Thyroid Scintigraphy Research Articles

Transoral endoscopic thyroidectomy by vestibular approach in Viet Nam: surgical outcomes and long-term follow-up.

The transoral endoscopic thyroidectomy by vestibular approach (TOETVA) has been developed for early-stage thyroid cancer treatment as well as benign thyroid nodules worldwide including Viet Nam, with low rate of complications and excellent results. However, there has not been any comprehensive studies with a large number of patients and long-term follow-up in our country. Therefore, we conducted this study to evaluate the results of treatment by TOETVA for benign and malignant lesions of thyroid gland in Viet Nam. A prospective study was performed on 326 eligible patients who underwent TOETVA due to thyroid cancer and benign thyroid nodules in Department of Oncology and Palliative Care, Hanoi Medical University Hospital from July 2018 to April 2021. The clinical, surgical, and pathological characteristics, postoperative complications, and visual analog scale (VAS, 0-10cm) score in day 1, 4, and 7 after surgery, long-term oncological and surgical outcomes were recorded. The mean age was 36.9 ± 9.8years. 231 patients (70.9%) were diagnosed with differentiated cancer and 95 patients (29.1%) were diagnosed benign tumors of thyroid gland. In the cancer group, 12 patients (5.2%) undergone TOETVA had T3b-intraoperative-stage diagnosis, 219 patients (92.2%) were diagnosed T1 according to AJCC 8th. After 1month of surgery, among thyroid cancer patients, there was no abnormality reported by thyroid scintigraphy and neck ultrasound as well as in unstimulated-Tg and anti-Tg values. The mean number lymph-node dissected in the cancer group was 6.1 ± 4.1 (range 0-21 nodes). However, only 2.6 ± 1.8 metastasis nodes were discovered (range 1-8 nodes), and the maximum size of these nodes was less than 2mm. 81 patients presented occult lymph-node metastasis among thyroid cancer patients with cN0 stage (account for 35%). The occult lymph-node metastasis was 34.2% and 50% in patients diagnosed with T1 and T3b groups, respectively. The median postoperative hospital stay was 5.4 ± 0.7days. Postoperatively, transient hypoparathyroidism was recorded in 12 patients (4.8%), transient hoarse was noted in 9 patients (3.6%), and numb chin was identified in 7 patients (2.8%). No permanent complication was noted. VAS score on first postoperative day was 4.5 ± 0.8. Median follow-up time was 12 (3-25) months. No recurrence was recorded. TOETVA is an innovative and revolutionary technique in the treatment of benign thyroid nodules, as well as early-stage differentiated thyroid cancer. The results of oncology, postoperative complications, and satisfied outcomes supported the wide application of TOETVA in Viet Nam.

Prevalence of Marine-Lenhart syndrome on 99mTc-thyroid scintigraphy and response to radioiodine: A single institutional retrospective study.

ABSTRACTMarine-Lenhart Syndrome is a rare entity, described as Graves’ disease with coexisting functioning thyroid nodules. It is often diagnosed on thyroid scintigraphy as a cold nodule with surrounding extranodular hyperactivity initially and postradioiodine ablation, they regain function on the follow-up thyroid scintigraphy due to endogenous thyroid-stimulating hormone (TSH) stimulation. We retrospectively reviewed all thyroid scintigraphy database performed between January 2018 and March 2020 in our institute. We searched patients with Graves’ disease with the following criteria to suggest Marine-Lenhart Syndrome: (a) initial thyroid scintigraphy showing features of Graves’ disease with coexistent poorly functioning nodules (b) There is normalization of uptake within the nodule on thyroid scan after radioiodine ablation suggestive of endogenous TSH stimulation (this also indirectly proves nodules are TSH dependent), (c) nodule(s) is/are benign on fine-needle aspiration cytology. Four patients (1.46%) were confirmed as Marine-Lenhart Syndrome as per the criteria. Three patients were female, and one was male. The eye signs were present in two of four patients. Two patients had two hypofunctioning nodules, whereas the remaining two had a single nodule and required re-ablation with radioiodine. Marine-Lenhart Syndrome requires special attention as these patients are relatively radioiodine resistant, require higher activity for iodine-131; however, it is curable with radioiodine treatment.

Thyroglossal duct cyst - old and new surgical approach

The thyroglossal duct cyst (TDC) results from a failure in obliterating the embryogenic duct produced during thyroid migration and it represents the most common type of developmental cyst encountered in the neck region. Material and methods: In the First Surgical Clinic from “Sf. Spiridon” County Clinical Emergency Hospital Iasi, Iasi, between 1998 to 2021, 21 patients with thyroglossal duct cyst were diagnosed and treated. All medical records were reviewed. Results: The thyroglossal duct cysts are located as midline cysts of the neck in all cases. The mean age was 39.2 years (13-66 years). The treatment performed was a variant of Sistrunk’s procedure in which the thyroglossal tract was excised to a variable extent, with central hyoidectomy. The size of the cyst ranged from 1.2 to 4 cm (mean 2.6 cm). Postoperative course was uneventful in all cases. No recurrence was recorded in this series. We describe a case, a 42 years old women, with asymptomatic mass in the anterior part of the neck found a 6 months before, when the patient was referred us with lithiasic obstructive jaundice (we performed ERCP + laparoscopic cholecystectomy). The treatment performed was a variant of Sistrunk’s procedure in which the thyroglossal tract was excised by minimally invasive video-assisted approach, variation of Miccoli’s technique. Postoperative course was uneventful. The follow-up 1 and 2 years no recorded recurrence and thyroid scintigraphy was normal. Conclusions: The standard surgical approach to TDC is Sistrunk’s operation with low recurrence rates. Although the results and the operative time are the same as in traditional surgery, minimally invasive video-assisted approach has better cosmetic result and a less painful course.

Comparison of Low-Energy and Medium-Energy Collimators for Thyroid Scintigraphy with123I

CE credit: For CE credit, you can access the test for this article, as well as additional JNMT CE tests, online at https://www.snmmilearningcenter.org Complete the test online no later than March 2025. Your online test will be scored immediately. You may make 3 attempts to pass the test and must answer 75% of the questions correctly to receive Continuing Education Hour (CEH) credit. Credit amounts can be found in the SNMMI Learning Center Activity. SNMMI members will have their CEH credit added to their VOICE transcript automatically; nonmembers will be able to print out a CE certificate upon successfully completing the test. The online test is free to SNMMI members; nonmembers must pay $15.00 by credit card when logging onto the website to take the test.123I thyroid scintigraphy can be performed with either a low-energy or a medium-energy (ME) collimator. The high-energy photon emissions from 123I cause septal penetration with scattered photons, which deteriorate image quality. The aim of this study was to evaluate the impact of collimator choice on 123I thyroid scintigraphy in clinical practice. Methods: Forty-seven patients who underwent thyroid planar scintigraphy with both a low-energy, high-resolution (LEHR) collimator and a ME collimator were prospectively recruited using the same imaging protocol. Image quality, collimator sensitivity, and estimation of thyroid size were assessed between LEHR and ME collimators and were compared with thyroid ultrasonography as the gold standard. Results: Images acquired with the ME collimator demonstrated reduced scattered background noise, improved thyroid-to-background contrast, and increased sensitivity in the thyroid gland compared with images acquired by the LEHR collimator. Manual measurement of the thyroid length is more accurate using the ME collimator. Automatic estimation of the thyroid area using the same thyroid threshold is larger in ME collimator images than in LEHR collimator images. Conclusion: Compared with the LEHR collimator, the ME collimator generates cleaner 123I thyroid scintigraphy images with less background noise and has higher collimator sensitivity for thyroid imaging. Different thyroid thresholds should be used to estimate the thyroid area and volume between low and ME collimators.

Türk Bir Popülasyonda Normal Tiroid Teknesyum- 99m Perteknetat Alım Aralığının Belirlenmesi

Aim: This study aimed to determine the normal range for thyroid uptake of technetium-99m (99mTc) pertechnetate in a Turkish population.Methods: The retrospective study included 73 (54 females, 19 males) consecutive euthyroid patients, all of whom underwent thyroid scintigraphy using 99mTc-pertechnetate as a component of parathyroid scintigraphy for parathyroid adenoma localization. The value of thyroid uptake of 99mTc-pertechnetate at the 20th minute was calculated for each patient.Results: The mean patient age was 56.4±15.2 years; the mean thyroid-stimulating hormone level was 1.15±0.48 uIU/mL. The median and interquartile range values of 99mTc-pertechnetate uptake were 0.8% and 0.56–1.15%, respectively. The normal range for thyroid uptake of 99mTc-pertechnetate was determined to be 0.26–1.64%. There was a negative correlation between 99mTc-pertechnetate uptake and age (r =-0.33, p=0.002).Conclusion: We propose that our new normal range for thyroid uptake of 99mTc-pertechnetate based on significantly lower values compared with those currently in use in Turkey is appropriate for use to evaluate thyroid function in thyroid disorders in the population of Istanbul.

Fusing deep and handcrafted features for intelligent recognition of uptake patterns on thyroid scintigraphy

Thyroid scintigraphy is an important investigation for the clinical diagnosis of thyroid diseases. Thyroid diseases often present characteristic abnormal patterns in scintigraphic images. In this study, we developed an automated recognition model for thyroid uptake patterns. These patterns were classified into six categories, and they are diffusely increased, diffusely decreased, heterogeneous, focally increased, focally decreased, and normal. This study is the first report on such data for automated thyroid pattern interpretation to the best of our knowledge. A thyroid uptake pattern recognition network (TPRNet) was developed, using deep and handcrafted features of thyroid patterns to perform classification. The method can be trained using the traditional back-propagation algorithm. An in-house dataset that contains 4263 thyroid scintigraphic images was constructed to train and validate the TPRNet. Furthermore, an external test dataset that includes 1318 images was constructed to test the TPRNet. Experimental results show that the proposed method is effective for recognizing thyroid patterns in scintigraphic images. It outperforms compared methods, notably in the external test dataset, demonstrating the good generalization ability of the TPRNet. The proposed method is also compared against four physicians’ judgments on recognizing thyroid patterns, resulting in a performance that is comparable to that of experienced doctors, showing that it could be used in clinical practice.

A dosing algorithm for individualized radioiodine treatment of cats with hyperthyroidism.

BackgroundRadioiodine (131I) is the treatment of choice for hyperthyroidism in cats, but current 131I‐dosing protocols can induce iatrogenic hypothyroidism and expose azotemia.ObjectivesTo develop a cat‐specific algorithm to calculate the lowest 131I dose to resolve hyperthyroidism, while minimizing risk of iatrogenic hypothyroidism and subsequent azotemia.AnimalsOne thousand and four hundred hyperthyroid cats treated with 131I.MethodsProspective case series (before‐and‐after study). All cats had serum concentrations of thyroxine (T4), triiodothyronine (T3), and thyroid‐stimulating hormone (TSH) measured (off methimazole ≥1 week). Using thyroid scintigraphy, each cat's thyroid volume and percent uptake of 99mTc‐pertechnatate (TcTU) were determined. An initial 131I dose was calculated by averaging dose scores for T4/T3 concentrations, thyroid volume, and TcTU; 80% of that composite dose was administered. Twenty‐four hours later, percent 131I uptake was measured, and additional 131I administered, as needed, to deliver an adequate radiation dose to the thyroid tumor(s). Serum concentrations of T4, TSH, and creatinine were determined 6 to 12 months later.ResultsThe median calculated 131I dose was 1.9 mCi (range, 1.0‐10.6 mCi); 1380 cats required additional 131I administration on day 2. Of the cats, 1047 (74.8%) became euthyroid, 57 (4.1%) became overtly hypothyroid, 240 (17.1%) became subclinically hypothyroid, and 56 (4%) remained hyperthyroid. More overtly (71.9%) and subclinically (39.6%) hypothyroid cats developed azotemia than euthyroid cats (14.2%; P < .0001).Conclusions and Clinical ImportanceOur algorithm for calculating individual 131I doses resulted in cure rates similar to historical treatment rates, despite much lower 131I doses. This algorithm appears to lower prevalence of both 131I‐induced overt hypothyroidism and azotemia.

A Rare Case of Coexistence Ectopic Lingual Thyroid and Thyroglossal Cyst with Tc 99m Thyroid Scintigraphy.

Lingual thyroid is a very rare anomaly and is usually incidentally found in patients that have hypothyroidism or mass in throat. This case however had another mass in the submandible with diagnosis of thyroglossal cyst. Thyroglossal duct cyst is the most common congenital neck mass. About 50% of cases present before the age of 10 and second group age present in young adulthood. We present a 27-year-old man who presented with sub-mental mass. The patient had also hypothyroidism. A CT scan was performed to confirm the diagnosis. The CT scan confirmed submental cyst and incidentally discovered lingual thyroid along with absence of thyroid tissue in its normal pretracheal position. The patient had symptoms of hypothyroidism and he was treated with levothyroxin. Our case report highlights a rare and unusual situation because of the coexistence of a thyroglossal cyst and a partially functional lingual thyroid.

Molecular Imaging for Thyrotoxicosis and Thyroid Nodules.

After exclusion of exogenous iodine overload, radioiodine uptake (RAIU) testing with 123I or 131I enables the accurate evaluation and quantification of iodine uptake and kinetics within thyroid cells. In addition, scintigraphic evaluation with 123I or 99mTc-pertechnetate (99mTc04-) provides the topographic distribution of thyroid cell activity and allows the detection and localization of ectopic thyroid tissue. Destructive thyrotoxicosis is characterized by abolished or reduced uptake whereas productive thyrotoxicosis (i.e., hyperthyroidism "sensu strictu") is characterized by high RAIU with scintigraphically diffuse (i.e., Graves disease and diffuse thyroid autonomy) or focal (i.e., autonomously functioning thyroid nodules [AFTN]) overactivity. Accordingly, RAIU or thyroid scintigraphy are widely used to differentiate different causes of thyrotoxicosis. In addition, several radiopharmaceuticals are also available to help in differentiating benign from malignant thyroid nodules and inform clinical decision making. In fact, AFTNs can be safely excluded from fine-needle aspiration biopsy while either 99mTc-methoxyisobutylisonitrile (MIBI) and 18F-FDG may complement the work-up of cytologically indeterminate cold nodules and contribute to reducing the need for diagnostic lobectomies/thyroidectomies. Finally, RAIU studies are also useful for calculating the administered therapeutic activity of 131I to treat hyperthyroidism and euthyroid multinodular goiter. All considered, thyroid molecular imaging allows us to characterize molecular/functional aspects of different thyroid diseases, even before clinical symptoms become manifest and remains integral to properly managing such conditions. Our present paper summarizes basic concepts, clinical applications, and potential developments of thyroid molecular imaging in patients affected by thyrotoxicosis and thyroid nodules.

CONGENITAL HYPOTHYROIDISM BY ATHYREOSIS About a new case from the Dysmorphology, Congenital and Developmental Anomalies Unit

&nbsp;The objective of this work is to contribute to the promotion of neonatal screening for congenital hypothyroidism in our daily practice. In the Kingdom of Morocco, neonatal screening is in the process of generalization, but some newborns escape this screening activity. The authors report the case of a female infant aged 14 months, resulting from a pregnancy followed and carried to term in a maternity hospital. She presented with a delay of psychomotor acquisitions with chronic constipation, macroglossia and respiratory difficulties.&nbsp; The clinical examination found a staturoponderal delay, facial puffiness, a hoarseness of the voice, an umbilical hernia and a psychomotor delay concerning the holding of the head and the sitting position. The biological assessment showed a deep peripheral hypothyroidism. The cervical ultrasound showed the absence of thyroid gland visualization. Thyroid scintigraphy with Tc99m showed the total absence of fixation of the tracer at the level of the thyroid lodge, absence of ectopic focus at the level of the axis of the thyroglossal tract. The bone age was in favor of the bone age of a newborn. Through this case, the authors underline the importance of carrying out neonatal screening for congenital hypothyroidism&nbsp; by all physician taking care&nbsp; all newborns while awaiting the generalization throughout the Morocco. All this, to avoid the serious and avoidable complications of this disease. &nbsp

Lingual thyroid: An incidental cytological finding

Lingual thyroid (LT) is a developmental defect due to the failure of the thyroid gland to descend to its normal cervical location during embryogenesis. Lingual thyroid has an overall prevalence of 1 in 100,000 to 1in 3,00,000 and is seven to ten times more common in females than in males .Lingual position represents the most frequent ectopic location accounting up to 90% of ectopic cases. It is found at the junction of the anterior two thirds and the posterior third, between the epiglottis and the circumvallate papillae. Most cases are asymptomatic, however, increase in size can cause local symptoms like upper airway obstruction, dysphagia and hemorrhage at any time from infancy to adulthood. Thyroid scintigraphy, neck ultrasound, CT- scan, MRI are some diagnostic modalities that play a vital role in diagnosing ectopic thyroid gland. Treatment of this anomaly includes exogenous L-thyroxine hormone administration, radioiodine ablation therapy and surgery. We hereby report a rare case of lingual thyroid in a young girl reported by fine needle aspiration cytology.

Dual attack: targeting the rare co-occurrence of myasthenia gravis and Graves' disease with radioactive iodine therapy.

SummaryOccasionally, autoimmune disorders can come in twos. This double trouble creates unique challenges. Myasthenia gravis co-existing with autoimmune thyroid disease occurs in only about 0.14–0.2% of cases. The patient is a 27-year-old man with a 2-month history of bilateral ptosis, diplopia, with episodes of easy fatigability, palpitations, and heat intolerance. On physical exam, the patient had an enlarged thyroid gland. Myasthenia gravis was established based on the presence of ptosis with weakness of the intraocular muscles, abnormal fatigability, and a repetitive nerve stimulation study indicated neuromuscular junction disease. Episodes of fluctuating right shoulder weakness were also noted. He was also found to have elevated FT3, FT4, and a suppressed TSH. Thyroid ultrasound revealed thyromegaly with diffused parenchymal disease. Thyroid scintigraphy showed increased uptake function at 72.4% uptake at 24 h. TRAb was positive at 4.1 U/L. Patient was started on pyridostigmine which led to a significant reduction in the frequency of ocular muscle weakness. Methimazole was also initiated. Radioactive iodine at 14.9 mci was instituted for the definitive management of hyperthyroidism. After RAI, there was abatement of the hyperthyroid symptoms, as well as improvement in the status of the myasthenia gravis, with ptosis, diplopia, and right arm weakness hardly occurring thereafter despite the reduction of the pyridostigmine dose based on a symptom diary and medication intake record. Two distinct autoimmune conditions displayed a markedly improved clinical course with the institution of radioactive iodine therapy for Graves’ disease.Learning pointsThe presence of ptosis, diplopia, and fluctuating muscle weakness are atypical in Graves’ disease and should prompt an investigation on the existence of concurrent myasthenia gravis. A prompt diagnosis of both conditions will enable the institution of appropriate management that would target both rare and challenging autoimmune diseases.Selecting the therapeutic options with minimal risk of morbidity and mortality, which could lead to maximal benefit especially in a resource-limited setting is paramount.Targeted non-surgical management can lead to the remission of two autoimmune diseases which can result in patient satisfaction and improved quality of life.

Further Evidence That Defects in Main Thyroid Dysgenesis-Related Genes Are an Uncommon Etiology for Primary Congenital Hypothyroidism in Mexican Patients: Report of Rare Variants in FOXE1, NKX2-5 and TSHR.

Mexico shows a high birth prevalence of congenital hypothyroidism (CH) due to thyroid dysgenesis (TD). PAX8 defects underlie only 1% of these cases and NKX2-1 does not seem to be involved. Here, we analyzed other TD-related genes in 128 non-related Mexican patients (females 77.3%; 6 months to 16.6 years) with non-syndromic CH-TD diagnosis established by clinical evaluation, thyroid hormone serum profiling, and scintigraphy (74%) or ultrasonography (26%). We performed Sanger sequencing of FOXE1, NKX2-5, and TSHR and evaluated copy number variations (CNVs) in TSHR, FOXE1, PAX8, and NKX2-1 by multiplex ligation-dependent probe amplification. Odds ratios for TD risk were explored for FOXE1 polyalanine stretches [polyAla-rs71369530] in cases and controls (N = 116). Five rare missense changes cataloged as benign (NKX2-5:p.(Ala119Ser)-rs137852684), of unknown significance (FOXE1:p.(Ala335Gly)-rs543372757; TSHR:p.(Asp118Asn)-rs1414102266), and likely pathogenic (FOXE1:p.(Gly124Arg)-rs774035532; TSHR:p.(Trp422Arg)-rs746029360) accounted for 1.5% (N = 2/128) of clinically relevant genotypes (supported in part by protein modeling) in CH-TD. No CNVs were identified, nor did polyAla > 14 alanines in FOXE1 significantly protect against TD. The present and previously published data collectively show that small clinically relevant germline variants in PAX8, FOXE1, and TSHR are found in only a very small proportion (2.5%) of isolated CH-TD Mexican patients.

Abstract #1004269: Subacute Thyroiditis in Patients Infected with SARS-COV-2

Subacute thyroiditis (SAT) is an inflammatory disorder of the thyroid gland that causes destructive thyrotoxicosis and is attributed to a viral or post-viral response. The Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus enters human cells through the angiotensin-converting enzyme 2 (ACE2) receptor. Thyroid follicular cells express the ACE2 receptor, thus making thyroid tissue a possible target of direct infection by the SARS-CoV-2 virus. The aim was to describe cases of SAT associated with SARS-CoV-2 infection to alert physicians that SAT may be a manifestation of SARS-CoV-2 infection. We describe clinical, biochemical, and imaging features of 11 patients with SAT related to SARS-CoV-2 infection. All patients were female (age, 30-45 years). Neck pain radiated to the jaw, fatigue, tremors, and palpitations were the main presenting symptoms and were associated with fever and asthenia. Physical examination revealed mild tremors of the extremities, a diffuse and painful goitre, and enlarged and tender cervical and submandibular lymph nodes. At biochemical evaluation, inflammatory markers were high. Thyroid function tests were suggestive of destructive thyroiditis. TSH was suppressed, free thyroxine (FT4) and free triiodothyronine (FT3) levels were elevated, and serum thyroglobulin was markedly increased (175 ng/ml; referral range 2.68-33.2). Anti-thyroid peroxidase, anti-thyroglobulin, and thyroid-stimulating hormone receptor antibodies were negative. At neck ultrasound the thyroid was enlarged, with diffuse and bilateral hypoechoic areas and absent vascularization at colour Doppler. Thyroid scintigraphy showed markedly reduced 99mTc-perthecnetate uptake in the gland. Reverse transcription-polymerase chain reaction for SARS-CoV-2 using nasopharyngeal and oropharyngeal swabs were positive. Chest X-rays and computed tomography scanning of the chest were normal. Symptoms were alleviated a few days after commencement of treatment (aspirin in 3 patients, prednisone in 2 patients, paracetamol in 3 and ibuprofen in 3) together with propranolol for tachycardia and tremors. Ten weeks after the onset of SAT, all patients were asymptomatic and inflammatory markers had returned to normal range. Eight patients were euthyroid, whereas 3 were with subclinical hypothyroidism. Conclusion: Clinicians should be aware of thyroid manifestations potentially associated with COVID-19.

Management of Thyrotoxicosis Induced by PD1 or PD-L1 Blockade.

ContextThyrotoxicosis is a common immune-related adverse event in patients treated with programmed cell death protein-1 (PD1) or programmed cell death protein ligand-1 (PD-L1) blockade. A detailed endocrinological assessment, including thyroid ultrasound and scintigraphy, is lacking, as are data on response to treatment and follow-up.ObjectiveThe aim of this study was to better characterize the thyrotoxicosis secondary to immune checkpoint inhibitors, gaining insights into pathogenesis and treatment.MethodsWe conducted a retrospective study of 20 consecutive patients who had normal thyroid function before starting immunotherapy and then experienced thyrotoxicosis on PD1 or PD-L1 blockade. Clinical assessment was combined with thyroid ultrasound, 99mtechnecium scintiscan, and longitudinal thyroid function tests.ResultsFive patients had normal or increased scintigraphic uptake (Sci+), no serum antibodies against the thyrotropin receptor, and remained hyperthyroid throughout follow-up. The other 15 patients had no scintigraphic uptake (Sci–) and experienced destructive thyrotoxicosis followed by hypothyroidism (N = 9) or euthyroidism (N = 6). Hypothyroidism was more readily seen in those with normal thyroid volume than in those with goiter (P = .04). Among Sci– individuals, a larger thyroid volume was associated with a longer time to remission (P < .05). Methimazole (MMI) was effective only in Sci+ individuals (P < .05).ConclusionAdministration of PD1- or PD-L1–blocking antibodies may induce 2 different forms of thyrotoxicosis that appear similar in clinical severity at onset: a type 1 characterized by persistent hyperthyroidism that requires treatment with MMI, and a type 2, characterized by destructive and transient thyrotoxicosis that evolves to hypothyroidism or euthyroidism. Thyroid scintigraphy and ultrasound help in differentiating and managing these 2 forms of iatrogenic thyrotoxicosis.

Subacute Thyroiditis in COVID-19 Patients.

As a result of the COVID-19 pandemic that occurred in the last year, it has been revealed that severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) does not only cause viral respiratory tract infection but can also affect many organs in the short or long term. In our study, we aimed to reveal that COVID-19 infection affects the endocrine system and triggers subacute thyroiditis (SAT) in the acute period. In our retrospective study, the ear-nose-throat examination, internal diseases consultation (investigation of COVID-19 symptoms and polymerase chain reaction [PCR] test), routine blood tests, T3, T4, thyroid-stimulating hormone, antithyroglobulin (anti-TG), antithyroid peroxidase (anti-TPO), thyroid scintigraphy, and thyroid ultrasonography results of 5 patients who applied to the otorhinolaryngology clinic due to complaints of neck pain and odynophagia between April 2020 and February 2021 were examined. All 5 patients were female patients (30.4 years) with odynophagia and pain in the front lower region of the neck. These patients had no previous history of thyroiditis. COVID-19 PCR tests of the patients diagnosed with SAT were positive, and there were no typical COVID-19 signs and symptoms except odynophagia and neck pain. It comes in view that SARS-COV-2 affects thyroid functions and causes SAT and the main symptoms in patients are pain in the neck and odynophagia.

Is it possible to eliminate the number of inappropriate thyroid surgeries combining scintigraphy and cytology?

Objective: Although fine needle aspiration cytology (FNAC) is the most reliable, safe and accurate method for the clinical management of abnormal thyroid nodules, 5%-15% of cases lead to indeterminate diagnoses and surgery is the recommended practice for them as they may be malignant. Nevertheless, the majority of cases with indeterminate cytology are benign, so the risk of unnecessary surgery is significant. In our study we combined FNAC and scintigraphy in order to reduce the number of inappropriate surgeries. Subjects and Methods: From 219 patients with thyroid fine needle aspiration cytology 33(9 males and 24 females) aged 18-73 years, had indeterminate FNAC diagnoses and were referred for scintigraphy. Surgery was performed in all cases. The results of FNAC, scintigraphy and histology were collected and compared. Results: From 33 cases with indeterminate cytology 32 had a benign histological diagnosis and only one was malignant (follicular Ca). That case had a positive scan. All cases with negative thyroid scans (29/33) were benign. False positive scans were 3, whereas one scan was true positive with final diagnosis follicular carcinoma. Conclusion: This study showed that combining the FNAC with the thyroid scintigraphy in cases of thyroid nodules with indeterminate cytology it is possible to reduce the number of inappropriate surgeries from 32 to 3.

Management of Thyrotoxicosis Induced by PD1 or PD-L1 Blockade

Context: Thyrotoxicosis is a common immune-related adverse event in patients treated with PD1 or PD-L1 checkpoint inhibitors. A detailed endocrinological assessment, including thyroid ultrasound and scintigraphy is missing, as are data on response to treatment and follow-up. Objectives: To better characterize the thyrotoxicosis secondary to immune checkpoint inhibitors, gaining insights into pathogenesis and informing management. Methods: We conducted a prospective cohort study of 20 consecutive patients who had normal thyroid function before starting immunotherapy and then experienced thyrotoxicosis upon PD1 or PD-L1 blockade. Clinical assessment was combined with thyroid ultrasound, scintigraphy, and longitudinal thyroid function tests. Results: Five patients had normal scintigraphic uptake (Sci+), no serum antibodies against the TSH receptor, and remained hyperthyroid throughout follow-up. The other 15 patients had no scintigraphic uptake (Sci-) and experienced destructive thyrotoxicosis followed by hypothyroidism (N= 9) or euthyroidism (N= 6). Hypothyroidism was more readily seen in those with normal thyroid volume than in those with goiter (P= 0.04). Among Sci- subjects, a larger thyroid volume was associated to a longer time to remission (P<0.05). Methimazole (MMI) was effective only in Sci+ subjects (P<0.05). Conclusions: Administration of PD1 or PD-L1 blocking antibodies may induce two different forms of thyrotoxicosis that appear similar in clinical severity at onset: a type 1 characterized by persistent hyperthyroidism that requires treatment with MMI, and a type 2 characterized by destructive and transient thyrotoxicosis that evolves to hypo- or eu-thyroidism. Thyroid scintigraphy and ultrasound help differentiating and managing these two forms of iatrogenic thyrotoxicosis

Non-MAS Non-APS Rare Case: Co-Occurrence of Graves’ Disease (GD), Latent Autoimmune Diabetes in Adult (LADA), Systemic Lupus Erythematosus (SLE), and Ulcerative Colitis (UC)

Background: Advancement in medical technology has allowed us to diagnose complicated autoimmune diseases. There is a growing report of multiple autoimmunity co-occurence. Multiple Autoimmune Syndrome (MAS) is a combination of at least three autoimmune diseases, whereas Autoimmune Polyendocrine Syndromes (APS) comprise autoimmunity that involves multiple endocrine gland. Case Illustration: A 47-year old female came with chief complaint of palpitation. She had a history of systemic lupus erythematosus in the last three years, after suffering from malar rash, alopecia, and polyarthritis. Her 24-hour urine protein was 1575 mg. She routinely consumes methylprednisolone, hydroxychloroquine, and mycophenolic acid. She also experienced hematochezia and the biopsy from colonoscopy revealed chronic colitis with crypt destruction. She was diagnosed with ulcerative colitis and was treated with mesalazine. Since last year, her blood glucose was consistently high, accompanied with polydipsia and polyuria. She was treated with metformin, despite persistent increase in her A1C, as well as fasting and random blood glucose. We performed GAD65 test which came back positive, hence we diagnosed her with latent autoimmune diabetes in adult. In the past three months, she experienced palpitations, tremor, diarrhea, diaphoresis, and unexplainable weight loss. No exophthalmos was found, but she complained of an enlargement around her neck. We run thyroid hormone test, her TSHs was <0.003 (0.35-4.94 μIU/mL) and FT4 was 4.17 (0.70-1.48 ng/mL). Her ultrasound revealed diffuse enlargement of both thyroid with increased vascularization. We diagnosed her with Graves’ disease and treated her with methimazole and propranolol. Discussion: This case highlighted the rare co-occurrence of four autoimmune diseases. The underlying genetic predisposition of individual with autoimmune disease, will make them prone to develop multiple defect in their self-tolerance mechanism. However, the strict criteria of APS or MAS constrained us from putting all her autoimmunities into one big umbrella. Based on epidemiological data, hyperthyroidism in female productive age, with diffuse thyroid enlargement, is commonly due to Graves’ disease. However, this diagnosis needs to be further evaluated with thyroid scintigraphy and confirmed with TSH-receptor antibody test. Conclusion: Improvement in medical diagnostic tools as well as better understanding of the underlying pathophysiology will make it inevitable to find more autoimmunity co-occurrence in the future. In order to keep up with this progress, the traditional classification of APS or MAS should be reviewed to allow clinician to see the case in one big entity. Keywords: GD, LADA, SLE, UC

Graves’ Disease and Evans’ Syndrome as First Manifestation of Systemic Lupus Erithematosus

Abstract Background: Graves’ disease is the most common cause of hyperthyroidism triggered by antibodies called thyroid-stimulating immunoglobulin (TSI) which stimulates an overproduction of thyroid hormones. Evans’ syndrome is a rare condition characterized by autoimmune hemolytic anemia and immune thrombocytopenic purpura. Systemic lupus erythematosus (SLE) is also an autoimmune disease with extreme heterogeneity and potentially involvement of any organ or system. It is well known when a patient is diagnosed with an autoimmune disease, it is about time to show up other manifestations of another one, just as it happened in this case report. Clinical Case: A 31-year-old pregnant woman (22 weeks) was admitted to the obstetric emergency room due to headaches, weakness and tinnitus. During anamnesis, she said she was diagnosed with hypertension several weeks before she was pregnant. At physical examination, a 160/100 mm/Hg blood pressure and a heart rate over 100 bpm were found. Initial tests were solicited congruent with severe thrombocytopenia (20 000/mm3) and severe anemia (6 gr/dl), there was also a modest increase in transaminases levels. Transfusion support was needed and a “HELLP syndrome” was diagnosed. Gynecologists decided to perform an emergency hysterotomy and the end of pregnancy. During the post-operative care and the following days, the patient persisted with an average of 100 bpm heart rate and hypertension despite of the use of antihypertensive medication. Physicians also noticed the presence of malar rash and goiter. Thyroid hormones levels where requested and the results were consistent with primary hyperthyroidism (TSH: &amp;lt;0.005 Mu/L, FT4: &amp;gt;100 pmol/L). Further tests were required such as TSI (positive), a thyroid scintigraphy (high thyroid uptake), antinuclear antibodies (ANA: + 1/160 speckled pattern, anti- Smith: +) and extractable nuclear antigen antibodies (ENA) panel. Grave’s disease and SLE were diagnosed. Rheumatologists suggested that the diagnosis of HELLP Syndrome was unclear and they strongly believed that thrombocytopenia and anemia during pregnancy were part of Evans’s syndrome and at the same time of SLE. Antithyroid drugs (thiamazol), beta blockers (propranolol) hydroxychloroquine and corticoids (prednisone) were given to the patient with an excellent clinical and biochemical response. Conclusion: A 25% of patients with SLE can be diagnosed with an autoimmune thyroid disease, such as Graves’ disease (1). Frequent evaluation of thyroid hormones and antithyroid antibodies should be performed in patients with SLE, especially when there are related symptoms of a thyroid disorder.