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Case Report Rupture without warning Simon Schimmack, Hubertus Schmitz-Winnenthal, Frank Bergmann, Markus W Büchler, Christoph M Seiler Lancet 2011; 377: 966 In April, 2010, a 58-year-old woman with an endemic operations done under local anaesthesia by Schwoeber Department of General, goitre presented with an acute swelling of her neck with and colleagues between 1906 and 1923. Five of the Visceral, and Transplantation dyspnoea, dysphagia, and headache. She was from an 18 patients died.2 Few cases of a spontaneously ruptured Surgery (S Schimmack MD, iodine-defi cient area of Germany, and had no history of thyroid gland cyst with notable haemorrhage have been H Schmitz-Winnenthal MD, Prof M W Büchler MD, neck trauma or infectious diseases. On examination she reported since then.3 Spontaneous ruptures of thyroid Prof C M Seiler MD), and was in respiratory distress and had elevated blood pres- glands are likely to occur only in the presence of a pre- Department of Pathology sure (160/90 mm/Hg). Her temperature, pulse rate, and existing condition such as multinodular goitre, thyroid (F Bergman MD), University of electro cardiogram were normal. Blood tests showed cysts, or, as in our patient, an undiagnosed adenoma. The Heidelberg, Heidelberg, Germany normal haemoglobin concentration and thyroid function. walls of the adenomas are very fragile due to degeneration, Correspondence to: Chest radiography showed displacement of the trachea to and