Case Presentation:
39-year-old Yemeni gentleman, diagnosed with toxic multinodular goitre
(Graves’ disease), malignant papillary thyroid carcinoma, and thyroid
orbitopathy. He underwent total thyroidectomy and received steroids
along with retrobulbar radiotherapy for his orbitopathy. After failure
to respond to initial treatment, patient was referred to rheumatology
team, and was started on AZA (100mg daily) and Rituximab (2 doses of
1gram iv rituximab, 2 weeks apart).
On his first presentation to emergency department (ED), 1 week after
starting the immunosuppressive medications, patient complained of neck
pain and swelling associated with fever, pain and difficulty to swallow,
and difficulty to breath while lying supine. Patient was conscious,
oriented with stable vital signs. The physical examination revealed
diffuse submandibular swelling. Trachea was central with normal
cardiopulmonary examination. Proper airway assessment was carried out by
the ENT team and reported that his airway is patent with normal findings
in indirect and fibreoptic laryngoscopy. The lab investigations showed
leukocytosis and elevated inflammatory markers with normal thyroid
function test (TFT). Emergency neck ultrasound was performed, and it
ruled out any collection or abscess. Chest and neck soft tissue X-rays
were normal. So patient was discharged on empiric antibiotics
(amoxicillin/clavulanic acid) with plan to do neck CT Imaging as
outpatient.
However, patient had discontinued his immunosuppressive medication since
he developed his symptoms until he was reviewed by the Rheumatology team
2 days later in the clinic. As these medications were not commonly known
to cause sialadenitis, plan was made to proceed with dose of second dose
of rituximab and continue on daily AZA.