Synchronous Presentation of Type 2 Marine-Lenhart Syndrome and Differentiated Thyroid Carcinoma Manifesting as Thyroid Storm

Abstract

Marine-Lenhart syndrome (MLS) is a rare condition characterized by the coexistence of hyperfunctioning thyroid nodules and Graves' disease (GD). The prevalence of thyroid nodules and thyroid cancer is higher in patients with GD. We report a case of 42-year-old female who presented with thyroid storm and found to have underlying GD. An initial thyroid ultrasound (US) revealed two nodules classified as TIRADS 3, whereas a repeat US after achieving euthyroidism, showed changes in the size and consistency of these nodules and identified a new nodule with classification of TIRADS 6 nodule. A 24-h radioactive iodine thyroid uptake scan demonstrated a diffuse increase uptake (75.1%) with one hyperfunctioning and two warm nodules, including the newly identified TIRADS 6 nodule. Fine-needle aspiration (FNA) biopsy confirmed papillary thyroid cancer (Bethesda VI) in a right (R) warm nodule (the TIRADS 6 nodule), while the other two nodules were benign (Bethesda II). The patient underwent a R hemithyroidectomy that was complicated by recurrent laryngeal nerve (RLN) injury. Pathology examination revealed unifocal papillary thyroid microcarcinoma with positive anterior surgical margin. The patient was furtherly treated with radioactive iodine therapy thyroid nodules with GD should be managed cautiously. Emerging evidence challenges the previous notion that hyperthyroidism provides protection against thyroid cancer. The association between GD and thyroid malignancy remains an area of ongoing investigation, with variable management strategies and prognostic implications reported in the literature.

Figure 1

Initial thyroid ultrasound when patient has thyroid storm. (A) Right (R) thyroid lobe in longitudinal axis with heterogenous echogenicity and measuring¹ 6.31 cm × ²2.63 cm. (B) R thyroid lobe in transverse axis with heterogenous echogenicity measuring¹ width 3.12 cm and volume 24.74 mL. (C) R thyroid mid-pole nodule in longitudinal axis measuring¹ 3.3 cm × 21.7 cm. (D) R thyroid mid-pole nodule in transverse axis and measuring¹ 2.1 cm. Mid-pole, solid (2), isoechoic (1), wider-than-tall (0), smooth (0), and no calc (0). Measuring 3.3 cm× 1.7 cm × 2.1 cm. Points: 3. TIRADS 3. (E) R thyroid lobe doppler in transverse axis with hypervascularity. (F) Left (L) thyroid lobe in longitudinal axis with heterogenous echogenicity measuring¹ 6.56 cm ײ 2.47 cm. (G) L thyroid lobe in transverse axis with heterogenous echogenicity and measuring width¹ 2.99 cm and volume 23.18 mL. (H) L thyroid mid-pole nodule in longitudinal axis and measuring 1 2.5 cm× 2 0.8 cm. (I) L thyroid nodule in transverse axis measuring¹ 1.4 cm. Mid-pole, Almost completely solid (2,) isoechoic (1), wider-than-tall (0), ill-defined (0), and no calc (0). Measuring 2.5 cm × 0.8 cm × 1.4 cm. Points: 3. TIRADS 3. (J) L thyroid lobe doppler in transverse axis with hypervascularity but less than the R side.

Figure 2

Follow-up thyroid ultrasound after 9 months while patient is clinically and biochemically euthyroid. (A) R mid-pole thyroid nodule in longitudinal axis measuring¹ 2.94 cm × ² 1.61 cm. (B) R mid-pole thyroid nodule in transverse axis³ 1.94 cm. Mid-pole, solid (2), isoechoic (1), wider-than-tall (0), ill-defined (0), and no calcs (0). Measuring 2.9 cm × 1.6 cm × 1.9 cm. Points: 3. TIRADS 3. (C) R lower pole thyroid nodule in longitudinal axis measuring¹ 1.52 cm × ² 1.8 cm. (D) R lower pole thyroid nodule in transverse axis measuring 3 1 cm. Lower pole, mixed cystic and solid (1), hypoechoic (2), taller-than-wide (3), ill-defined (0), and no calcs (0). Measuring 1.5 cm × 1.8 cm × 1 cm. Points: 6. TIRADS 6. (E) L mid-pole thyroid nodule in longitudinal axis measuring¹ 1.6 cm × ² 0.8 cm. (F) L mid-pole thyroid nodule in transverse axis measuring ³ 1.4 cm. Mid-pole, almost completely solid (2), hypoechoic (2), wider-than-tall (0), ill-defined (0), and no calcs (0). Measuring 1.6 cm × 0.8 cm × 1.4 cm. Points: 4. TI-Rads: 4. (G) L thyroid doppler in longitudinal axis with normal vascularity. (H) R thyroid doppler in longitudinal axis with hypervascularity more than the L side.

Figure 3

Radioactive iodine thyroid uptake scan. (A) Anterior view, (B) right lateral view, and (C) left lateral view. 213.247 microcurie I-123 sodium iodide orally with 24 h radioactive iodine uptake of 75.1% of the administered dose (normal range 10%–35%) in the whole thyroid gland (comptabile with Graves' disease). Increased radiotracer uptake within sonographically demonstrated right midpole thyroid nodule consistent with hyperfunctioning thyroid nodule (green arrow).

Figure 4

Right lower Thyroid nodule fine-needle aspiration biopsy shows malignant papillary thyroid cancer cells; Bethesda VI. (A) benign thyroid cells and hypercellular malignant cells with papillary architecture (yellow arrow) (H&E low power). (B) Right lower pole biopsy with malignant thyroid cells with enlarged and elongated nuclei (black arrow) (H&E high power).

Figure 5

Right hemithyroidectomy gross and microscopic pathology. (A) Right hemithyroidectomy shows benign cells with follicular arrangement (black arrow) and malignant thyroid cells with hypercellularity and papillary architecture (green arrow). H&E low power and high power of malignant cells in the right side. (B) Intrathyroidal parathyroid tissue with fat cells, adipose tissue (blue arrow), and chief cells (orange arrow). (C) Overlap between malignant thyroid cells (green arrow) and parathyroid tissue (orange arrow) indicating intrathyroidal parathyroid tissue (H&E high power). (D) Gross pathology of the right hemithyroidectomy with large mid-pole nodule, the hyperfunctioning nodule, and smaller lower pole nodule which harbors the papillary thyroid cancer.