A Rare Complication following Thyroid Percutaneous Ethanol Injection: Plummer Adenoma.
Percutaneous ethanol injection (PEI) is a technique used only for benign thyroid nodules, cystic or mixed cystic-solid with a large fluid component. It is a quite low-cost, safe, and outpatient method of treatment. Rare and severe complications have been described after PEI: jugular vein thrombosis and severe ethanol toxic necrosis of the larynx combined with necrotic dermatitis. Moreover, only four thyrotoxicosis cases due to Graves’ disease have been reported. We report a case of 58-year-old female with a voluminous thyroid cystic nodule, occupying almost the entire left thyroid lobe. Our patient had already performed surgical visit and intervention of thyroidectomy had been proposed to her, which she refused. At baseline, our patient has a normal thyroid function with negative autoantibodies. According to the nodular structure, intervention of PEI has been performed with a significant improvement of compressive symptoms and cosmetic disorders. About 30 days after treatment, there was a significant volume reduction, but patient developed an acclaimed symptomatic thyrotoxicosis. After ruling out several causes of hyperthyroidism and according to the thyroid scintigraphy findings, we made the diagnosis of Plummer adenoma. To our knowledge, our patient is the first case of Plummer adenoma following PEI treatment of nontoxic thyroid nodule.
We report a case of a 58-year-old female presented to our center with a voluminous thyroid nodule overall size of 40 × 33 × 26 mm (volume of 17.9 ml), occupying almost the entire left thyroid lobe (Figure 1). Our patient had already had a surgical visit and an intervention of thyroidectomy had been proposed to her, which she refused. A thyroid function test demonstrated TSH 0.8 mIU/l, FT3: 3.77 pg/ml, and FT4: 1.37 ng/dL (normal values for TSH: 0.3–3.74 mIU/l; FT3: 2.2–4.2 pg/ml, and FT4: 0.8–1.7 ng/dL), peroxidase antibodies (TPOAb) 31.2 IU/ml and thyroglobulin antibodies (TgAb) 18 IU/ml (normal values for TPOAb: 0–60 UI/ml; TgAb: 0–60 UI/ml). After evaluation, symptom score and cosmetic score were positive. A thyroid ultrasound demonstrated a right lobe with a normal volume and a left lobe with increased volume (right volume 6.1 ml, left volume 22.2 ml), with normal echogenicity and moderately inhomogeneous echotexture. Due to the nodular structure, intervention of PEI was proposed to which she expressed favorable consensus.
Before PEI, our patient had been submitted to fine needle aspiration on this mixed cystic-solid thyroid nodule, with a cytological diagnosis of Thy2: nonneoplastic. With the patient in a supine position, a total dose of 5 ml of 95% sterile ethanol was injected slowly via a 22 gauge needle under real time ultrasound guidance . We monitored the injection as a hyperechogenic region and completed the procedure in five minutes. After a successful PEI procedure, color Doppler examination showed complete disappearance of intranodular hypervascularization.
Following PEI treatment, the patient detected immediate improvement of compressive symptoms and cosmetic disorders. About 30 days after the treatment there was a significant volume reduction (5.9 ml versus baseline volume of 17.9 ml, volume reduction rate of 67%) but the patient complained of dyspnea, tremors and tachycardia. The cardiorespiratory function parameters were as follows: blood pressure 150/85 mmHg, heart rate 112/min with an ECG highlighted sinus tachycardia, breath frequency 20/min, and oxygen saturation 96%. Thyroid hormone tests showed a framework of acclaimed thyrotoxicosis TSH < 0.01 mIU/l; FT3: 5.8 pg/ml, FT4 19.1 ng/dL (normal values for TSH: 0.3–3.74 mIU/l; FT3: 2.2–4.2 pg/ml; and FT4: 0.8–1.7 ng/dL). Autoantibodies measurements were performed (TRAb, TPOAb, and TgAb) to investigate the cause of thyrotoxicosis. These autoantibodies were undetectable and we ruled out the diagnosis of Graves’ disease and hashitoxicosis. The lack of neck pain and the normality of acute inflammation parameters (erythrocyte sedimentation rate (ESR) and PCR) allowed us to exclude the diagnosis of subacute thyroiditis. The patient was therefore submitted to thyroid scintigraphy which showed a left nodule under complete functional autonomy, corresponding to the nodule treated with PEI (Figure 2). Based upon clinical, laboratory, and imagistic findings, a diagnosis of Plummer adenoma was made. After thyrostatic treatment (methimazole 15 mg/day for 3 months) and beta-blockers (Propranolol 40 mg 1 cpr every 8 hours for 3 months), the patient has been treated with radioiodine therapy (131I), achieving a euthyroid status.
In spite of the fact that severe complications after PEI treatment are rare, they should be considered in subjects who have indication to this kind of treatment.
Comment: I have never seen this complication.