Recurrent massive hemoptysis from tracheal varices caused by a large goiter of Graves’ disease

Background

Tracheal varices are rare but cause massive or repeated hemoptysis that can be life-threatening. Patients with Graves’ disease or adenomatous goiter sometimes show compressive symptoms by a diffuse large goiter. However, it is extremely rare to form tracheal varicose veins that cause hemoptysis. We herein report a case of massive hemoptysis from tracheal varices caused by a large Graves’ goiter.

Case presentation

An 82-year-old woman was diagnosed with Graves’ disease and had been treated with thiamazole for 15 years. She was taken to an emergency room because of massive hemoptysis. Bronchofiberscope revealed hemorrhage from remarkable varicose veins in the tracheal mucosa. Apixaban for concurrent paroxysmal atrial fibrillation was immediately withdrawn. After endotracheal epinephrine administration for recurrent bleeding, she was transferred to us. She presented with a large goiter that occupied her neck, suggesting that compression by the enlarged goiter may have caused tracheal varices. Preoperative echocardiography revealed tricuspid regurgitation and elevated pulmonary artery pressure that may have supported forming tracheal varices. Upon anesthesia induction, intubation was carefully conducted under bronchoscopy with endotracheal epinephrine administration, and total thyroidectomy was performed. The postoperative course was uneventful and she was discharged in 1 week. Bronchoscopy at 1 month after the operation showed complete disappearance of the tracheal varices.

Conclusion

Although tracheal varices due to compression by a large goiter are extremely rare, pulmonary hypertension may further accelerate establishing tracheal varices that leads to massive and recurrent hemoptysis. Tracheal varices associated with a large goiter can be treated by total thyroidectomy with careful intubation.