Objective : Follicular thyroid cancer usually presents as thyroid mass. Distant metastasis as presentation is uncommon. Here, we present a case of aggressive follicular thyroid cancer who presented with shortness of breath, cough and hemoptysis and was mistaken for possible disseminated tuberculosis
Methods : n/a
Results : Clinical case: A 67-year-old female with PMH of DM2 and ulcerative colitis, on azathioprine and infliximab, presented to ER with complaints of shortness of breath, hemoptysis and cough for few months. She was found to be hypoxic. Chest x-ray showed bilateral lung nodules and CT scan revealed multiple nodules in the lungs bilaterally. It also showed heterogenous enlargement of right lobe of thyroid, a low-density lesion in left lobe and lytic lesion at T6 vertebrae. MRI of thoracic spine showed diffuse T6 vertebral body metastatic disease with involvement of the posterior elements causing severe central stenosis and foraminal stenosis at T5-T7. Due to history of use of infliximab for ulcerative colitis and her presentation, she was admitted in isolated room with airborne precaution to rule out disseminated tuberculosis. Three samples of sputum for AFB and PPD test were negative. She was discharged with out-patient follow up. But she developed abdominal pain and leg weakness and readmitted within few days. She, then underwent T5-T7 resection and open biopsy of T6. Biopsy of T6 vertebrae was positive for metastatic carcinoma. Thyroid Ultrasound a 6.3 cm mass in right lobe and 2 cm mass in left lobe. Lab result showed normal TSH, Thyroglobulin was 31,069 ng/ml (2.8 – 40.9), Tg-Ab 2 and Anti Tg Ab was 1.3 iu/ml (<2). FNAs from both lobes came back atypical with Afirma GSC reporting suspicious for malignancy from right mass and benign from other. Initially, she refused to go for thyroidectomy and was treated with XRT for spine lesion. She subsequently underwent total thyroidectomy. Pathology revealed follicular thyroid carcinoma with gross extrathyroidal extension invading subcutaneous soft tissues, larynx, trachea, esophagus. She was treated with 150 mCI of I-131 after surgery.
Discussion : Follicular thyroid carcinoma spreads via hematogenous route and can have distant metastasis in 10 to 15% of cases. It commonly metastasis to bone and lung and less commonly to liver, brain, bladder and skin. It usually presents with goiter and it is uncommon to present as distant metastasis. Our case initially presented with typical features of tuberculosis in the context of infliximab use for ulcerative colitis and was mistaken.
This case highlights devastating presentation of an occult follicular thyroid carcinoma and can be mistaken for other illness.
Louisiana State University, Shreveport
Clinical Fellow - Department of Endocrinology and Metabolism, Louisiana State University, Shreveport, LA, USA.
Assistant Professor of Clinical Medicine
LSU Health Shreveport
Assistant Professor of Clinical Medicine LSU Health Shreveport, Louisianan, USA. Section of Endocrinology