Ho-Cheol Kang

A case of masked toxic adenoma in a patient with non-thyroidal illness

BackgroundNon-thyroidal illness (NTI) refers to changes in thyroid hormone levels in critically ill patients in the absence of primary hypothalamic-pituitary-thyroid dysfunction, and these abnormalities usually resolve after clinical recovery. However, NTI can be accompanied by primary thyroid dysfunction. We report herein a case of a woman with NTI accompanied by primary hyperthyroidism.Case presentationA 52-year-old female was admitted to the intensive care unit with heart failure and atrial fibrillation. She had a longstanding thyroid nodule, and a thyroid function test revealed low levels of triiodothyronine and free thyroxine as well as undetectable thyroid stimulating hormone (TSH). She was diagnosed with NTI, and her TSH level began to recover but not completely at discharge. The thyroid function test was repeated after 42 months to reveal primary hyperthyroidism, and a thyroid scan confirmed a toxic nodule.ConclusionThis case suggests that although NTI was diagnosed, primary hyperthyroidism should be considered as another possible diagnosis if TSH is undetectable. Thyroid function tests should be repeated after clinical recovery from acute illness.

Parafibromin immunohistochemical staining to differentiate parathyroid carcinoma from parathyroid adenoma.

Parafibromin is a protein encoded by the HRPT2 oncosuppressor gene, and the expression is reported to be decreased or absent in parathyroid carcinomas.

Higher TSH level is a risk factor for differentiated thyroid cancer

Higher thyroid‐stimulating hormone (TSH) levels are associated with differentiated thyroid cancers (DTC). To validate this association, we compared TSH levels obtained from euthyroid patients with DTC with TSH levels from controls in the general population.

LY294002 inhibits monocyte chemoattractant protein-1 expression through a phosphatidylinositol 3-kinase-independent mechanism

The effects of LY294002 (LY29) and wortmannin (WM), inhibitors of phosphatidylinositol 3‐kinase (PI3K), on monocyte chemoattractant protein‐1 (MCP‐1) expression by human umbilical vein endothelial cells were investigated. Complete inhibition of interleukin (IL)‐1β‐induced Akt phosphorylation occurred at 50 μM LY29 or 100 nM WM. At these concentrations, LY29, but not WM, significantly inhibited constitutive and IL‐1β‐induced MCP‐1 expression at both protein and mRNA levels. LY303511 (LY30), an inactive analogue of LY29, also inhibited MCP‐1 expression. LY29 and LY30 inhibited activation of nuclear factor‐κB (NF‐κB). These results suggest that LY29 inhibits MCP‐1 expression at least in part via suppression of NF‐κB, independent of PI3K, and the structure of LY29 and LY30 may be a novel template for development of new anti‐inflammatory drugs.

Severe Hypothyroidism Induced by Thyroid Metastasis of Cholangiocarcinoma

We report a case of severe hypothyroidism in a cholangiocarcinoma patient with metastasis to the thyroid gland. A 58-year-old man was admitted for upper abdominal discomfort and multiple palpable neck nodules. Abdominal computed tomography (CT) demonstrated the presence of a 4.7-cm tumor in the right hepatic lobe, and core needle biopsy revealed it to be cholangiocarcinoma. Neck CT showed a diffuse, low attenuation thyroid gland, and fine-needle aspiration (FNA) demonstrated metastatic adenocarcinoma. Thyroid function tests were initially normal, but the size of the thyroid gland decreased and severe hypothyroidism developed after chemotherapy was implemented for cholangiocarcinoma. In a patient with malignant disease and a goiter, the possibility of a metastatic tumor involving the thyroid should be seriously considered. Metastatic thyroid cancer and thyroid dysfunction are probably infrequent, but diagnosis is important in the institution of appropriate therapy.

Calcinosis Cutis Universalis with Joint Contractures Complicating Juvenile Dermatomyositis

Case Report A 37-year-old Korean man presented with immobilization due to joint contracture and multiple ulcers on the back. When he had been 8 years old, he had had diffi culty in walking and shoulder elevation because of leg weakness, and these symptoms were aggravated with time. At the age of 20 years, he could not stand up at all, and he lay on the bed due to limitation of the range of movement of all his joints. His medical history included type 2 diabetes mellitus, angina pectoris, constipation, tinnitus, myopia and depression. His family history was noncontributory. On physical examination, he was immobilized because of joint contractures and his fl exed left elbow ( fi g. 1 a). Skin fi ndings included hard diffuse subcutaneous nodules on the abdomen and multiple scars and ulcers on the back where milk of calcium was discharged ( fi g. 1 b). There was severe atrophy of all extremities, hyperkeratotic plaques on the extensor joint areas as well as confl uent atrophic violaceous erythema with telangiectasia on the face and neck. On the dorsum of the hand, mild erythematous macules in the distal and proximal interphalangeal joint areas were observed. There were capillary loops on the scrotum that showed telangiectasia, atrophy of skin and easy bleeding upon minor trauma ( fi g. 2 ). Blood cell count, serum electrolytes and urinalysis were within normal limits. Creatine kinase was normal and search for antinuclear (1: 80) and anti-Ro antibodies positive, but other autoantibodies, including anti-Jo,

Agenesis of the Dorsal Pancreas: A Case Report and Review of the Literature

Partial or complete agenesis of the dorsal pancreas is a rare congenital anomaly that results from the embryological failure of the dorsal pancreatic bud to form the body and tail of the pancreas. To date, four cases have been reported in Korea. We report an additional case; a 25-year-old woman presented with diabetes mellitus and abdominal pain. Abdominal computed tomography (CT) revealed a normal-appearing pancreatic head, but the body and tail were not visualized. Endoscopic cholangiopancreatogram (ERCP) revealed a short pancreatic duct in the uncinate process and the head and the duct of Santorini draining into the minor papilla. Abdominal magnetic resonance imaging (MRI) findings were similar to the CT and ERCP results. The patient was diagnosed with partial agenesis of the dorsal pancreas by CT, ERCP and MRI.

Characteristics of Korean Patients with Antithyroid Drug-Induced Agranulocytosis: A Multicenter Study in Korea

Background Antithyroid drugs (ATDs) can lead to the development of agranulocytosis, which is the most serious adverse effect. Characteristics of ATD-induced agranulocytosis (AIA) have seldom been reported due to the rarity. In this study, we characterized the clinical features for AIA in Korean patients. Methods We retrospectively reviewed data from patients with AIA diagnosed between 1997 and 2014 at four tertiary hospitals. Agranulocytosis was defined as an absolute neutrophil count (ANC) below 500/mm3. Results The mean age of the patients (11 males, 43 females) was 38.2±14.9 years. Forty-eight patients (88.9%) with AIA had fever and sore throat on initial presentation, 20.4% of patients developed AIA during the second course of treatment, and 75.9% of patients suffered AIA within 3 months after initiation of ATD. The patients taking methimazole (n=39) showed lower levels of ANC and more frequent use of granulocyte-macrophage colony-stimulating factor than propylthiouracil (n=15) users. The median duration of agranulocytosis was 5.5 days (range, 1 to 20). No differences were observed between the long (≥6 days) and short recovery time (≤5 days) groups in terms of age, gender, ATDs, duration of ATDs, or initial ANC levels. Four patients (7.4%) who were taking ATDs for less than 2 months died of sepsis on the first or second day of hospitalization. Conclusion The majority of AIA incidents occur in the early treatment period. Considering the high fatality rate of AIA, an early aggressive therapeutic approach is critical and patients should be well informed regarding the warning symptoms of the disease.

The Recovery of Hypothalamic-Pituitary-Adrenal Axis Is Rapid in Subclinical Cushing Syndrome

Background In subclinical Cushing syndrome (SC), it is assumed that glucocorticoid production is insufficient to cause a clinically recognizable syndrome. Differences in hormonal levels or recovery time of the hypothalamic-pituitary-adrenocortical (HPA) axis after adrenalectomy between patients with overt Cushing syndrome (OC) and SC remain unknown. Methods Thirty-six patients (10 with OC and 26 with SC) with adrenal Cushing syndrome who underwent adrenalectomy from 2004 to 2014 were reviewed retrospectively. Patients were treated with glucocorticoid after adrenalectomy and were reevaluated every 1 to 6 months using a rapid adrenocorticotropic hormone (ACTH) stimulation test. Results Levels of basal 24-hour urine free cortisol (UFC), serum cortisol after an overnight dexamethasone suppression test (DST), and serum cortisol and 24-hour UFC after low-dose DST and high-dose DST were all significantly lower in patients with SC compared with OC. Basal ACTH levels showed significantly higher in patients with SC compared with OC. The probability of recovering adrenal function during follow-up differed significantly between patients with OC and SC (P=0.001), with significant correlations with the degree of preoperative cortisol excess. Patients with OC required a longer duration of glucocorticoid replacement to recover a normal ACTH stimulation test compared with patients with SC (median 17.0 months vs. 4.0 months, P<0.001). Conclusion The HPA axis recovery time after adrenalectomy in patients with SC is rapid and is dependent on the degree of cortisol excess. More precise definition of SC is necessary to achieve a better management of patients and to avoid the risk of under- or over-treatment of SC patients.

Diffuse Metastasis to the Thyroid: Unique Ultrasonographic Finding and Clinical Correlation

Cases of metastases to the thyroid gland seem to be increasing in recent years. The clinical and ultrasonographic findings of diffuse metastases have been sparsely reported. Thirteen cases of diffuse metastases to the thyroid gland were documented by thyroid ultrasonography-guided fine needle aspiration cytology between 2004 and 2013. We retrospectively reviewed the patients with diffuse thyroid metastases. The most common primary site was the lung (n=9), followed by unknown origin cancers (n=2), cholangiocarcinoma (n=1), and penile cancer (n=1). Eleven patients were incidentally found to have thyroid metastases via surveillance or staging FDG-PET. Other 2 patients were diagnosed during work-up for hypothyroidism and palpable cervical lymph nodes. On ultrasonography, the echogenicity of the enlarged thyroid gland was heterogeneously hypoechoic or isoechoic, and reticular pattern internal hypoechoic lines were observed without increased vascularity found by power Doppler ultrasonography (3 right lobe, 2 left lobe, and 8 both lobes). In the 8 patients who had involvement of both lobes, 3 had hypothyroidism. In conclusion, ultrasonographic finding of diffuse metastasis is a diffusely enlarged heterogeneous thyroid with reticular pattern internal hypoechoic lines. Thyroid function testing should be performed in all patients with diffuse thyroid metastases, especially those with bilateral lobe involvement. Graphical Abstract