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20 year old male with wheezing…

September 6, 2013

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20 year old male presents with neck fullness and wheezing.  Had the sensation of “fullness” for about a year, worsening significantly over the past week.  Now he complains primarily of trouble swallowing and wheezing.

On exam the patient has a definite right sided neck mass, minimally mobile but unclear if associated with the thyroid.  Lungs with a biphasic wheeze and sats low 90s.  Positive Pemberton’s sign with facial plethora and JVD when he raised his arms above his head.  Here is his neck CT with IV contrast:

CT scout goiter CT goiter 1 CT goiter 2

The CT revealed a 4.9 x 4.2cm multi cystic mass occupying the right lobe of the thyroid with some tracheal compression.  TSH <0.02.  The patient was admitted and approximately 45ml of fluid was drained from his cystic lesion with significant improvement in his symptoms initially, although this fluid recurred over the subsequent month.  He is currently being worked up for thyroid pathology and may undergo a hemithyroidectomy in the near future.
On a side note, here is a NEJM article discussing “Pemberton’s Sign”:
Of note, there is some controversy surrounding the use of iodinated contrast in patient’s with suspected thyroid masses.  This iodine bolus may interfere with a subsequent radioiodine scan, and theoretically may delay a patient’s therapy with radioactive iodine, if ultimately indicated.
Image Contributor:  Aaron Hougham, MD

Author:  Aaron Hougham, MD

References

1.  Basaria S, Salvatori R.  Pemberton’s Sign.  N Engl J Med 2004; 350: 1338.

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