RETROSTERNAL THYROID GOITER PRESENTING WITH RESPIRATORY DISTRESS

Abstract

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Thyroid dysfunction worldwide is common; however, respiratory distress secondary to retrosternal extension of massive thyroid goiter is a rare occurrence. In developed populations, thyroid dysfunction can be attributed in large part to underlying autoimmune disorders and presents as a spectrum of dysfunction. Here we present a patient with a 1-year history of enlarging thyroid goiter and two days of respiratory distress. CASE PRESENTATION: A 53-year-old male with hyperthyroidism and goiter admitted to the hospital on 9/9/19 with two days of progressive shortness of breath and dysphagia. He had intermittent palpitations, anxiety, 80-pound weight loss, and a large “mass” in his neck since 2018. He was hospitalized in October 2018 for cholecystectomy complicated by iatrogenic colon injury and sepsis, where he was exposed to multiple doses of iodinated contrast with repeat CT scans. He was told at that time that his “thyroid was overactive” and imaging showed a goiter measuring 5 x 3 x 2 cm on the left and 1.2 x 2 x 1.5 cm on the right, homogenous in structure without nodules. Thyroid storm ensued in January 2019, at which point he was started on methimazole 25 mg daily. On admission, TSH was 78 and free T4 1.1. There was pronounced nontender goiter. He was tachypneic and in mild distress, complaining of orthopnea, with positive Pemberton’s sign—facial plethora with bilateral arm raise. He did not require oxygen supplementation. CT scan at that time measured the goiter as 9.9 x 6.5 cm on left and 10 cm x 6.2 cm on the right, with extension into the retrosternal space (Figures 1, 2, and 3). Day 2 of hospitalization, his dyspnea had improved. ENT evaluation indicated that thyroid function should be optimized prior to surgery. He was discharged with appointments for ENT and endocrinology. No pulmonary function tests were obtained at that time. He was last seen in January and February of 2020, doing well, dyspnea and dysphagia resolved, and is now taking 25 mcg levothyroxine per endocrinology for TSH 4.5 and free T4 0.5. He reports his goiter has decreased in size. Total thyroidectomy to be planned in the coming months, but has not yet been done. All antibodies tested have been negative. DISCUSSION: It is important to recognize the complications of enlarging thyroid goiters that extend into the retrosternal space. These can range from dysphagia and dyspnea to complete respiratory failure requiring intubation and mechanical ventilation. CONCLUSIONS: While optimization of thyroid function is important, early surgical intervention is prudent in these cases, as further complications of acute and chronic airway obstruction may arise. Reference #1: Garingarao, C.J., Añonuevo-Cruz, C., & Gasacao, R. (2013). Acute respiratory failure in a rapidly enlarging benign cervical goitre. BMJ Case Reports, 1-4. Published online: 2013 Jul 20. Doi: 10.1136/bcr-2013-200027. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736632/ Reference #2: Ioannidis, O., Dalampini, E., & Chatzopoulos, S., et al. (2011). Acute respiratory failure caused by neglected giant substernal nontoxic goiter. Arquivos Brasileiros de Endocrinologia & Metabologia, 55(3), 229-232. https://doi.org/10.1590/S0004-27302011000300009 Reference #3: Taylor, P., Albrecht, D., Scholz, A. et al. (2018). Global epidemiology of hyperthyroidism and hypothyroidism. Nature Reviews: Endocrinology, 14, 301–316. https://doi.org/10.1038/nrendo.2018.18 DISCLOSURES: No relevant relationships by Kendall Creed, source=Web Response No relevant relationships by Arunee Motes, source=Web Response No relevant relationships by Victor Test, source=Web Response No relevant relationships by Divya Vangipuram, source=Web Response