Rheumatoid Nodules in Thyroid Gland Parenchyma as an Expression of Rheumatoid Arthritis

A Case Report

Efthimios Sivridis; Maria Kouroupi; Michael Ioannis Koukourakis; Stella Arelaki; Nikolaos Lyratzopoulos; Alexandra Giatromanolaki

Disclosures

J Med Case Reports. 2019;13(159) 

In This Article

Case Presentation

A 33-year-old Greek woman was found to have hypothyroidism following a thorough investigation of migraines, after a road traffic accident. The event was complicated with craniocerebral injury necessitating tracheostomy. Her past medical history included RA of 3-year duration treated with methotrexate (2.5 mg three times per day), and topiramate medication for migraines (200 mg twice a day). On clinical examination, the thyroid gland was painless and not palpable. Laboratory tests confirmed a positive rheumatoid factor (RF) with normal antithyroglobulin (anti-TG) and thyroid peroxidase antibodies (anti-TPO) (16 U/ml and 16.7 U/ml, respectively). An ultrasound-guided fine needle aspiration biopsy performed in a private clinic showed distinct nodules in the lower pole of the left thyroid lobe, which were reported as being suggestive, though not conclusive, of malignancy (category V Bethesda).[12] She was put on thyroxine (T4) treatment and when she became euthyroid with thyroid-stimulating hormone (TSH) of 0.89 μIU/ml, triiodothyronine (T3) of 1.30 ng/mL, and T4 of 7.2 μg/dl, she was subjected to a total thyroidectomy in our hospital.

The resected thyroid specimen, received in three pieces (4 × 3 × 1.5 cm; 4.5 × 2.7 × 1 cm; and 5 × 2.5 × 1 cm), was surrounded by multiple adhesions; its total weight was 36 g. Two of the specimens exposed a cut surface composed of clusters of small irregular follicles separated by reticular connective tissue, while the gland architecture of the third specimen (5 × 2.5 × 1 cm) was replaced in part by five small areas of amorphous necrotic tissue. On microscopic examination the necrotizing lesions (0.2 to 0.4 cm in greatest diameter) corresponded to rheumatoid nodules, composed of a central area of fibrinoid necrosis surrounded by palisading histiocytes; these, in turn, were encircled by fibroblasts, lymphocytes, and plasma cells (Figure 1). There was a proliferation of small blood vessels around the nodule, lacking any perivascular inflammation. Yet, the surrounding thyroid tissue showed focal lymphocytic thyroiditis, with typical germinal centers, alternating with stromal fibrosis. No evidence of infection, sclerosing thyroiditis, thyroid carcinoma, or lymphoma was noted.

Figure 1.

Rheumatoid nodule a x10 magnification, b x40 magnification

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