A case of sarcoidosis and sarcoid granuloma, papillary carcinoma, and Graves' disease in the thyroid gland

Sarcoidosis is a systemic chronic granulomatous disease of unknown etiology most commonly affecting young females. The disease was first described in the thyroid gland in 1938. Our patient, a 27-year-old male with known sarco idosis, was referred to the National University Hospital for acute symptoms of thyrotoxicosis (weight loss of 6 kg, tremor, thyroid enlargement, and t achycardia). Laboratory findings showed suppressed serum thyrotropin (TSH, <0.03 mU/L I [0.5-4.20]), increased total thyroxine (T-4) (223 nmol/L, [60- 140]), and triiodothyronine (T-3) (8.5 nmol/L, [1.5-2.7]). Furthermore, Tc- (99)m pertechnetate scintigraphy disclosed diffuse accumulation of the isot ope confirming the diagnosis of Graves' disease. During the next 18 months of antithyroid treatment (thiamazole, Thycapzol(R)) hyperthyroidism was dif ficult to control, the thyroid gland gradually enlarged, and surgery was re commended. Initially, the patient declined surgery but after an additional 18 months, he accepted surgery. During the 36-month period of antithyroid d rug treatment TSH was suppressed (<0.01 mU/L) and T3 often elevated despite high doses of thiamazole. Total thyroidectomy was performed, and histologi c examination of the removed thyroid tissue confirmed the diagnosis of Grav es' disease and also the presence of sarcoid granuloma and metastatic papil lary adenocarcinoma with spread to neck lymph nodes. Four months later, a m odified radical neck dissection was performed with removal of neck lymph no des followed by external radiation therapy (2 Gy x 32 fractions to the neck ). The concomitant presence of sarcoidosis, papillary carcinoma, and Graves ' disease in a thyroid gland, to our knowledge, has not previously been des cribed in the literature.