CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Richard C. Cabot, Founder, Nancy Lee Harris, M.D., Editor, Jo-Anne O. Shepard, M.D., Associate Editor, Eric S. Rosenberg, M.D., Associate Editor, Alice M. Cort, M.D., Associate Editor, Sally H. Ebeling, Assistant Editor, Christine C. Peters, Assistant Editor
Case 38-2010 — A 13-Year-Old Girl with an Enlarging Neck Mass
Madhusmita Misra, M.D., M.P.H., Sareh Parangi, M.D., Douglas S. Ross, M.D., Randheer Shailam, M.D., and Peter M. Sadow, M.D., Ph.D.
N Engl J Med 2010; 363:2445-2454December 16, 2010
ArticleReferences
PRESENTATION OF CASE
Dr. Michelle L. Katz (Pediatrics): A 13-year-old girl was seen in the
pediatric endocrinology clinic of this hospital because of an enlarging neck mass.
Eight days earlier, the patient noted swelling of her neck and pain on swallowing. Two days later, her primary care provider noted that the patient had an enlarged thyroid gland. The level of serum thyrotropin was 5.59 μIU per milliliter (reference range, 0.28 to 3.89), free thyroxine 0.88 ng per deciliter (reference range, 0.58 to 1.64), and total triiodothyronine 159 ng per deciliter (reference range, 87 to 178). The anti–thyroid peroxidase antibody level was 244 IU per milliliter (reference range, <35), and the antithyroglobulin antibody level was greater than 3000 IU per milliliter (reference range, <40); complete blood count and electrolyte levels were normal. The patient was referred to the pediatric endocrinology unit at this hospital, where she was seen 5 days later.
The patient reported tightness in her neck and occasional nausea but no difficulty breathing or swallowing. She did not have a sensation of feeling hot or cold; changes in weight, appetite, degree of thirst, energy level, hair, or skin; palpitations; diarrhea; constipation; abdominal pain; vomiting; urinary frequency; skin lesions; or musculoskeletal symptoms.
The patient was born after a full-term gestation, without complications. Menarche occurred at 9 years of age, and her menstrual cycles had recently become regular, lasting about 5 days. Her most recent menses had begun 16 days earlier. She reported migraines approximately once a month and other headaches once or twice weekly that did not awaken her from sleep or occur in the early morning. She took over-the-counter analgesics as needed for headaches and had no known allergies. She lived with her parents and two younger siblings and did well in school. Her mother, maternal grandmother, maternal aunt, and cousin had hypothyroidism, and a thyroid nodule that had recently developed in her mother was being evaluated.
On examination, the patient appeared well. The height was 162 cm (77th percentile for age), the weight 59.4 kg (88th percentile), and the body-mass index (the weight in kilograms divided by the square of the height in meters) 22.6 (86th percentile). The blood pressure was 126/66 mm Hg, and the pulse 79 beats per minute. There was no exophthalmos, and extraocular movements were normal. The thyroid was firm and possibly had an ill-defined mass on the left. The right lobe measured 4.5 cm and the left lobe 6.5 cm in greatest dimension; the left lobe was rotated laterally more than the right. There were no enlarged cervical lymph nodes. The patient was fully pubertal and the remainder of the physical and neurologic examination was normal. The administration of levothyroxine (50 μg daily) was begun, and ultrasonography of the thyroid gland was scheduled.
Fifteen days after the patient's initial evaluation, her mother called to report that the thyroid gland was increasing in size. The next day, ultrasonography of the thyroid revealed a diffusely enlarged thyroid, with the left lobe (5.9 cm by 3.6 cm by 2.7 cm) larger than the right (5.1 cm by 2.1 cm by 1.9 cm). The parenchyma was heterogeneous. A predominantly cystic lesion in the right isthmus had a hyperechoic component and showed minimal Doppler flow. Multiple punctate, hyperechoic foci were present diffusely in the thyroid gland. Numerous lymph nodes lay on either side of the thyroid gland, lateral to both common carotid arteries and posterior to the left clavicular head. Lateral to the left common carotid artery, there was an enlarged lymph node (1.2 cm by 1.9 cm by 0.5 cm), with echotexture resembling that of the thyroid.
Nine days later, on a repeat physical examination, the thyroid had increased in greatest dimension to 6 cm on the right and 7 cm on the left and was firm to palpation. Small cervical lymph nodes were palpable. The patient had pain during swallowing but reported no weight change, hoarseness, or difficulty breathing.
A diagnostic procedure was performed.
TO BE CONTINUED
Richard C. Cabot, Founder, Nancy Lee Harris, M.D., Editor, Jo-Anne O. Shepard, M.D., Associate Editor, Eric S. Rosenberg, M.D., Associate Editor, Alice M. Cort, M.D., Associate Editor, Sally H. Ebeling, Assistant Editor, Christine C. Peters, Assistant Editor
Case 38-2010 — A 13-Year-Old Girl with an Enlarging Neck Mass
Madhusmita Misra, M.D., M.P.H., Sareh Parangi, M.D., Douglas S. Ross, M.D., Randheer Shailam, M.D., and Peter M. Sadow, M.D., Ph.D.
N Engl J Med 2010; 363:2445-2454December 16, 2010
ArticleReferences
PRESENTATION OF CASE
Dr. Michelle L. Katz (Pediatrics): A 13-year-old girl was seen in the
pediatric endocrinology clinic of this hospital because of an enlarging neck mass.
Eight days earlier, the patient noted swelling of her neck and pain on swallowing. Two days later, her primary care provider noted that the patient had an enlarged thyroid gland. The level of serum thyrotropin was 5.59 μIU per milliliter (reference range, 0.28 to 3.89), free thyroxine 0.88 ng per deciliter (reference range, 0.58 to 1.64), and total triiodothyronine 159 ng per deciliter (reference range, 87 to 178). The anti–thyroid peroxidase antibody level was 244 IU per milliliter (reference range, <35), and the antithyroglobulin antibody level was greater than 3000 IU per milliliter (reference range, <40); complete blood count and electrolyte levels were normal. The patient was referred to the pediatric endocrinology unit at this hospital, where she was seen 5 days later.
The patient reported tightness in her neck and occasional nausea but no difficulty breathing or swallowing. She did not have a sensation of feeling hot or cold; changes in weight, appetite, degree of thirst, energy level, hair, or skin; palpitations; diarrhea; constipation; abdominal pain; vomiting; urinary frequency; skin lesions; or musculoskeletal symptoms.
The patient was born after a full-term gestation, without complications. Menarche occurred at 9 years of age, and her menstrual cycles had recently become regular, lasting about 5 days. Her most recent menses had begun 16 days earlier. She reported migraines approximately once a month and other headaches once or twice weekly that did not awaken her from sleep or occur in the early morning. She took over-the-counter analgesics as needed for headaches and had no known allergies. She lived with her parents and two younger siblings and did well in school. Her mother, maternal grandmother, maternal aunt, and cousin had hypothyroidism, and a thyroid nodule that had recently developed in her mother was being evaluated.
On examination, the patient appeared well. The height was 162 cm (77th percentile for age), the weight 59.4 kg (88th percentile), and the body-mass index (the weight in kilograms divided by the square of the height in meters) 22.6 (86th percentile). The blood pressure was 126/66 mm Hg, and the pulse 79 beats per minute. There was no exophthalmos, and extraocular movements were normal. The thyroid was firm and possibly had an ill-defined mass on the left. The right lobe measured 4.5 cm and the left lobe 6.5 cm in greatest dimension; the left lobe was rotated laterally more than the right. There were no enlarged cervical lymph nodes. The patient was fully pubertal and the remainder of the physical and neurologic examination was normal. The administration of levothyroxine (50 μg daily) was begun, and ultrasonography of the thyroid gland was scheduled.
Fifteen days after the patient's initial evaluation, her mother called to report that the thyroid gland was increasing in size. The next day, ultrasonography of the thyroid revealed a diffusely enlarged thyroid, with the left lobe (5.9 cm by 3.6 cm by 2.7 cm) larger than the right (5.1 cm by 2.1 cm by 1.9 cm). The parenchyma was heterogeneous. A predominantly cystic lesion in the right isthmus had a hyperechoic component and showed minimal Doppler flow. Multiple punctate, hyperechoic foci were present diffusely in the thyroid gland. Numerous lymph nodes lay on either side of the thyroid gland, lateral to both common carotid arteries and posterior to the left clavicular head. Lateral to the left common carotid artery, there was an enlarged lymph node (1.2 cm by 1.9 cm by 0.5 cm), with echotexture resembling that of the thyroid.
Nine days later, on a repeat physical examination, the thyroid had increased in greatest dimension to 6 cm on the right and 7 cm on the left and was firm to palpation. Small cervical lymph nodes were palpable. The patient had pain during swallowing but reported no weight change, hoarseness, or difficulty breathing.
A diagnostic procedure was performed.
TO BE CONTINUED
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