Sarcoidosis of thyroid

Case contributed by Dr Gaurav Som Prakash Gupta

Presentation

Two weeks history of bilateral parotid swelling. The patient also complains of dryness of mouth and dryness of eyes since last 2 weeks. The swelling is painless

Patient Data

Age: 40-45 years old
Gender: Male

Ultrasound neck at initial presentation

Modality: Ultrasound

The right lobe of thyroid measures 17mm x 37mm x 16mm. It appears to be mildly bulky and shows multiple superiorly and anteriorly located markedly hypoechoic lesions measuring from few millimeter to a maximum size of 8mm. Some of the focal lesion appears to be conglomerated.

Multiple similar appearing hypoechoic nodules also noted in the isthmus, largest of them measuring up to 9.9mm x 5.9mm. This nodule shows well defined margins, but appears to be conglomerated with adjacent located nodules. The left lobe of thyroid also shows three to four similar appearing hypoechoic nodules measuring only between 2mm to 4mm in size and showing well defined margins. Left lobe of thyroid is normal in size and measures approximately 13mm x 12mm x 27mm. The peripheral interface of thyroid gland appears to be maintained. There is evidence of at least one paratracheal lymph node on the left side measuring 6mm x 3mm showing fatty hila and oval shape.

Evidence of significant supraclavicular lymph node noted on the right side measuring up to 16mm x 11mm showing rounded shape, mildly hypoechoic and thickened texture with maintained vascularity and no evidence of neo angiogenesis. This lymph nodes shows well defined margins. Surrounding fat planes appear normal. No significant adenopathy was noted elsewhere in the jugular chain on either side in the region of level III, IV, V or VI.

Bilateral parotid glands are markedly enlarged and the right parotid gland measures up to 44mm x 18mm and the left parotid gland also shows similar sizes. The both parotid glands shows diffusely heterogeneous texture due to presence of multiple tiny hypoechoic nodules, some of them showing conglomeration. This nodule shows similar morphology as that of previously described thyroid nodules. The nodules appears to be solid in appearance as suggested by intralesional vascularity and unlikely to represent abscess or liquefication. No obvious dilated duct is noted. There is also evidence of one to two intraparotid lymph nodes on both side. A significant appearing retroparotid lymph node noted on the right side measuring up to 18mm x 7mm.

Chest X ray- PA view

Modality: X-ray

Nodular prominence of the bilateral hila and the bilateral paratracheal stripes suggesting possibility of hilar and broncho pulmonary adenopathy - consider possibility of sarcoidosis. Further evaluation by CT scan is recommended.

CT thorax with contrast

Modality: CT

 Multiple mediastinal and bilateral hilar lymph nodes are noted. 

Lymph nodes also seen in portahepatis and peri pancreatic region of head of pancreas.

Case Discussion

This middle aged man presented with two weeks history of bilateral parotid swelling. For further evaluation. The patient also complains of dryness of mouth and dryness of eyes since last 2 weeks. The swelling was painless.  The Ultrasound evaluation raised suspicion of some disseminated granulomatous disease- in present clinical context, the possibility of Sarcoidisis was strong. The subsequent lab investigations favored this diagnosis-

ESR-37mm/1st hr

ACE levels-133IU/L(normal 8-65 IU/L)

Serum calcium -9.9 mg/dl

The history of dry mouth and dry eyes is also classical. The X-ray was ordered by Radiologist after ultrasound, which raised suspicion of mediastinal adenopathy. Subsequently CT thorax confirmed the adenopathy.

The tissue diagnosis was performed using FNAC from the thyroid as well as parotid-:

FNAC from Thyroid was reported as follows-:

Cellular smears showed clusters of scattered and epitheloid histocytes in the background of blood. occasional clusters of scattered follicular epithelial cells were seen admixed with colloid. Few foreign body type giant cells were seen. 

Conclusion: Granulomatous inflammation.

FNAC of Parotid was reported as follows:

Cellar smears showed clusters of scattered and epitheloid histocytes in the background of blood. occasional  clusters of scattered acinar cells were seen . Few foreign body type giant cells were seen with scattered lymphoplasmocytes. 

Conclusion: Gramulomatous inflammation.

The d/d based on the FNAC remains saroidosis and tuberculosis. However, clinical presentation is almost confirmatory for Sarcoidosis.  Lab is also suportive. The patient was started on steroids and showed dramatic response to the steroids both radiologically and clinically. 

However  the Tb Gamma interferon release assay  revealed-

QuantiFERON TB Gold       Positive 
QuantiFERON Nil Value     1.167 IU/ml
QuantiFERON TB Ag           2.674 IU/ml
QFT TB Ag minus Nil          1.51 IU/ml
QuantiFERON Mitogen      8.94 IU/ml

Thus  Tb Gamma interferon release assay was positive.
Therefor , an excisional  biopsy was performed from the right supracalvicular node.

The HPE report showed-:

Findings are consistent with granulomatous Lymhpadenitis. No caseation necrosis was seen.

Special AFB stain were negative.

The AFB culture also turned out to be negative.

Patient has responded remarkably with steroid. 

 

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Case Information

rID: 33021
Case created: 27th Dec 2014
Last edited: 17th May 2016
System: Chest
Inclusion in quiz mode: Included

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