갑상선결핵 - 증례보고및문헌고찰 Tuberculosis of the Thyroid Gland - Report of Two Cases and Review of the Literatures Se Yeom Park, M.D., Jong Geun Lee, M.D., Bong Ok Yoo, M.D., Oh Kyoung Kwon, M.D. and Myoung Jin Joo, M.D. 1 Purpose: Tuberculosis of the thyroid gland is very rare and some cases were reported in Korea since 1968. We experienced a case of tuberculous thyroiditis and found a old case in our medical center. This report is about the two case and the review of all cases reported about tuberculosis of the thyroid gland in Korea. Methods: We present the case of a 55-year-old woman with thyroid tuberculosis who has been treated with antituberculous medication because of tuberculous meningitis during 6 months. We performed thyroid isthmectomy and she is now taking the antituberculous drugs. We found a case of 40- year-old woman who underwent extended thyroid lobectomy, Lt. in 1985 at our medical center. We reviewed the 18 literatures with 29 cases of tuberculosis of the thyroid gland reported in Korea and analyzed total 31 cases (reported 29 cases and our 2 cases). Results: 28 patients were women and only 2 patients were over 60 years old. 26 patients had complained the neck mass. Duration of symptoms were below 6 months in 18 cases. There were associated symptoms like as weight loss, easy fatigue or generalized weakness, dysphagia, palpitation, fever, chills and/or anorexia. Only 9 patients had underlying tuberculosis - 2 meningitis, 2 pneumonia, 3 lymphadenopathy and 2 pneumonia combined with meningitis. But 3 patients were newly diagnosed as old or active pulmonary tuberculosis at the time of diagnosis of thyroid tuberculosis. Thyroid function was normal in 9 cases and abnormal in 5 cases. 3 cases were diagnosed nonoperatively and 15 patients of surgically treated 28 cases were underwent lobectomy. AFB stain was positive in only 13 cases and 2 cases were positive of culture with negative AFB stain. All of cases were diagnosed by pathology as granulomatous tuberculosis with caseous necrosis. Conclusion: Either surgical resection plus antituberculous medications or only medications are effective and recurrences were not reported after any initial treatments. So preoperative evaluation is very important and will guide the patient and the surgeon to the most effective management. (Korean J Endocrine Surg 2005;5:100-108) Key Words: Thyroid gland, Tuberculosis Departments of Surgery and 1 Pathology, Presbyterian Medical Center, Jeonju, Korea
박세염 외 갑상선 결핵 101 ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ 럼 보이는 물질이 찬 것처럼 보였다(Fig. 1). 컴퓨터 단층 촬 영 결과 갑상선 협부에서 상부 종격동까지 이어지는, 변연 부 조영 증강이 동반된 액상의 저음영 종괴가 관찰되었으 며, 이는 식도와 연관되어 보였다(Fig. 2). 식도 게실 의심 하에 식도 조영술 시행하였으나, 특이소견 보이지 않았다. 갑상선종 의심 하에 수술을 시행하기로 하였다. 입원 당시 활력징후는 모두 정상이었으며, 전신 상태는 비교적 양호 해 보였다. 이학적 검사상 전경부의 무통성의 부드러운 부 종 외에는 특이소견 없었다. 흉부 X-선 상 특이소견 보이지 않았고, 갑상선 기능 검사상 T3 1.56 ng/dl, T4 8.19μg/dl, free T4 1.33 ng/dl, TSH 0.55μU/ml로 모두 정상 범위였다. Fig. 1. Neck ultrasonogram Heterogenous hypoechoic mass with necrosis is present in thyroid isthmic portion. A 전신 마취 하 수술 시야에서 3 cm 크기의 괴사성 낭성 종괴가 갑상선 협부에서 발견되었으며, 동결절편 검사 상 육아종성 염증 소견 보여 갑상선 협부 절제술을 시행하였 다. 병리조직검사: 얻은 검체는 4 2 cm 크기에 근육조직이 유착되어 있으며, 절단 시 노란 색으로 괴사된 내용물이 있 었다. 현미경적 소견은 육아종성 염증과 중심부에 건락선 괴사를 동반한 다양한 크기의 결핵성 결절이 산재해 있었 고, AFB 염색에서 결핵균이 발견되었다(Fig. 3). 환자는 수 술 후 항결핵제 다시 투여하며 추적 관찰 중이다. 증례 2. 40세 여자(병록번호 426079) 주 소: 6개월 전부터 촉지된 전경부 종괴 과거력: 특이사항 없음. 가족력: 특이사항 없음. Chest PA: 특이사항 없음. 병 력: 입원 4개월 전, 2개월 전부터 촉지된 전경부 종괴 를 주소로 외과 외래 방문. 갑상선 기능 검사상 정상 범위를 보였고, 갑상선 스캔 상 냉결절 소견을 보여 하시모토 갑상 선염 의심 하에 일단 지켜보기로 하였다. 입원 2개월 전 침 삼키기 곤란한 증세가 심해져 시행한 갑상선 검사 상 T3 3.24 ng/dl, T4 13.18μg/dl, free T4 4.08 ng/dl, TSH 1.81μU/ml 로 갑상선 기능 증가 소견 보여, 항 갑상선제 투여 후 악성 종양 감별 목적으로 확대 갑상선 좌엽 절제술(Extended thyroid lobectomy, Lt.) 시행하였다. 수술 후 얻은 검체의 병 리조직 검사상 상피양 세포와 주변부 섬유화를 동반한 결 핵성 육아종 소견을 보였다. 환자는 수술 후 항결핵제 6개 월 투약 후 외래 방문하지 않았다. B Fig. 2. (A) Pre-enhanced CT. Oval shaped hypodense mass is located in isthmic portion of thyroid extending to upper mediastinum. (B) Contrast-enhanced CT. Well demarcated, non-enhanced cystic mass with peripheral rim enhancement is seen in isthmus of the thyroid gland.
102 대한내분비외과학회지 제 5 권 제 2 호 2005 ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ A C B Fig. 3. (A) Microscopic examination. A granuloma with thyroid follicles is present (H&E, 40), (B) Microscopic examination. Chronic granulomatous thyroiditis with caseous necrosis is seen (H&E, 100), (C) Microscopic examination. A acid-fast organism is noted (AFB, 400). Table 1. A summary of 31 cases of tuberculosis of the thyroid gland reported from 1968 to 2005 in Korea ꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚ Character Refe Date Sex Age CC Duration Symptoms TB history TFT Procedure Pathology AFB of mass -rence ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ 1968 F 53 Mass 1 mon T, H, M p, d No but SaT, LN 1 old chest 1968 F 40 Mass 15 yrs Dp, v, a, No but CGT 1 w, f, I active chest 1968 F 37 Swelling 2 yrs p, n, d, Dp, CGT 2 a, wl, f 1972 F 38 Swelling 4 mons n, d, a, f LAP (2 mons) CGT, LN + 3 1978 F 26 Mass 1 week Pl, S Eu I & D CGT 4 Cx (+) 1979 F 28 Mass 1 mon T, H, F p, wl CGT 5 ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ