SESSION TITLE: ILD Student/Resident Case Report Posters
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Papillary carcinoma, usually subclinical, is the most common thyroid cancer. Miliary lung metastasis and multiple nodules have been described and associated with respiratory symptoms. We present a patient diagnosed unexpectedly with papillary thyroid carcinoma after reporting progressive exertional dyspnea with hypoxia.
CASE PRESENTATION: A 59 year old male with four-pack-year remote smoking history, hypertension and hypertriglyceridemia presented with six months of new-onset progressive dyspnea with less than one flight of stairs and cough, despite Levaquin, Zithromax, Symbicort and three steroid tapers. He reported low grade fevers and unintentional weight loss of 17 lbs. over the past year. Cardiac stress test was negative. He denied chemical exposures, illicit drug use and reported minimal alcohol use. Medications included albuterol, amlodipine and fenofibric acid. Vitals were BP 122/80, HR 98, RR 16 with resting oxygen saturation 94% on room air, decreasing to 77% upon ambulation and requiring 6L oxygen to maintain saturations above 88%. Exam was only notable for crackles in the lower third of each lung. CBC with differential and BMP were unremarkable except WBC 12.1. ABG 7.37/49/72/28/94%. Noncontrast CT chest depicted ill-defined centrilobular ground glass nodules and moderate associated ground glass opacity with traction bronchiectasis and minimal honeycombing bilaterally. Pulmonary function tests revealed a mild restrictive deficit with DLCO 38% of predicted.
DISCUSSION: Given the rare association of fenofibric acid with ILD, it was discontinued. Prednisone 80mg daily was initiated. Symptoms persisted and he underwent surgical lung biopsy. Pathology revealed UIP pattern ILD with papillary proliferation, with specialized stains suggestive of papillary thyroid carcinoma. Thyroid US subsequently demonstrated a heterogeneous thyroid gland with multiple nodules, largest 1.5x1x0.7cm, hypoechoic with lobulated margins and both coarse and micro-calcifications. FNA confirmed papillary thyroid carcinoma. Our patient underwent total thyroidectomy with compartment dissection. Pathology identified classical type multifocal and bilateral well-differentiated partially encapsulated papillary thyroid carcinoma with partial capsular invasion, minimal extrathyroidal extension and 4/11 lymph nodes positive. Post-operatively, he received radioactive iodine therapy.
CONCLUSIONS: This is the first reported case of papillary thyroid carcinoma presenting as interstitial lung disease. There is one previously reported case of metastatic papillary thyroid carcinoma and severe airflow obstruction due to extensive nodular pulmonary metastases1. Their patient’s airflow obstruction decreased with improvement in hypoxia as he underwent therapy with sorafenib and radioactive iodine. We eagerly await our patient’s post-RAI follow-up.
Reference #1: Manganaris C, Wittlin S, Xu H, et al. Metastatic papillary thyroid carcinoma and severe airflow obstruction. Chest. 2010;138(3):738-742.
DISCLOSURE: The following authors have nothing to disclose: Sheetal Gandotra, Todd Sheppard, Niyati Chiniwala
No Product/Research Disclosure Information