Thyroid sarcoidosis

Case contributed by Gaurav Som Prakash Gupta
Diagnosis certain


Two weeks history of bilateral painless parotid swelling. The patient also complains of dryness of the mouth and dryness of the eyes for two weeks.

Patient Data

Age: 45 years
Gender: Male

US neck initial presentation


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

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

Evidence of significant supraclavicular lymph node noted on the right side measuring up to 16 x 11 mm showing rounded shape, mildly hypoechoic and thickened texture with maintained vascularity and no evidence of neoangiogenesis. This lymph node 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 44 x 18 mm and the left parotid gland also shows similar sizes. Both parotid glands show diffusely heterogeneous texture due to the 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 appear to be solid in appearance as suggested by intralesional vascularity and are 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 sides. A significant appearing retroparotid lymph node was noted on the right side measuring up to 18 x 7 mm.

Chest X ray- PA view


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

CT thorax with contrast


Multiple enlarged mediastinal and bilateral hilar lymph nodes are noted. Enlarged lymph nodes are also seen in the porta hepatis and peripancreatic region of the head of the pancreas.

Case Discussion

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

  • ESR: 37mm/1st hr
  • ACE levels: 133 IU/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 the radiologist after the 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 epithelioid histiocytes 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 epithelioid histiocytes 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 differential diagnosis based on the FNAC remains sarcoidosis and tuberculosis. However, the clinical presentation is almost confirmatory for sarcoidosis.  The lab is also supportive. The patient was started on steroids and showed a 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.
Therefore, an excisional biopsy was performed from the right supraclavicular node.

The histopathology report showed findings consistent with granulomatous lymphadenitis. No caseation necrosis was seen. Special AFB stains were negative. The AFB culture also turned out to be negative.

The patient has responded remarkably with steroids. 

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