Category: Thyroid

LONG STANDING [7 YEARS] GRAVES' DISEASE, WITH RECENT MONSTROUS THYROID ENLARGEMENT- SECOND PATHOLOGY?

Monday, Apr 8
1:00 AM – 2:00 AM

Objective :

A challenging case of long standing Graves’ hyperthyroidism and Orbitopathy, with recent monstrous thyroid enlargement. Second pathology?


Methods :

A 59 year male presented with swelling in the neck x 1 year, rapidly growing x 6 months, difficulty in swallowing, breathing, and speaking x 2 weeks and increased sleep x 1 year. Known case of Graves hyperthyroidism x 7 years [T3= 5.09 (0.6-1.8 ng/ml); T4= 24.6 (4.5-12.6 µg/dl); TSH< 0.001 (0.35-5.50 µIU/mL), with Orbitopathy, treated with Carbimazole.


 


Thyroid: Grade 4, Firm, diffuse, highly vascular with bruit and thrill; Orbitopathy ++++, proptosis +++; enlarged veins on chest/arms. Severe obstructive sleep apnoea [AHI= 64]. 


Surgery: Total Thyroidectomy [Large “multinodular” goitre; highly vascular, multiple dilated veins over gland of larger calibre]. Patient’s symptoms relieved. L thyroxine replacement.


Results :

Endocrinology:   Predominantly T3 Toxicosis; TSH-0.02 (0.35-5.50 µIU/ml); TSH receptor antibody: 31.8 (N < 1.7); TPOAb: 384 [0-5.6 IU/ml].


Ultrasound: Diffusely enlarged heterogeneous thyroid; Right Lobe: 13 x 6 x 4.8cm; Left Lobe: 13 x 6.3 x 4.7cm; Heterogeneously hypoechoic echotexture; Increased vascularity; No lymphadenopathy. Multiple tiny scattered microcalcifications. Diagnosis: Diffuse thyroiditis with secondary multinodular goiter.


Thyroid Uptake Scan: Enlarged thyroid, increased trapping function of thyroid gland: Graves Disease


MRI Neck:Monstrous Goitre; Right lobe: 5.9 x 4.2 x 12.7 cm; Left lobe: 6.0 x 4.5 x 14.3 cm; Isthmus: 2.5 cm; Multiple 2-5 mm sized cystic areas/septae in both lobes.  No retrosternal extension. Mass effect on trachea. Superiorly enlargement upto floor of mouth. Posteriorly extending upto midline in prevertebral region.


Histopathology: Adenomatous hyperplasia with dyshormonogenetic features.  Cystic changes with secondary [benign] papillae- broad core. No inclusions/grooves.


Discussion :

Rapid increase in goitre in pre-existing long standing Graves disease, merits special attention. It usually signifies Second pathology.


Possibilities: Malignancy: Papillary carcinoma; Primary lymphoma of thyroid.  Benign lesions:  Haemangioma of the thyroid – rare; Lymphoepithelial cysts of the thyroid – rare.


 


Conclusion :

Final Diagnosis:


“Lymphoepithelial cysts of the thyroid, on top of Graves pathology”.


This is a peculiar rare benign cystic disease of thyroid, which usually develops on top of autoimmune thyroid disease. Our patient had both Graves disease and Hashimotos thyroiditis, with supporting evidence of multiple cysts in both lobes of thyroid. Incidentally subcentimeter sized cysts were present in both lobes of liver and left kidney.

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Vasanthi Nath

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology, Diabetes, Internal Medicine, Geriatrics
Clinical Interests: Neuroendocrinology and Neurometabolism, Metabolic Myopathies; Thyroid tumors, Geriatric Endocrinology, Inpatient Diabetes Care and Endocrine Emergencies; Type 1 diabetes across ages

Muralidhara Krishna

Consultant Faculty Endocrinology Diabetes Biochemistry
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty: Endocrinology Diabetes Metabolism; Associate Professor: Clinical Biochemistry and Laboratory Medicine
Specialties: Endocrinology Diabetes Metabolism; Clinical Biochemistry
Clinical Interests: Diabetes mellitus; Thyroid Disorders; Obesity; Dyslipidemia.

Ashim Sinha

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center, Australia

Chairperson and Director, Endocrinology Diabetes; James Cook University, Cairns and Cairns Base Hospital and Diabetes Centre; Cairns & Hinterland Hospital & Health Services, Cairns, North Queensland, Australia.

Kavitha Muniraj

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty; Director Medical ; Director Research; Trustee
Specialties: Endocrinology Diabetes; Clinical Research
Clinical Interests: Pituitary Adrenal disorders; Bone health; Cardiovascular Health; Thyroid dysfunction; Diabetes Pharmacotherapy; Clinical Pharmacology; Pharmacovigilance; Clinical research Safety and Audits

Chandraprabha S

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology Diabetes Metabolism
Clinical Interests: Pregnancy Diabetes, Pregnancy Thyroid Dysfunction, Women Health, Geriatric Endocrinology, Diabetes mellitus and Mental Health, Spiritual Medicine

Reshma B. Vijay

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology Diabetes and Metabolism
Clinical Interests: Pediatric Endocrinology; Diabetes mellitus; Insulin Pumps, Continuous Glucose Monitoring and Artificial Pancreas; Growth and Puberty; Thyroid; Pituitary Adrenal disorders

Jayalakshmi T

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty

Specialties: Endocrinology, Diabetes, Internal Medicine,
Clinical Interests: Diabetes mellitus, Cardiovascular Health, Thyroid, In Patient Diabetes Care, Endocrinology Metabolic emergencies and critical care

Babitha D. T

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology, Diabetes
Clinical Interests: Endocrine disorders of pregnancy, Pregnancy Diabetes, Cardiovascular Health, Thyroid, Inpatient diabetes care and endocrine metabolic emergencies

Nidhi Garg

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
bangalore, Karnataka, India

Designation: Senior Consultant and Faculty
Specialties: Diabetes and Metabolism
Clinical Interests: Comprehensive diabetes care, In-patient diabetes and metabolic care, Perioperative diabetes management, Diabetes and endocrine emergencies – Metabolic Intensive Care, Obesity management, Lipids and preventive cardiology, Gestational diabetes, Thyroid disorders, Type 1 diabetes across ages

Apoorva Govind

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
bangalore, Karnataka, India

Designation: Resident
Specialties: Endocrinology, Diabetes, Internal Medicine, Pediatrics
Clinical Interests: Diabetes mellitus, Cardiovascular Health, Thyroid, Pediatric Diabetes Endocrinology

MD Chitra

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center

Designation: Consultant and Faculty; Trustee
Specialties: Endocrinology Diabetes; Clinical Research
Clinical Interests: Diabetes, Obesity, Dyslipidemia, Osteoporosis, Pituitary Adrenal disorders; Bone health; Cardiovascular Health; Thyroid dysfunction;

Vasudha Srikanth


India

Siddartha Dinesha

Resident, Medicine Diabetes Endocrinology
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center

Designation: Resident: Medicine; Endocrinology Diabetes, Samatvam Endocrinology Diabetes Centre and Jnana Sanjeevini Medical Centre and Diabetes Hospital
Specialties: Endocrinology, Diabetes, Internal Medicine

Nalini Ryasa

Keerthana Haridas

Monica Narayanaswamy

Resident doctor
Samatvam jnana sanjeevini diabetes hospital and medical centre
Chintamani, India

Sri Srikanta