Goiter Research Articles

Impact of iodine intake on the pathogenesis of autoimmune thyroid disease in children and adults.

Thyroid hormone (TH) regulates the body's metabolism and iodine, a vital trace mineral, is vital for TH synthesis. As a TH biosynthesis catalyst, iodine has a substantial role in our health. When there is a modest iodine deficit, the thyroid gland grows autonomously, resulting in thyrotoxicosis. Those who consume excessive iodine risk developing hypothyroidism and thyroid autoimmunity. A transient hyperthyroid condition may rapidly increase iodine consumption. Iodine deficiency is common across the globe, and provision of supplementary iodine, in forms such as iodized salt or vegetable oil, has many benefits. Vegetarians, for instance, may not consume adequate amounts of iodine in some countries with high iodine content. Reduced dietary iodine intakes may be a consequence of efforts to reduce salt intakes to prevent hypertension. In addition, iodine consumption is decreasing in many countries, even among those where endemic goiter has previously been eradicated, leading to the re-emergence of iodine-deficiency-related disorders such as goiter. This review will discuss how iodine can contribute to the development of thyroid disease.

Histopathologic Pattern of Thyroid Disease in 1351 Thyroidectomy Patients

BackgroundThyroid disease poses a major clinical problem. Knowledge of the pattern and distribution of thyroid disease is important to establish prevention and treatment protocols. This is hampered by lack of data.MethodsThis is a retrospective descriptive study of histopathology reports on thyroid tissue surgically excised from patients over a 10-year-period (from 2009-2020) at a major teaching hospital. Demographic data on patients included the age, gender, geographical location and ethnic origin.Results A total of 1351 histopathological reports on thyroid patients were studied. Twenty one patients (1.6%) had thyroglossal cysts and 1330 patients (98.4%) had goiters. The mean age was 40.6 years (SD±13.25), (range 11-85years). The majority (88%) were females Most of our patients come from Khartoum (76.3%), followed by White Nile (6.4%), and El Gazira states (4.5%). The commonest ethnic groups affected were the Nuba (11.6%) and Jaalin (8%). The majority of patients (85%) had benign thyroid diseases, and only (15%) had neoplastic disease. Simple multinodular goiter (SMNG) accounted for (78.6%) of benign thyroid disease. Follicular adenoma was the commonest benign neoplasm (98%), whereas papillary carcinoma was the commonest malignant tumour (44.9%), followed by follicular carcinoma and Hurthle cell tumours (43.9%). Medullary and anaplastic carcinomas each accounted for (4.1%) of patients.Conclusions The study identified the histopathological pattern of thyroid disease. SMNG was the commonest benign disease. Follicular and Hurtle cell carcinoma combined were almost as frequent as papillary carcinoma. Prevention of SMNG by iodinization, early detection of thyroid neoplasms, and studies on goitrogens should be activated.

Graves’ disease, myxedema and papillary thyroid carcinoma

Graves’ disease (GD) is the leading cause of hyperthyroidism and diffuse toxic goiter in iodine-sufficient geographical areas. GD is associated with classical manifestations such as ophthalmopathy and thyroid dermopathy, in addition to diffuse goiter, which may be the site of carcinomas, as a complication. Case report: A 52-year-old womanpresented with goiter and symptoms compatible with hyperthyroidism, such as heat intolerance, weight loss, fatigue, increased sweat, tachycardia, fine tremors, increased intestinal transit, anxiety, emotional lability, insomnia, exophthalmos, and pretibial myxedema. A complementary investigation confirmed the diagnosis of hyperthyroidism(high free T4 and total T3 levels and low thyroid-stimulating hormone - TSH levels). Ultrasound images showed diffuse enlargement of the thyroid lobes by approximately 10 times and the presence of three thyroid nodules, one of which was larger than 2 cm with heterogeneous echogenicity and vascularization throughout the nodule; ultrasound-guided fine needle aspiration revealed cytology compatible with Bethesda IV; scintigraphy revealed a low uptake area (cold nodule) amid a diffuse high-uptake goiter. A thyroidectomy was performed, and the anatomical specimen diagnosis revealed papillary thyroid carcinoma in the right lobe, with adjacent parenchyma compatible with GD.Histopathological examination of the skin showed the presence of myxedema compatible with Graves’ dermopathy. The patient evolved with the normalization of TSH levels and a reduction of cutaneous manifestations. Conclusion: GD abnormalities may not be restricted to the classic clinical manifestations, and a careful investigation may reveal the coexistence of carcinomas.

Первичная заболеваемость тиреоидной системы и йодное обеспечение организма взрослого населения Заводского района г. Минска

Currently, iodine deficiency diseases are one of the most common diseases of non-infectious origin. In the Republic of Belarus, preventive measures are being taken to eliminate the problem of iodine deficiency, in particular, a state strategy has been developed and implemented, the main measure of which is the mandatory use of only iodized salt in the food industry and public catering. Despite the measures taken, the problem of iodine deficiency remains relevant, especially for children and pregnant women. According to the results of the assessment of iodine sufficiency in the world, published by the RIAC on Surveillance for Iodine Deficiency Diseases (ICCIDD) - a global non-commercial, spheral need created for the use of iodine deficiency and the consequences of its negative examination on health, adequate iodine intake is provided in the Republic of Belarus. In 2016, the Global Iodine Network published maps characterizing iodine sufficiency for two main assessment categories - school-age children and pregnant women, confirming the status of the Republic of Belarus as a country with adequate iodine sufficiency. However, despite the results achieved, from the standpoint of medical monitoring, the quality of studies conducted to monitor the iodine supply of the population, the risks of excessive salt intake remain relevant. In this paper, a comparative analysis of the dynamics of the primary incidence of thyroid pathology in the population of the Zavodskoy district of the city of Minsk for the period 2016-2020 was carried out. According to the results of the analysis, a positive trend in the primary incidence of simple goiter, nodular non-toxic goiter and thyroiditis was revealed, while the dynamics of the primary incidence of hypothyroidism did not change. According to the data presented, the presence of iodine deficiency with a median urinary iodine excretion of 196.15 gg/l was revealed in pregnant women of the Zavodskoy district of Minsk in 2021. An analysis of the questionnaire survey of the nature of the nutrition of pregnant women showed that most of the surveyed do not know about the benefits of using iodized salt for the development of the fetus, and therefore the reason for the formation of iodine deficiency in the body of pregnant women is the insufficient intake of iodine in the body and refusal to take iodine preparations. In the surveyed region, 22 % of women do not comply with the prescription of endocrinologists about the need to take iodine-containing drugs.

Consumption of Cruciferous Foods, Ingestion of Glucosinolates and Goiter in a Region of Eastern Algeria

This study is about the estimation of the consumption of cruciferous vegetables, and the search for a possible relationship between the ingestion of glucosinolates provided by these foods and the emergence of endemic goiter. A prospective cohort survey was carried out on 1098 subjects residing in the district of EL-MILIA (Algeria) where endemic goiter is known to estimate the consumption of crucifers. Total glucosinolates levels in cruciferous vegetables, cabbage, cauliflower, fresh and cooked turnip and radish were determined by the glucose release method. The goiter was detected by clinical investigation. Both various fresh and cooked cruciferous vegetables have the same total glucosinolates levels as reported in other studies. The prevalence of endemic goiter was 17.5 %. The average consumption of crucifers was 380.30 g per person a week, i.e. 54.32 g per person a day, and the weekly ingestion of glucosinolates per person was 369.4 μmoles, or 52.7 μmoles per day. No dependence was observed between the consumption of glucosinolates and the disease in general. However, isolated stage 2 and 3 of goiter were dependent on the consumption of glucosinolates ; stage 1 was not related to the disease. Despite the current consumption, at EL-MILIA, we estimate that glucosinolate’s ingestion does not cause goiter, but may worsen the condition of subjects already affected.

Incidence and treatment outcomes of Graves’ disease in Thailand: a single-center retrospective observational study

BackgroundTreatment patterns and outcomes of Graves’ disease (GD) are variable around the world. However, studies on treatment outcomes of GD from the Asian populations are limited. We aimed to evaluate treatment outcomes of GD in Thailand.MethodsPatients with new diagnoses of GD in a single center between 2014–2018 were retrospectively reviewed. The diagnosis of GD was based on clinical features, which included diffuse goiter, Graves’ orbitopathy (GO), pretibial myxedema and acropachy.ResultsThe age-adjusted incidence of GD was 26.57 per 100,000 per year. The study included 355 patients aged 15 years or above with a follow-up period of at least 24 months. Antithyroid drug (ATD) was the most popular first-line treatment modality with 98.7% patients receiving the treatment, followed by radioactive iodine (RAI) treatment in 1.3% patients. The most effective treatment modality was surgery with a remission rate of 100%. ATD had a lowest remission rate of 23.8%. Multivariable Cox regression analysis showed GO (HR 1.76, 95% CI 1.08–2.88) and initial TSH < 0.01 uIU/ml (HR 1.61, 95% CI 1.14–2.28) were significant factors associated with an increased treatment failure rate.ConclusionTreatment failure with ATD in patients with GD was frequent in this population. The diagnosis of GD based solely on clinical features may explain the high treatment failure rate in this study. More definitive treatment could be used to prevent relapse and complications of the disease.

Mechanism of development of residual goitre and associated thyroid disorders

In post salt iodination period, endemic goiter that generally develops for iodine deficiency is found prevalent in many regions, including India, despite adequate iodine intake. Such goiters are termed as residual goiters. Consumption of dietary goitrogens could be the possible regulator in the persistence of residual goitre and associated disorders. Residual goitres exist in Manipur, India for the consumption of bamboo shoots (BS). Therefore, to study the actions of BS on major thyroid hormone synthesizing regulatory factors at cellular and molecular levels on isolated thyrocytes conducted perusing expression of NIS, TPO, Tg and PDS proteins as well as mRNA and protein expression of NIS, TPO, Tg, PDS, MCT8 and PAX8 with and without extra iodine in in-vitro studies. Simultaneously, ROS generation in terms of H2O2 and antioxidant status, NO, LPO were assayed. Cellular and DNA damage and oxidation, including cell cycle alterations after BS exposure, were also investigated. Precursors and metabolic end products of cyanogenic glycosides on phytochemical analysis found in BS. It has pleiotropic effects on thyrocytes. It repressed the activities of Na+-K+-ATPase, TPO and D2, as well as reduced the expression of NIS, TPO, Tg, PDS proteins and MCT8 and PAX8, at mRNA level. All these effects of BS are mediated through increased ROS levels as H2O2 upsurge leading to a perturbed pro-oxidant antioxidant balance in thyrocytes associated with cellular and DNA damage and oxidation. Increased LPO and NO levels upon exposure of BS extract triggered plasma membrane and organelle damage of thyrocytes, which are major sites of NIS, TPO, PDS and MCT8, leading to thyroid disfunction. Cellular and DNA damage/oxidation was observed that leads to disruption of normal cell cycle pattern of thyrocytes which in turn causes changes in apoptotic proteins Bax, Bcl-2 and p53. These changes imply imbalance of cell death and proliferation equilibrium leading to disease conditions as found in goitre upon exposure to BS extract. Extra iodine prevents goitrogenic/anti-thyroid influences of BS on such actions to an extent. Thyroid diseases among residual goitrous population following consumption of BS evaluated by their iodine nutritional and salt iodization status, serumT3, T4 and TSH profiles, TPO- and Tg-Ab antibodies, thyroid ultrasonography, the prevalence of hypo- and hyperthyroidism and cytomorphological features. Goitrous populations are affected by subclinical and overt hypo- and hyperthyroidism with elevated thyroid autoantibodies, hypoechoic thyroid and thyroiditis. This study concludes that residual goitrous individuals are affected by different autoimmune thyroid disorders. Excess thiocyanate from dietary goitrogens of cyanogenic origin (BS) is responsible for the development of residual goitre followed by its progression towards different thyroid autoimmune disorders.

Familial Dysalbuminemic Hyperthyroxinemia Induced by Mutation R218H of Albumin

Familial Dysalbuminemic Hyperthyroxinemia (FDH) is thought of no clinical significance, but tends to to misdiagnosed and mistreated as Graves’ hyperthyroidism with long time. In a Chinese family to explore clinical characteristics, hereditary features and gene variation of FDH and its effect on pregnancy. Methods: Two propostitus (a father and his son) with hyperthyroidism were re-diagnosed as FDH due to the canonical profile of measured thyroid hormones. After screening thyroid function of the whole family, eight affected of FDH were identified among total thirteen lineal relatives. They were studied in terms of clinical history, biochemical and hormone examination, thyroid imaging and TSH secreting test by dexamethasone and bromocriptine. Three members accepted gene analysis with the next generation sequencing followed by Sanger method. Productive history was investigated in five spouse of the whole family. Results: In the two propostitus, FDH exhibited very high total thyroxine (T4) and mild high total triiodinethyronine (T3), and normal free T4 and T3 besides normal thyroid stimulating hormone (TSH). In addition, ultrasound discovered diffuse goiter and enhanced blood flow, and 99mTc uptake increased, while TSH receptor antibody and pituitary MRI scan remained normal. Other six family members had similar changes of the thyroid hormones and normal TSH which could be suppressed dramatically by dexamethasone and bromocriptine, then were suspected of FDH and thereafter confirmed with gene analysis. Among these eight FDH, four were misdiagnosed with hyperthyroidism and mistakenly received anti-thyroid medication at least one year. Gene analysis of three members revealed R218H variation of albumin gene. Conclusions: R218H associated FDH shows canonical changes of thyroid hormones with increased thyroid function, high penetrance and misdiagnose rate with hyperthyroidism, it exerts no effect on pregnancy.

The advantage of the combined use of intraoperative neuromonitoring and percutaneous ultrasonography of the larynx as a screening for postoperative vocal cord paresis

Background. One of the most common complications during thyroid surgery after hypoparathyroidism is a violation of the mobility of the vocal folds - paresis or paralysis of the larynx. The incidence of damage to the recurrent laryngeal nerves during primary surgical interventions can vary from 1 to 30%. Intraoperative neuromonitoring is the most effective method to reduce the amount of damage to the laryngeal nerves during surgical interventions on the thyroid and parathyroid glands. Assessment of the state of the vocal cords in the preoperative and postoperative period is crucial. In the preoperative period, this helps establish baseline characteristics and identify pre-existing laryngeal paresis, while postoperative early identification of vocal cord paresis helps develop a rapid treatment plan. Indirect laryngoscopy is still considered the reference standard for vocal cord examination. The main advantage is the ability to visualize the vocal cords in 99% of cases. However, this is an invasive procedure that can be painful and uncomfortable for patients, and increases medical costs and lead time.Materials and methods. The results of intraoperative neuromonitoring were analyzed in 25 patients who underwent total thyroidectomy according to indications (diffuse nodular non-toxic goiter — 17 patients (68%), diffuse nodular toxic goiter — 4 patients (16%), autoimmune thyroiditis, diffuse — nodular form — 4 patients (16%)), from September 2021 to February 2022. The patients’ age ranged from 18 to 73 years. There were 23 women (92%), men — 2 (8%). In the study, a C2 neuromonitor (InoMed, Germany), an electrode for EMG recording on an endotracheal tube, and a bipolar forked stimulating probe were used. To assess the mobility of the vocal folds, all patients underwent percutaneous ultrasonography before and after thyroid surgery.Results and discussion. In 20 patients (80%) before surgery on transcutaneous ultrasound of the larynx, the visualization of the structures of the larynx was good (grade 4-5), in 2 male patients (8%), the visualization of the structures of the larynx was satisfactory (grade 3), in 3 women (older than 45 years (12%)) — visualization of the structures of the larynx was satisfactory (grade 3), in all 25 patients (100%) — complete or normal symmetrical movement of the vocal folds (grade I). During the performance of precision extrafascial thyroidectomy in 3 patients (12%), a decrease in the amplitude of oscillations was recorded during stimulation of the left recurrent laryngeal nerve and the left vagus nerve, in order to prevent bilateral paresis of the larynx, it was decided to confine ourselves to hemithyroidectomy followed by a staged right-sided hemithyroidectomy. A day after the performed left-sided hemithyroidectomy, percutaneous ultrasound of the larynx in 2 patients showed a violation of the mobility of the vocal fold on the left (grade II), in 1 patient — symmetrical movement of the vocal folds (grade I) — a false positive reaction. In 22 patients (88%) who underwent total thyroidectomy on percutaneous ultrasound of the larynx, complete or normal symmetrical movement of the vocal folds (I degree).Conclusion. Intraoperative neuromonitoring is an effective tool to localize the recurrent laryngeal nerves regardless of whether a loss of signal (LOS) has occurred, as well as to determine the type of LOS (LOS 1, LOS 2) and staged thyroidectomy in the presence of LOS. Percutaneous vocal cord ultrasonography is currently an effective screening tool, saving 80% of patients from unnecessary invasive laryngoscopy. The complex of these methods should be an obligatory component in surgical interventions on the thyroid and parathyroid glands.

Thyroid disorders and their role in the pathogenesis of glaucoma

The literature analysis confirms the interrelationship of thyroid gland pathology and glaucoma. Patients with diffusetoxic goiter (DTG) and endemic goiter have an especially high risk of developing glaucoma, while those with autoimmune thyroiditis face a moderate risk. The prevalence of primary open angle glaucoma (POAG) in patients over 40 with endocrine ophthalmopathy is reliably associated with the male gender and the duration of the disease longer than 60 months. An increased risk of POAG is noted in men with hypothyroidism averagely aged 69. In most cases, ophthalmic hypertension that accompanies endocrine pathology does not need any topical hypotensive treatment. The main pathogenetically validated therapy of thyroid disorders results in a reduction of IOP level and an improvement of fluid outflow from the eye.

Features of the diagnosis of primary hyperparathyroidism in children

Background. Primary hyperparathyroidism (PHPT) is a rare pathology in pediatric and adolescent patients. Collection, analysis and generalization of the literature data and experience of the leading clinics allow to develop unified, statistically substantiated approaches to diagnostics and surgical treatment of this group of patients.Material and methods. The article presents a retrospective analysis of 17 cases of PHPT in children and adolescents aged from 6 to 18 years operated on in the department of Surgery of St.-Petersburg State Pediatric Medical University in the period from 1973 till 2021. Among those operated there were 10 girls and 7 boys, the M:F ratio was 1:1.4. The mean age of the patients was 12,9±0,71 years.Results and discussion. The main criteria of the disease diagnosis were elevated blood calcium and parathormone levels, excessive urinary calcium secretion. Manifest forms of the disease were diagnosed in 10 (58,8%) of 17 children. In 3 (17,6%) cases the parathyroid neoplasms were accompanied neither by clinical, nor laboratory manifestations of the disease and were regarded as incidentalomas. Another 4 (23.5%) patients had only laboratory changes (hypercalcemia and hyperparathyrinaemia) that manifested themselves preoperatively. These observations were referred to the asymptomatic form of PHPT.In 7 (41.2%) cases parathyroid adenomas were found and removed during surgeries for various thyroid diseases (thyroid cancer in 5 cases, diffuse toxic goiter in 1 case). An incidental finding of parathyroid adenoma was during prophylactic thyroidectomy for Sipple syndrome.A radioisotope method proved to be the most informative way to localize parathyroid tumors.Conclusion. The diagnosis of the disease in manifest sporadic cases does not differ from that in adults. Genetic study is indicated in the presence of a family history of multiple involvement of the parathyroid glands. Surgical treatment with removal of parathyroid tumor is the main method, which allows to achieve complete recovery.

Frequency and nature of thyroid pathology in children and adolescents with type 1 diabetes mellitus and its influence on sexual development

Objective — to assess the frequency and nature of thyroid gland pathology in children and adolescents with type 1 diabetes mellitus (DM 1) and to determine its impact on somatic and sexual development.&#x0D; Materials and methods. Investigation involved 117 children and adolescents with DM 1, aged from 9 to 18 years (54 boys and 63 girls), who were under observation in the clinic of the Institute of Children and Adolescents Health Care. All children underwent thyroid gland (TG) ultrasound examination. The assessments included physical and sexual development of patients, the state of carbohydrate metabolism according to the glycosylated hemoglobin (HbA1c) levels. Creation of the database and statistical processing of the results were carried out using the packages of Microsoft Excel and SPSS 17.0 statistical methods.&#x0D; Results and discussion. Thyropathies were diagnosed in 41.0 % of DM 1 patients (from the, 20.5 % had diffuse nontoxic goiter, 17.1 % autoimmune thyroiditis (AIT), 3.4 % nodules, cysts). AIT was mostly often determined in girls (22.2 %), and diffuse nontoxic goiter in boys (31.5 %). Among boys with harmonious physical development, 51.6 % had thyroid pathology. In case of sexual development abnormalities, almost half of girls (46.7 %) and a third of boys (33.3 %) had thyropathies. Thyropathies were significantly more often identified in adolescents with the DM 1 onset in childhood (71.4 %) and early puberty (80.0 %), duration of diabetes from 5 to 10 years (48.3 %), and suboptimal compensation (63.3 % in boys and 50.0 % in girls).&#x0D; Conclusions. The high frequency of thyroid pathology has been established among children and adolescents in whom DM 1 developed at the age of 4—5 years (71.4 %). It has been shown that the increased AIT risk exists in both girls and boys. A significant percentage of thyropathies among children in the early puberty period (80.0 %) was established. The obtained results confirmed the need for careful monitoring of the thyroid gland in children and adolescents with DM1, especially in the period of puberty.

Thyroid Surgery in Children: A 5-Year Retrospective Study at a Single Paediatric Surgical Center and Systematic Review.

The aim of this study was to analyse and evaluate our 5-year experience in paediatric thyroid surgery, as well as the specificities of this kind of surgery in the literature. This retrospective study was based on 19 operations in 17 patients aged from 5 to 17 years who were operated on due to thyroid pathology from 2017 until 2022. We presented data on surgical procedures and complications following surgery. Most of the patients were adolescent girls. The most common clinical presentations included enlarged thyroid gland, followed by thyroid nodules and hyperthyroidism. Eight total thyroidectomies, five left lobectomies, five right lobectomies, and three central neck dissections were performed. The most common histopathological diagnosis was hyperplastic diffuse colloid goitre, followed by papillary carcinoma, cystic nodule, follicular adenoma, Hashimoto thyroiditis and toxic adenoma. Postoperative course was uneventful, with four mild complications (one wound infection, one manifest hypocalcaemia, and two transitory recurrent laryngeal nerve paralysis). In our literature review, eighteen full-text articles were included and analysed. This study demonstrated that thyroid surgery in paediatric population is a safe and efficient procedure. Thyroid pathology in children significantly differs from that in the adults, and paediatric surgeons should be included into the team managing such cases.

ODP518 Three Cases of Autoimmune Thyrotoxicosis after the BNT162b2 mRNA Covid-19 Vaccine

Abstract Background Various vaccines have been produced around the world in the battle against coronavirus disease 2019 (COVID-19) in the past year. Clinical trials and approvals of these vaccines were expedited at an unprecedented speed, with some of them approved under emergency use. Since March 2021, government coordinated vaccination program using two types of vaccines against COVID-19 were being undertaken in Hong Kong. BNT162b2 mRNA COVID-19 vaccine under the name of BioNTech was one. While it is a promising measure to control COVID-19, the new mRNA vaccine technology does cast some doubts, particularly its safety. In addition to the commonly reported injection site reactions and systemic upsets, less reported reactions after this new vaccine requires more clarifications. Here, we report 3 cases of autoimmune thyrotoxicosis all happened soon after the vaccination. Clinical Cases: Case1 A 40-year-old man with family history of thyroid cancer (mother had thyroid cancer with operation done) developed palpitations 17 days after receiving the first dose of BioNtech vaccine. Investigations confirms Graves’ thyrotoxicosis as evidenced by elevated fT4 and suppressed sTSH with positive thyroid stimulating immunoglobulin (TSI) and a diffuse vascular goiter on ultrasound (USG) thyroid. He was started on a course of anti-thyroid drug and had been advised to defer the second dose of vaccine until clinically stable. Case2 A 44-year old lady without personal/family history of thyroid disease developed progress neck swelling and palpitation with tremor 3 days after receiving the first dose of BioNtech vaccine. Investigations confirmed Graves’ thyrotoxicosis with elevated fT4 and suppressed sTSH with positive TSI, anti-TPO, and anti-ATG. USG thyroid showed diffuse vascular goiter. She was treated with a course of anti-thyroid drug and had been advised to defer the second dose of vaccine until stabilization of thyroid function. Case3 A 56-year-old man with positive family history of thyrotoxicosis (elder brother with history of thyrotoxicosis treated with radioactive iodine) developed progressive weight loss, increased appetite, insomnia, palpitation, and tremor around 7 days after the first dose of BioNtech vaccine. Patient only presented to an Endocrinologist for further workup 63 days after the first dose (42 days after second dose of BioNtech). Biochemically he had high fT4, suppressed sTSH, with positive anti-ATG, anti-TPO and TSI. USG thyroid revealed a small diffuse goiter. He was treated with a course of anti-thyroid drug with regular follow-up and monitoring. Conclusion This is the first case-series in Hong Kong demonstrating the possible triggering of Graves’ thyrotoxicosis after BioNTech vaccination. TSI and USG thyroid are invaluable tools to confirm the autoimmunity nature of the disease. Further studies are needed to clarify the prevalence, mechanisms, preventions, and treatments of this vaccine complication. Presentation: No date and time listed

PSAT293 Uncommon Presentation of Hashimoto Thyroiditis

Abstract Hashimoto thyroiditis (HT) is the most common cause of hypothyroidism in developed countries, which presents with diffuse goiter or atrophic gland. Staii et al. reported a 7.4 per cent prevalence of localized HT diagnosed by fine needle aspiration (FNA) cytology in euthyroid patients during thyroid cancer screening. Although, a transient solitary focal presentation of HT in euthyroid patients has not been described so far. Here we describe a case of localized HT presented with a thyroid mass peripartum, which progressed into diffuse thyroiditis after FNA biopsy. A 27-year-old woman who is 10-day post-partum presents to our endocrine clinic for thyroid mass evaluation noticed by her spouse a few weeks before delivery. The patient has no hypothyroid, hyperthyroid, or mass effect symptoms. On the physical exam: BP 100/64 mmHg, Temp 36.5 C, HR 76 bpm, RR 20 bpm, BMI 24.6 kg/m2. There is a palpated 5-cm non tender right thyroid nodule. Thyroid stimulating hormone (TSH) is 2.04 uiu/ml (N: 0.3-4.2). Thyroid ultrasound (US) shows a 47×25×31 mm right hyperechoic nodule with some septation of hypoechoic areas. It has thin continuous halo, smooth but lobulated margins and Grade 3 doppler. No microcalcification is seen. Left lobe and isthmus are homogenous with no nodules. There is a reactive lymphadenopathy on the right cervical region. An ultrasound guided-FNA cytology shows clusters of follicular cells forming micro- and macro-follicles with background of hemorrhage but no colloid is seen. Cytology is suspicious of a follicular neoplasm, Bethesda IV category. Diagnostic Lobectomy is discussed but the patient opts for repeat biopsy at a different facility. She presents with a similar cytology result after 3 months. She elects follow up as she remains asymptomatic. After 6 months follow up, she has spontaneous reduction of the nodule size and it is not palpated. Neck US shows diffusely heterogeneous gland with hypoechoic areas and significant reduction in size of the right hyperechoic nodule to 22×14×11 mm. Ultrasound findings are suggestive of thyroiditis and further labs are requested. Thyroid peroxidase antibodies &amp;gt;1000 iu/mL (N: &amp;lt;5.61), anti-thyroglobulin antibodies 161.71 iu/mL (N: &amp;lt;4.11), TSH 3.4 uiu/ml (N: 0.35-4.9), free T4 is 10.38 pmol/L (N: 9-19), thyroglobulin 76.76 ng/mL (N: 3.5-77). These findings suggest that HT may present as a localized form in euthyroid phase and should be considered in the differential diagnosis of thyroid nodule. Serologic evidence of HT and serial US follow-up should be recommended instead of other unnecessary procedures. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

LBSAT310 A Rare Disease Engulfing Thyroid And Masquerading As Common Thyroid Disorders

Abstract Introduction – Langerhans cell histiocytosis (LCH) is a rare clonal disorder caused by the CD207+ Langerhans cells derived from the myeloid origin. We present a case of LCH where it mimicked Hashimoto's and Riedel's thyroiditis and completely infiltrated the thyroid gland. Case description – A 54-year-old female was initially diagnosed with hypothyroidism, goiter, and bilateral parotid and submandibular glands enlargement. CT imaging revealed a diffuse goiter which imposed infraglottic airway narrowing and a suspicious left inferior thyroid nodule. Biopsy revealed atypia of undetermined significance. GSC showed a 50% suspicion of malignancy with a negative BRAF. Follow up imaging revealed increased infiltrative masses within the salivary glands, enlarging thyroid gland, and increased infiltration of the superior component of the right thyroid lobe into the submandibular space. A core needle biopsy revealed a background of acute and chronic inflammation without evidence of malignancy. Sjogren's, sarcoidosis and IgG4 diseases were ruled out. She was then referred to us after a myriad of work up. She had a diffusely enlarged goiter with a crusted area of skin over the thyroid gland and significant bilateral parotid swelling. We repeated a thyroid ultrasound which revealed diffusely enlarged and heterogeneous thyroid glands with pseudo-nodules and 3 suspicious nodules greater than 1cm on right and left lobes. She also had prominent reactive lymphadenopathy. Her submandibular glands were hypoechoic, avascular, markedly enlarged and abnormal appearing. She underwent total thyroidectomy. Pathology revealed proliferation of histiocytes, few islands of lymphoid tissue, and eosinophilic micro abscesses without any identifiable thyroid parenchyma in the entire resected specimens. Immunohistochemistry confirmed the diagnosis of Langerhans Cell Histiocytosis with atypical features. BRAF (V600E/V600K) mutation was again not detected. Flow cytometry showed no evidence of neoplastic myeloid blast population. She was referred to an oncologist for further management of LCH. Discussion – Our patient had a remarkably diffuse goiter with a sonographic appearance mimicking Hashimoto's thyroiditis or Riedel's thyroiditis. Initial thyroid FNA failed to reveal LCH. The diagnosis was reached only after total thyroidectomy. Treatment depends on single or multi-system involvement, presence or absence of risk organ involvement, and presence or absence of BRAF mutation. Conclusion In the cases of infiltrated thyroid diseases, Langerhans cell histiocytosis should be on the differential diagnosis, especially if there is concomitant infiltrative process in other organs. The sonographic finding can mimic Hashimoto's or Riedel's thyroiditis which may lead to misdiagnosis and treatment delay. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

ODP522 Thyroid Sarcoidosis: A Rare Manifestation of Systemic Sarcoidosis

Abstract Introduction Sarcoidosis is a multisystem granulomatous disease of unknown aetiology characterized by noncaseating granulomas. Thyroid infiltration remains extremely rare. If present, it can cause diffuse goitre and rarely a solitarythyroid nodule. Almost all patients are euthyroid. Here, we report a case of systemic sarcoidosis with thyroid involvement. Case presentation A21-year-old female of Nepalese origin with past medical history of Asthma presented with painful eyes and was diagnosed with bilateral anterior uveitis. Symptoms improved with topical Dexamethasone and Cyclopentolate. A screening chest radiograph showed significant hilar adenopathy. Chest CT scan confirmed extensive mediastinal adenopathy particularly in the right paratracheal, subcarinal and hilar node suggestive of sarcoidosis. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) revealed non-necrotising granulomas. There was no evidence of tuberculosis on any materials obtained. TB-PCR and AFB were both negative. Further investigations showed raised serum ACE (163 units/L) with normal adjusted calcium levels and normal 24-hour urine calcium levels. During follow up, she developed palpable cervical and submandibular lymphadenopathy. Systemic examination revealed a smooth goitre and erythema nodosum. She did not have any neck pain and remained clinically euothyroid. Thyroid ultrasound showed several small microlobulated hypoechoic regions in both thyroid lobes, the largest measuring 7 mm in the right and left upper poles. Fine needle aspiration cytology revealed granulomata consistent with thyroid sarcoidosis. The thyroid MDT recommend conservative management with periodic clinical and biochemical assessment. She remains well at 6 months of follow up. Conclusion Sarcoid granulomata within the thyroid gland remains rare. This case report illustrates that in patients with known sarcoidosis, careful thyroid assessment should be carried out. Presentation: No date and time listed

RF11 | PMON26 A Lump By Any Other Name: A Case of Diffuse Large B Cell Lymphoma of the Thyroid

Abstract Patient is a 49-year-old female with a past medical history of hypothyroidism who presented to the endocrinology office for evaluation of a neck mass. A thyroid ultrasound in 2020 had shown significantly enlarged and diffusely heterogenous thyroid gland compatible with diffuse thyroid goiter without nodules. Her neck swelling worsened and therefore a thyroid ultrasound was repeated and showed a large hypoechoic nodule in the left thyroid gland. She had no symptoms such as night sweats, fevers, or weight loss. A computed tomography (CT) scan of the neck with contrast was obtained on 7/20/2020 showing a markedly enlarged thyroid gland with multiple &amp;gt;1 centimeter (cm) thyroid nodules, with a suspected exophytic extension nodule medial to the left lobe. Multiple adenopathy was present with an enlarged left lower cervical lymph node and a right-sided level 4 lymph node concerning for thyroid malignancy with local metastatic disease. She underwent a fine needle aspiration (FNA) with flow cytometry of the lymph node on 9/2/2020 which was benign. Her goiter continued to increase in size and she was referred to endocrine surgery for fine needle core biopsy of the left thyroid nodule which was favorable for diffuse large B cell lymphoma (DLBCL) with a germinal center phenotype on 4/5/2021. Flow cytometry was positive for CD-10 mature B cells. FNA biopsy of the left lower cervical lymph node showed polymorphic lymphocytes and rare macrophages. She was staged IIE. She underwent 4 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and received 18 rounds of consolidation radiation after completion of chemotherapy. She had near-complete response to treatment and is now monitored through routine follow-ups. Primary thyroid lymphoma is a rare condition characterized as a lymphomatous process involving the thyroid gland without any contiguous spread or distant metastasis at the time of diagnosis. It comprises nearly 1% to 5% of all thyroid malignancies and is more common in women. DLBCL is the most common histiotype and accounts for 50% to 70% of all cases. Patients may notice a unilateral or bilateral rapidly enlarging neck mass with compressive symptoms, but B symptoms are less common. Nearly 30% to 40% of patients carry a diagnosis of hypothyroidism at the time of diagnosis as the lymphomatous process replaces the normal thyroid parenchyma. Diagnosis is made usually via core needle biopsy and flow cytometry since FNA biopsy is frequently inconclusive. Treatment is with chemotherapy, usually R-CHOP, and radiation therapy with an overall 5-year prognosis of 34.5%. Surgical decompression may be necessary if compressive symptoms are present. While this is a rare disease, providers should be cognizant of DBLCL especially when faced with a presentation such as the one summarized in this report. Presentation: No date and time listed

ODP521 THYROID HORMONE RESISTANCE SYNDROME

Abstract Introduction The Thyroid hormone resistance syndrome is characterized by decreased tissue sensitivity to thyroid hormones. The incidence is about 1/50,000. We present two clinical cases of this disease. Clinical case 1A 59-year-old woman was evaluated for presenting palpitations for more than one year during exercise and rest. Also, she noticed heat even in the winter. Headache, hair loss, dry skin, capillary fragility were other complaints. She denies trembling in the hands, diarrhea and subcutaneous edemas. Cardiologist didn't find any cardiac alterations. Holter showed sinus tachycardia with average heart rate 84/min (59-135/min). No evidence of ectopic beats. Bisoprolol 5mg/day was indicated. Three years ago, in routine control "high thyroid hormones" was found. A year ago, one doctor said her "that she had altered thyroid hormones". Her daughter has hyperthyroidism recentely diagnosed. The physical exam showed uniform goiter. Not acanthosis. Slight distal tremor. Soft skin, no edemas. No exophthalmos. Her first blood profile showed: Total T3 1.15 (0.8-2), Total T4 14.34 (5.1-14.1) TSH 5.43 (0.27-4.2) Free T4 1.81 (0.93-1.7). The second one showed Free T3 3.25 (2-4.4), Free T4 1.94 (0.93-1.7), TSH 4.78 (0.27-4.2). The thyroid antibodies: TSI, AbTG and AbTPO were negative. Pituitary hormone profile was normal and according to the age. Pituitary MRI was normal. Clinical case 2 A 15-year-old male was evaluated for tachycardia, weight loss, nervousness, anxiety, and sweaty hands. Evaluated by Cardiology, the Holter monitor shows sinus tachycardia. In endocrinology department, the clinical evaluation showed only goiter and sweaty hands. Hepatic and renal profile were normal. Urinary and blood catecholamines and norepinephrine were normal. His first blood profile showed: Total T3 1.54 (0.8-2), Total T4 14.56 (5.1-14.1) Free T4 1.79 (0.93-1.7), TSH 0.54 (0.27-4.2). The second profile: Total T4 14.37 (5.1-14.1), Free T4 1.8 (0.93-1.7), TSH 0.48 (0.27-4.2). The thyroid antibodies: TSI, AbTG and AbTPO were negative. The thyroid ultrasound showed diffuse goiter. The pituitary MRI didn't show any lesions. He started treatment with Metoprolol every 24 hours. In both patients, we can´t made genetic testing because is not available in country. Discussion The thyroid profile in patients with thyroid hormone resistance syndrome is very characteristic: they present with elevated free thyroid hormones and normal or slightly elevated TSH. It is important to rule out alterations in transporter proteins, the presence in serum of a factor that interferes with hormonal determination, or a TSH-producing pituitary tumor. The diagnosis requires a high degree of suspicion. BibliographyMARBAN CALZON, Mercedes; GONZALEZ JIMENO, Alicia; GARCIA BERMEJO, Alba, BELMONTE PINTRE, Zaira. Perfil hormonal tiroideo poco frecuente. Síndrome de resistencia a hormonas tiroideas. Rev Pediatr Aten Primaria[online]. 2019, vol.21, n.81BERNAL J. Sindromes de resistencia a las hormonas tiroideas. Endocrinología y Nutrición. 2011. Vol 58, Num 4.1 Presentation: No date and time listed

ODP515 Severe thyrotoxicosis caused by subacute thyroiditis

Abstract Background Subacute thyroiditis, also named giant cell thyroiditis, painful thyroiditis, and de Quervain's thyroiditis, usually presents with neck pain or discomfort, a tender diffuse goiter and mild or moderate elevation of serum free T4 and T3 levels. Here we report a case of subacute thyroiditis patient presenting with severe thyrotoxicosis. Clinical case: A 27-year-old woman with no significant past medical history presents to the emergency room with palpitations and abnormal EKG with heart rate at 160 beats per minute. She developed a sore throat 3 days prior to the presentation, but she did not have neck pain or fever. She reports a 3-month history of hair loss, headaches and weight gain. Labs showed significantly elevated free T4 greater than 7.7 ng/dl (0.8-1.7) and free T3 level at 20.7 pg/ml (2. 0-4.8), and suppressed TSH less than 0. 01 uIU/ml (0.45-4.5) and normal ESR at 15 mm/hour. Her TPO antibody was greater than 1300 u/ml. Thyroid stimulating immunoglobulin (TSI) and TSH receptor antibody (TRab) were obtained but results were pending when she was discharged from the hospital. She has no typical clinical features of subacute thyroiditis with normal ESR and her free T3 and free T4 levels were significantly elevated. She was discharged on Methimazole and Propranolol and to do neck ultrasound as outpatient and follow-up TSI and TRab results and repeat free T4 and T3 in 1 week. Her neck ultrasound revealed mild hypervascularity but no Graves’ features. Her TSI and TRab were negative and free T4 level had no improvement even on significant dose of Methimazole. All the findings argue against Graves’ disease, but support subacute thyroiditis. Then Methimazole was discontinued and Prednisone was started at 20 mg daily and quickly taper to 5 mg daily in 2 weeks then stopped. After on Prednisone for 3 weeks, her free T4 was close to normal at 2. 0 ng/dl, T3 normal at 120 ng/dl, although TSH is suppressed. After stopped Prednisone for 2 weeks, her free T4, T3 and TSH were all back to normal. She is currently euthyroid without any medication at 5 months after her initial presentation. Conclusion Treatment of patients with subacute thyroiditis is pain relief with NSAID or Prednisone when NSAID is not effective. Anti-thyroid medications are rarely effective even in subacute thyroiditis patient with thyroid storm. Our case illustrated the role of corticosteroids in the treatment of subacute thyroiditis patient with severe thyrotoxicosis. Neck ultrasound and thyroid antibodies including TSI and TRab are critical to make a correct diagnosis in subacute thyroiditis patient with severe thyrotoxicosis. Presentation: No date and time listed