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.