Background: Preexisting chronic autoimmune thyroiditis is the only known risk factor for thyroid lymphomas, a rare variant of thyroid cancer. Here, we describe a male patient with previously undiagnosed Hashimotos thyroiditis who presented with severe airway compromise due to a thyroid lymphoma.
Case report: 60 y/o, former smoker, presented with 2 month neck fullness and dyspnea that awakened him throughout the night due to malpositioning of his neck. He had no other symptoms. A neck and head CT demonstrated a thyroid goiter, with each thyroid lobe measuring 11.0 cm×4.0 cm with mass effect on the airway, hypopharynx, and esophagus. The patient was emergently intubated for airway protection. Thyroid studies were significant for subclinical hypothyroidism (TSH of 9.7 uIU/ml and fT4 of 0.85 ng/dl) with positive anti-tPO antibodies (2030 uIU/ml) consistent with Hashimotos thyroiditis. Thyroid ultrasound showed diffuse heterogeneous texture and biopsy showed plasmacytoid cells and lymphoplasmacytic infiltrate involving fibrous tissue. Flow cytometry confirmed a B- cell lymphoma with plasmacytic differentiation. The patient was started on chemoradiation.
Conclusions: Severe airway compromise may occur in up to 25% of patients with thyroid lymphoma. Given the dramatic clinical presentation of rapid growth and airway compromise, the clinical impulse is to treat surgically with a total thyroidectomy. However, the differential diagnosis of a rapidly growing goiter includes lymphoma, which can be quickly diagnosed with a core biopsy and flow cytometry. Such lymphomas respond quickly to the combination of chemotherapy (with steroid component) and local radiation, potentially obviating the need for tracheotomy.