Isabel Manita

Thyroid Tuberculosis with Abnormal Thyroid Function-Case Report and Review of the Literature

OBJECTIVE To report an extremely rare case of thyroid tuberculosis (TT) with abnormal thyroid function and to review the related literature. METHODS We present the patients history, clinical findings, laboratory test results, imaging examinations, cytological data, management, and follow-up. In addition, we perform a review of the previously published cases of TT and give special attention to those with hypothyroidism. RESULTS A 45-year-old Indian man presented to the outpatient clinic with neck swelling and respiratory and constitutional symptoms. Cervical ultrasound revealed a thyroid nodule and a necrotic right cervical adenopathy. Fine-needle aspiration cytology (FNAC) was performed and purulent material was removed from thyroid and lymph node. In both specimens, the culture was positive for Mycobacterium tuberculosis complex, and a cytological examination revealed epithelioid cell granulomas and necrosis. Mycobacterium tuberculosis complex was also identified by sputum culture. Antibiotic testing revealed sensitivity to all first-line drugs. A diagnosis of disseminated tuberculosis with thyroid and cervical lymph node involvement was made. Thyroid function was consistent with subclinical hyperthyroidism that subsequently evolved to hypothyroidism, requiring thyroid hormone replacement, and reflected tuberculous thyroiditis. Anti-tuberculosis drugs were started with good therapeutic response. CONCLUSION TT is a rare condition and its association with thyroid function abnormalities is even rarer. To our knowledge this is the third report of hypothyroidism related to TT and the first to identify a period of hyperthyroidism preceding hypothyroidism. Despite its rarity, TT should be considered in the differential diagnosis of neck mass. FNAC is a useful procedure and thyroid function should be monitored.

Malignant Paraganglioma Presenting With Hemorrhagic Stroke in a Child

Sympathetic paragangliomas are rare catecholamine-secreting tumors of extra-adrenal origin, and their diagnosis in children is even more infrequent. They usually manifest as hypertension, palpitations, headache, sweating, and pallor. Malignant paragangliomas are identified by the presence of metastasis. Hemorrhagic stroke in the pediatric population is a life-threatening condition with several etiologies. We report here the case of a 12-year-old boy with malignant sympathetic paraganglioma presenting with hemorrhagic stroke. Severe hypertension was found and the patient evolved into a coma. Brain computed tomography scan showed right thalamus hemorrhage with intraventricular extension. After clinical improvement, further investigation revealed elevated catecholamine and metanephrine levels, and 2 abdominal tumors were identified by computed tomography. Resection of both lesions was performed, and histologic findings were consistent with paraganglioma. Multiple metastatic involvement of bones and soft tissues appeared several years later. Genetic testing identified a mutation in succinate dehydrogenase subunit B gene, with paternal transmission. 131I-metaiodobenzylguanidine therapy was performed 3 times with no tumoral response. Our patient is alive, with adequate quality of life, 25 years after initial diagnosis. To our knowledge, this is the first pediatric case of paraganglioma presenting with hemorrhagic stroke. Intracerebral hemorrhage was probably caused by severe hypertension due to paraganglioma. Therefore, we expand the recognized clinical spectrum of the disease. Physicians evaluating children with hemorrhagic stroke, particularly if hypertension is a main symptom, should consider the possibility of catecholamine-secreting tumors. Metastatic disease is associated with succinate dehydrogenase subunit B mutations and, although some patients have poor prognosis, progression can be indolent.

IgG4-related Hashimoto’s thyroiditis – A new variant of a well known disease

Hashimotos thyroiditis (HT) has been characterized for many years as a well-defined clinicopathologic entity, but is now considered a heterogeneous disease. IgG4-related HT is a new subtype characterized by thyroid inflammation rich in IgG4-positive plasma cells and marked fibrosis. It may be part of the systemic IgG4-related disease. We report a case of a 56-year-old Portuguese man who presented with a one-month history of progressive neck swelling and dysphagia. Laboratory testing revealed increased inflammatory parameters, subclinical hypothyroidism and very high levels of thyroid autoantibodies. Cervical ultrasound (US) demonstrated an enlarged and heterogeneous thyroid gland and two hypoechoic nodules. US-guided fine needle aspiration cytology was consistent with lymphocytic thyroiditis. The patient was submitted to total thyroidectomy and microscopic examination identified typical findings of HT, marked fibrosis limited within the thyroid capsule and lymphoplasmacytic infiltration, with >50 IgG4-positive plasma cells per high-power field and an IgG4/IgG ratio of >40%. After surgery, serum IgG4 concentration was high-normal. Symptoms relief and reduction in laboratory inflammatory parameters were noticed. Thyroid function is controlled with levothyroxine. To our knowledge we report the first case of IgG4-related HT in a non-Asian patient. We also perform a review of the literature regarding IgG4-related disease and IgG4-related HT. Our case highlights this new variant of the well known HT, and helps physicians in recognizing its main clinical features, allowing for proper diagnosis and treatment.

Horner syndrome as a manifestation of thyroid carcinoma: a rare association

An 82-year-old patient presented a progressively growing hard thyroid nodule, and left ptosis. Additionally, ophthalmologic evaluation revealed ipsilateral miosis, diagnostic findings of Horner syndrome. Computerized tomography revealed a 7.5-cm thyroid mass infiltrating the main neck vessels. Although clinical and imaging data were suggestive of poorly differentiated thyroid carcinoma, fine-needle aspiration led to the diagnosis of papillary carcinoma. Paliative care was proposed to the patient due to the advanced stage of the neoplasm and to significant comorbidities. Horner syndrome is an infrequent manifestation of thyroid disorders and benign etiologies are more often implied. Malignant thyroid neoplasms represent a rare cause of Horner syndrome. However, an appropriate and prompt diagnosis is paramount for timely treatment of rare thyroid malignancies.

CO005. AVALIAÇÃO DO IMPACTO DOS NOVOS CRITÉRIOS DE DIAGNÓSTICO DE DIABETES GESTACIONAL – EXPERIÊNCIA DO HOSPITAL GARCIA DE ORTA

Introducao: Os hidratos de carbono (HC) sao o principal nutriente a influenciar a resposta glicemica pos-prandeal. A terapeutica com esquema intensivo de insulina pressupoe a utilizacao da contagem de HC, essencial na determinacao da dose exata de insulina rapida a administrar. Objetivo: Verificar se os doentes diabeticos tipo 1 submetidos a tratamento intensivo de insulina, e com contagem de HC: aplicam a contagem diariamente; a realizam com rigor; conhecem a sua razao HC/Insulina. Metodos: Aplicacao de um questionario para avaliacao da contagem de HC em tres refeicoes (uma refeicao principal e duas intermedias, uma com e outra sem lacticinios), elaborado para o efeito. Tipo de estudo: Observacional transversal. Populacao: Sessenta e dois individuos, com HbA1c media de 8,18% ± 1,29, da consulta externa dos servicos de endocrinologia/nutricao deste centro hospitalar. Resultados: Do total da amostra, quinze individuos (24,2%) dizem nao cumprir a contagem de HC, dando como principal motivo falta de tempo (53,5%). Constatou-se que: na refeicao intermedia com lacticinios, com 52 g de HC, a contagem realizada variou entre 4 g e 127 g (min e max), sendo a media de 52,0 ± 18,1 g e apenas vinte e dois individuos (41,5%) eram rigorosos; na refeicao intermedia sem lacticinios, com 40 g de HC, variou entre 3 e 150 g (min e max), com media de 39,6 ± 18,9 g, sendo a maioria dos inquiridos (58,5%) rigorosa; na refeicao principal, com 51g de HC, nenhum doente foi rigoroso, variando a contagem entre 10 e 215 g, com uma media de 55,0 ± 31,0. Analisando o conhecimento relativo a razao HC/Insulina, verificou-se que 8,1% a desconhece. Conclusao: Um grande numero de doentes diabeticos nao conhece a sua razao HC/Insulina e nao aplica a contagem de HC no seu dia a dia. A contagem de HC e realizada com uma elevada percentagem de erro o que dificulta o controlo metabolico.

CO015. CONTROLO GLICÉMICO EM 115 DIABÉTICOS TIPO 2, DURANTE 3 ANOS: ESTUDO RETROSPECTIVO DO MUNDO REAL

Introducao: A Pneumonia Adquirida na Comunidade (PAC) e uma patologia frequente e com uma importante morbimortalidade. A Diabetes Mellitus (DM) aumenta o risco e complicacoes de doencas infecciosas. Todavia, carece estabelecer se a DM e a glicemia na admissao sao factores de prognostico em doentes com PAC. Objetivo: Avaliar a relacao entre DM/glicemia na admissao e desenvolvimento de complicacoes, duracao do internamento e mortalidade em doentes com PAC; e a relacao entre controlo glicemico e existencia de complicacoes em diabeticos. Metodos: Estudo observacional, analitico e retrospectivo dos adultos admitidos no Hospital de Braga entre Outubro/2011 e Marco/2012, com PAC. Consultaram-se os processos clinicos electronicos e para avaliacao da mortalidade aos 30 e 90 dias efectuaram-se, adicionalmente, chamadas telefonicas. Utilizaram-se os testes Qui-quadrado, Mann-Whitney, Kruskal-Wallis e regressao logistica. Resultados: Dos 440 doentes incluidos, 51,1% eram mulheres, 83,1% idosos e 29,3% diabeticos. Destes, 48,8% tinham HbA1c doseada no internamento (mediana de 6,8%, percentil 25: 6,3%, percentil 75: 7,8%). A mediana da glicose na admissao foi 134 mg/dL (P25: 111 mg/ dL, P75: 176 mg/dL). Os diabeticos pertenciam a faixas etarias mais elevadas (p = 0,002), apresentaram maior gravidade da pneumonia, avaliada pelo CRB-65 (p = 0,025), mais complicacoes (p = 0,001) e mais dias de internamento (p = 0,001). A DM revelou-se um preditor de complicacoes (p = 0,008). Nao se demonstrou relacao entre a DM e a mortalidade, nem entre os niveis de HbA1c e complicacoes, tempo de internamento e mortalidade. Por outro lado, verificou-se um aumento gradual dos dias de internamento para niveis mais elevados de glicose na admissao (p = 0,016) e uma tendencia para complicacoes nos doentes hiperglicemicos. Porem, nao houve diferencas estatisticamente significativas entre niveis de glicose e mortalidade. Conclusao: A DM e a hiperglicemia na admissao sao factores de mau prognostico em doentes admitidos com PAC, associando-se a prolongamento do tempo de internamento e, nos diabeticos, a aumento das complicacoes.