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.