In adults, proposed routes of infection for AST include lymphatic or hematogenous spread, direct inoculation of the thyroid or surrounding anatomy, direct extension of an abscess, and spread through a pyriform sinus fistula, usually in the setting of preexisting thyroid disease or an immunocompromised state [2, 11]. Based on the patient's history, several mechanisms may explain her AST. She was an IV drug user who presented with an MSSA abscess in her forearm, along with MSSA bacteremia. Thus, there is the strong possibility for hematogenous spread of MSSA from the forearm abscess to the thyroid. Although the patient denied injecting heroin into her neck or shoulders, there is also the possibility for direct inoculation of the thyroid. Furthermore, the patient had a preexisting multinodular goiter of one-year duration that showed follicular lesion of undetermined significance on cytology. Abnormal thyroid structures, such as multinodular goiters, nodules, or malignancies, have been postulated to make the thyroid gland more susceptible to suppuration . In particular, Erdamar et al. found that the enzymatic free radical defense system was impaired in 41 patients with multinodular goiters and papillary carcinomas . A weakened antioxidant defense mechanism may predispose the thyroid to bacterial infections. Few other cases in the literature report AST in the context of a preexisting multinodular goiter [13–15].