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Al Hassan MS, El Ansari W, Darweesh A, Sharaf Eldeen MZ, Obiedat S, Abdelaal A. Mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) in the thyroid mimicking a painless subacute (De Quervain's) thyroiditis on presentation, fine needle aspiration and cytology, and ultrasound findings: A rare case report. Int J Surg Case Rep 2023; 106:108147. [PMID: 37080143 PMCID: PMC10140790 DOI: 10.1016/j.ijscr.2023.108147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/22/2023] Open
Abstract
INTRODUCTION We report a rare case of mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) in the thyroid mimicking painless subacute (De Quervain's) thyroiditis. PRESENTATION OF CASE Patient with history of hypothyroidism presented with huge non-tender goiter, compression symptoms and choking, no lymphadenopathy. Ultrasound (US) showed large thyroid lobes. There was a small hypoechoic nodule, and nonspecific lymphadenopathy. Fine needle aspiration/cytology (FNAC) of right thyroid nodule showed scant follicular cells, abundant polymorphic lympocytes, epithelioid histiocytes, and tingible body macrophages, suggestive of De Quervain's (granulomatous) thyroiditis. Total thyroidectomy was decided due to compression symptoms and huge goiter. DISCUSSION Intraoperative, thyroid was huge with no adhesions to the strap muscles/trachea. Total thyroidectomy with lymph node biopsy was undertaken. There were no complications. Postoperatively, the patient's condition was stable, breathing normally, and neck wound was clean. PTH was 11 pg/mL and calcium was 2.16 mmol/L, suggesting impending transient hypocalcemia. Histopathology showed lymphoepithelial lesions as clusters of lymphocytes within the thyroid follicles epithelium (MALT Balls). Immunohistochemical staining showed that the neoplastic lymphocytes were B cells and stained positive with B-cell markers CD20 and PAX5, but were negative for Cyclin D1 and for T cell markers CD3, CD5 and CD43. The patient was discussed at the lymphoma MDT meeting and the decision was to start the patient on radiotherapy which the patient received. CONCLUSION Thyroid MALT lymphoma can mimic painless subacute thyroiditis. The triad of a large swelling of non-tender goiter with compression symptoms during a short period; FNAC findings suggestive of thyroiditis; and US showing enlarged thyroid lobes might cause confusion to the unsuspecting practitioner. Histopathology after excision provides definitive diagnosis.
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Affiliation(s)
| | - Walid El Ansari
- Department of Surgery, Hamad General Hospital, Doha, Qatar; College of Medicine, Qatar University, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Adham Darweesh
- Department of Clinical Imaging, Hamad General Hospital, Doha, Qatar
| | | | - Sarah Obiedat
- Department of Laboratory Medicine & Pathology, Hamad Medical Corporation, Doha, Qatar
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Al Hassan MS, El Ansari W, Petkar M, Al Sharani SA, Abdelaal A. Subacute (De Quervain's) thyroiditis presenting as painful thyroid nodule suspicious of papillary thyroid carcinoma: Case report. Int J Surg Case Rep 2022; 96:107329. [PMID: 35792407 PMCID: PMC9284041 DOI: 10.1016/j.ijscr.2022.107329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION We report a case of subacute thyroiditis (SAT) in a 29 -year-old female who presented with painful thyroid swelling. PRESENTATION OF CASE Patient presented with neck pain, tender neck swelling and generalized fatigue. She had no history of neck or chest radiation or compressive symptoms. Ultrasound (US) imaging reveled bilateral nodules of the thyroid gland. Lymph nodes were unremarkable. FNAC was suspicious for papillary thyroid carcinoma. The patient was discussed at the thyroid multidisciplinary meeting, and after deliberation the decision was to offer the patient the choice of repeating FNAC of the bilateral nodules in one month or to proceed with total thyroidectomy. DISCUSSION Despite being aware of the possibility that the final pathology could be benign, the patient insisted on total thyroidectomy, given that her FNAC results were suspicious of papillary thyroid carcinoma, and in order to avoid recurrence of the condition and the pain. Following the patient's preference, total thyroidectomy was performed, and surgery was not straightforward as intraoperatively, there was a diffusely inflamed gland. Histopathology findings revealed benign pathology. Follow up until 1.5 years showed that the patient was satisfied, and with normal voice. CONCLUSION SAT is a painful but potentially self-limiting. In some cases, FNAC findings might be suspicious for papillary thyroid carcinoma. Treatment is mostly conservative, but if the pain is severe and the patient insists on surgery as in our case despite the possibility of the condition being of benign pathology, then surgery should be undertaken.
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Affiliation(s)
| | - Walid El Ansari
- Department of Surgery, Hamad General Hospital, Doha, Qatar,College of Medicine, Qatar University, Doha, Qatar,Weill Cornell Medicine–Qatar, Doha, Qatar,Corresponding author at: Department of Surgery, Hamad General Hospital, Doha, Qatar.
| | - Mahir Petkar
- Department of Laboratory Medicine and Pathology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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Redondo-Sendino Á, Perea-Amurrio M. Manejo de la tiroiditis subaguda por el médico de familia. Semergen 2019; 45:e1-e2. [DOI: 10.1016/j.semerg.2018.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/26/2018] [Accepted: 04/02/2018] [Indexed: 10/28/2022]
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Jonas C, Bertrand C, Michel L, Donckier JE. Painful thyroid nodule, a misleading presentation of subacute thyroiditis. Acta Chir Belg 2016; 116:301-304. [PMID: 27537984 DOI: 10.1080/00015458.2016.1147262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Typical presentation of subacute thyroiditis (SAT) is an anterior neck pain radiating up to the jaw and ear, often associated with asthenia and fever. Biology shows hyperthyroidism and inflammation. The thyroid uptake is low at scintigraphy. However, the clinical presentation of SAT may be misleading. We report two cases of SAT whose initial manifestation was a painful thyroid nodule suspected of malignancy. In both cases, ultrasound feature was a heterogeneous, hypoechoic, ill-defined area with a low vascularization on colour Doppler. These areas were interpreted by radiologist as nodules. Surgery was then considered. Such a presentation should be known by clinicians to prevent unnecessary surgery.
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Affiliation(s)
- Corinne Jonas
- Department of Endocrinology, CHU Dinant-Godinne, Yvoir, Belgium
| | | | - Luc Michel
- Department of Surgery, CHU Dinant-Godinne, Yvoir, Belgium
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Valentini RB, Macedo BMD, Izquierdo RF, Meyer ELS. Painless thyroiditis associated to thyroid carcinoma: role of initial ultrasonography evaluation. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:178-82. [DOI: 10.1590/2359-3997000000104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 08/11/2015] [Indexed: 11/22/2022]
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Pan FS, Wang W, Wang Y, Xu M, Liang JY, Zheng YL, Xie XY, Li XX. Sonographic features of thyroid nodules that may help distinguish clinically atypical subacute thyroiditis from thyroid malignancy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:689-696. [PMID: 25792585 DOI: 10.7863/ultra.34.4.689] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate sonographic features for distinguishing clinically atypical subacute thyroiditis from malignant thyroid nodules. METHODS A total of 165 hypoechoic thyroid nodules without calcification in 135 patients with histologic diagnosis were included in this study. These nodules were classified into 2 groups: a thyroiditis group (55 nodules in 36 patients) and a malignancy group (110 nodules in 99 patients). The sonographic features of the groups were retrospectively reviewed. RESULTS No significant differences were detected for the variables of marked echogenicity, a taller-than-wide shape, and mixed vascularity. However, a poorly defined margin was detected more frequently in the thyroiditis group than the malignancy group (P < .05); it yielded a high capability for differential diagnosis of atypical subacute thyroiditis, with sensitivity and specificity of 87.3% and 80.9%, respectively. Centripetal reduction echogenicity was observed exclusively in the thyroiditis group, with high specificity (100%) but low sensitivity (21.8%) for atypical subacute thyroiditis diagnosis. All of the thyroiditis nodules with a positive color signal showed noninternal vascularity (negative predictive value, 100%). CONCLUSIONS There is a considerable overlap between the sonographic features of atypical subacute thyroiditis and thyroid malignancy. However, the margin, echogenicity, and vascularity type are helpful indicators for differential diagnosis of atypical subacute thyroiditis.
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Affiliation(s)
- Fu-shun Pan
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound (F.P., W.W., Y.W., M.X., J.L., Y.Z., X.X.), and Department of Vascular and Thyroid Surgery (X.L.), First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Wang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound (F.P., W.W., Y.W., M.X., J.L., Y.Z., X.X.), and Department of Vascular and Thyroid Surgery (X.L.), First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan Wang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound (F.P., W.W., Y.W., M.X., J.L., Y.Z., X.X.), and Department of Vascular and Thyroid Surgery (X.L.), First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ming Xu
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound (F.P., W.W., Y.W., M.X., J.L., Y.Z., X.X.), and Department of Vascular and Thyroid Surgery (X.L.), First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jin-yu Liang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound (F.P., W.W., Y.W., M.X., J.L., Y.Z., X.X.), and Department of Vascular and Thyroid Surgery (X.L.), First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan-ling Zheng
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound (F.P., W.W., Y.W., M.X., J.L., Y.Z., X.X.), and Department of Vascular and Thyroid Surgery (X.L.), First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao-yan Xie
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound (F.P., W.W., Y.W., M.X., J.L., Y.Z., X.X.), and Department of Vascular and Thyroid Surgery (X.L.), First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Xiao-xi Li
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound (F.P., W.W., Y.W., M.X., J.L., Y.Z., X.X.), and Department of Vascular and Thyroid Surgery (X.L.), First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Li LX, Wu X, Hu B, Zhang HZ, Lu HK. Localized subacute thyroiditis presenting as a painful hot nodule. BMC Endocr Disord 2014; 14:4. [PMID: 24397799 PMCID: PMC3893553 DOI: 10.1186/1472-6823-14-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 12/31/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND A diagnosis of subacute thyroiditis is readily considered when patients present with a particular set of typical clinical characteristics. Subacute thyroiditis sometimes presents as a solitary cold nodule; however, the presence of a hot nodule in patients with subacute thyroiditis is exceedingly rare. CASE PRESENTATION Here, the case of a 57-year-old woman complaining of pain in the left neck and fatigue for two weeks is presented. Physical examination revealed a painful and tender nodule with a diameter of approximately 1.5 cm in the left neck, although all laboratory tests, including white blood cell count, neutrophil percentage, erythrocyte sedimentation rate (ESR), thyroid function, and thyroglobin levels, were normal. A neck ultrasound revealed a hypoechoic mass (1.5 × 0.8 cm) in the left thyroid, and thyroid scintigraphy of the left thyroid with Technetium-99 m (99 m-Tc) demonstrated a focal accumulation of radiotracer. Furthermore, fine-needle aspiration biopsy from the nodule revealed the presence of multinuclear giant cells. The patient was well; there was no cervical mass detected upon palpation following two months of prednisone treatment, and follow-up ultrasound screening and scintigraphy demonstrated the disappearance of the nodule. CONCLUSION This case, presenting with a localized painful hot nodule, normal thyroid function, normal ESR, and normal serum thyroglobulin levels, is a rare case of subacute thyroiditis, which should be considered during differential diagnosis.
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Affiliation(s)
- Lian-Xi Li
- Department of Endocrinology and Metabolism, Shanghai Diabetes Institute; Shanghai Clinical Center for Diabetes; Shanghai key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Xing Wu
- Department of Ultrasonography, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Bing Hu
- Department of Ultrasonography, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Hui-Zhen Zhang
- Department of Pathology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Han-Kui Lu
- Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China
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Atypical de Quervain's thyroiditis masquerading as papillary thyroid cancer. ACTA ACUST UNITED AC 2013; 60:158-9. [DOI: 10.1016/j.endonu.2012.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 03/13/2012] [Accepted: 03/13/2012] [Indexed: 11/17/2022]
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A Comparison Between Two Imaging Techniques for the Diagnosis of Subacute Thyroiditis (De Quervain Thyroiditis). Clin Nucl Med 2010; 35:862-4. [DOI: 10.1097/rlu.0b013e3181f49adc] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Yair Liel
- Endocrine Unit, Soroka University Medical Center, Beer-Sheva, Israel
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Raupach T, Karaus M. [Pharyngitis, massive ESR elevation and hyperthyroidism in a 71-year-old female patient]. Internist (Berl) 2005; 45:1182-8. [PMID: 15322709 DOI: 10.1007/s00108-004-1259-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We present a 71-year-old female patient suffering from a sore throat with unilateral neck swelling, pain on swallowing, subfebrile temperatures and general fatigue persisting for several weeks without any clinical signs of hyperthyroidism, although laboratory findings show high concentrations of T(3) and T(4) and a low TSH. A massive ESR elevation is found as well. Ultrasound reveals an inhomogeneous pattern of the thyroid gland with low echogenicity. (99m)Tc pertechnetate uptake is suppressed. The diagnosis of acute/subacute thyroiditis de Quervain is concluded. Therapeutic application of prednisone leads to a swift improvement, yet two weeks later asymptomatic hypothyroidism is diagnosed, requiring substitution of thyroxine. We discuss de Quervain's thyroiditis and the differential diagnosis of inflammatory disorders of the thyroid gland.
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Affiliation(s)
- T Raupach
- Evangelisches Krankenhaus Göttingen-Weende
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