Spontaneous hemorrhage of an ectopic mediastinal thyroid.

We wish to report an unusual cause of chest pain and hemoptysis. A 62-year-old woman presented with persistent cough and mild substernal chest discomfort. She had previously noted one episode of blood-tinged sputum. Physical examination was completely normal. Initial laboratory data included a normal CBC, chest x-ray film, and sputum analysis. Bronchoscopy revealed the anterior midtrachea to be erythematous and ecchymotic, with intact mucosa. Washings were normal. Mild chest discomfort persisted, and a CT of the thorax revealed an anterior mediastinal mass measuring 2.4 cm. Mediastinoscopy was performed, with removal of a multiocular mass from the anterior mediastinum. Pathologic review of the material revealed multifocal hemorrhage and thyroid tissue with areas of degeneration but no malignancy. The patient has no further hemoptysis, and her chest pain resolved postoperatively. Thyroid scan with I’s’ revealed a normal cervical thyroid. CT of the thorax 20 months later revealed no abnormalities, and the patient has remained asymptomatic. There are a great variety of tumors and cysts that occur in the mediastinum.’ Ectopic thyroid tumors solely within the mediastinum constitute less than one percent of surgically-removed goiters.3 These are usually asymptomatic thyroid adenomas, but may be associated with signs and symptoms of compression or hyperthyroidism. True intrathoracic thyroid tissue, or an ectopic mediastinal thyroid, occurs rarely and should not be confused with the common mediastinal extension of cervical goiter.4’ Intrathoracic goiter, as defined by the whole or bulk of the goiter within the mediastinum, is almost always an extension of thyroid tissue in the neck. They generally arise from the lower pole or isthmus of the thyroid, with 75 percent located in the anterior mediastinum. Patients usually are asymptomatic, but may have symptoms of compression, or rarely maybe hyperthyroid. Degenerative changes such as hemorrhage, cyst formation and calcifications are demonstrable in approximately 50 percent of goiters. Females predominate by 3:1, are most often in their 60s, and are usually euthyroid. The patients are noted to have a palpable thyroid gland in the neck, and chest x-ray examination usually reveals an anterior mediastinal mass. Treatment for the symptomatic patient is total excision of the goiter. A mediastinal thyroid could represent all of the patient’s thyroid tissue, therefore scanning of the neck post administration of I’s’ is suggested to confirm a normal cervical gland. This patient had a unique presentation of a primary anterior mediastinal thyroid with chest pain and hemoptysis. Routine chest x-ray was normal, but CT of the thorax revealed an anterior mediastinal mass, and pathologic review post-excision demonstrated acute hemorrhage and necrosis. Although rare, ectopic thyroid tissue in the anterior mediastinum should be considered as a cause of hemoptysis or chest pain.