DISCUSSION
During the pandemic, the diagnosis of clinical respiratory syndromes
causing dyspnea must be promptly done to establish the proper treatment1. Patients with goiter can present with dyspnea due
to tracheal compression, usually inspiratory and positional dyspnea2. However, longstanding goiter presents asymptomatic
along years and dyspnea occurs only during upper airways infections,
pneumonia and even after moderate to heavy exertions.
Patient with goiter affected by COVID-19 infection should present with
more severe dyspnea, misdiagnosing a mild viral disease that contributed
to the dyspnea or lung commitment with poor oxygenation and severe
dyspnea 3. Intravenous corticosteroid may improve
tracheal edema in inflammatory upper airways, postponing the clinical
investigation until surgical treatment 4. Lung imaging
evaluation helps to evaluate pulmonary involvement.
Hypercoagulability and frequent venous thromboembolic events are well
established in COVID-19, particularly lower extremities and lung
thrombosis 5. Upper limb deep vein thrombosis is also
well known in patient with central venous catheters and cancer6. Prophylactic anticoagulation is recommended in
patient with COVID-19 and high D-dimer concentration, as in the
described patient 1,5. Thrombolysis is only
recommended in the presence of severe symptoms and signs.
In the meantime, patients with goiter may have thrombosis7. The patient here described had a giant goiter, with
tracheal and esophagus compression, occupying the mediastinum and showed
acute deep vein thrombosis of superior venous system (subclavian and
jugular veins). Several cases of goiters causing superior vena caval
syndrome were described, particularly from iodine insufficient areas and
giant goiters 8-10. Pemberton“s sign, a reversible
facial congestion after elevation of both arms, is indicative of
superior vena cava syndrome due to obstruction of the thoracic inlet11.
Nonetheless upper limb deep vein thrombosis is rarely described in
patient with goiter, probably due to the slow growth of the thyroid,
which permits the development of collateral circulation and compensation
of venous flux compression 7.
We speculated that COVID-19 pro-thrombotic status combined with low
dynamic flow due to the large intrathoracic goiter, particularly in the
right side, resulted in the deep vein thrombosis of subclavian and
jugular veins in the presented case.
We have been unable to find a previous case report of extensive deep
vein thrombosis in a patient with COVID-19 and a giant intrathoracic
longstanding goiter.