.74 ng/dL. The authors interpreted this pattern as acute, destructive thyroid injury associated with acute suppurative thyroiditis rather than excessive autonomous hormone production. Blood cultures produced no growth after five days, and a respiratory viral polymerase chain reaction test was negative, leaving no identified pathogen in the case.

Imaging demonstrated the infection’s extensive anatomical reach. A lateral neck radiograph showed widening of the prevertebral soft tissue. Contrast-enhanced CT identified a 1.3 × 1.6 × 2.9 cm rim-enhancing collection within an enlarged left thyroid lobe, with extension into the visceral, prethyroid and retropharyngeal spaces. A contiguous 0.7 × 1.3 × 1.5 cm collection was also present in the left parapharyngeal region. The collection produced mass effect on the airway, but there was no mediastinal extension or vascular thrombosis. Flexible laryngoscopy during the acute episode showed a patent airway, normally mobile vocal cords and no pooling of secretions. It also failed to demonstrate a pyriform sinus fistula, a congenital tract that can connect the oropharynx with the thyroid and is often sought in children with left-sided infections.

After discussion between the pediatric and otorhinolaryngology teams, the child was treated conservatively with intravenous ceftriaxone and clindamycin. The authors said surgery was not pursued because the airway remained open, the patient was not systemically toxic, and serial monitoring showed clinical improvement. The team planned to intervene for airway compromise, clinical deterioration, failure of inflammatory markers to improve within 48–72 hours, abscess enlargement on repeat imaging or systemic toxicity. The child became afebrile by day two and resumed eating and drinking. By day three, C-reactive protein had fallen to 3.84 mg/dL and procalcitonin to 0.06 ng/mL, supporting the decision to continue non-operative care rather than proceed with drainage.

An ultrasound-guided aspiration was attempted on day four in an effort to obtain material for cytological and microbiological analysis. The lesion appeared heterogeneous and predominantly hypoechoic with internal echoes rather than a discrete, anechoic fluid collection. Real-time imaging showed the needle tip within the target throughout the procedure, but no material could be aspirated. The authors therefore considered that the inflammatory collection had limited liquefaction. With subacute thyroiditis and an evolving inflammatory phlegmon remaining in the differential, the diagnosis continued to rest on the clinical presentation and imaging rather than a specimen-based microbiological result. A follow-up ultrasound on day five measured the left thyroid collection at 1.0 × 1.2 × 3.0 cm. Because CT and ultrasound used different modalities and imaging planes, the investigators interpreted the comparison as showing no convincing progression rather than a measurable reduction.

By day seven, the C-reactive protein concentration had normalized at 0.54 mg/dL, and the boy was discharged after receiving seven days of intravenous ceftriaxone and clindamycin. He then completed three weeks of oral cefixime and clindamycin, producing a total antibiotic course of four weeks. The oral combination was chosen to retain coverage for streptococcal, staphylococcal and anaerobic organisms while allowing treatment to finish outside the hospital. The course was completed without reported adverse effects or tolerability problems. The boy’s biochemical thyrotoxicosis remained asymptomatic, so no antithyroid treatment was given. His thyroid function had returned to normal at reassessment about 14 months later, with TSH at 2.32 µIU/mL, free T3 at 3.44 pg/mL and free T4 at 0.98 ng/dL. A barium swallow at that visit showed no radiological evidence of a pyriform sinus fistula.

The report distinguishes the infection’s transient thyroid effects from conventional hyperthyroidism. In acute suppurative thyroiditis, inflammation can injure thyroid follicles and release stored thyroid hormone into the circulation, producing suppressed TSH and elevated free T3 and T4 without increased hormone synthesis. The authors state that thionamides, which reduce hormone synthesis, are therefore generally not useful for this destructive process; management is supportive and includes thyroid-function monitoring. In this case, the boy had no symptoms of thyrotoxicosis and received no antithyroid therapy. However, thyroid function was measured at admission and only again about 14 months later, with no intermediate values. The precise time course of recovery could not be established, and an intervening hypothyroid phase could not be excluded.

Several limitations constrain what this case can establish. No causative organism was identified because the aspiration yielded nothing and blood cultures were sterile, and the initial distinction between an abscess and an evolving inflammatory phlegmon therefore rested partly on imaging and clinical assessment. The family missed early follow-up appointments, and no outpatient ultrasound was performed, so the timing of sonographic resolution remains unknown. Although the child was well and had normalized thyroid function without recurrence at the delayed visit, a single negative laryngoscopic examination or barium swallow cannot definitively exclude an intermittently patent or collapsed pyriform sinus fistula. The findings also cannot be generalized to children with airway compromise, systemic toxicity, mediastinal involvement or other warning signs. The report’s practical message is that airway status, systemic condition and treatment response may matter more than the apparent extent of infection alone when deciding whether drainage is necessary, but the authors explicitly describe this observation as hypothesis-generating.

Subject of Research: Pediatric case report of non-operative management of a multispace thyroid abscess with transient thyrotoxicosis.

Article Title: Case Report: Conservative management of pediatric thyroid abscess with multispatial extension and transient thyrotoxicosis

Article References: Almutairi, A. K. (2026). Case Report: Conservative management of pediatric thyroid abscess with multispatial extension and transient thyrotoxicosis. Frontiers in Pediatrics, 14, Article 1951613. https://doi.org/10.3389/fped.2026.1951613

Image Credits: AI Generated

DOI: 10.3389/fped.2026.1951613

Keywords: pediatric thyroid abscess, acute suppurative thyroiditis, conservative management, deep neck infection, transient thyrotoxicosis, antibiotic therapy, pyriform sinus fistula, ultrasound-guided aspiration, case report, Case, Report, Conservative