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A woman with an abnormal mass in the thyroid gland

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A 69 year old woman presented with a sudden history of dysphagia and stridor. A month earlier she had noticed neck swelling and hoarseness of voice after a bout of flu. Her appetite was fine, weight steady, and there was no history of fever or night sweats.

Past history included a hysterectomy, and she had had insulin dependent diabetes for the past 10 years. She did not have any family history of diabetes or thyroid disease and her medications included insulin and hormone replacement therapy. On examination she was acutely short of breath with cyanosis and frank stridor. There were no signs of thyroid overactivity but she had obvious vitiligo in her neck and shoulder area. Neck examination revealed a hard and fixed non-tender swelling mainly in the midline with some prominence on the left side. The rest of her systemic examination was unremarkable.

She was given intravenous hydrocortisone and started on insulin infusion and regular oral steroids. Blood tests showed a normal full blood count, erythrocyte sedimentation rate, calcium, and renal and liver function. A thyroid profile showed a free thyroxine concentration of 22.4 pmol/l (normal range 9.6–26.5 pmol/l) and thyroid stimulating hormone of 6.6 mU/l (normal range 0.6–4.8 mU/l) indicative of “compensated euthyroidism”. The thyroperoxidase antibody level was strongly positive.

She was started on thyroxine and gradually she began to feel a lot better. Fine needle aspiration/tru-cut biopsy of her neck mass was attempted but was non-conclusive on two successive occasions.

Questions

(1)
What other investigations would you consider?
(2)
What is the diagnosis and what is it commonly mistaken for?
(3)
What is a common predisposing factor?
(4)
What is the treatment and prognosis of this condition?

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