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Medications masking thyroid lymphomas: A diagnostic challenge
Y.D.Kwan*, J.Y.Gan**, D.K.T.Loke***
* Otorhinolaryngology, Khoo Teck Puat Hospital
** Otorhinolaryngology, Khoo Teck Puat Hospital
*** Otorhinolaryngology, Khoo Teck Puat Hospital
Introduction:
Primary thyroid lymphomas are rare neoplasms and account for 1-2% of thyroid malignancies, and 1.2 to 1.7% of all Non-Hodgkin’s lymphoma. Early diagnosis is important as cure without the need for extensive surgery is possible if treated timely.
Aims/ Methods:
We report two clinical cases in which diagnosis of primary thyroid lymphoma was complicated by the use of “Sabah snake grass” Clinacanthus Nutans (CN), commonly used as a complementary and alternative medicine in South East Asia, and of oral steroid therapy.
Results:
First patient, a 47 year-old male presented with left posterior neck swelling found to be a necrotic lymph node on computed tomography (CT) scan. Bilateral thyroid nodules were also noted. Fine needle aspiration cytology (FNAC) was indeterminate. At follow-up, the lymph node was found to have resolved. The patient alluded that he had been taking CN as complementary therapy. Subsequent FNAC returned negative for lymphoma. A left hemithyroidectomy was offered to the patient for a Bethesda III nodule in his left thyroid lobe and histology confirmed the diagnosis of diffuse large B cell lymphoma.
Second patient, a 54 year-old female with a background of Hashimoto’s thyroiditis on oral steroid therapy presented with progressive enlargement and hardening of her goitre. This was initially diagnosed as Hashimoto’s thyroiditis after multiple FNAC and negative immunocytochemistry tests. Her goitre increased in size with the cessation of steroid therapy and histology from a partial isthmusectomy and excision biopsy of the Delphian lymph node revealed diffuse large B cell lymphoma.
Conclusions:
CN has been shown to possess antioxidant and antiproliferative properties against cultured cancer cell lines. Steroids are a recognized treatment for lymphoma and has been shown to inhibit growth of lymphomas. Consumption of these may mask the disease. Also, regular follow-up of lymphocytic thyroiditis cases for the development of lymphoma is recommended.
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