A 42-year-old female presented to us with the right-sided limb weakness and diplopia for the past 3 months and altered sensorium for the past 15 days. She had a history of fever for 2 days to begin with, following which she developed weakness of the right upper limb, which gradually progressed to the right lower limb. There was no history of any chronic illness such as TB, diabetes mellitus, or hypertension. He was a homemaker and had no history of exposure to any chemical or radiation. On examination, she was disoriented to time, place, and person. Her vitals were pulse rate of 100/min, blood pressure of 110/70 mmHg, and respiratory rate of 26/min. There was no neck rigidity, and Kernig's sign was absent. Pupils were bilaterally reactive to light. There was bilateral sixth nerve palsy. On motor system examination, muscle bulk was normal bilaterally, and there was an increased tone in the right-sided limbs, and power was 1/5 in the right-sided limbs and 5/5 in the left-sided limbs. Plantar reflexes were bilaterally extensor. Deep tendon reflexes were exaggerated on the right side of the body.
Her blood parameters were grossly normal on admission. Her hemoglobin was 15.1 g/dl, white blood cell count 15000/mm3, and erythrocyte sedimentation rate 30 mm/h, liver function tests and renal function tests were normal. HIV test by enzyme-linked immunosorbent assay was negative. Chest X-ray showed miliary mottling of lung fields [Figure 1]. Her contrast-enhanced magnetic resonance imaging brain was suggestive of multiple ring-enhancing lesions in the cortex suspected to be tuberculoma or metastasis.
On further work-up, her sputum samples were sent, which were negative for acid-fast bacilli. Contrast-enhanced computed tomography (CT) of the neck, thorax, and abdomen were done to find out primary pathology. CT scan findings were as follows: innumerable solid micronodules diffusely scattered in both lungs in random distribution, and there were mediastinal, right paraesophageal, subcarinal, and paratracheal lymph node largest being 2.1 cm x 2.2 cm. A thyroid nodule of size 1 cm x 0.85 cm was present in the left lobe. There was multiple hyper enhancing nodule present consistent with metastasis along with few retroperitoneal lymph nodes.
All these features were suggestive of disseminated malignancy. In suspicion of thyroid malignancy, ultrasound-guided fine-needle aspiration cytology of the thyroid swelling was planned. Ultrasound neck showed a solitary mass in the left lobe of the thyroid gland with an irregular outline, located in the subcapsular region, and demonstrating vascularity along with multiple subcentimeter size lymph nodes. Histology was suggestive of Bethesda category VI malignancy with the possibility of poorly differentiated papillary carcinoma or metastatic adenocarcinoma. Further, excisional biopsy of the thyroid gland and postoperative radioactive iodine therapy were planned, but the patient succumbed before any intervention.