A pregnant woman with autoimmune thyroiditis and recurrent goiter

A 27-year-old woman was first referred at the age of 14 with cosmetic complaints due to an echographically diffuse, euthyroid goitre. Tests for antibodies against thyroid peroxidase and thyroglobulin were positive. Thyroid-suppression therapy with levothyroxine resulted in regression of the goitre. At the age of 26 there was a transitory recurrence of the goitre during a pregnancy, during which time the thyroid peroxidase antibodies became strongly positive. Six months post partum the goitre recurred again, accompanied by pain in the throat and fever. The C-reactive protein level was strongly elevated. Serology established the diagnosis of viral thyroiditis due to a Coxsackie-B virus. The size of the goitre decreased after treatment with acetylsalicylic acid and prednisone. Two months later the goitre again showed further growth, now in association with cervical lymphadenopathy and an enlarged left parotid gland. Histology revealed a non-Hodgkin lymphoma of the type diffuse large B-cell (stage II), very likely a primary thyroid lymphoma. The lymphoma was refractory to cyclophosphamide-doxorubicin-vincristine-prednisolone (CHOP); this was followed by intensive chemotherapy and autologous stem-cell transplantation, resulting finally in a complete remission. The goitre disappeared and thyroid peroxidase antibodies were no longer detectable. Primary thyroid lymphoma is a rare disease, but autoimmune thyroiditis appears to be an important predisposing factor.