SUN-397 A Rare Case of Spontaneous Thyroid Hemorrhage Related to Anticoagulation Use and Multinodular Goiter

Abstract Disclosure: S. Ntelis: None. A. Karachaliou: None. S. Bhimineni: None. K. Mekala: None. Background: Spontaneous thyroid hemorrhage is a rare cause of non-inflammatory neck swelling, associated with pain, and seldom airway compromise. We present a case of spontaneous thyroid hemorrhage related to anticoagulation use and thyroid nodules.Clinical Case: An 80-year-old woman, with history of non-toxic multinodular goiter, atrial fibrillation (on apixaban), rheumatoid arthritis and past history of ischemic stroke, presented emergently with a 2-day history of worsening dysphagia, pain, swelling and purplish black discoloration of the neck. CT scan showed diffuse hematoma in the left anterior neck, surrounding and adjacent to the left thyroid lobe. Effacement and blunting of the posterior left lower thyroid gland was noted, concerning for thyroid hemorrhage. There was no evidence of active extravasation on angiography. She was intubated for airway protection. Apixaban was discontinued. Prothrombin complex concentrate was given. Repeat CT scan showed a stable hematoma; therefore, no surgical intervention was pursued. She was extubated on the fourth day of hospitalization after a successful spontaneous breathing trial. Hospital course was complicated by episodes of atrial fibrillation with rapid ventricular response and therefore, decision was made to restart apixaban prior to discharge. Left atrial appendage occlusion was performed three months later. She was temporarily transitioned to warfarin per her preference in preparation for the procedure. Anticoagulation was stopped subsequently in another three months and aspirin was initiated. She had persistent voice hoarseness attributed to chronic cervical osteophytes, acutely worsened by intubation-related trauma. Laryngeal videostroboscopy was unremarkable. TSH remained normal (0.63 μIU/ml).Clinical Lessons: Chronic anticoagulation is a risk factor for non-traumatic thyroid hematoma. Cases of thyroid hemorrhage related to warfarin use have been reported in literature. Thyroid nodules are also associated with increased risk for thyroid hematoma. High vascularization and artero-venous shunting inside the nodules are considered possible pathogenic mechanisms. The incidence is not known. A single-center retrospective study reported 59 cases of spontaneous thyroid hemorrhage in 631,129 patients who were seen in the emergency department during a 10-year period, of which only 4 patients were noted to be on chronic anticoagulant therapy. Imaging with CT scan can confirm the diagnosis, however, focus on airway management is critical when presenting with acute airway compromise. Conservative management with serial imaging is appropriate, especially in the absence of airway symptoms. While fine needle aspiration may be considered, surgical evacuation is required for expanding hematomas or persistent respiratory symptoms. Presentation: Sunday, July 13, 2025