LETTERS TO THE EDITOR

The Importance of Imaging Proceduresin Evaluating Painful Neck Masses: Two Patientswith a Painful Internal Jugular Vein Thrombosis

Kenji Ohba, Akio Matsushita, Miho Yamashita, Tomoharu Takada, Norio Muramatsu, Hiroyuki Iwaki, HideyukiMatsunaga, Hiroshi Morita, Shigekazu Sasaki, Yutaka Oki, and Hirotoshi Nakamura

Dear Editor:

Internal jugular vein thrombosis (IJVT) is a rare but poten-tially life-threatening status, as it can lead to fatal pulmonaryembolism. One of its clinical manifestations is a painful an-terior neck mass (1). Here, we report two patients with IJVT inwhom a painful anterior neck mass initially suggested sub-acute thyroiditis (SAT).

The first patient was a 68-year-old woman with Graves’disease, in remission after antithyroid drug treatment, whoconsulted our hospital for right anterior neck pain. Palpationrevealed a painful firm 6.5 cm · 4.0 cm nodule on the right sideof her neck. It extended from the level of the laryngeal prom-inence to the supraclavicular region. Since the mass was painfuland appeared consistent with an enlarged right thyroid lobe,SAT was considered. Unexpectedly, thyroid function tests in-dicated she was euthyroid and the serum thyroglobulin (Tg)was normal but the serum C-reactive protein level was high(4.5 mg/dL). Thyroid ultrasonography (US) revealed a diffusehypoechoic and moderately heterogeneous thyroid gland,consistent with treated Graves’ disease, but no features of SAT.US also showed a hypoechoic spindle-shaped mass of 6.3 cm ·2.0 cm in the noncompressible right internal jugular vein (IJV)that was laterally adjacent to the thyroid lobe (see Supple-mentary Data, available online at www.liebertonline.com/thy). D-dimer (normal range < 1.0lg/mL) was 6.3lg/mL andfibrinogen (normal range 150–400 mg/dL) was 449 mg/dL.She was hospitalized and diagnosed with IJVT associated withstomach cancer after examinations that included contrast-en-hanced computed tomography (CT) and endoscopic biopsy.

The second patient was a 51-year-old woman referred to ourhospital because of suspected SAT. She complained of a one-week history of right anterior neck pain and vague right shoul-der and brachial discomfort. A painful, firm, 8.0 cm · 4.0 cmnodule was palpable in the region of the right thyroid lobe.Although SAT was suspected, thyroid function tests andserum Tg were normal. As US indicated a hypoechoic throm-bus of 7.4 cm · 3.2 cm in the right IJV (see SupplementaryData), and since both D-dimer and fibrinogen were high(6.0 lg/mL and 429 mg/dL, respectively), she was admittedto our hospital. Thrombosis of the IJV and subclavian vein

caused by a Pancoast tumor was diagnosed using US, contrast-enhanced CT, and subsequent transbronchial lung biopsy.

Deep vein thrombosis (DVT) occurs most commonly in thelower extremities or pelvis. IJVT is uncommon in the wholeDVT because only about 10% of DVT develops in the internaljugular, axillary, and subclavian veins in the upper torso.Pulmonary embolism, a life-threatening complication, occurswith similar frequency in patients with DVT in the lower andupper extremities, at rates of 3%–36% (2). Since the mortalityrate of pulmonary embolism is as high as 10%–30%, the earlyidentification and treatment of DVT are mandatory. The lo-cation of an upper torso DVT is not important in this regard,as the mortality is similar among thromboses of the subcla-vian, axillary, and IJV (3).

Central venous catheters and malignant neoplasms aretwo leading causes of IJVT. Two mechanisms have beensuggested for the positive relationship between thrombo-genesis and malignant neoplasms. One is the occurrence of ahypercoagulable state in malignancy and the other is venousstasis due to compression or direct tumor invasion of veins (1).Patients 1 and 2 appeared to have the former and latterfactors, respectively.

Painful anterior neck masses are usually associated withthyroid-related lesions, such as SAT, acute infectious thy-roiditis, or hemorrhage in a thyroid nodule. Other very rarepainful neck lesions include cervical lymphadenitis and in-fected cysts (4). Our two cases were confused with SAT be-cause the palpation findings closely resembled those of SAT,and because initial imaging procedures were not performed.US is an easily available and useful noninvasive method forevaluating such conditions. It is widely accepted that non-compressibility of a normally compressible vein with orwithout a visible thrombus is definitive proof of IJVT. Thesensitivity and specificity of US for IJVT is 78%–100% and82%–100%, respectively. CT has also been useful for the as-sessment of IJVT, the main advantage of which is the detec-tion of pulmonary embolism, together with IJVT (2).

In conclusion, we encountered two patients with IJVTwhose clinical findings resembled SAT. Imaging modalitiessuch as US and CT are important for the close evaluation ofpainful neck masses.

Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan.

THYROIDVolume 22, Number 5, 2012ª Mary Ann Liebert, Inc.DOI: 10.1089/thy.2011.0234

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Disclosure Statement

The authors declare that no competing financial interestsexist.

References

1. Chowdhury K, Bloom J, Black MJ, al-Noury K 1990 Sponta-neous and nonspontaneous internal jugular vein thrombosis.Head Neck 12:168–173.

2. Baarslag HJ, Koopman MM, Reekers JA, van Beek EJ 2004Diagnosis and management of deep vein thrombosis of theupper extremity: a review. Eur Radiol 14:1263–1274.

3. Ascher E, Salles-Cunha S, Hingorani A 2005 Morbidity andmortality associated with internal jugular vein thromboses.Vasc Endovascular Surg 39:335–339.

4. Kharchenko VP, Kotlyarov PM, Mogutov MS, Alexandrov YK,Sencha AN, Patrunov YN, Belyaev 2010 Ultrasound diagnos-tics of neck masses. In: Ultrasound Diagnostics of ThyroidDiseases, First edition. Springer, New York, NY, pp 175–183.

Address correspondence to:Kenji Ohba, M.D., Ph.D.

Second DivisionDepartment of Internal Medicine

Hamamatsu University School of Medicine1-20-1 Handayama, Higashi-ward

Hamamatsu, Shizuoka 431-3192Japan

E-mail: kenji26@hama-med.ac.jp

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