A Woody Thyroid
A.Abbara, M.Mehta, K.Baynes, R.Bell, Department of Endocrinology, Ealing Hospital NHS Trust.
A 42 year old gentleman presented with a 2 week history of a diffuse hard neck swelling, dysphagia and night sweats. He was found to have new onset hypothyroidism and was started on levothyroxine. His ESR was normal at 5mm/hr. A neck ultrasound demonstrated a markedly enlarged thyroid with increased vascularity and bilateral cervical lymphadenopathy. A CT neck additionally demonstrated a 1.5cm enhancing nodule in the left strap muscle. An ultrasound guided thyroid FNA showed mature lymphocytes, but no thyroid tissue nor any evidence of malignancy. A core biopsy demonstrated reidel’s thyroiditis. He was started on prednisolone 50mg od, but only tolerated this for a couple of weeks before he withdrew due to side effects. He was given a trial of tamoxifen, but chose to discontinue treatment after 6 months due to lack of beneficial effect. After being counselled regarding the challenges of carrying out surgery in this condition, he declined surgical management, nor further medical therapy with azathioprine.
Riedel’s Thyroiditis is a fibrosclerotic infiltrative disorder of the thyroid gland(2,3). It was first described by Riedel in 1896 and there are less than 300 reported cases. It occurs 3 times more commonly in females and the median age of onset is 51yrs (5,6,7). In one third of patients it may be part of a multifocal fibrosclerosis, involving retroperitoneal, retro-orbital or mediastinal spaces (1,2,3,8). It may present with a painless rapidly enlarging goitre, cervical pressure, dysphagia or dyspnoea (7). The thyroid is oft described as ‘woody’ and fixed to adjacent structures. The main differential diagnoses are the fibrous variant of Hashimoto’s thyroiditis, granulomotous thyroiditis, solitary fibrous tumour and lymphoma (7). There may be an elevated white cell count or ESR. 50% have positive thyroid autoantibodies and 25% develop hypothyroidism (7,8). The thyroid appears hypoechoic / hypovascular on ultrasound and has reduced uptake on technetium scanning (2,3,7). Surgery is technically difficult due to obscured surgical planes and may be unsuccessful, whilst carrying an increased risk of complications (7). Hence close liaison between endocrinologists and ENT surgeons is important in appropriately advising patients of their treatment options in this rare condition.
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