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.