University NM School of Medicine Albuquerque, United States
Disclosure(s):
Amir Modarres: No financial relationships to disclose
A thyroid mass mimicking malignancy
Introduction Thyroid malignancy is often the leading diagnosis in the evaluation of large thyroid nodules or masses identified incidentally or due to compressive symptoms. However, as illustrated in this case, maintaining a broad differential diagnosis is essential to avoid delays in appropriate management. We describe a patient who presented with severe dysphagia caused by a large thyroid mass with an unexpected etiology.
Case Description A 53-year-old male presented to a critical access hospital with a 2-week history of progressive dysphagia to both solid and liquid. His medical history included alcohol abuse, homocysteinemia, and a remote history of deep vein thrombosis for which he had completed anticoagulation. On examination, he was noted to have anterior neck swelling with tenderness to palpation. He exhibited no dyspnea or dysarthria. A CT scan of the neck revealed a 6 x 4 x 6 cm loculated thyroid mass concerning for malignancy. Laboratory evaluation demonstrated TSH 0.007µIU/mL, FT4 3.8 ng/dL, Total T3 146 ng/dL, TSH receptor Ab < 1.10 intlU/L, and WBC 12.6 K/µL. Flexible indirect laryngoscopy showed edema of the supraglottic structures, but mobile vocal cords and no evidence of airway compromise. At this time, thyroid malignancy was the leading cause of the patient’s symptoms. Therefore, a fine needle aspiration was performed, and it yielded cloudy, viscous fluid; cytology revealed an abundance of neutrophils. Because the patient exhibited no systemic signs of infection aside from mild leukocytosis, he was managed with amoxicillin-clavulanate and closely monitored. Despite oral antibiotic therapy, the patient’s dysphagia persisted through hospital day 7. Repeat imaging demonstrated interval progressive enlargement of the neck mass to 10.7 x 6.7 x 3.8 cm, including a multiloculated fluid collection involving the thyroid and surrounding structures. The patient underwent incision and drainage of the thyroid, yielding frank purulent fluid. Following drainage, the patient’s dysphagia resolved, and he was discharged home on hospital day 13 with a diagnosis of thyroid abscess responsible for his presenting symptoms. At a 3-month follow-up visit, the patient reported complete resolution of his symptoms. His thyroid function test showed subclinical hypothyroidism (TSH 4.9 µIU/mL, FT4 0.9ng/dL), and he was started on thyroid replacement therapy.
Conclusion: This case demonstrates a rare cause of acute thyroiditis in a patient who had no prior structural neck abnormalities. Although rare, thyroid abscesses could bring diagnostic ambiguity. The presentation of thyroid abscess could be very non-specific and mimic other etiologies, such as thyroid cancer or goiter. Therefore, clinicians should maintain a high index of suspicion to prevent morbidity and delay in care.
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