CASE HISTORY
A 74-year-old female was admitted to ward after 3 days of fever and dyspnea. At admission, the peripheral oxygen saturation was 85% on room air. Due to worsening respiratory distress and hypoxemia, the patient required invasive mechanical ventilation. Upon intensive care unit admission, the level of D-dimer was 36.77 ug/mL (RI < 0.5), and a computed tomography revealed bilateral ground-glass opacities, compatible with COVID-19 (Figure 1). Dexamethasone 6 mg/day and enoxaparin 40 mg/day were initiated. At physical examination, a large goiter was palpable and no visible collateral cervical vessels and arms edema were noticed. The tomography revealed a multinodular goiter with calcification, with predominantly right lobe enlargement, extending 4.9 cm below the sternal notch and occupying medium mediastinum with tracheal compression and deviation as well as esophagus displacement (Figure 2). Thrombosis of the right subclavian vein and the inferior segment of the left internal jugular vein were diagnosed (Figure 3). No collateral circulation was seen. Systemic thrombolysis was discarded due to the absence of significant symptoms or signs of venous compression. Before COVID-19, the patient did not complain of cervical enlargement, pain, dyspnea or dysphagia. TSH level was 0.73 mIU/L (RI 0.27-4.20), free T4 was 1.62 ng/dL (RI 0.93-1.70) and negative thyroperoxidase antibodies, indicating normal thyroid function. The patient recovered of COVID-19 after 15 days of hospitalization. At Hospital discharge, anticoagulation was changed to rivaroxaban. The patient returned to the outpatient care after 6 months, with no chest pain, dysphonia or obstructive complains, such as dyspnea or dysphagia. Pemberton“s sign was absent. Total thyroidectomy with thoracotomy was scheduled.