Percutaneous Ethanol Injection in Benigh Thyroid Nodules / 대한내분비학회지

BACKGROUND: Percutaneous ethanol injection(PEI) performed in guidance of ultrasonography has been used in cases of thyroid cyst and autonomous functiong thyroid nodule(AFTN). We performed this study to determine the feasibility of PEI on the various type of benign cold nodules(solid, pure cyst, complex cyst) and AFTN. METHOD: Ninety patients(age 41+12 years; 83 women and 7 men) with hot and cold nodule were included in this study. All cases were subjected to FNAB, and sono-guided in cases of complex cyst, at least twice with results of colloid nodule. T4 suppression treatment was done for cold solid nodules for at least 6 months and cases which had partial response(50% or more volume reduction but no further volume decrease on T4 suppression) were included in this study. After PEI, we classified AFTN into three different response groups; complete response (normali- zation of TFT and thyroid scan finding), partial response(normalized freeT4 but suppressed TSH or persistently suppressed scan), or failure group. Each subtypes(solid, pure cyst, complex cyst) of cold nodules were also classified into three groups in accordance with volume reduction; complete response(above 90% of volume reduction), partial response(50-90%), and failure(below 50% or increase in size) group. RESULTS: Overall responses rate of PEI for benign thyroid nodule were complete; 70(78%), partial; 18(20%), and failure; 2(2%). In 27 cold solid nodules, complete response was observed in 23(85%) and partial response in 4(15%). In 11 pure cysts, complete response was observed in 7(64%), partial response in 3(27%), and 1 case(9%) of failure was lost after 1 trial of PEI. In 45 cases of complex cyst, complete response was observed in 36(80%), partial response in 8 (18%), and 1 case(2%) of failure was subjected to operation with pathology report of Hiirthle cell adenoma. In 7 cases of AFTN, complete response was observed in 4(57%) and partial response in 3(43%). We observed complications during PEI therapy such as transient neck pain(n=10), transient unilateral vocal cord palsy(n=l), and intracavitary hemorrhage(n=2), transient hypotension during ethanol injection(n 1). CONCLUSION: Our data suggest that efficacy of PEI(57%) in AFTN is inferior to conventional therapies like surgery and radioiodine, but still can be an alternative therapeutic modality in selected cases. In cold nodules, especially of solid type and complex cyst, PEI may have feasibility as a therapeutic modality in restricted cases. Further studies of prolonged follow-up for the possibility of neglecting occult malignancy are warranted.

A Case of Ventricular Fibrillation Aassociated with Hyperthysoidism / 대한내분비학회지

The cardiovascular manifestations in hyperthyroidism are sinus tachycardia, paroxysmal supraventricular tachycardia, atrial flutter, atrial fibrillation, atrioventricular block, bundle branch block(especially right bundle branch block), angina pectoris, heart failure and cardiomyopathy. Of these, angina pectoris is commonly seen in hyperthyroidism with coronary artery disease and the potential mechanisms have been attributed to the increased metabolic demand and consequently increased cardiac work which result in the more demand of coronary blood flow than that can be delivered via a fixed atherosclerotic coronary artery stenosis. Hyperthyroidism associated anginas without underlying coronary artery stenosis have also been reported where the mechanism of these was suspected to be the coronary vasospasm. Ventricular fibrillation may occur in the thyrotoxic patients due to myocardial ischemia such as variant angina, but it is very rare in the condition without previous heart disease. A 30-year-old male was admitted to the hospital because of palpitation, weight loss and proptosis for the previous 3 months. There was no history of effort related chest pain, syncope, drug abuse or medical illnesses such as diabetes mellitus, hypertension. The laboratory results were, TSH: 0.38uU/mL(0.4~5,0 uU/mL), free T4: 8.9ng/dL(0.8~1.9ng/dL), TSH receptor antibody: 43.6%(-15~15%), antiTPO antibody: 5000 IU/mL(0~100 IU/mL). The initial EKG showed normal sinus rhythm. He was diagnosed as Graves disease with ophthalmopathy, class 3a and was put on propylthiouracil 200 mg po tid, propanolol 40 mg po tid and started solumedrol pulse therapy for the exophthalmos on the first day of admission. He was found to have generalized tonic seizure with apnea attack on second hospital day and twice thereafter. Ventricular fibrillation was documented at that time. DC cardioversion was performed with successful response. After the attack, he was treated as accelerated hyperthyroidism namely with increased dosage of propylthiouracil, dexamethasone and Lugols solution, The echocardiogram, treadmill test, ergonovine echocardiography, coronary angiography and electrophysiologic study disclosed no abnormalities. Further episodes of ventricular fibrillation didnt occur after being euthyroid state. In conclusion, we report a case of ventricular fibrillation associated with hyperthyroidism itself without underlying coronary artery disease with brief review of literatures.