A 60-year-old Caucasian male complains of difficulty swallowing which has rapidly worsened within the last two weeks. The patient noticed a swelling on the front of his neck that started growing for the past month. He was otherwise in his normal state of health. He also complains of fevers, night sweats, and weight loss. He denies cough, dyspnea, chest pain, headache, abdominal pain, skin rashes, and urinary symptoms. His past medical history is significant for mild hypertension treated with hydrochlorothiazide, as well as a small goiter for the past 10 years. He states that his blood tests for thyroid hormone levels were normal, and he has never taken thyroid hormone preparations in the past. His family history is positive for a mother and several other family members with hypothyroidism. He has a smoking history of 15-pack-years but quit 25 years ago. He does not drink alcohol. Physical examination reveals a large, irregular, non-tender swelling over the inferior aspect of his neck. The lower margin of this swelling can not be palpated. He develops facial plethora and venous engorgement of the neck veins after raising his arms above the shoulder for 20 seconds. CBC and basic chemistries are normal. TSH is 26.0 μU/ml (normal 0.35-5.0 μU/ml) and free T4 is 0.2 μg/dl (normal 0.8 to 1.8 μg/dl). Antithyroid peroxidase antibodies are detected in very high titers. What is the most likely diagnosis in this patient?

Question

A 60-year-old Caucasian male complains of difficulty swallowing which has rapidly worsened within the last two weeks.  The patient noticed a swelling on the front of his neck that started growing for the past month.  He was otherwise in his normal state of health.  He also complains of fevers, night sweats, and weight loss.  He denies cough, dyspnea, chest pain, headache, abdominal pain, skin rashes, and urinary symptoms.  His past medical history is significant for mild hypertension treated with hydrochlorothiazide, as well as a small goiter for the past 10 years.  He states that his blood tests for thyroid hormone levels were normal, and he has never taken thyroid hormone preparations in the past.  His family history is positive for a mother and several other family members with hypothyroidism.  He has a smoking history of 15-pack-years but quit 25 years ago.  He does not drink alcohol.  Physical examination reveals a large, irregular, non-tender swelling over the inferior aspect of his neck.  The lower margin of this swelling can not be palpated.  He develops facial plethora and venous engorgement of the neck veins after raising his arms above the shoulder for 20 seconds.  CBC and basic chemistries are normal.  TSH is 26.0 μU/ml (normal 0.35-5.0 μU/ml) and free T4 is 0.2 μg/dl (normal 0.8 to 1.8 μg/dl).  Antithyroid peroxidase antibodies are detected in very high titers.  What is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: This patient describes a prior history of a mild goiter; however, there has been a recent rapid increase in the size of his thyroid gland which is likely the cause of his difficulty swallowing. Pemberton's test consists of having the patient raise his arms over his head for up to 60 seconds. The presence of facial plethora or engorgement of neck veins is strongly suggestive that the thyroid is the source of the patient's obstructive symptoms. Inability to palpate the inferior edge of the thyroid is also suggestive that there is substernal extension. This patient's laboratory tests consisting of elevated TSH and low T4 confirm that he is hypothyroid. The positive antithyroid peroxidase antibodies make Hashimoto's thyroiditis the most likely cause of this patient's hypothyroidism. Patients with Hashimoto's often have a mildly enlarged thyroid gland. This may have been the cause of the patient's mild goiter over the past 10 years, but would not explain the rapid growth of the patient's thyroid gland over the past several weeks. The most likely diagnosis in this case is thyroid lymphoma. The primary risk factor for the development of thyroid lymphoma is preexisting Hashimoto's thyroiditis in which there is chronic lymphocytic infiltration of the thyroid gland. Thyroid lymphoma should be suspected in patients with a history of Hashimoto's who have a rapidly enlarging thyroid gland and subsequent obstructive symptoms. (Choice A) Colloid goiter is a cause of thyroid enlargement in adolescent girls who have normal thyroid function tests and negative antithyroid antibodies. (Choice B) Follicular thyroid cancer may present as a palpable nodule but should not be this rapidly progressive. (Choice C) Medullary thyroid cancer usually presents as a thyroid nodule, sometimes in the presence of Multiple Endocrine Neoplasm. It is a neoplasm of the thyroid gland C cells and typically has an elevated calcitonin level. (Choice D) Papillary thyroid cancer also usually presents as a palpable nodule but should not progress this rapidly. Educational objective: Thyroid lymphoma usually presents as rapid enlargement of the thyroid gland in patients with Hashimoto's thyroiditis. Pemberton's sign is the presence of facial plethora or neck vein distention when the arms are raised and confirms an enlarged thyroid gland as the cause of esophageal obstructive symptoms.

A 60-Year-Old Caucasian Male Complains of Difficulty Swallowing Which Has