Filipe Cunha

Graves' disease in a mediastinal mass presenting after total thyroidectomy for nontoxic multinodular goiter: a case report

BackgroundThyrotoxicosis after total thyroidectomy is mostly iatrogenic. Rarely, a hyperfunctional thyroid remnant or ectopic tissue may be the cause. There are few cases of Graves’ disease arising from thyroid tissue located in the mediastinum and none in which Graves’ disease was diagnosed only after surgery. We report the case of a patient with Graves’s disease in a mediastinal thyroid mass presenting 7 years after total thyroidectomy for nontoxic goiter.Case presentationA 67-year-old Caucasian woman presented with palpitations, fatigue and weight loss. She had a history of total thyroidectomy for nontoxic multinodular goiter at the age of 60 without any signs of malignancy on microscopic examination. She had been medicated with levothyroxine 100 μg/day since the surgery without follow-up. She was tachycardic, had no cervical mass or eye involvement. Her thyroid-stimulating hormone levels were suppressed (0.000 μU/mL) and her free thyroxine (3.22 ng/dL) and free triiodothyronine (8.46 pg/mL) levels increased. Neither mediastinal enlargement nor trachea deviation was found on chest roentgenogram. Levothyroxine treatment was stopped but our patient showed no improvement on free thyroxine or free triiodothyronine 10 days later. Thyroglobulin was increased to 294 mg/mL. A cervical ultrasound scan revealed no thyroid remnant. Her anti-thyroid-stimulating hormone receptor antibodies were high (19.7 U/L). Corporal scintigraphy demonstrated increased intrathoracic radioiodine uptake. A computed tomography scan confirmed a 60 × 40 mm mediastinal mass. Methimazole 10 mg/day was started. Three months later, her thyroid function was normal and she underwent surgical resection. Microscopic examination showed thyroid tissue with no signs of malignancy.ConclusionsAlthough thyrotoxicosis after total thyroidectomy is mostly due to excessive supplementation, true hyperthyroidism may rarely be the cause, which should be kept in mind. The presence of thyroid tissue after total thyroidectomy in our patient may correspond to a remnant or ectopic thyroid tissue that became hyperfunctional in the presence of anti- thyroid-stimulating hormone receptor antibodies.

Effect of different bariatric surgery type on the leukocyte formula

BACKGROUND Obesity is associated with higher leukocyte counts, whereas weight loss decreases these counts. It is unknown if different bariatric surgery (BS) types have different effects on leukocytes. OBJECTIVES The aim of the study was to determine predictors of leukocyte and their subset count variation in patients submitted to BS. SETTING Tertiary care university hospital, Porto, Portugal. METHODS This was a retrospective analysis of patients submitted to Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), or sleeve gastrectomy (SG). Leukocyte and subset counts were compared between baseline and 1-year postsurgery and between BS types. A multivariate linear regression model was built to study determinants of leukocyte and subset variation. RESULTS We analyzed 764 patients: 238 submitted to LAGB; 452 to RYGB, and 74 to SG. Mean age was 42 years and 86.6% were women. All BS types were associated with a decrease in leukocyte and neutrophil counts but the variation in body mass index and homeostatic model assessment (HOMA-IR) were the only variables independently associated with a decrease 1-year postsurgery. Monocytes increased in patients submitted to LAGB and decreased in those who underwent RYGB and SG. The BS type was independently associated with monocyte variation. Patients who underwent RYGB and SG had a decrease in monocyte counts of 77/µL and 62/µL, respectively, compared with LAGB. CONCLUSION Weight and insulin resistance are the main predictors of leukocyte and neutrophil variation after BS. The specific type of BS is a determinant of monocyte count variation independent of the amount of weight loss or the degree of insulin resistance improvement.

Graves' disease in a mediastinal mass presenting after total thyroidectomy for nontoxic multinodular goitre

Case report: A 67-year-old woman presented with palpitations, fatigue and weight loss. She had a history of TT for nontoxic multinodular goitre at the age of 60 without any signs of malignancy on microscopic examination. She was medicated with levothyroxine 100 μg/day since the surgery without follow-up. She was tachycardic and had no cervical mass nor eye involvement. The TSH levels were suppressed (0.000 μU/ml) and the free T4 (3.22 ng/dl) and free T3 (8.46 pg/ml) increased. No mediastinal enlargement nor trachea deviation on chest roentgenogram. Levothyroxine treatment was stopped but patient showed no improvement on free T 4 or free T3 10 days later. Thyroglobulin was increased: 294 mg/ml. Cervical ultrasound revealed no thyroid remnant. Anti-TSH receptor antibodies were high (19.7 U/l). Corporal scintigraphy demonstrated increased intrathoracic radioiodine uptake. CT scan confirmed a 60×40 mm mediastinal mass. Methimazole 10 mg/day was started. Three months later her thyroid function was normal and she was submitted to surgical resection. Microscopic examination showed thyroid tissue with no signs of malignancy.