Triple thyroid ectopia – a rare case report Central precocious puberty in a 1year 9 months old girl presented only with cyclical vaginal bleeding SUBIR CHANDRA SWAR, PRAVEEN KUMAR DEVARBHABI. TAPAS DAS, NEERAJ SINHA, SATYAM CHAKRABORTY. LAXMI DEY, ASISH KUMAR BASU, ANIMESH MAITI, ANIRBAN SINHA Medical College,Kolkata,India Triple thyroid ectopia – a rare case report Devarbhavi P, Swar S, Das T, Sinha N, Sinha A, Maiti A, Basu A Department of Endocrinology & Metabolism ,Medical College,Kolkata,India Introduction Ectopic thyroid tissue is a rare entity resulting from abnormal embryogenesis of thyroid gland during its descent from the base of the tongue in to the neck. Ectopic thyroid is most common form of thyroid dysgenesis worldwide. But in India it is less common than Agenesis.1 Ectopic tissue can be multiple. Some reports of dual ectopic have been published but reports of triple ectopia of thyroid is extremely rare in literature. Radionucide thyroid imaging: Tc -99m pertechnetate tracer Conclusion Developmental defects occurring at an early stage of embryogenesis generate ectopic thyroid tissue, residing anywhere along the gland’s embryological descending pathway, as well as in distant areas. Mutation in gene transcription factors like TITF‑1(Nkx 2‑1), Foxe1 (TITF‑2) and PAX‑8 which are involved in migration and differentiation of thyroid is responsible for dysgenesis. A few cases of dual ectopic thyroid have been reported. In most dual thyroid cases the lesion is lingual and subhyoid. Triple ectopic thyroid is extremely rare and only few cases are reported in literature.2,3 Thyroid scanning using technetium Tc-99m is the most useful tool for definitive diagnosis. Additional CT scans or MRI may help in defining the extent or location of the ectopic thyroid gland. If the patient is both asymptomatic and euthyroid, no treatment is required. The main concern is risk of thyroid carcinomas, and in most cases papillary carcinoma arising from ectopic thyroid tissue. So careful follow up is needed and FNAC is warranted in case of enlargement of ectopic tissue.4   Case report 12 year old Indian girl presented with midline swelling in the neck first noted at one year of age. Only concern was cosmetic in a otherwise asymptomatic child. Birth history , developmental milestones were normal. On examination: Normal anthropometry and bone age with normal sexual maturity for the age. Thyroid was not palpable at its normal site. A 3x3cm swelling in the midline above thyroid cartilage soft, non tender, smooth surface moving with deglutition, and small another swelling just above this was noted. There was no lymphadenopathy. General and systemic examination revealed no abnormality. Thyroid function test was suggestive of subclinical hypothyroidism (free T4:1.20ng/dl and TSH: 7.66mic IU/ml) and –ve for anti TPO Ab. FNAC revealed colloid goitre with no evidence of malignancy. ANT RT LAT Fig 3 : Radionuclide imaging (Ant view) shows absence of functioning thyroid tissue at its usual position. Instead 3 foci of functioning thyroid parenchyma (arrows) in ectopic location. 1. Largest focus with Tc99m uptake of 1.9% extending from suprahyoid to sub mandibular region. 2.Second focus is in midline corresponding to swelling below chin above the large nodule 3.Another small mildly hypo functioning focus (LAT view) in posterior part of tongue i.e Lingual thyroid Fig 1A:Clinical photograph (Arrows) showing two midline neck swelling Fig 1B: Arrow Showing lingual thyroid Thyroid Imaging: USG Thyroid and Neck: Bibliography Dayal D, Sindhuja L, Bhattacharya A, Sodhi KS, Sachdeva N. Agenesis and not ectopia is common in North Indian children with thyroid dysgenesis. Indian J Endocr Metab 2014;18:97-9 Kuramoto R, Oikawa K, Fujita K, Oridate N, Fukuda S (2013) Triple Ectopic Thyroid: A Case Report and Review of Literature. Thyroid Disorders Ther 2: 126. Rahalkar M, Rahalkar A, Solav S. A rare case of triple thyroid ectopia. Indian J Endocr Metab 2014;18:238-40. Noussios G, Anagnostis P, Goulis DG, Lappas D, Natsis K. Ectopic thyroid tissue: Anatomical, clinical, and surgical implications of a rare entity. Eur J Endocrinol 2011;165:375-82. Fig 2A: Ultrasound neck showing absent thyroid gland in its normal anatomical location Fig 2B: Midline soft tissue swelling in the upper neck with sub lingual extension measuring 26x17x09mm, heterogenous with normal vascularity and a linear calcific focus within the lesion