Abstract
Dear Editor:
In a super-aging society, we encounter various medical issues, including accidental ingestion of a foreign body. The majority of ingested foreign bodies will pass spontaneously without endoscopic intervention. However, ingested foreign bodies fixed in the esophagus can lead to various complications. We report a patient who ingested a press-through package (PTP), a commonly used packaging for tablets, which did not pass through spontaneously, instead remaining at the entrance of the esophagus. As a result, retention of the PTP caused destructive thyroiditis. A careful history led to suspicion of accidental ingestion of a foreign body. This is the first report of a patient with destructive thyroiditis caused by accidental ingestion of a PTP.
A 78-year-old Japanese woman complained of a sore throat. Laryngeal fiberscope inspection revealed no abnormal findings. She had a low-grade fever and tenderness in her neck. The patient was referred to a hospital specializing in thyroid diseases with suspicion of subacute thyroiditis. The patient had painful swelling of the thyroid, and there was no laterality of pain. Serum levels of free thyroxine (fT4) and free triiodothyronine (fT3) were elevated to near the upper limit of the reference range (fT4 1.50 ng/dL [0.70–1.60] and fT3 3.51 pg/mL [1.70–3.70]). The serum level of thyrotropin (TSH) was reduced (TSH 0.227 mIU/L [0.30–5.00]), and the serum levels of thyroglobulin (Tg) and C-reactive protein (CRP) were elevated (Tg 1413 ng/mL [0.00–46.05] and CRP 1.6 mg/dL [0.0–0.5]). These findings were compatible with subacute thyroiditis. Ultrasonography examination revealed that there was a high echo line posterior to the left thyroid lobe, as shown in Figure 1A. Although this distinct finding was present, it was initially overlooked.
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A subsequent careful medical history revealed that she had taken a lot of supplement tablets packaged in PTP during a recent trip. The symptoms appeared shortly after the trip. The clinical course of her illness and the review of the thyroid ultrasonography suggested the possibility of destructive thyroiditis due to accidental ingestion of supplement tablets. Foreign body localization by ultrasonography is well established, and ultrasonography has proven to be reliable (1,2). Cervicothoracic computed tomography (CT) imaging showed a radio-opaque foreign body in the esophageal entrance, as shown in Figure 1B. There was a small square object surrounded by air, and the thyroid border was unclear. The patient was thus diagnosed with destructive thyroiditis caused by a foreign body.
Esophagogastroduodenoscopy (EGD) examination revealed a PTP wedged in the esophagus entrance (Fig. 1C). We gently pushed the PTP into the stomach, grasped one of the sharp edges, and drew the sharp end of the PTP into the hood (Fig. 1D and E). We then gently withdrew the endoscope with the other sharp edge at the trailing end. After removal, EGD examination revealed linear ulcers positioned bilaterally in the esophageal entrance (Fig. 1F). She was administered a proton pump inhibitor and antibiotics for three days. Three weeks after discharge, thyroid function returned to normal levels.
Destructive thyroiditis is a comparatively uncommon disease, and its common etiologies include painful subacute thyroiditis, postpartum thyroiditis, and drug-induced thyroiditis. Among drug-induced forms of thyroiditis, it has been reported that interleukin-2, tyrosine kinase inhibitors, amiodarone, interferon alfa, checkpoint inhibitors, and lithium can cause destructive thyroiditis with thyrotoxicosis or hypothyroidism. In the present case, foreign-body ingestion was responsible for the destructive thyroiditis. A careful history, which led to the suspicion of accidental ingestion of a PTP, and CT scanning were useful for establishing the diagnosis.
The medical history is fundamental for the diagnostic process. Hampton et al. stated that the medical history can contribute up to 80% of the factors leading to a diagnosis (3). The patient's remark that she had taken a lot of supplement tablets packed in PTP during a trip led to the suspicion of accidental ingestion of a foreign body and finally to the correct diagnosis. If she had been misdiagnosed with subacute thyroiditis, she may have been treated with oral steroids for several weeks, and this could have led to more serious complications such as abscess formation in the mediastinum. Even trivial complaints should thus be heeded, as they can provide useful clues that may lead to the correct diagnoses. We must be aware that ingested foreign bodies that cannot be passed through spontaneously can lead to destructive thyroiditis especially in elderly patients.
Footnotes
Author Disclosure Statement
The authors declare no conflict of interest.