The anomalous goitre: an unusual presentation of multi-nodular goitre
F Beatty, R Baburaj, The Hillingdon Hospital, F Palazzo, Imperial Healthcare NHS Trust.
A 39-year-old was seen at routine antenatal appointment when she was 6 weeks pregnant with her first child in 2013. She had noticed swelling in the neck consistent with an enlarged thyroid gland. Despite a family history of Gravesí disease, her TFTs were considered normal for pregnancy and thyroid peroxidase antibodies were negative.
An ultrasound showed multi-cystic changes consistent with a multi-nodular goitre. There was one nodule of 6 x 2.3 cm in the right lobe but there was no evidence of posterior extension or tracheal narrowing. A FNA of the large nodule was Thy 2, i.e. benign. She remained asymptomatic and the remainder of her pregnancy was unremarkable.
Three years after her initial diagnosis with multi-nodular goitre, she started to experience intense burning pain in the left shoulder, radiating down the left arm, accompanied by mild swelling and dilatation of the superficial veins in the left arm.
Her pain settled for a brief period but returned in the left shoulder and again radiated down the left arm, this time in the exact distribution of the C7 nerve. In 5-6 weeks the pain had become constant. She returned to Endocrinology clinic and was clinically noted to have a large goitre.
An urgent CT neck with contrast showed no thrombosis, but a significantly enlarged thyroid gland causing extensive venous and tracheal compression. The goitre had compressed the trachea; at its narrowest point the coronal width of the trachea measured 3mm. She underwent an urgent total thyroidectomy with no post-operative complications.
The majority of patients with cervico-mediastinal goitres are symptomatic, however the predominant symptoms are more commonly respiratory distress and super vena cava obstruction (SVCO). This patient presented with symptoms and signs consistent with compression of the veins of the upper limb and the brachial plexus which is unusual.
It is not uncommon for the normal, physiological changes of pregnancy to reveal pre-existing thyroid pathology. What is unusual in this case is that the patient remained asymptomatic throughout pregnancy; her compressive symptoms began three years post-partum.
This presentation of multi-nodular goitre was therefore anomalous not only in its presentation but also in its timing, at 3 years post-partum.