Toxic Goiter Research Articles

25-year experience of surgical treatment of thyroid diseases in a multidisciplinary hospital

BACKGROUND: Every year there is an increase in the number of patients with thyroid diseases, thus improving surgical treatment methods with decreased traumatic effect and postoperative complications, remains relevant. AIM: To summarize the results of 25-year work of the team (surgeons and endocrinologists) of specialists from the multidisciplinary hospital of Saint Petersburg and the departments of the North-Western State medical university named after I.I. Mechnikov on the diagnosis and treatment of patients with surgical pathology of the thyroid gland. MATERIALS AND METHODS: The results of surgical treatment of 3977 patients with thyroid diseases operated accoding to the traditional Kocher approach, asymmetric “floating” mini-approach and video-assisted mini-approach were analyzed. RESULTS: In the analyzed time period, a rapid increase in the number of minimally invasive techniques for surgical operations on the thyroid gland is characteristic, which are used for nodular euthyroid goiter, multi-nodular euthyroid goiter and toxic thyroid adenoma. With the help of traditional approach, surgical intervention was performed mainly for diffuse toxic goiter and multinodular toxic goiter. The introduction of new techniques and approaches in the provision of medical care to patients with surgical diseases of the thyroid gland can significantly improve the results of treatment. CONCLUSIONS: 25-year experience of the endocrinological center of the Elizabethan Hospital demonstrates that collaboration of departments and doctors of a multidisciplinary hospital allows to introduce new approaches to treating surgical thyroid diseases and improve its results without increasing the number of postoperative complications.

Use of rituximab in the of immunoinflammatory rheumatic diseases combined with Graves' disease (autoimmune polyglandular syndrome in adults): case report and literature review

Rituximab (RTM) is a chimeric (murine and human) monoclonal antibody against B-lymphocytes (CD20). RTM is widely used in hematology for lymphoproliferative diseases and in rheumatology for rheumatoid arthritis, Sjögren's disease, some types of vasculitis and systemic connective tissue diseases. The administration of RTM is associated with a depletion of B-cells mediated by the regulation of apoptosis and cytotoxic effects via complement-dependent and antibody-dependent mechanisms. Considering the pathogenesis of autoimmune damage in Graves' disease (GD), an autoimmune thyroid disease associated with thyrotoxicosis, the use of RTM could be effective in this pathology. We present three patients with a combination of diffuse toxic goiter and rheumatic pathology treated with RTM; different outcomes of GD were observed.

Australian males and females have similar rates of presentation for symptomatic and advanced thyroid cancer: Retrospective analysis of the Australian New Zealand Thyroid Cancer Registry.

Thyroid cancer is more commonly diagnosed in females, however recent research has challenged whether this finding is due to a true difference in biology or rates of diagnosis, with concerns that over-diagnosis may be a factor in differences. The rates of symptomatic versus incidental diagnosis by males and females is not well known. This study used the Australian and New Zealand Thyroid Cancer Registry (ANZTCR) to explore whether symptomatic presentation varies between sexes. Retrospective analysis on ANZTCR data between 2017 and 2022 was performed. Symptomatic cases were those with thyroid compressing symptoms, toxic goiter, Graves' disease, or abnormal laryngoscopy. Cases with asymptomatic goiter or surgeries for a thyroid nodule were classified as incidental. Among 1082 patients with differentiated thyroid cancer, 32% of males and 38% of females presented with symptomatic thyroid disease (p=0.06). A similar rate of presentation of advanced thyroid cancer (T3/4) was seen with male and female patients (n=70, 47% vs. n=79, 53%). Females exhibited a higher prevalence of low-risk relapse cancers according to American Thyroid Association stratification (66.3% vs. 50.4%), whereas males exhibited a higher prevalence of high-risk relapse cancers compared to females (27.3% vs. 15.3%, p<0.001). Regression showed symptoms were associated with more advanced T stage (OR=1.62, p=0.02). Symptomatic presentation was similar between males and females, but symptomatic presentation was associated with larger cancers. This study highlights comparable rates of symptomatic detection between males and females with DTCs and symptomatic presentations were responsible for less than 40% of presentations.

Characteristics of the fetus in pregnant women with thyroid diseases

BACKGROUND: Thyroid dysfunction can cause adverse effects on metabolic changes in the body and disturbances during the gestational period and intrauterine development of the fetus. In developing prevention methods, it is crucial to objectively substantiate and re-confirm theoretical assumptions. AIM: To assess the functional state of the fetus in pregnant women with certain thyroid diseases. MATERIAL AND METHODS: The results of instrumental studies in 118 pregnant women, who were divided into three clinical groups, were analyzed. Group 1 (44 people) consisted of patients with autoimmune thyroiditis (AIT). Group 2 (52 people) included patients with diffuse toxic goiter. Group 3 (control group) consisted of 22 pregnant women who had no somatic pathology and gestational complications. Thyroid diseases were diagnosed by an endocrinologist during a consultation in the third trimester of pregnancy based on laboratory and instrumental data. The functional state of the fetus was assessed using the total result of cardiotocographic and ultrasound studies, for which Partecust (Siemens, Germany) and Aloka-1700 (Hitachi, Japan) were used. Statistical processing of clinical material was performed using StatSoft software (Russia). RESULTS: A comprehensive assessment of the adaptive capabilities of the fetus showed changes in its functional state in pregnant women with thyroid pathology. Prognostically, the most crucial characteristic in pregnant women with autoimmune thyroiditis and diffuse toxic goiter is a decrease to 0–1 point in indicators that determine motor activity and tone, respiratory movements, and reaction to a non-stress test. Among patients with autoimmune thyroiditis and diffuse toxic goiter, a high assessment of the biophysical profile of the fetus occurred 4 and 3.4 times, respectively, less often than among women with a normal pregnancy (among pregnant women without somatic pathology and gestational complications). CONCLUSION: Disturbances in thyroid gland function during the gestational period can have an adverse effect on the development of the fetus, which is a theoretical basis for the development of treatment and preventive methods aimed at improving perinatal outcomes in this group of patients.

6472 Methimazole Induced Agranulocytosis: Uncommon Complication of a Common Medication

Abstract Disclosure: R. Kaur: None. L. Kaur: None. A. Sridhar: None. T. Chaudhary: None. N. Patel: None. Methimazole (MMI) induced agranulocytosis is a rare and life threatening adverse effect that usually occurs within 3 months of drug initiation and can rapidly lead to overwhelming infection. It is reported in 0.1 to 0.5 % of patients on treatment with methimazole. MMI is a standard drug used in graves disease and toxic multinodular goiter. We report a case of MMI induced agranulocytosis in an elderly female with recently diagnosed toxic multinodular goiter. A 66 year old female with past medical history of recently diagnosed toxic multinodular goiter for which she was started on methimazole 80mg/day two months ago presented to the emergency department with chief complaint of severe sore throat associated with rapidly increasing pharyngeal pain and fever over the past 24 hours. She was lethargic, febrile with temperature of 102 F, tachycardic with heart rate of 115/minute and hypotensive with blood pressure of 108/64 mm Hg. Physical examination revealed diffuse pharyngeal and tonsillar erythema with bilateral purulent exudate with tender anterior cervical lymphadenopathy. Thyroid was enlarged, firm, irregular and nontender. Pulmonary, cardiac and abdominal exam was unremarkable. Lab work showed severe leukopenia with WBC count of 1,600/mm3, neutropenia with absolute neutrophil count of 0.0 x 1000/ul (normal range 1.8-7.3 x 1000/ul) and erythrocyte sedimentation rate and C reactive protein were both elevated. Blood cultures and fungal cultures showed no growth. Urinalysis and urine culture were both unremarkable. She had an extensive haematological, rheumatological and infectious disease workup for neutropenia, which was largely unrevealing. Rapid streptococcal testing was negative but throat cultures grew beta haemolytic streptococci. Treatment included suspending methimazole, administering antimicrobial therapy with piperacillin - tazobactam, acyclovir and fluconazole. She was also started on a granulocyte colony stimulating factor. Patient presented satisfactory evolution with progressive increase in leukocyte count and remission of symptoms by day 5 of treatment, rendering further bone marrow testing unnecessary. Antibiotics were changed to oral amoxicillin-clavulanic acid after throat culture results were available and the patient was discharged in stable condition. One month after discharge she underwent total thyroidectomy for definitive cure and is currently followed up as an outpatient by endocrinology. The objective of this case report is to present an uncommon case of agranulocytosis secondary to use of methimazole and to increase awareness among the physicians about the need to consider this diagnosis in patients on this medication. It is also advised that these patients be educated about the drugs side effects, a practice that may avert suffering and unnecessary costs. Presentation: 6/3/2024

6925 A Rare Case of Metastatic Papillary Thyroid Carcinoma Confined to Cervical Lymph Node with No Identifiable Primary Tumor In The Thyroid Gland. A Diagnostic Conundrum

Abstract Disclosure: R. Abdelmasih: None. W. Pan: None. Introduction: Papillary thyroid carcinoma (PTC) is the most common treatable thyroid cancer (TC) with very good prognosis. Metastatic PTC either in the lymph node LN or extra-nodal with no primary thyroid lesion identified is a rare phenomenon referred to as occult thyroid carcinoma (OTC). Despite its rarity, it is reported and constitute a diagnostic conundrum. herein we present a case of metastatic PTC identified in cervical lymph nodes (LN) without a primary tumor in the thyroid gland confirmed with surgical pathology. Case Presentation: A 43-year-old female with history of post-ablative hypothyroidism after treatment of toxic nodular goiter for 10 years, with no family history of thyroid cancer presented with incidentally found left 1.8 Heterogeneous hypoechoic solid nodule with lobulated borders and internal calcifications along with left-sided 0.8 LN without normal fatty hilum on Ultrasound Head and Neck. Fine needle aspiration of the left thyroid nodule and suspicious LN revealed PTC in the left LN though the thyroid nodule sample was non-diagnostic. CT of head and neck showed partially calcified thyroid nodule, Hyperattenuating 8 mm left III LN without fatty hilum, and 9 mm left II calcified LN. Patient underwent total thyroidectomy, central neck, and left lateral neck dissection. Surgical pathology showed no malignancy in thyroid gland or central LNs and 1 out 5 LN of the left neck dissection showed PTC with tumor grading of pT0 pN1b pMNA. patient underwent whole-body thyrogen-stimulated thyroid scan which showed iodine avid tissue in the thyroid bed followed by high-dose I-131 radioactive iodine ablation (RAI). Discussion: OTC refers to impalpable incidental TC less than 10 mm per the WHO. Boucek et al classify OTC into four categories, recently a fifth category was added, in which metastasis is confirmed either in regional LN or distant metastasis though thyroid tissue is confirmed to be benign per pathology and imaging evaluation, our patient falls in the fifth category. Hypothesis of this phenomenon is not well understood, one suggested explanation is missed diagnosis due to not enough sample or if lesion is less than 3 mm. another hypothesis is tumor spontaneous regression, or regression secondary to treatment that was inadequate to treat the systemic process of the tumor, which we believe our patient fits in this hypothesis, given that she underwent RAI ablation many years ago. Tumor regression is very rare and reported to be 1 in 140,000 cases. Another theory suggests that PTC can arise in ectopic thyroid tissue. This case is to shed light on a rare clinical and pathological entity to avoid missed diagnoses. Prognosis depends on the extent of metastasis, with favorable one when it is limited to regional LN and worse with distant metastasis. More cases reports are warranted to help guide further management of such cases due to the lack of available guidance in use of RAI surveillance and ablation. Presentation: 6/1/2024

7618 Thyroid Nodules, Normal Thyroid Levels, and Chronic Anxiety: A Case for Sub-Clinical Toxic Multinodular Goiter

Abstract Disclosure: C.M. Barrera: None. Introduction: Chronic anxiety and panic disorders, as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), are the most common psychiatric conditions. Hyperthyroidism is a known cause of both chronic anxiety and panic disorder. Case 1: A 36-year-old overweight Latin female is referred for evaluation of multiple thyroid nodules. The thyroid ultrasound was heterogeneous, with multiple bilateral nodules. In her history, the patient has chronic anxiety with panic attacks resulting in frequent emergency room visits. The TSH and T4 levels were TSH 0.59 mIU/L (0.40-4.5) and T4 10.7 mcg/dL (5.1-11.9). An I[1]23- Thyroid Scan showed a hot nodule with mild suppression and an uptake of 31.8% (The top limit is 35%). The patient started methimazole 2.5 mg daily, and after two months, her chronic anxiety and panic attacks resolved. Post-methimazole TSH rose to 1.18 mIU/L, and T4 10.0 mcg/dL and she has weaned off anxiety medications. Case 2: A 49-year-old overweight Latin female is referred for increased thyroid nodules. She complained of six months of tachycardia and anxiety. The TSH and T4 levels were TSH of 0.828 mIU/L (0.40-4.5) and T4 of 7.9 mcg/dl (4.5-12.0). An I[1]23-Thyroid Scan showed no dominant hot or cold nodules, with an uptake of 36.4% (The top limit is 35%, within normal error limits). She started methimazole 5 mg daily, resolving her tachycardia and anxiety within five weeks. Post-methimazole TSH was 1.64 mIU/L (0.45-4.5), and T4 6.7 mcg/dL (4.5-12.0). Case 3: A 60-year-old overweight Latin female is referred for evaluation of multiple thyroid nodules of ten years. She complained of chronic anxiety and panic attacks for two years. The TSH and T4 were normal at TSH 0.36 mIU/L (0.35- 5.50) and T4 9.7 mcg/dL (4.5-10.9). The thyroid ultrasound showed multiple bilateral nodules. An I[1]23-Thyroid Scan showed a suspected hot nodule without appreciable suppression and an uptake of 33% (The top limit is 35%). The patient started methimazole 5 mg daily. After eight weeks, she reported the resolution of most of her chronic anxiety with post-methimazole TSH 2.39 mIU/L and T4 7.1 mcg/dL (4.5-12.0). Discussion: The normal range of TSH, typically from 0.4-4.5 mIU/L, is calculated by measuring the TSH levels among a normal population. The group range then determines the laboratory reference range. This contrasts with individual values, which have a narrower range, suggesting that each person has a unique thyroid level. This suggests that TSH levels at the extremum, associated with hyperfunctioning nodules contributing to a rise in uptake, may not be normal for that patient and may explain the anxiety and other symptoms. Learning Points: Evolving multiple autonomous thyroid nodules lowers TSH levels while raising thyroid uptake. Symptoms of chronic anxiety and panic attacks can predate abnormal thyroid levels and resolve with low-dose methimazole. Presentation: 6/1/2024

7588 Coexistent Toxic Nodular Goiter And Primary Hyperparathyroidism (PHPT), A Combo With Diagnostic And Management Implications

Abstract Disclosure: D. Dave: None. A. Bhan: None. S.D. Rao: None. About 17-84% of patients with PHPT have concomitant thyroid disorders, but the prevalence of coexistent hyperthyroidism in PHPT varies 9-14 %. A vast majority had Graves’ disease with only 3 cases of toxic multinodular goiter (MNG) and PHPT reported in the literature as of 2022 ([1]). We present a rare case of coexistent toxic MNG and PHPT. Case Description: A 68y woman presented with recent 23 kg unintended weight loss and palpitations, but no other symptoms. Denied having kidney stones or fractures. On examination she had fine tremors of hands, MNG without exophthalmos. An ultrasound showed multinodular MNG with cystic lesions. A diagnosis of toxic MNG was made. Laboratory results were: TSH (&amp;lt;0.01 uIU/mL), free T4 1,68 ng/dL (normal: 0.61-1.44 ng/ml), high serum Ca (11.0 - 11.4 mg/dl) over 4y, but PTH was unavailable prior to the visit when it was 107 pg/ml and 89 pg/ml after 3 months of antithyroid therapy. Despite clinical and biochemical euthyroidism after 3 months, serum Ca and PTH levels remained high (11.4 mg/dl and 89 pg/ml respectively). Because she had pulmonary embolism a few years ago, we deferred parathyroidectomy until complete remission of hyperthyroidism. Discussion: Hypercalcemia is the biochemical hallmark of PHPT but can occur in 2-10% of patients with hyperthyroidism alone but only 1% of those will have coexistent PHPT. When these two conditions coexist, hypercalcemia is moderate to severe, and an occasional patient may present with hypercalcemic crisis (2). Prior to the availability of PTH assays, it was a challenge to diagnose coexistent PHPT. Hypercalcemia in hyperthyroidism responds to propranolol but not in PHPT, although the response is variable (3). With the availability of sensitive PTH assays, this maneuver is not necessary. In most cases, current PTH assays distinguish hypercalcemia of hyperthyroidism with suppressed PTH from coexistent PHPT in whom PTH level is non-suppressed or elevated. Monitoring serum Ca and PTH levels during therapy of hyperthyroidism would be useful as normalization of serum Ca and PTH has occasionally been reported (4). In our patient, serum Ca and PTH levels remained high with 3-months of methimazole and atenolol. The impact of both conditions on bone and mineral metabolism are profound, with fractures and kidney stones. Since kidney stones are uncommon in hyperthyroidism, presence of kidney stone in a hyperthyroid hypercalcemic patient should alert the possibility of PHPT. Similarly, significant decrease in bone density in such patient also raises the possibility of PHPT. Prompt diagnosis and appropriate treatment of both conditions is necessary to avoid irreversible complications.

8584 Quite High Thyroglobulin Levels in Thyroid Cancer in the Absence of Structural Lesion: Lab Interference or Microscopic Disease with Elevated Thyroglobulin?

Abstract Disclosure: M. Ahmad: None. A.P. Calimag: None. B. Arshad: None. J.T. Chaiban: None. Introduction: Thyroglobulin (Tg) is standard practice for follow-up of differentiated thyroid cancer (TC). Due to existence of thyroglobulin antibodies (Tg Ab) and Heterophile antibodies, Tg immunometric assays may be subject to interference. We present 2 challenging cases of TC with elevated Tg with absence of structural disease. Both tested positive for Epstein-Barr virus antibodies to viral capsid antigen (EBV anti VCA ab). DESCRIPTION: Case 1: 70 y.o Pt found to have calcified thyroid nodule on CT cervical spine. Thyroid ultrasound (U/S) revealed a left thyroid nodule- FNA being papillary thyroid cancer (PTC) with Bethesda 6. She had total thyroidectomy and central left lateral neck dissection. Pathology revealed PTC with 3/14 l.nodes +ve for cancer. Her Tg was 40.5 (1.2 - 35.0 ng/mL) 6 days after surgery, she received 100 mCi of radioactive Iodine (RAI). Subsequent WBS showed uptake in thyroid bed only. On follow ups, Tg started to rise persistently. PET CT unremarkable and her commensurate unstimulated Tg was 12. PET CT with interval development of a hypermetabolic focus in the postsurgical bed of thyroid and hypermetabolic cervical l.nodes. She received 100 mCi RAI + WBS that was negative for recurrence. Her Tg transiently improved but then was persistently elevated in the range 8.1-11.6 ng/ml on multiple checks. Repeat thyroid U/S did not show residual disease. Her Tg antibodies (Tg Ab) as well as Heterophile Antibody and HAMA were negative. Tg by LC-MS, was elevated in the range of 7.5 to 10.8 ng/ml. EBV anti VCA ab, IgG were positive. Case 2: 76 y.o lady initially diagnosed with toxic compressive goiter, found to have follicular thyroid cancer (FTC) after total thyroidectomy: a 5.5 cm FTC with minimal capsular/lymphatic invasion, no extrathyroidal extension, and negative margins. She received 103.7 mCi RAI after surgery. Subsequent WBS showed uptake only in the thyroid bed. Postoperatively Tg levels decreased to the range 1.6 to 5.1 ng/ml. Follow-up WBS a year later was unremarkable, and the Tg started to rise. CT scan of the chest and neck were negative. Tg by LC-MS was elevated in the range 1.6-9.2 ng/ml. PET CT was negative. Tg Ab as well as Heterophile Antibody and HAMA were negative. She tested positive for EBV anti VCA ab, IgG as well. Conclusion: Both case were elderly females- almost similar age, one with PTC and one with FTC- that had excellent structural response, but incomplete biochemical response. Measurement of Tg by LC-MS is recognized as an accurate method for Tg quantification. LC-MS assays are based on peptide quantitation after tryptic digestion which itself can have limitations due to existence of abnormal polymorphic tumor thyroglobulin (for which not much literature is available). The elevated Tg could be related to assay interference from EBV anti VCA ab (a cause or coincidence!?) or a possibility of persistent microscopic disease, hence longitudinal follow up of patients is important. Presentation: 6/2/2024

Patterns, treatment outcome and associated factors of surgically treated thyroid disease at public hospitals in Eastern Ethiopia: a retrospective cross-sectional study

BackgroundThyroid disease is a global health problem and the most common type of endocrine disorder next to diabetic mellitus, accounting for around 30–40% burden of the endocrine disorders.ObjectiveThe objective of the study was to assess patterns, treatment outcome and associated factors of surgically treated thyroid disease at Public Hospitals in Eastern Ethiopia.MethodsThe study was conducted among surgically treated patients for thyroid disorders using a retrospective cross-sectional study design by reviewing all patients’ charts. A data abstraction sheet was used to collect relevant data, and the collected data was analyzed using SPSS version 26 software. Bi-variable and multivariable binary logistic regression was employed to assess the association between dependent and independent variables.ResultsThe study was conducted on 200 patients’ medical records who had complete information. Out of this, 84.5% were female and 66.5% of patients’ age was between 20 and 40 years. Toxic goiter was the most common thyroid disease which accounted for 49.5%. Hemorrhage and Hypocalcemia were the most common complications after surgery. Anterior neck swelling of greater than 15 years [(AOR: 52.892 CI = 95% (6.087–459.5.68) (P-0.000)], Total/ near total thyroidectomy [(AOR: 20.139 CI = 95% (4.059–99.931) P-00.000] were significantly associated with complicated post-operative course, while female sex [(AOR: 0.124 CI = 95% (0.34–0.494) P- 0.003)] was associated with lower risk of developing post-operative complications.ConclusionThis study showed that 9.5% of operated patients with thyroid disease had complicated post-operative course. Long standing goiter and total/ near total thyroidectomy were significantly associated with complicated post-operative course.

Anesthesia in Caesarean Section Patients with Hyperthyroid

Thyrotoxicosis is defined as a state of excess thyroid hormone and is not synonymous with hyperthyroidism, which is the result of excessive thyroid function. The prevalence of hyperthyroidism ranges from 0.2% to 1.3% in iodine-sufficient regions of the world. The combination of increasing FT4 and suppressing TSH is one way to enforce the hyperthyroidism diagnosis. The case of a 22-year-old woman with a diagnosis of G6P3A2H3 premature contractions has been reported , who came to the surgical room at Dr. HOSPITAL. Suhatman MARS to perform a caesarean section. Based on the pre-operative physical examination carried out, it was found that the patient's physical status was ASA II. In this patient, regional anesthesia will be planned. The patient has a history of hyperthyroidism since ± 10 years ago and regularly takes Thyrozol once a day during pregnancy and controls it with a specialist in Internal Medicine. Theoretically, this shows that the suspected condition of the patient is hyperthyroidism and if continued it could lead to Graves' disease, toxic nodular goiter, subclinical hyperthyroidism, or other conditions that lead to hyperthyroidism so surgery must be carried out taking this situation into account.

Manajemen Anestesi Operasi Total Thyroidectomy Pada Pasien Struma Multinodosa: Laporan Kasus

Goiter is an enlargement that occurs in the thyroid gland. Goiter can be classified based on physiology (euthyroidism, hypothyroidism, and hyperthyroisdism), morphology (diffuse and nodular goiter) and clinically (toxic and non-toxic goiter). Multinodular goiter is an enlargement of the thyroid gland with multiple nodules in which the thyroid gland follicles experience changes both morphologically and functionally. The characteristics of nontoxic multinodose goiter are slow, continuous and expanding growth. Surgery is one treatment for most types of goiter. The operation is performed under general anesthesia. Operative procedures performed on the head and neck are high-risk operations that can cause brain damage and result in death. Therefore, it’s necessary to prepare an anesthesia plan as well as appropriate pre-operative, intra-operative and post-operative management to avoid complications that may occur. Mrs. BP, 65 years old, came with complaints that a lump had appeared in his neck since approximately 2 years ago and had grown to approximately 5 cm in the last 1 year. In 2003 the patient underwent partial thyroidectomy under general anesthesia. This case report aims to look at anesthetic management in patients with multinodose goiter, where appropriate anesthetic management also determines the success and prognosis of surgical procedures in these patients.

The Causes of Thyrotoxicosis, Clinical Features, and Treatment Strategies in a Former Iodine Deficient Area

Thyrotoxicosis is a hypermetabolic condition caused by excess thyroid hormones in the circulation with/without increased production from the thyroid gland. In this prospective study, we aimed to investigate the causes of thyrotoxicosis, clinical features, and treatment strategies in a former iodine-deficient area. Thyroid function tests, antithyroid and antithyroid receptor antibodies, and routine thyroid ultrasonography was obtained, and a thyroid scintigraphy/radioactive iodine uptake test was performed on need. A statistically significant difference was found between toxic multinodular goiter (TMNG) and Graves’ disease (GD) groups when mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) values were analyzed. TSH levels were significantly lower in GD patients compared to those in TMNG and TNG patients, but free triiodothyronine (FT3) and free thyroxine (FT4) values were higher. A high level of TSH receptor antibody (TRAb) was observed in patients with normal antithyroid peroxidase (Anti-TPO). TRAb levels were found to be high. Anti-TPO and anti-thyroglobulin (Anti-Tg) levels were observed to be positively correlated with sT3 and sT4 levels. TMNG is the leading cause of thyrotoxicosis; despite sufficient iodide intake in our former iodine-deficient region, TMNG is characteristically seen in older patients with much lower thyroid hormone levels than GD. According to the study results, the diagnosis of patients with thyrotoxicosis, their clinical presentation, the treatment they will receive, early detection of postoperative complications were predicted

Protocolo diagnóstico y terapéutico de las tiroiditis

Thyroiditis refers to an inflammation of the thyroid gland, with a variable impact on its functionality. In this protocol, thyroiditis is classified according to its progression as chronic, subacute, acute, or variable course. The epidemiology, etiology (autoimmune, infectious, traumatic, environmental, pharmacological, etc.), pathophysiology, and clinical course differ among the different types of thyroiditis. Some progress with characteristic pain and others are painless. The diagnosis is generally easy and clinical. A medical record and physical examination are essential as well as a good differential diagnosis between the types of thyroiditis and with other thyroid diseases such as Graves-Basedow disease and toxic multinodular goiter. In most cases, the treatment is simple if a proper diagnostic orientation is performed.

Tirotoxicosis e hipertiroidismo

Thyrotoxicosis is a clinical condition secondary to excess thyroid hormones (TH). It can be caused by increased synthesis and release of TH by the thyroid gland (hyperthyroidism, the most common cause) as well as by thyroid inflammation and destruction, ectopic production, or exogenous administration of TH. The diagnosis is biochemical and based on the determination of thyroid stimulating hormone (TSH) and thyroid hormones (thyroxine and triiodothyronine). To plan effective treatment, it is crucial to identify the underlying cause. Graves-Basedow disease is the most common cause, followed by toxic multinodular goiter and toxic thyroid adenoma. Less frequent, although relevant, are thyroiditis, extrathyroidal TH production, and factitious thyrotoxicosis. Some imaging tests, such as a Doppler ultrasound and thyroid scintigraphy, are helpful in the etiological diagnosis. The goal of treatment is to achieve symptoms control and reduce TH synthesis and secretion through the use of drugs or radical treatments (radioiodine or surgery).

Characteristics of Well Differentiated Thyroid Carcinoma Associated with Hyperthyroidism

This paper aim to report characteristics of well differentiated thyroid carcinoma associated with hyperthyroidism: Grave’s disease, toxic multinodualr goiter, and toxic uninodular goiter.

Papillary thyroid carcinoma revealed by toxic goiter: a case report

Papillary thyroid carcinoma revealed by toxic goiter: a case report

A case of giant toxic nodular goiter with dyspnea by pulmonary hypertension and obstructive symptom

A case of giant toxic nodular goiter with dyspnea by pulmonary hypertension and obstructive symptom

A Lower Prevalence of Central Nervous System and Higher Prevalence of Cardiac Symptoms Characterises Indian Patients with Thyrotoxic Storm: A Retrospective Analysis.

Thyroid storm is an uncommon but life-threatening presentation of thyrotoxicosis with a mortality rate of 10%. Our objective was to study the demographics, clinical and biochemical characteristics, and outcomes of inpatients diagnosed with thyroid storm in the Indian context. This retrospective study was conducted by analysing the institutional electronic medical records (EMR) of all patients admitted with thyroid storm from 2004 to 2020 with a Burch-Wartofsky score (BWS) of ≥45. Thirty-five patients with a BWS ≥45 were included, of whom 71.4% were women, with a mean age of 44.9 ± 10.2 years. 43% did not have any prior history of thyrotoxicosis. Graves' disease was the most common underlying aetiology (71.4%), followed by toxic multinodular goitre (14.3%). Cardiovascular (94.3%) and gastrointestinal-hepatic dysfunction (88.6%) were the most common clinical manifestations. Features of Central nervous system (CNS) dysfunction were seen in only 42.3% of patients diagnosed with a thyroid storm. The Japanese Thyroid Association (JTA) criteria diagnosed only 26 patients (74.3%) with "definite" thyroid storm. The mortality rate was 8.6%, and all three patients expired within 48 hours of admission. Nearly one in every two patients with thyroid storm had previously undiagnosed thyrotoxicosis. Toxic multinodular goitre is a notable aetiology in Indians. Features of CNS dysfunction, considered relatively specific for thyroid storm, were less prominent in our series. The JTA criteria might alter the classification of some patients diagnosed with a thyroid storm, when compared to the BWS score due to fewer CNS features among Indian patients.

The role of autoimmune thyroid disorders in patients with alopecia areata

Objective: The aim of this study was to investigate the association of thyroid autoimmunity with alopecia areata (AA) by examining thyroid stimulating hormone (TSH) and thyroid autoantibody levels. In addition, to compare the epidemiologic data obtained with the data of our country. Methods: Our study was organized as a cross-sectional, retrospective study. The study was performed on patients between the ages of 2-65 years who were admitted to our outpatient clinic between 01.01.2008 and 31.12.2011, who were clinically or histopathological diagnosed with AA, examined for etiology and thyroid autoantibodies were requested. Patients under two years of age and over 65 years of age, patients with no thyroid autoantibodies and pregnant patients were excluded. Results were expressed as mean±standard deviation and median values. Mann-Whitney U test was used to compare TSH, anti-TG antibody (Anti-TG) and anti-TPO (Anti-TPO) antibody values in the variables of nail involvement, psychiatry, comorbidity and family history. Spearman correlation analysis was used to examine the relationships between age and disease duration and TSH, Anti-TPO and Anti-TG variables. Results: In our study, 65 (42.8%) of 152 patients were female and 87 (57.2%) were male. The ages of the patients ranged between 2-65 years and the mean age was 26.5±14.6 years. The mean age of females was 27.5±14.4 and 25.7±14.9 in males. Elevated thyroid autoantibodies were found in a total of 29 patients, 21 of whom were female and 8 of whom were male. Of these 29 patients, 10 had hypothyroidism, 2 had chronic thyroiditis and 3 had toxic multinodular goiter. 14 patients did not return after the examination at the internal medicine outpatient clinic, so the diagnosis of thyroid disease could not be reached. The mean TSH, Anti-TG and Anti-TPO values were 2.27±1.57, 29.2±99 and 71.5±2.2, respectively. When these values were analyzed separately as men and women, they were found to be 2.6±2.02, 41.8±1.23 and 134±2.8 in women and 1.99±1.03, 19.8±75.6 and 24.5±1.32 in men. There was a significant difference between men and women in terms of Anti-TG and Anti-TPO values (p=0.011 and p=0.001, respectively). A significant correlation was found between disease duration and Anti-TPO positivity (p=0.045); however, a similar relationship was not found between disease duration and Anti-TG positivity (p=0.34). Conclusions: As a result of this study, although there was a significant correlation between anti-TPO and duration of AA, the association between thyroid autoimmunity and AA was not found to be statistically significant. This may be due to the fact that humoral autoimmunity plays a role in thyroid autoimmunity and primarily cellular autoimmunity plays a role in AA. In addition, the epidemiologic data of our study were similar to the data of studies conducted in our country.