Graves' Disease and Papillary Thyroid Carcinoma in a Patient with Active Sarcoidosis

ABSTRACT

Sarcoidosis is a systemic granulomatous disease of unknown etiology. In most cases, mediastinal lymph nodes and lung parenchyma are involved. In addition, the eyes, skin, abdominal organs, central nervous system or the joints might be involved during the course of the disease. Sarcoidosis has been found to be related with other autoimmune diseases such as thyroiditis. In this report, we present the case of a patient in whom hyperthroidism was found and Graves’ disease and papillary thyroid carcinoma were diagnosed while being investigated with a preliminary diagnosis of sarcoidosis. A 50-year-old male patient was admitted to our chest diseases clinic with the complaints of cough with colorless sputum, joint pain, weakness, weight loss (36 kgs), palpitations, tremor of the hands and pain in the right eye. Mediastinal lympadenopathy was detected on CT scan. Laboratory tests demonstrated hypercalcemia and low levels of parathyroid hormone (PTH). Eye examination revealed uveitis. Bronchoscopy was planned to confirm the diagnosis of sarcoidosis. Thyroid function test was performed and the patient turned out to have hyperthyroidism with high free T4 and low TSH levels. TSH receptor antibody titer was 71 U/L (0- 14 U/L). Ultrasonographic examination demonstrated enlarged thyroid gland and heterogeneous parenchyma with increased blood flow pattern. 4- and 24-hour radioiodine uptakes were 30% and 60%, respectively and scintigraphy findings were compatible with diffuse toxic goiter. On Hertel exophthalmometer, the measurements of the right and left eye were 23 and 24 mm, respectively. The diagnosis of Graves’ disease was made and thionamide therapy was started. Since active ophthalmopathy was present and the patient did not want to receive medical therapy for a long time, surgery was the best option for definitive therapy. The patient was prepared for the surgery with lugol solution (3x10 drops daily) and after eutyroidism was achieved, bilateral total thyroidectomy was performed. Before and after surgery, the patient was given 20 mg methylprednisolone in order to control hypercalcemia due to sarcoidosis and to control eye symptoms caused by Graves’ disease. The postoperative pathology report was compatible with thyroiditis and 6 mm micropapillary carcinoma at one focal area in the right lobe. The patient received radioactive iodine therapy after thyroidectomy. Sarcoidosis occurs as a result of immune response created against environmental and genetic factors in the presence of a triggering agent. The disease can involve many organ and systems. The classical pathological finding is granulomatosis without caseification. Autoimmune thyroiditis may accompany the disease in any stage and hypo or hyperthyroidism may develop. In our case, hyperthyroidism developed during the active phase of the disease and, interestingly, papillary thyroid cancer was detected although there were no thyroid nodules found by preoperative thyroid ultrasonography.