Goitre, lymphoma and the doughnut sign: What is happening he
The present case has been published in BMJ. A 65-year-old woman, with a known case of Hashimoto’s thyroiditis on eltroxin for 15 years, presented with progressive diffuse swelling neck for 2 months. She also gave a history of difficulty in swallowing and breathing for 1 week.

On examination, she had respiratory distress, low oxygen saturation (85% on pulse oximeter) and cyanosed tongue. Systemic examination was unremarkable except for goitre (grade 2) and stridor. As the saturation was not improving with supplemental oxygen, she underwent an emergency tracheostomy.

Subsequently, a contrast-enhanced CT scan of the neck showed large lobulated heterogeneously enhancing lesion in the region of thyroid gland encasing all major structure of neck including trachea. Core biopsy and immunohistochemistry (CD45, CD20, CD10 and BCL6 positive) confirmed the diagnosis as diffuse large B cell lymphoma (DLBCL).

The patient received R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone). After 1 month, she was asymptomatic with >50% decreased swelling, and the tracheostomy tube was removed.

Learning points
• Any follow-up case of Hashimoto’s thyroiditis presenting with a rapidly enlarging neck mass, hoarseness of voice or difficulty in breathing or eating should be suspected of lymphoma transformation.

• The patient who develops doughnut sign is more symptomatic due to compressive symptoms.

• Prompt supportive care (tracheostomy in the index case) and definitive therapy (R-CHOP) is rewarding with a successful outcome.

Read more here: http://casereports.bmj.com/content/2018/bcr-2018-226581.full
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