A TIGHT COLLAR: A UNIQUE PRESENTATION OF PAPILLARY THYROID CANCER

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Carotid sinus hypersensitivity (CSH) can be caused by a multitude of clinical syndromes. Rarely, head and neck tumors can also present with symptoms of CSH due to excessive stimulation of the carotid sinus. Diagnosis in such cases may be delayed because of the rarity of this presentation. It is crucial to recognize the underlying cause of CSH to prevent lethal outcomes. We present a case of papillary thyroid cancer with an unusual clinical presentation. CASE PRESENTATION: 27-year old female with no significant past medical history presented to our hospital with syncopal episodes. The patient reported that she has been experiencing several episodes of dizziness and loss of consciousness for ten days. These episodes reportedly occur when she gets up from a sleeping position. The patient denied having diarrhea, vomiting, decreased oral intake, or using any medications. On presentation, she had positive orthostatic vital signs with a drop in systolic blood pressure by 55 mm Hg and diastolic blood pressure by 40 mm Hg on standing up from a sleeping position. Physical examination was notable for a left thyroid nodule. Laboratory investigations were unremarkable. Electrocardiogram demonstrated bradycardia with a heart rate of 55 beats/minute with no evidence of conduction abnormalities. She subsequently underwent a computerized tomography scan of the neck that revealed a left-sided thyroid nodule that was further confirmed on the ultrasound as being a hypoechoic mass lateral to the left carotid artery. Since the findings were concerning for a malignant lesion, she underwent fine-needle aspiration biopsy that demonstrated papillary thyroid cancer. She subsequently underwent thyroidectomy with a complete resolution of symptoms. The syncopal episodes were attributed to carotid sinus hypersensitivity in the presence of a thyroid mass in an otherwise young female. DISCUSSION: The compression of the carotid sinus by malignant neoplasms in the neck can potentially cause cardio-inhibition and vaso-depression leading to syncope and presyncope. The pathogenesis is attributed to autonomic dysregulation and increased baroreceptor sensitivity. Although most cases of CSH are self-limiting, some might lead to conduction abnormalities and necessitate pacemaker placement. Early diagnosis and treatment are vital to prevent lethal outcomes such as atrioventricular blocks or sinus pauses due to excess vagal stimulation. Hence, a thorough history and physical examination, and a broad differential is the key to manage this condition appropriately. CONCLUSIONS: Unexplained abrupt episodes of bradycardia and syncope should alert the physician of the possibility of carotid sinus compression. This may be caused by a neck mass and should warrant a detailed physical examination and thorough workup for obstructive head and neck masses. Reference #1: Toscano M, Cristina S, Alves A (February 19, 2020) Carotid Sinus Syndrome in a Patient with Head and Neck Cancer: A Case Report. Cureus 12(2): e7042. DOI:10.7759/cureus.7042 Reference #2: Korkmaz, Ö., Göksel, S., Özlü, H., & Berkan, Ö. (2014). Papillary thyroid cancer located in the carotid bifurcation mimicking carotid body tumors. Ulusal cerrahi dergisi, 31(1), 52–54. https://doi.org/10.5152/UCD.2014.2658 DISCLOSURES: No relevant relationships by Ayesha Azmeen, source=Web Response No relevant relationships by Dimitrios Drekolias, source=Web Response No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Sana Hyder, source=Web Response No relevant relationships by Srimathi Manickaratnam, source=Web Response No relevant relationships by Mahati Paravathaneni, source=Web Response