J. Endocrinol. Invest. 10: 105, 1987

LETTER TO THE EDITOR

Acute thyroid swelling after fine needle aspiration biopsy

Sir,

Since the introduction of fine needle aspiration biopsy (FNAB) for the diagnosis of thyroid tumors there has been increasing interest in this method, owing to its effectiveness, as well as to its safety (1). Even in large series very few instances of morbidity are reported, and the most common complication is a transient local hematoma. We wish to report here a case of acute thyroid swelling after FNAB of the gland, in which a definite etiology could not be proven. To our knowledge only one previous report of an analogous case has been published (2) in which, however, no sonographic or surgical follow-up was performed. A 63-yr-old woman presented for the evaluation of a solitary nodule in the right lobe of her thyroid. A radioac­tive pertechnetate scan revealed that the nodule was cold; an ultrasound examination demonstrated that it was solid, hypoechoic, 38 x 25 x 25 mm in size. Hormon­al values, determined by radioimmunoassay, were: to­tal thyroxine 6.2 I1g/ dl (normal, 5-12), total triiodothyr­onine 104 ng/ dl (normal, 80-220), thyrotropin 2.0 I1U/ml (normal, 0.5-6.5). Puncture and aspiration of the nodule were then per­formed with a 22-gauge needle and a 20 ml plastic syringe, without previous local anesthesia. Two passes were made with the same needle and syringe. At the second pass the patient swallowed while the' needle was still in situ. The needle was promptly withdrawn in order to avoid excessive trauma. The amount of mate­rial obtained was not sufficient to make a diagnosis. Immediately after the withdrawal of the needle the right thyroid lobe enlarged rapidly, soon followed by the left lobe. The entire gland enlarged almost thre~ times and we were concerned about the possibility that an hema­toma had formed, but no ecchymosis appeared. With cold packs in a few hours the thyroid returned to normal size, although the neck remained slightly painful for five days. We were unable to perform an ultrasonography during the swelling of the gland, but it was performed a week later and no difference was noticed from the previous sonographic scan. Under ultrasound monitor­ing the puncture and the aspiration of the nodule were repeated (22-gauge needle, 20 ml plastic syringe): no

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thyroid swelling occurred this time, and sufficient mate­rial was obtained to make a diagnosis of follicular neo­plasm. The patient underwent a surgical thyroid exploration, with perioperatory histological diagnosis of follicular carcinoma, and a total thyroidectomy was performed 22 days after the episode of swelling. The definitive histopathological diagnosis confirmed the presence of a follicular carcinoma in a micro-macrofollicular goiter. No signs of previous peri- or intraglandular hematoma were found at the intervention. fhe cause of the episode of acute thyroid swelling remains therefore unexplained. We think it possible to be blood causing the swelling, but this clinical suspi­cion is questioned by our negative findings. Even minor episodes of hemorragic infarction may be in fact histo­logically evident up to 37' days after a clinically un­eventful FNAB of the thyroid (3). We do not believe we have inadvertently injected air into the gland as no signs of emphysema could be detected. An inflamma­tory or allergic etiology seems also unlikely, owing to the extremely rapid onset of swelling and to the fact that we did not inject any drug.

Silvio Dal Fabbro, Renzo Barbazza, Carlo Fabris, and Renzo Perelli Presidio Ospeda/iero, ULSS n° 3 - 32100 Bel/uno, Italy

REFERENCES 1. L6whagen T., Linsk J.

Aspiration biopsy cytology of the thyroid gland. In: Linsk J., Franzen S. (Eds.), Clinical aspiration cytol­ogy. J.B. LiPPLncott, Philadelphia, 1983, p. 61.

2. Haas SN. Acute thyroid swelling after needle biopsy of the thyroid. tJ. Engl. J. Med. 307: 1349, 1982.

3. Jones J.D., Pittman D.L., Sanders L.R. Necrosis of thyroid nodules after fine needle aspiration. Acta Cytol. 29: 29, 1985.