Article Text
PDF
Statistics from Altmetric.com
Description
A 65-year-old man, who was a never smoker and enjoyed unremarkable past health, presented to the emergency department due to massive haemoptysis. The patient suffered from a brief pulseless electrical activity arrest of 4 min soon after arrival. The patient was then transferred to the intensive care unit after emergency endotracheal intubation. Contrast-enhanced CT (CECT) of the thorax showed consolidation within dependent areas of the right upper and lower lobes, compatible with aspiration of blood products (figure 1A). Cavitation and chronic lung changes were absent (figure 1B). There was no bronchial artery dilatation or hypertrophy on CT angiogram. Fibreoptic bronchoscopy performed via the endotracheal tube could not identify any endobronchial lesions. Bronchoscopic aspirates sent for microbiological evaluation were negative. Evaluation of the upper airway by an otorhinolaryngologist was unrevealing.
(A) Axial contrast-enhanced CT (CECT) of the thorax showed dependent patchy consolidation and ground glass change (white arrow) in right upper lobe of lung, in keeping with clinical history of massive haemoptysis. (B) A selected image of CECT of the thorax reformatted in coronal plane. There was no focal lung lesion or bronchiectasis detected. (C) Axial CECT at the neck level showed an ill-defined hypoenhancing lesion (white arrow) in the asymmetrically enlarged right thyroid lobe, partially abutting the endotracheal tube. The thyroid cartilage was absent on the right side (white arrowhead), suspicious of underlying erosion and endotracheal invasion. (D) CECT at the neck level reformatted in the sagittal plane. The white arrows mark the expected border of the trachea. The normal space between the endotracheal tube and thyroid was obliterated by the thyroid mass, suggestive of underlying invasion.
On reviewing the CECT scan of the thorax, an enlarged right thyroid lobe was seen (figure 1C,D). Bedside ultrasonography of the thyroid showed an irregular hypoechoic mass within the thyroid gland, which encircled the trachea (figure 2A). Evidence of invasion into the adjacent strap muscle (figure 2B) and into the thyroid cartilage (figure 2C) could be appreciated. Abnormal vascular growth extending towards the anterior tracheal rings was seen (figure 2D). Fine-needle aspiration of thyroid tissue confirmed the diagnosis of papillary thyroid carcinoma. The patient underwent surgical tracheostomy, followed by complete thyroidectomy and survived.
(A) Axial ultrasonography (US) showed an irregular, taller-than-wide hypoechoic mass (white arrow) with internal calcifications (white arrowhead) epicentred in the right thyroid and abutted the trachea. The open white arrowheads mark the tracheal ring. (B) Axial US showed the mass invading the strap muscle superficially on the right side. (C) Midline sagittal US showed the thyroid mass eroding through the thyroid cartilage (white arrows) into the trachea, abutting the endotracheal tube (white arrowheads). The sonographic caliper markers mark the border of the thyroid mass. (D) Colour Doppler US in sagittal plane confirmed abnormal vascularity of the mass extending into the trachea. The white arrows mark the anterior border of the trachea.
Discussion
Massive haemoptysis is a medical emergency, which requires initial stabilisation and airway control, followed by rapid localisation and haemostasis of the bleeding site. Common aetiologies include necrotising bacterial and fungal pneumonia, pulmonary tuberculosis, underlying bronchiectasis and lung malignancies. Fibreoptic bronchoscopy and CECT are essential and complementary evaluations to identify the source of haemorrhage.1 Upper airway bleeding, such as posterior epistaxis, may masquerade as massive haemoptysis and is important to rule out. In our patient, initial investigations were all negative, which prompted us to search for an alternative aetiology.
Thyroid cancers with tracheal invasion rarely present as massive haemoptysis, which have been reported in isolated case reports.2 3 In our case, fibreoptic bronchoscopy could not identify tracheal erosion from malignant thyroid tissue due to presence of endotracheal tube. Ideally and where feasible, complete examination of the airway should include withdrawal of the endotracheal tube either completely or at least to the level of the vocal cords. Ultrasonography of the thyroid is useful for rapid and non-invasive diagnosis of thyroid malignancy at bedside.4–6 Nodal metastases and extrathyroidal extension (ETE) are readily detectable by ultrasonography.4 7 An additional advantage is the ability to increase diagnostic yield of fine-needle aspiration biopsy (FNAB) with ultrasound guidance as compared with palpation-guided FNAB.6 Ultrasonographic features suggestive of thyroid malignancy include marked hypoechogenicity, irregular margins, punctate microcalcifications and chaotic intrinsic hypervascularity,4 5 8 all of which were present in our case. Gross ETE into adjacent structures including strap muscle, trachea and recurrent laryngeal nerve are important sonographic features of locally advanced thyroid cancers.7 Locally invasive thyroid cancer should not be missed as a differential diagnosis of massive haemoptysis, especially when initial workup for common causes is non-revealing.
Ethics statements
Patient consent for publication
Ethics approval
This was only an image submission with best efforts to keep the patient unidentifiable. Patient consent has been obtained prior to submission. Participants gave informed consent to participate in the study before taking part.
Footnotes
Contributors WW-SN was the lead author involved in drafting the initial manuscript and preparing the images. KC provided radiological expertise including interpretation and description of the images. All authors contributed to the writing, review and final approval of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.