PAPILLARY THYROID CANCER CAUSING AUTONOMIC DYSFUNCTION

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Dysautonomia is the dysfunction of the autonomic nervous system which regulates involuntary bodily functions. Common causes include diabetes mellitus, Parkinson’s, amyloidosis, Lyme disease and paraneoplastic syndromes. We present an unusual case of dysautonomia due to carotid sinus syndrome (CSS) caused by papillary thyroid cancer with extra-thyroid spread producing mass effect on the carotid sinus and carotid sympathetic plexus. CASE PRESENTATION: 26-year-old female with no past medical history who presented with recurrent syncope. She complained of malaise and anisocoria for six days prior to admission. On admission, the patient was noted to have positive orthostatic vital signs, however was clinically euvolemic. Head CT and CTA of head and neck demonstrated a calcified thyroid nodule in the left lobe, measuring 2.2x1.5cm, and a suspected venous varix 2.3x3.1cm in the left lower neck. Ultrasound of the thyroid confirmed the presence of the thyroid nodule with architecture concerning for malignancy. Additionally, the venous varix seen on CTA was noted to be an extra-thyroid mass. MRI of the neck then demonstrated a left carotid space mass exerting mass effect on the left jugular vein. A fine needle aspiration followed signifying papillary thyroid carcinoma. The patient subsequently had a thyroidectomy with neck exploration for removal of the extra-thyroid mass. Following the surgical intervention, the patient’s syncopal episodes and orthostatic hypotension improved. Clinical impression was that the extra-thyroid mass that was causing mass effect on her carotid was compressing the carotid sinus leading to autonomic dysfunction. DISCUSSION: Dysautonomia is a common complication that is commonly caused by a systemic condition affecting the autonomic nervous system. On literature search, dysautonomia has yet to be described as being caused by compression of the carotid artery sympathetic plexus due to papillary thyroid cancer. Carotid sinus syndrome is a cause of syncope following carotid baroreceptor sensitivity. In our case, the patient was experiencing recurrent syncopal episodes from external compression of her carotid artery due to the left carotid space metastatic lesion and mydriasis due to carotid sympathetic plexus invasion. Common causes of CSS include male gender, atherosclerotic disease, prior neck surgeries and radiation. External mass compression is a very rare cause of CSS particularly from papillary thyroid carcinoma which rarely metastasizes. CONCLUSIONS: Syncope is a common presentation to the emergency department. Dysautonomia is a common cause, particularly in people with known systemic processes such as diabetes or Parkinson’s. However, in a young adult, recurrent syncope is an unusual presentation and requires a thorough work up including imaging of the neck. Dysautonomia and CSS should be evaluated for as an uncommon, but possible, cause of syncope in young adults. Reference #1: Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol 2017. Reference #2: Krediet CT, Parry SW, Jardine DL, et al. The history of diagnosing carotid sinus hypersensitivity: why are the current criteria too sensitive? Europace 2011; 13:14. DISCLOSURES: No relevant relationships by Chad Conner, source=Web Response No relevant relationships by Erika Faircloth, source=Web Response No relevant relationships by Nikola Perosevic, source=Web Response