The diagnostic and therapeutic approach for pregnant women with thyroid nodules can present a challenge, especially concerning surgical procedures. In the context of malignant diagnosis, by fine needle aspiration (FNA), during pregnancy, the uncertainty lies in performing surgery. This article reports the case of a 41-year-old pregnant woman in her first gestation, who sought medical care complaining of right shoulder pain. Imaging workup depicted the destruction of the humeral head and involvement of the surrounding soft tissue. She was 20 weeks pregnant. The histological report favored the diagnosis of malignancy and the thyroid as the primary site. At 30 weeks of gestation, the patient underwent a cesarean section, a total thyroidectomy, and total resection of the metastasis. The child was born healthy, but one year after the diagnosis, the patient died. Bone and soft tissue metastasis of thyroid neoplasms are not very common and indicate poor prognosis.

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Bone marrow biopsy of a 30-year-old man with pancytopenia. Necrotic granuloma is seen in Figure 1A (H&E, 200x) and B (H&E, 400x). The main finding is the big and circular fungi in granuloma macrophages. Morphology is classic of Paracoccidioides brasiliensis due to the multiple sporulations in a specific rudder appearance. Differential diagnosis could be cryptococcosis, however Figure 1. (A) (H&E, 200x) Bone marrow biopsy with a necrotic granuloma. (B) (H&E, 400x) Necrosis in bone marrow biopsy. Necrosis can be a negative factor for prognosis, according the literature. (C) (H&E, 400x) Bone marrow biopsy: images of multiple fungi with classical morphology of Paracoccidioides braziliensis. (D) (Groccot-Gomori, 400x) Structures in bone marrow biopsy are positive and indicate multiple sporulations in typical rudder appearance. (E) Macroscopic image from autopsy. (F) Lung (2,530 g, reference value: 750 g) with congestion, consolidated aspect and multiple white circular foci whose histology is demonstrated in the figure F (H&E, 200x). Each white small circular foci is a granuloma and this macroscopic pattern is a miliary dissemination. (G) Macroscopic image from the spleen. The liver had a similar pattern which is also a miliary dissemination. (H) (H&E,100x) Spleen section for histology. Note necrosis on the left and multiple granulomas on the right. (I) (Groccot-Gomori, 400x) A structure fungi in spleen section with two sporulations, another feature from this microorganism.

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