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CASE REPORT
Year : 2013  |  Volume : 1  |  Issue : 3  |  Page : 135-137

Incidental caseating granuloma of thyroid gland presenting with concomitant Graves' disease and multifocal papillary microcarcinoma


1 Department of Endocrinology, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
2 Department of Pathology, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia

Date of Web Publication30-Oct-2013

Correspondence Address:
Muneera A Al Shareef
Department of Endocrinology, King Fahad Armed Forces Hospital, PO Box 9862, Jeddah 21159
Saudi Arabia
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DOI: 10.4103/1658-600X.120852

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  Abstract 

A 36-year-old Saudi woman presented with symptoms and signs of hyperthyroidism and was diagnosed to have Graves' disease. She was initially treated with antithyroid medications with no response. Subsequently, she underwent a total thyroidectomy. The histopathology of the specimen revealed caseating granulomatous thyroid suggestive of tuberculosis and multifocal papillary thyroid microcarcinoma

Keywords: Caseating granulomatous thyroidits, Graves disease, papillary carcinoma of thyroid


How to cite this article:
Al Shareef MA, Khan MP, Al-Jabri KS, Eltayeb AA. Incidental caseating granuloma of thyroid gland presenting with concomitant Graves' disease and multifocal papillary microcarcinoma. J Health Spec 2013;1:135-7

How to cite this URL:
Al Shareef MA, Khan MP, Al-Jabri KS, Eltayeb AA. Incidental caseating granuloma of thyroid gland presenting with concomitant Graves' disease and multifocal papillary microcarcinoma. J Health Spec [serial online] 2013 [cited 2019 Jul 20];1:135-7. Available from: http://www.thejhs.org/text.asp?2013/1/3/135/120852


  Introduction Top


Well-differentiated thyroid cancer and Graves' disease have been reported in several cases; however, the presence of concomitant TB has not been described in the literature. We report a case with a combination of all three pathologies in thyroid tissue with a review of literature.


  Case Report Top


A 36-year-old woman presented with palpitations, heat intolerance, weight loss and insomnia. On clinical examination, she was anxious with a pulse rate of 110/min regular, and blood pressure 138/87 mmHg. She had tremors in her hands, bilateral proptosis with positive lid lag and retraction. Her thyroid gland was diffusely enlarged, firm and smooth with no palpable cervical lymph nodes. Erythrocyte sedimentation rate was 34 mm/hr, chest x-ray was normal, thyroid stimulating hormone (TSH) 0.005 U/ml (normal range 0.27 - 4.2), free thyroxine (T4), 70.95 ng/dl (normal range 12 - 22), TSH receptors antibodies 136 (normal range less than 1.8 IU/L). Thyroid ultrasound showed an enlarged hypervascular gland with bilateral cysts of which the largest one was 3.8 × 2.3 mm with one focal calcification in the cyst [Figure 1]. A diagnosis of Graves' disease was made. The patient was started on antithyroid medications. She became pregnant soon after diagnosis, and during her pregnancy, she required high doses of antithyroid medication to control her hyperthyroid state. After delivery, she underwent a near total thyroidectomy. The histopathology of the thyroid gland revealed caseating granulomatous thyroiditis, giant Langhans cells and a heavy infiltration of lymphocytes in a background of a multinodular goiter, which was highly suggestive of tuberculosis (TB) [Figure 2]; and incidentally, multifocal papillary microcarcinoma with a maximum size 0.7 cm [Figure 3] was also detected. The granulomas were negative for acid-fast-bacilli (AFB) on a Ziel-Neelsen's (ZN) stain and a specimen taken from thyroid tissue for polymerase chain reaction (PCR) to detect Mycobacterium (MTB) complex was also negative. The patient was started on a nine months course of antituberculous treatment and she did well.
Figure 1: Ultrasound of the thyroid showing a cyst with calcification (see arrow)

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Figure 2: Showing caseating granuloma (black arrow), with Langhans giant cells (white arrow) and heavy infiltration of thyroid tissue with lymphocytes [H and E stain, ×100]

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Figure 3: Showing papillary carcinoma (white arrow) with granuloma (black arrow) [H and E stain, ×100]

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  Discussion Top


Thyroid TB is a rare disease even in the countries in which TB constitutes an endemic disease. Although, in recent years, the incidence of extrapulmonary TB has been showing a progressive increase, thyroid involvement is extremely rare. The prevalence of thyroid TB varies from 0.1 - 0.6% in histologically diagnosed specimens. [1] The exact reasons for this rarity of thyroid TB is unknown. [2] The rarity of this disease may be attributed to various factors including bactericidal properties of colloid material and high thyroid blood flow. [3] Tuberculosis infection of thyroid may present first in the thyroid or appear secondary to a tuberculous process elsewhere. Granulomatous lesions are not pathognomonic of TB, as they may be seen in sarcoidosis and subacute thyroiditis. The caseating necrosis, giant Langhans cells and lymphocyte infiltration, if present, as in our case, confirms the diagnosis of TB. The presence of AFB in the specimen consolidates the diagnosis, but MTB is rarely seen by the ZN stain of thyroid specimens. [4],[5] Detection of MTB, DNA from the thyroid specimen by PCR, is used in recent years as useful tool to provide an alternative for rapid diagnosis of thyroid TB in AFB negative cases. However, PCR for MTB may be positive in 55% of cases. [6]

It is quite interesting to note in our patient that thyroid TB was seen with Graves' disease and multifocal micropapillary carcinoma, which may be the first such case described in the literature. The coexistence of Graves' disease with papillary carcinoma of thyroid is well-known and reported in several cases in the literature. [7],[8] In one study, 7.8% of surgically treated Graves' disease thyroid specimens showed papillary thyroid carcinoma. [9] The coexistence of papillary carcinoma and TB thyroid is extremely rare and a literature review revealed one case report. [10]

Graves' disease is a relatively common disease and multinodularity in the thyroid gland in Graves' disease is not uncommon. In view of the existence of other pathologies, careful scrutiny of these nodules should be undertaken and suspicious nodules should be subjected to fine-needle-aspiration, and operated thyroid specimens of Graves' disease carefully search for other coexistent pathologies like papillary carcinoma and TB, because of definitive treatment available for such coexisting pathological conditions.

 
  References Top

1.Coller FA, Huggins CB. Tuberculosis of the thyroid gland: A review of the literature and report of five new cases. Ann Surg 1926;84:804-20.  Back to cited text no. 1
    
2.Corton RS, Kumar V, Robbins SL. Robins Pathological Basis of Disease, 5 th Ed. USA: WB Sanders Company; 1994. p. 326 & 382.  Back to cited text no. 2
    
3.Pundit AA, Joshi AS, Ogale SB, Sheode JH. Tuberculosis of thyroid gland. Indian J Tuberc 1997;44:205.  Back to cited text no. 3
    
4.Khan EM, Haque I, Pandey R, Mishra SK, Sharma AK. Tuberculosis of the thyroid gland: A clinicopathological profile of four cases and review of the literature. ANZ J Surg 1993;63:807-10.  Back to cited text no. 4
    
5.Kevin MC, Birengal S, Okca F. Tuberculosis of the thyroid gland: A case report. Clin Microbiol Infect 2001;7:514.  Back to cited text no. 5
    
6.Gupta N, Sharma K, Barwad A, Sharma M, Rajwanshi A, Dutta P, et al. Thyroid tuberculosis-role of PCR in diagnosis of a rare entity. Cytopathology 2011;22:392-6.  Back to cited text no. 6
    
7.Phitayakorn R, McHenry CR. Incidental thyroid carcinoma in patients with Graves' disease. Am J Surg 2008;195:292-7.  Back to cited text no. 7
    
8.Al-Ommari AA, Haddad FH, Khushman HM, Malkawi OM. Graves disease and papillary thyroid cancer. An association that can be missed. Saudi Med J 2005;26:1280-2.  Back to cited text no. 8
    
9.Gerenova J, Buysschaert M, de Burbure CY, Daumerie C. Prevalence of thyroid cancer in Graves' disease: A retrospective study of a cohort of 103 patients treated surgically. Eur J Intern Med 2003;14:321-5.  Back to cited text no. 9
    
10.Suri VS, Sakhuja P, Malhotra V, Gondal R, Singh S, Sidhu N. Co-existent tuberculosis and papillary carcinoma thyroid. Trop Doct 2002:32:118.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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