We report two ladies who presented with thyroid dysfunction associated with neck swelling. In both cases within ten days of consultation they developed rapid enlargement of their mass associated with marked swelling of an arm.
Case 1. A 63 year old lady developed sudden onset of a thyroid swelling associated with a new diagnosis of primary hypothyroidism . She had lost weight and felt tired. On examination she had a moderately enlarged woody goitre, there was no associated lymphadenopathy. TSH was 15.26 milliunits per litre ( normal 0.38-4.7) and FT4 11.5 picomoles per litre (normal 11-20). Thyroid peroxidase antibodies were elevated at 1212 kilounits per litre (normal 0-60). She was commenced on thyroxine .Ten days later the mass had enlarged and caused venous obstruction of her right arm. CT scan showed an extensive swelling arising from the thyroid, obliterating the right internal jugular and extending to the aorta. Open biopsy confirmed non Hodgkin's lymphoma of diffuse large B cell subtype.
Case 2. A 44 year old lady was found to have a goitre and hyperthyroidism and was commenced on antithyroid drugs. TSH was less than 0.6 milliunits per litre and FT4 27.1 picomoles per litre. Seven days later she developed a painful swelling in the left side of her neck associated with a painful swollen left breast and arm. CT scan showed an extensive mass arising in the neck and extending into the mediastinum. Biopsy showed a high grade B cell lymphoma. She was treated with chemotherapy and radiotherapy and after a relapse further chemotherapy and stem cell transplant. She remained on antithyroid treatment for a further year.
These two cases are unusual presentations of B cell lymphoma initially presenting with thyroid dysfunction and goitre, but then with a dramatic increase in size of the neck swelling and venous obstruction.