ODP470 Compressive Goiter with COVID-19: An Unusual Etiology of Respiratory Distress Requiring Endotracheal Intubation with Surgical Resection

Abstract

Introduction Gradual enlargement of multinodular goiter (MNG) may compress surrounding structures which may progressively cause complications of tracheal stenosis and airway compromise. Surgical resection remains the gold standard treatment in MNG patients presenting with respiratory distress. In the current global COVID -19 pandemic, compressive goiter should be a differential diagnosis in patients with stable benign thyroid goiter presenting with dyspnea. We present a case of MNG with life threatening airway obstruction during an active COVID-19 infection. Case presentation A 74-year-old female with a history of hyperthyroidism with multi-nodular goiter and recurrent atrial fibrillation status-post ablation, was transferred to the intensive care unit for treatment after being intubated for respiratory distress at a nearby hospital. She was diagnosed with hyperthyroidism about 40 years ago and managed with methimazole. Over the last two years, thyroid ultrasound and prior imaging showed MNG with patent but moderate tracheal narrowing; fine-needle aspiration (FNA) confirmed benign colloid nodules with cystic degeneration. She was pending cardiac clearance for surgery when symptoms acutely worsened two days before admission. On initial assessment, she was hemodynamically stable, afebrile, with oxygen saturation of 86% on room air. She was alert and able to follow commands. On physical examination, she had stridor and thyromegaly was evident with mild tenderness on palpation. Cardiopulmonary examination was remarkable for coarse breath sounds. Labs showed TSH 4.82 (Normal 0.3 - 4.5 ulU/mL), FT4 0.64 (Normal 0.5- 1.26 ng/dL). Respiratory panel test came back positive for SARS-CoV-2. Racemic epinephrine and albuterol nebulizers were administered to help with her symptoms. CT scan of the neck revealed a severe narrowing and mild rightward shift of the trachea by a large multinodular goiter, prompting the decision to intubate for airway protection. CT scan of the chest with contrast demonstrated the large MNG with tracheal stenosis. Her methimazole dose was adjusted. After cardiac clearance, she underwent thyroidectomy through a transcervical approach. Levothyroxine and calcium supplementation were started post-surgery. She was extubated two days after her thyroidectomy. Pathology results showed no evidence of malignancy. Discussion Acute airway obstruction by large MNG requiring emergent airway protection is rare. Typically airway compromise from large otherwise stable benign goiters results from sudden hemorrhage into a cyst, upper respiratory tract infection leading to tracheal edema, or worseningcomorbid conditions. During the COVID-19 pandemic, acute respiratory failure and shortness of breath is typical of worsening disease course. This case highlights the importance of maintaining wider differentials of respiratory failure even and we need to consider worsening of tracheal narrowing with a large goiter due to tracheal edema from SARS- CoV-2 Infection. Thyroidectomy before SARS-CoV-2 infection may have reduced her need for emergent intubation for acute respiratory failure by improving pre existing airway compression. Presentation: No date and time listed

Case report: Preliminary study on the diagnosis and treatment of respiratory distress in patients with giant nodular goiter complicated with severe COVID-19

“…Although ACE2 is expressed in the nose, oral mucosa, throat, and tongue, edema manifestations in the corresponding organs might occur ( 11 – 13 ). Another study by Tasnuva disclosed that dyspnea in giant nodular goiter with new COVID-19 pneumonia may be related to airway edema, thus, aggravating tracheal stenosis ( 4 ), and our findings in case 1 confirmed this view. However, we did not compare the relevant imaging data before the disease onset and did not perform a bronchoscopy to identify whether airway edema led to aggravated airway stenosis.…”

“…For choosing the timing of surgery, we suggest that before the COVID-19 progresses to critical illness, early surgery should be performed when the function of other organs is not significantly impaired, the earlier the operation, the greater the benefit to patients. Amin et al ( 4 ) also recommended that in nodular goiter patients with respiratory obstruction, a timely intervention to relieve airway obstruction is the best choice. By analogy, patients with other diseases that may lead to acute exacerbation of pulmonary inflammation (such as chronic obstructive pulmonary disease) superimposed with giant nodular goiter and tracheal compression may also give priority to surgical treatment.…”

“…Since the outbreak of novel coronavirus disease 2019 (COVID-19), which is caused by SARS-CoV-2, several COVID-19-related thyroid diseases have emerged, including subacute thyroiditis, autoimmune thyroid disorders, non-thyroidal illness syndrome, and thyroid dysfunction due to unknown causes ( 1 – 3 ). Although a few respiratory distress cases have been recorded in which patients presented with tracheal compression due to giant nodular goiter superimposed with novel COVID-19 infection, only one case has been reported by Amin et al ( 4 ). Moreover, it is still unknown whether novel COVID-19 infection can aggravate the tracheal compression symptoms and whether tracheal compression in giant nodular goiter cases can lead to prolonged COVID-19 pneumonia, which is difficult to treat.…”