Fungal thyroiditis in a lung transplant recipient: BMJ case
A 59-year-old man was admitted with 3 weeks of worsening shortness of breath 18 months after receiving a bilateral lung transplant for idiopathic pulmonary fibrosis. His immunosuppression included tacrolimus, everolimus and low-dose prednisone with no antifungal prophylaxis at the time of admission. CT chest revealed multiple, bilateral pulmonary nodules.

CT-guided biopsy revealed fungal hyphae. The initial CT and ultrasound of the neck at the onset of sore throat was negative; however, repeat CT neck for evolving neck pain and dysphasia during hospital course showed a mass-like lesion in the right thyroid lobe with extensive surrounding inflammatory changes.

The lesion was also visualised on ultrasound, where it appeared as a hypoechoic solitary nodule. Laboratory evaluation revealed hyperthyroidism, with a Thyroid Stimulating Hormone (TSH) of <0.01 µIU/mL (normal: 0.35–4.94 µIU/mL) and a free T4 of 2.72 ng/dL (normal: 0.70–1.48 ng/dL).

The patient was initiated on dual antifungal therapy with liposomal amphotericin and posaconazole, resulting in rapid resolution of neck pain. However, repeat CT neck 2 weeks after revealed a thyroid abscess in the right lobe, and subsequently the patient underwent right thyroid lobectomy and isthmusectomy.

Surgical debridement of the thyroid abscess revealed fungal hyphae; thus, confirming the diagnosis of fungal thyroiditis. A specific fungal pathogen was never successfully cultured from our patient. He was treated for presumed Aspergillus infection, the most common etiology of fungal thyroiditis, with clinical improvement.

Learning points
• Thyroiditis is a rare manifestation of disseminated fungal infection in immunocompromised hosts.

• Aspergillus spp are the most commonly implicated pathogen, although there are reports of cases due to Cryptococcus neoformans, Histoplasma capsulatum, Coccidioides immitis and Candida spp.
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