Objective <p>To present the clinical features and management perspectives of two patients with uncontrolled diabetes mellitus diagnosed with primary/idiopathic suppuration of the thyroid gland.</p> Methodology <p>Case report with literature review.</p> Results <p>Both patients had long-standing goiters and were diabetics with poor glycemic control. They developed acute thyroid abscesses and presented with skin ulcerations with discharge/granulations. Imaging revealed a grossly enlarged thyroid gland almost replaced by necrosis, with multiple heterogeneous loculations and abscess cavities in one patient, and a heterogeneous, multiloculated, thick-walled abscess with prominent peripheral ring enhancement, gas formation and cutaneous fistula in the other. Due to the mass effect, the airways deviated to the opposite side. Image-guided fine needle aspiration cytology revealed features of acute purulent inflammation in both patients, with underlying papillary thyroid carcinoma in one of them. No distant focus of inflammation as a source of dissemination could be identified. A total thyroidectomy was performed in one of the patients, while the other (with papillary thyroid carcinoma) refused any surgical intervention and was lost to follow-up. The clinical illustration of the two patients with acute thyroid abscesses has been supplemented with a literature review in the PubMed/MEDLINE database.</p> Conclusion <p>Acute thyroid suppuration of primary etiology is rare and is sparsely documented. Some forms of immunosuppression, like uncontrolled diabetes mellitus, generally act as predisposing factors. This report adds valuable insights to this seldom-encountered clinical entity, and analyzes the possible etiopathogenesis and clinical circumstances in which the thyroid that is otherwise resistant to suppurative infection gets affected.</p>