Left Thyroid Lobe Research Articles

Synchronous Occurrence of Papillary Thyroid Carcinoma and Mucosa-Associated Lymphoid Tissue Lymphoma: a Single Case Report

Papillary thyroid carcinoma (PTC) is a common lesion, accounting for 70–80% of all thyroid cancers, whereas mucosa-associated lymphoid tissue (MALT) lymphoma of thyroid gland is rare. A simultaneous occurrence of both malignancies is extremely rare. 57 years old Korean woman diagnosed with Hashimoto' s thyroiditis at left lobe of thyroid gland where atypical cells of undetermined significance at right lobe. Later, left lobe was confirmed with malignant lymphoma during series of fine-needle aspiration biopsy. Right lobe was interpreted as malignant lesions, such as papillary thyroid carcinoma based on ultrasonography images and previous biopsy results. Total thyroidectomy was performed. Pathology reported papillary thyroid carcinoma at right lobe and MALT lymphoma at left lobe. There were no post-operative complications and no recurrence yet reported. Since an association between Hashimoto' s thyroiditis and development of MALT lymphoma has been reported previously, a history of Hashimoto thyroiditis should be suspected MALT lymphoma.

Primary Mucosa-Associated Lymphoid Tissue Lymphoma of Thyroid with the Serial Ultrasound Findings.

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) of the thyroid gland is uncommon. Even though its natural history is not well defined, it is known to be indolent course. We present a case of primary MALT thyroid lymphoma with the serial sonographic findings in the patient presenting as the focal nodule. A 45-year-old woman visited our hospital for neck examination. Initially, fine-needle aspiration cytology in the focal hypoechoic lesion in the left thyroid lobe on ultrasound sonography was performed and consistent with Hashimoto's thyroiditis. However, the results of serial ultrasounds and core-needle biopsy revealed an extranodal marginal zone lymphoma of MALT on 4-year follow-up. Patients with a focal hypoechoic nodule with linear echogenic strands and segmental pattern in the background of Hashimoto's thyroiditis on ultrasonography should undergo careful surveillance for malignancy. Serial sonographic features in this case are meaningful in the understanding of the natural history of the extranodal marginal zone lymphoma of MALT of the thyroid.

Development of an Interactive GUI Tool for Thyroid Uptake Studies using Gamma Camera

Thyroid uptake study is a technique that requires injection of a radio-isotope/radiotracer emitting gamma rays into the blood stream of the patient to study the functionality of thyroid in accordance to its uptake. The Gamma Camera uses a LEAP (Low Energy All Purpose) collimator which handles only photons emitted from radio-isotopes having lower emission energies. Technetium-99m is used whose energy of emission is around 140 keV. For a typical Thyroid Uptake Probe where Iodine-131 having greater emission energy of 364 keV is preferred, but existing Thyroid Uptake software is not feasible. Therefore an Interactive GUI (Graphical User Interface) tool was developed using Fiji for determination of tracer uptake by manually drawing the Region of Interest around left and right thyroid lobes separately. Developed tool was tested on 35 real time thyroid cases and the uptake values obtained are compared with those obtained from the existing software tool.

Cervical Paraganglioma Mimicking Thyroid Nodule: A Rare Clinical Case.

Objective. Paraganglioma is a rare neuroendocrine tumor. When it is located in the neck, it is commonly misdiagnosed as other thyroid neoplasms. Case Report. We report a case of cervical paraganglioma in a 55-year-old female. Patient was admitted to our clinic with goiter and neck pain. Thyroid ultrasonography revealed a 20 mm solitary, heterogeneous nodule located in the upper pole of left thyroid lobe. Fine needle aspiration cytology was nondiagnostic. She underwent left lobectomy and histopathology showed paraganglioma. Discussion. Cervical paragangliomas should be considered in the differential diagnosis of thyroid nodules.

Thyroid Ultrasound Pitfalls: Esophageal Fibrovascular Polyp Mimicking Thyroid Nodule.

Background. Ultrasound (US) is the most accurate tool in the diagnosis of thyroid nodules if performed by expert physician. Misdiagnosis due to extrathyroidal lesions mimicking thyroid nodules is reported in literature. We describe the first case of an esophageal fibrovascular polyp misdiagnosed as a thyroid nodule on US examination. Patient Findings. A 54-year-old woman presented to emergency department for headache and underwent carotid Doppler extended to neck ultrasound with incidental finding of a nodule in the posterior side of the left thyroid lobe. A following thyroid US performed by an endocrinologist allowed the characterization of the lesion as an esophageal pathology, considering the extrathyroidal position, the typical peripheral hyperechoic spots and hypoechoic rim, the connection to the esophagus, and the swallowing connected movement. The patient was addressed to further investigations and finally to anterior pharyngotomy with histological diagnosis of esophageal fibrovascular polyp. Summary. Differential diagnosis between thyroid nodules and other neck lesions is important to prevent an unnecessary fine needle aspiration biopsy and to treat the extrathyroidal pathology. In this case, an US performed by an expert endocrinologist allowed detecting an esophageal fibrovascular polyp requiring surgical removal. In conclusion, the possibility of an esophageal pathology, and even fibrovascular polyp, should be considered during US thyroid examination.

Parathyroid Adenoma Completely Impacted within the Thyroid Gland: A Case Report

Ectopic parathyroid adenoma can be seen in various locations. Sometimes ultrasound and even fine needle aspiration studies cannot distinguish this lesion from thyroid lesions. A 29-year-old woman with a prominent nodule of left thyroid lobe was referred to surgical department. Thyroid function test were normal. She had no family history of parathyroid disease, other endocrine disease, and any other malignancies and had received no radiation. Ultrasonography revealed a solid and hypoechoic mass, 25x20 mm in size, with a regular shape and contour without calcification in the inferior of left lobe of the thyroid gland. For definite diagnosis, immunohistochemistry study of the lesion with three markers was done. Finally, PTH marker was positive in cytoplasms of cells so parathyroid adenoma was confirmed. Fine needle aspiration of the nodule was suspicious for follicular neoplasm; however, postoperative histopathology and immunohistochemistry revealed a parathyroid adenoma. Ultrasonography may be helpful to identify localized thyroid lesions especially in parathyroid adenoma.

Progressive Tracheal Erosion Consecutive to a Calcified Left Thyroid Lobe

A 66-year-old man came for treatment of neck pain associated with halitosis and lithoptysis. The patient had undergone right thyroid lobe resection 40 years earlier and had been treated with I 131 for a left thyroid adenoma. Computed tomography (CT) of the neck and chest evidenced a coarse dense calcification of the left thyroid lobe (Fig 1A). An air crescent was visible on axial CT (Fig 1B), suggesting a sinus toward the tracheal lumen. Bronchoscopy obviated an erosion of the left tracheal wall, disclosing the calcified thyroid (Fig 2A,B). The calcified left thyroid lobe was resected. The damaged tracheal wall was repaired by segmental resection. Follow-up bronchoscopy showed a satisfactory outcome.Fig 2View Large Image Figure ViewerDownload (PPT) Calcifications within the thyroid gland are common and may be a sign of benign or of malignant thyroid disease [1Komolafe F. Radiological patterns and significance of thyroid calcification.Clin Radiol. 1981; 32: 571-575Abstract Full Text PDF PubMed Scopus (32) Google Scholar]. Coarse calcification is caused by abnormal calcium deposition in the thyroid tissue, usually following inflammation or necrosis [1Komolafe F. Radiological patterns and significance of thyroid calcification.Clin Radiol. 1981; 32: 571-575Abstract Full Text PDF PubMed Scopus (32) Google Scholar]. In our patient, I 131 therapy seemed to be the first cause of the inflammation and necrosis, leading to calcification. Skin sinus formation from a calcified thyroid cyst has been described in prior reports [2Pal I. Sengupta S. Ramaswamy B. Saha S. Benign calcified thyroid cyst with skin sinus formation.Laryngoscope. 2008; 118: 75-77Crossref PubMed Scopus (4) Google Scholar]. This is a rare description of tracheal erosion and tracheal sinus formation.

Synchronized occurrence of oncocytic variant of papillary carcinoma of the thyroid and esophageal squamous cell carcinoma metastasis: case report

Metastasis to the thyroid is extremely rare. In recent years, there is an increase in metastasis to the thyroid. This may be related with common use of the fine-needle aspiration biopsy. Synchronized occurrence of the oncocytic variant of papillary carcinoma of the thyroid and metastasis into thyroid, especially of esophageal origin, is very rarely seen. We present a rare case of a 56-year-old female in whom a primary esophageal squamous cell carcinoma gave rise to a metastatic palpable mass in the left lobe of thyroid gland and oncocytic variant of papillary carcinoma of the thyroid in the right lobe of thyroid gland. J Clin Exp Invest 2015; 6 (4): 396-399 Key words: Metastasis, papillary carcinoma, squamous cell carcinoma, thyroid

(99m)Tc-MIBI Uptake in a Thyroid Adenoma with Diffuse Adipose Metaplasia.

A 71-year-old female underwent a (99m)Tc-MIBI scan to characterize a cold nodule (30mm) of the left thyroid lobe. The nodule showed diffuse uptake and retention of the radiotracer. After resection, histological examination demonstrated a microfollicular adenoma with diffuse white adipose metaplasia. Although mitochondria in brown adipose tissue have been widely studied, we have only a limited understanding of the relevance of mitochondria in white adipose tissue. Active mitochondria are present in white adipocytes, and this may account for the MIBI uptake, mimicking a hyperproliferation pattern, in our patient.

MULTIPLE MORPHOLOGICAL VARIATIONS IN THE THYROID GLAND: REPORT OF TWO CASES

The variety of multiple morphological variations in the thyroid gland is found as a result of disturbed organogenesis in humans as agenesis, hypoplasia, accessory, ectopy and hemiagenesis. In the routine undergraduate dissection of the thyroid gland, multiple anomalies of the thyroid gland were encountered in 50 and 60 years old female and male cadaver respectively. These were in form of absent isthmus with accessory thyroid lobe in between two lateral lobes, pyramidal lobe arising from left lobe of thyroid with levator glandulae thyroidae in first case. Second case showed narrow isthmus related to first tracheal ring and levator glandulae thyroidae arising from left lobe. In these case studies, we highlight various developmental anomalies of the thyroid gland as absent isthmus, pyramidal lobe and accessory lobe with levator glandulae thyroidae. Hence a thorough knowledge of such morphological variations of thyroid gland helps the surgeons in better planning of safe, effective and uncomplicated operative procedures in resection of thyroid and tracheotomy procedures.

Oncocytic parathyroid adenoma

IntroductionFine-needle aspiration cytology (FNAC) of thyroid nodules commonly reveals the presence of oncocytic cells (or Hurthle cells) in a follicular neoplasm. Histological examination is necessary to determine the benign or malignant nature of the tumour. However, oncocytic cells are also normally present in the parathyroid glands. Case reportA thyroid nodule was discovered on thyroid ultrasound in a woman with a history of left partial thyroid lobectomy. Fine-needle aspiration cytology revealed a follicular neoplasm comprising oncocytic cells (Hürthle cells). This woman also presented features of hyperparathyroidism with hypercalcaemia. 123I/99mTc-sestamibi and 18F-fluorocholine PET-CT scan revealed increased uptake over the remaining left thyroid lobe. Left lobectomy was completed together with thyroid exploration. Histological examination revealed a parathyroid adenoma in the residual thyroid tissue. Parathyroid hormone levels subsequently returned to normal. DiscussionCytomorphological similarities are often observed between parathyroid and Hürthle cell thyroid tumours. The parathyroid rather than thyroid nature of the tumour must be strongly suspected preoperatively in the presence of hyperparathyroidism.

Moans, Bones, Groans, and a Thyroid Mass

Parathyroid carcinoma accounts for less than 1 per cent of cases of primary hyperparathyroidism.1, 2 Its synchronous occurrence with thyroid carcinoma is rarer still, with only seven such patients previously reported in the literature.3, 4 We report another case, unique not only because the parathyroid carcinoma was found within the left thyroid lobe but also because of the presence of a synchronous papillary thyroid carcinoma within the contralateral thyroid lobe. The case illustrates the need for surgeons to be aware of the possibility of concomitant thyroid pathology and the potential for the synchronous occurrence of other endocrine neoplasms. Our case is a 56-year-old female who presented with hypercalcemia, complaints of pain in her left shoulder and hip and a history of recurrent kidney stones over a period of several months. One year prior to the present admission she had undergone an extensive workup for an intrathyroidal lesion located within the central aspect of the left thyroid lobe and for bilateral adrenal incidentalomas measuring 4.3 cm on the right and 1.7 cm on the left. Fine-needle aspiration biopsy of the thyroid nodule revealed parathyroid tissue. Biopsy of the larger of the two adrenal lesions was negative for malignancy. At that time she had bilateral ureteral stents placed for obstructive uropathy. She was discharged with instructions to follow up after recovery from her ureteral stenting to undergo resection of her presumed intrathyroidal parathyroid adenoma. She subsequently was readmitted because of worsening bone pain. On her subsequent presentation, physical examination her of head, neck, and cervical nodal basins were normal. Laboratory evaluations revealed hypercalcemia with a serum level of 12.2 mg/dL and a parathyroid hormone (PTH) level of 1246 pg/mL. Radiological imaging confirmed pyelocalyectasis from an obstructed stent in her left ureter and areas of osteitis fibrosa cystica in her left iliac crest and left humeral head. She was treated with intravenous saline infusion, diuresis, and cinacalcet (Sensipar™, Amgen™, Thousand Oaks, CA) to acutely control her hypercalcemia. A percutaneous nephrostomy tube was placed within the left renal pelvis and replacement of both ureteral stents were performed to relieve her recurrent obstructive uropathy. Ultrasound demonstrated two lesions in the thyroid: a solid 5.6 × 3 × 3.4 cm mass in the left lobe and a 1.4-cm hypoechoic lesion in the central aspect of the right lobe. A Single-photon emission computed tomography (SPECT-CT) study demonstrated the presence of an intrathyroidal mass within the left lobe with imaging characteristics consistent with parathyroid tissue (Fig. 1A and B). A 24-hour urine for metanephrines and vanillylmandelic acid were within normal limits. Fig. 1 SPECT-CT Scan, (A) Nuclear parathyroid imaging. (B) Tracer accumulation in left thyroid bed. She underwent total thyroidectomy and biopsy of the remaining three parathyroid glands. The right thyroid lobe contained a firm mass surrounded by a sclerotic capsule and frozen section confirmed the mass in the right lobe to be a follicular variant of papillary thyroid carcinoma. Pathology also confirmed intrathyroidal parathyroid carcinoma in the left lobe. A bilateral central compartment neck dissection was then performed. Final pathological examination confirmed the presence of both carcinomas, and demonstrated nodal metastases of papillary carcinoma to the right paratracheal lymph nodes. Intraoperative PTH determinations were obtained and demonstrated a drop from a preexcision level of 3300 pg/mL to a steady state value of 259 pg/mL at 60 minutes. The patient was scheduled to receive radioactive I131 ablation and was given levothyroxine at a dose sufficient to achieve thyroid-stimulating hormone suppression due to her nodal metastases. She underwent periodic measurements of serum calcium and PTH for follow-up of her parathyroid carcinoma. In addition, laparoscopic resection of her 4.3-cm nonfunctioning adrenal incidentaloma is planned, as is close follow-up of the contralateral smaller adrenal lesion to ensure benign biologic behavior. Parathyroid carcinoma, itself a rare tumor may be very rarely accompanied by synchronous thyroid cancer. More commonly parathyroid carcinoma may coexist with another parathyroid disease process, such as a parathyroid adenoma, hyperplasia, or a second parathyroid carcinoma.1–4 Our case of synchronous thyroid and parathyroid carcinomas is only the eighth such case reported3–4 (Table 1), and the first to coexist with bilateral adrenal incidentalomas. The spectrum of endocrine neoplasms encountered in this patient suggests the possibility that she has a genetic predilection for the development of endocrine neoplasia, albeit not the classically described syndromes of multiple endocrine neoplasia 1 or 2. Table 1 Previous Reported Cases of Synchronous Thyroid and Parathyroid Carcinoma

Open and Endoscopic Management of Fourth Branchial Pouch Sinus – Our Experience

Introduction Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common and usually present with recurrent left thyroid lobe abscesses. Objectives The authors present their experience in treating such cases that were observed exclusively in children. Methods The study involved performing a retrospective review of five cases in PSG Institute of Medical Sciences & Research. All cases were evaluated radiologically and with Direct Rigid hypopharyngoscopy. Definitive surgery was performed, including hemithyroidectomy. Results The patients consisted of five children, two boys and three girls. All of them presented with recurrent episodes of neck infection. Investigations performed included computed tomography (CT) fistulography, rigid hypopharyngoscopy and ultrasound, which were useful in preoperatively delineating pyriform sinus fistulous tract. All patients underwent neck exploration with excision of the fistulous tract and hemithyroidectomy. Upon follow-up, all patients are asymptomatic. Conclusions Recurrent neck abscesses in a child should alert the clinician to the possibility of a fourth branchial arch anomaly; therefore, children with this condition require a complete evaluation so the anomaly can be ruled out.

Parathyroid Carcinoma Manifesting as Recurrent Nephrolithiasis

Objective: To present a rare case of primary parathyroid carcinoma and discuss its clinical findings and management.
 Methods:
 Study Design: Case Report
 Setting: Tertiary Government Hospital
 Patient: One
 Results: A 54-year-old woman presented with a 3-year history of recurrent nephrolithiasis despite several courses of shock wave lithotripsy. She had persistent hypercalcemia and parathyroid hormone levels were noted to be elevated. Neck ultrasound showed a hypoechoic solid nodule measuring approximately 1.7 x 1.6 cm in the lateral inferoposterior aspect of the left thyroid lobe. Parathyroid scintigraphy revealed a focal uptake on the left lower thyroidal bed. The patient underwent left inferior parathyroidectomy with subtotal thyroidectomy and isthmusectomy Frozen section reported a parathyroid tumor and the final histopathologic results revealed a parathyroid carcinoma.
 Conclusion: A rare case of parathyroid carcinoma was presented, manifesting with recurrent nephrolithiasis. Elevated serum calcium and intact parathyroid hormone (iPTH) can confirm a primary hyperparathyroid problem. Neck ultrasound and parathyroid scintigraphy help in the localization of a parathyroid tumor. Only final histopathologic results can confirm the diagnosis of parathyroid carcinoma. Complete surgical excision is the treatment of choice and offers a good prognosis.
 Keywords: Parathyroid carcinoma, primary hyperparathyroidism

Killian-Jamieson Diverticulum Mimicking a Thyroid Tumor

A 42-year-old woman was referred to us for evaluation of a suspicious mass in her left thyroid gland. She had experienced left anterior neck pain and odynophagia for a few weeks. Ultrasonography (US) demonstrated a heterogenous and hypoechoic mass with bright internal hyperechoic foci and a partial surrounding halo involving the posterior aspect of the left thyroid lobe (Figure 1). Computed tomography (CT) of the neck with contrast enhancement demonstrated a soft tissue mass with internal air between the left back side of the thyroid and esophagus (Figure 2). Barium swallow pharyngoesophagography showed a barium-filled sac protruding from the left anterolateral wall of the cervical esophagus (Figure 3).

Prevalence of ectopic intrathyroidal thymus in Japan: the Fukushima health management survey.

Ectopic intrathyroidal thymus is thought to be a rare entity, often discovered incidentally, and is due to aberrant thymic migration during embryogenesis. The aim of this study was to determine the prevalence of ectopic intrathyroidal thymus in children using ultrasound screening. This study was cross-sectional and was conducted with the initial preliminary survey of the Fukushima Health Management Survey between October 9, 2011, and March 31, 2012, after the Fukushima Daiichi Nuclear Power Plant accident. A total of 37,816 children were examined in the survey. Diagnostic criteria are based on the ultrasonographic appearance of ectopic intrathyroidal thymus, which were round, oval, or polygonal hypoechoic or hyperechoic areas, with multiple granular and punctate echogenic foci. A total of 375 (0.99%) cases (164 girls) with ectopic intrathyroidal thymus were observed. The mean age was 7.0 years (range 0-18 years). Ectopic intrathyroidal thymus was located in the right (n=180), left (n=178), or bilateral (n=17) thyroid lobes. The incidence of ectopic intrathyroidal thymus was inversely correlated with age and body mass index. The results reflect the prevalence of ectopic intrathyroidal thymus using ultrasonography in the general population. Further examination will be needed by way of longitudinal follow-up.

Real-time shear wave elastography may predict autoimmune thyroid disease.

To evaluate and compare the values of the elasticity index as measured by shear wave elastography in healthy subjects and in patients with autoimmune thyroid disease, in order to establish if this investigation can predict the occurrence of autoimmune thyroid disease. A total of 104 cases were included in the study group: 91 women (87.5%), out of which 52 (50%) with autoimmune thyroid disease diagnosed by specific tests and 52 (50%) healthy volunteers, matched for age and gender. For all the subjects, three measurements were performed on each thyroid lobe and a mean value was calculated. The data were expressed in kPa. The investigation was performed with an Aixplorer system (SuperSonic Imagine, France), using a linear high-resolution 15-4 MHz transducer. The mean value for the elasticity index was similar in the right and the left thyroid lobes, both in normal subjects and in patients with autoimmune thyroid disease: 19.6 ± 6.6 vs. 19.5 ± 6.8 kPa, p = 0.92, and 26.6 ± 10.0 vs. 25.8 ± 11.7 kPa, p = 0.71, respectively. This parameter was significantly higher in patients with autoimmune thyroid disease than in controls (p < 0.001). For a cut-off value of 22.3 kPa, which resulted in the highest sum of sensitivity and specificity, the elasticity index assessed by shear wave elastography had a sensitivity of 59.6% and a specificity of 76.9% (AUROC = 0.71; p < 0.001) for predicting the presence of autoimmune thyroid disease. Quantitative elasticity index measured by shear wave elastography was significantly higher in autoimmune thyroid disease than in normal thyroid parenchyma and may predict the presence of autoimmune thyroid disease.

Hemi agenesis of Thyroid Gland in a Euthyroid Child having Positive Family History of Thyroid Disorder

Thyroid Hemiagenesis (THA) is a rare form of thyroid developmental anomaly. This developmental defect may or may not coincide with hormonal dysfunction. The detection of anomaly is quite incidental and infrequently found during investigations assessing thyroid functions. A three years old boy presented with gradual swelling in front of neck during last 2 months. He had no history of delayed milestones. Ultrasound imaging and thyroid scan by 99m -Technetium- pertechnetate revealed hemi agenetic development of left lobe of thyroid gland. His biochemical assessment showed euthyroid state. He had positive family history with hypothyroid maternal grandmother and congenital hypothyroid maternal cousin. Ultrasonography and thyroid scan are useful tools for demonstrating this form of dysgenesis of thyroid gland. Follow up monitoring of thyroid function at regular interval in children with congenital anomaly of thyroid gland should be done to take timely measures, if required. DOI: http://dx.doi.org/10.3329/bjnm.v17i1.22501 Bangladesh J. Nuclear Med. 17(1): 104-110, January 2014

Thyroid-specific changes following treatment with biological therapies in patients with rheumatic diseases.

Biological anti-rheumatic agents (BAA) may induce autoimmune phenomena. Evidence on thyroid-specific effects of these agents is relatively limited. We studied prospectively, over 3 years, 36 rheumatic patients treated with BAA (18 Infliximab and 18 Rituximab) and no prior exposure to biological therapies (group-1), with respect to their thyroid function, thyroid antibody titers, and thyroid ultrasonographic parameters, such as left inferior thyroid artery peak systolic velocity (ITA PSV), left thyroid lobe vascularity index (TL VI), and echogenicity. Twenty-eight rheumatic patients treated with disease-modifying anti-rheumatic drugs and/or glucocorticoids (group-2), 21 rheumatic patients not receiving any treatment (group-3), and 49 healthy individuals (group-4) were used for comparison. Thyroid function and autoantibody titers were not significantly altered at any stage irrespectively of the administered BAA, previously unknown autoimmune thyroid disease (AITD) status, and/or concomitant treatment with glucocorticoids. Left ITA PSV was significantly increased in group-1 patients (mean ± SD start: 25.5 ± 14.1 cm/s vs. end: 29.8 ± 11.1 cm/s, p = 0.038 and p < 0.001, respectively). Six group-1, 7 group-2, and 3 group-3 patients developed reduced thyroid echogenicity during follow-up (start: p = 0.003 and end: p < 0.001). Left ITA PSV, left TL VI, and echogenicity changes were not related to alterations in thyroid volume, thyrotropin hormone levels, and/or underlying AITD. Infliximab and Rituximab do not cause any alterations in thyroid function and/or autoimmunity, even in patients with previously undiagnosed AITD. Elevated left ITA PSV and reduced thyroid echogenicity may be early features signaling progression to AITD in patients treated with BAA.

Functional parathyroid cyst in a patient with systemic lupus erythematosus: a case report

SummaryFunctional parathyroid cysts are a rare cause of primary hyperparathyroidism and are often mistaken for thyroid cysts. Systemic lupus erythematosus (SLE) is also a very rare cause of hypercalcemia. We report the case of a 62-year-old woman, who was diagnosed with SLE 30 years ago, presenting with clinical and biochemical features of primary hyperparathyroidism. Laboratory investigation revealed increased serum calcium and parathyroid hormone (PTH) levels; neck ultrasonography (USG) revealed 40×34×26 mm cystic mass in the left lobe of thyroid gland. PTH level in the cysts was >2500 pg/ml, determined by USG-guided fine-needle aspiration (FNA). In this case, no evidence for potential pathogenic association between parathyroid cyst and SLE was uncovered. However, the recognition of this association is very important because the therapeutical strategy is completely different. Operative management is usually straightforward and alleviates symptoms and any biochemical abnormalities caused by the cyst.Learning points Functional parathyroid cysts are the rare cause of primary hyperparathyroidism and are often mistaken for thyroid cysts.SLE is also a very rare cause of hypercalcemia.Ultrasound-guided FNA of cystic fluid with assay for PTH level is an accurate method of differentiating parathyroid cyst from thyroid cyst.Appropriate management of functional parathyroid cysts is surgical excision.