A 48-year-old woman presented with a rapid enlargement of a preexisting goiter without compressive symptoms. Her past medical history included type 2 diabetes mellitus, hypertension, goiter, and primary hypothyroidism for fifteen years. There was no past or present history of smoking and her family history was unremarkable.
She was complaining of productive cough for two weeks. However, she did not have any history of fever, night sweats, or anorexia.
Clinical examination showed a normal body temperature, a body mass index of 35.88 kg/m2, a blood pressure of 120/80 mmHg, a regular pulse of 89 beats/min, and a normal respiration rate of 20 breaths/min. The lung breath sounds were normal without any rales being heard. Cervical examination revealed a plunging multinodular goiter without any lymphadenopathy. Other systemic and regional examinations did not show any abnormalities.
The blood routine tests showed a fasting blood glucose of 7.19 mmol/l, a plasma creatinine level of 49 mumol/l, a C-reactive protein level of 5 mg/l (reference range < 5 mg/l), an erythrocyte sedimentation rate of 57 mm/first hour, a red blood cells count of 4.38 * 106/mm3, a total hemoglobin concentration of 12.8 g/dl, a white blood cells count of 6800/mm3, a neutrophil count of 3640/mm3, and a lymphocyte count of 2220/mm3. Liver function tests were normal.
The thyroid function tests disclosed normal serum thyroid stimulating hormone (TSH) level at 0.5 muIU/ml (reference range: 0.35-4.94) and normal free thyroxin (FT4) level at 9.14 pmol/L (reference range: 8.5-25) on daily 100 mug of levothyroxine.
Thyroid ultrasound showed a heterogeneous multinodular goiter. Her chest X-ray showed a mediastinal enlargement and a suspicious lesion located at the upper lobe of the right lung. Cervical and chest computed tomography scan revealed an enlarged plunging multinodular thyroid gland (right lobe: 113 x 39 x 41 mm, left lobe: 90 x 53 x 44 mm) with an extension of the right lobe into Barety's space (Figure 1) and multiple bilateral lung nodules.
Sputum smear microscopy was negative.
Thyroid cancer was suspected. Fine needle aspiration (FNA) cytology was not available for technical reasons. Surgical treatment was indicated and the patient underwent a total thyroidectomy. Multiple lung biopsies were also performed using a left anterior minithoracotomy through the fifth intercostal space.
Histopathological examination showed a benign multinodular hyperplasia with epithelioid cell granulomas and giant cells (Figure 2). These morphological signs were compatible with multiple tuberculous foci of the thyroid gland. The histopathological examination of the lung biopsies showed foci of granulomatous inflammation along with caseous necrosis (Figure 3).
The diagnosis of tuberculosis involving both the lung and the thyroid gland was established and the patient was treated with antituberculosis drugs for 6 months.