LETTER TO EDITOR
Year : 2010 | Volume
: 53 | Issue : 3 | Page : 579--581
Tuberculosis of the thyroid presenting as multinodular goiter with hypothyroidism: A rare presentation
Abhideep Chaudhary1, B Nayak1, Sandeep Guleria1, Raman Arora2, Ruchika Gupta2, Mehar C Sharma2,
1 Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029, India
2 Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029, India
Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
|How to cite this article:|
Chaudhary A, Nayak B, Guleria S, Arora R, Gupta R, Sharma MC. Tuberculosis of the thyroid presenting as multinodular goiter with hypothyroidism: A rare presentation.Indian J Pathol Microbiol 2010;53:579-581
|How to cite this URL:|
Chaudhary A, Nayak B, Guleria S, Arora R, Gupta R, Sharma MC. Tuberculosis of the thyroid presenting as multinodular goiter with hypothyroidism: A rare presentation. Indian J Pathol Microbiol [serial online] 2010 [cited 2021 Oct 27 ];53:579-581
Available from: https://www.ijpmonline.org/text.asp?2010/53/3/579/68256
We recently came across an interesting case of a 40-year-old woman who presented with progressively increasing swelling over the anterior midline of the neck for 6 years. There was a recent development of difficulty in deglutition for the last 1 year. She had been diagnosed as hypothyroid 10 years back for which she was on thyroid hormone supplementation. There was no history of dyspnea or hoarseness of voice. Local examination revealed multinodular thyroid enlargement, moving well with deglutition. There was no fixity or retrosternal extension of thyroid swelling. No cervical or axillary lymphadenopathy was noted. Routine hematologic and biochemical investigations were within the normal range. The thyroid-stimulating hormone and free T4 were within the reference ranges. The levels of antithyroglobulin and antithyroid peroxidase antibodies were also normal. Chest radiograph and electrocardiogram was normal. Ultrasonography of the neck revealed multiple well-defined heterogenous hypoechoic nodules in both lobes with degenerative changes. Fine-needle aspiration cytology (FNAC) of the swelling was suggestive of colloid goiter with no evidence of malignancy. In view of multinodular goiter with associated pressure symptoms, the patient underwent subtotal thyroidectomy. Intraoperatively, an enlarged thyroid gland with nodular surface was noted. Adhesions were present between the surface of thyroid gland and sternocleidomastoid muscle. Recurrent laryngeal nerves were identified on both sides and preserved.
The thyroidectomy specimen measured 10 Χ 8 Χ 6 cm and weighed 320 gm. Gross examination showed an enlarged thyroid gland with multiple nodules involving both lobes-the largest nodule measuring 2 Χ 1.5 cm. On sectioning, the nodules were filled with necrotic material. Multiple histologic sections from the nodules revealed focal necrotizing granulomatous inflammation with Langhan's giant cells in a background of adenomatous goiter. Focal dystrophic calcification was also noted [Figure 1],[Figure 2]. Stain for acid-fast bacilli showed an occasional acid-fast bacillus in the giant cells. Hence, a final diagnosis of tuberculosis of thyroid was made. There was no pulmonary or lymph nodal focus of tuberculosis. The patient was not given antitubercular therapy since she underwent surgical removal of the thyroid.
Although tuberculosis of the thyroid has been reported since the nineteenth century, less than 200 cases exist in the available literature. The exact incidence of thyroid tuberculosis is not known, although various studies report a frequency varying from 0.2% in chronic thyroiditis to 7% among miliary tuberculosis cases.  Most of the cases in literature have been reported in middle-aged females, with the most common presentation being a solitary thyroid nodule. In some cases, it may also present as diffuse or multinodular goiter, acute or subacute thyroiditis, or rarely as an acute abscess.  Few patients have presented with pressure symptoms, such as dysphagia, dyspnea, and recurrent laryngeal nerve palsy or with cervical lymphadenopathy, raising suspicion of malignancy.  In patients of thyroid tuberculosis, signs of tuberculosis elsewhere in the body are rarely found.  This is also true in our patient in whom no systemic focus of tuberculosis was found.
Thyroid dysfunction associated with tuberculosis of thyroid is rare and very few cases of thyrotoxicosis  or hypothyroidism due to destruction of the thyroid by tuberculosis are reported in literature. FNAC is an effective way of preoperative diagnosis of tuberculosis of the thyroid gland.  However, in the present case, FNAC was suggestive of adenomatous goiter without any features of tuberculosis apparent on aspiration smears. Five types of presentationof tuberculosis of thyroid have been described in the literature: (1) multiple small lesions throughout the gland in association with miliary tuberculosis, (2) goiter with caseation, (3) cold abscess formation with chronic sinus, (4) chronic fibrosing tuberculosis which mimics de Quervan's thyroiditis, and (5) acute abscess formation.  Seeds et al laid down certain prerequisites for diagnosis of tuberculosis of the thyroid: (1) demonstration of acid-fast bacilli within thyroid, (2) a necrotic or abscessed gland, and (3) demonstration of a tuberculous focus outside the thyroid gland. However, acid-fast bacilli are not always found in histologic specimens; therefore, confluent epithelioid cell granulomas with caseous necrosis and giant cells are considered to be diagnostic of tuberculosis of the thyroid gland.  In our patient, granulomatous inflammation with occasional acid-fast bacilli was seen, assisting in making a diagnosis of tuberculosis.
Sarcoidosis and subacute granulomatous thyroiditis may also produce epithelioid cell granulomas in the thyroid gland but these can be differentiated from tubercular thyroiditis by the presence of caseation necrosis in the latter. Subacute granulomatous thyroiditis demonstrates giant cells surrounding the foci of degenerating follicles. There are few reports of tuberculous thyroiditis coexisting with a thyroid carcinoma, and this should be borne in mind in cases of granulomatous thyroiditis. 
The mainstay of therapy in thyroid tuberculosis is antitubercular medication and most of the cases do not require any surgical intervention if diagnosed preoperatively.  Few cases of tubercular abscess may need drainage and surgical removal of the thyroid gland is required only very rarely, especially in cases simulating carcinoma.
This case is being presented for the uniqueness of clinical presentation with hypothyroidism in a multinodular goiter harboring tuberculosis. FNAC did not assist in a preoperative diagnosis of thyroid tuberculosis, which could only be established in the thyroidectomy specimen. To the best of our knowledge, such a presentation of thyroid tuberculosis with multinodular goiter and hypothyroidism is not reported previously.
Tuberculosis of thyroid, although a rare condition, should be considered in the differential diagnosis of thyroid swellings, particularly in areas with high prevalence of tuberculosis. It can have a varied presentation as a solitary nodule, multinodular goiter, or a diffuse goiter. FNAC may help in arriving at a preoperative diagnosis and institution of medical therapy. In cases where this is not possible, surgery may be required, especially to exclude the possibility of carcinoma of the thyroid.
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