Coexistence of Hyperparathyroidism and Multinodular Goiter with Hashimotos Thyroiditis and Hyperthyroidism � A Rare Case Report

Thyroid disease and hyperparathyroidism (HPT) are among the most common endocrine disorders. Thyroid hormones play an important role in bone and calcium metabolism. The rate of HPT is greater in patients with thyroid disease than in the general medical population. Simultaneous occurrence of hyperthyroidism and hyperparathyroidism in the same patient is a rare combination. The clinical manifestations of hyperthyroidism may overshadow the more subtle and varied symptoms and signs of primary hyperparathyroidism. It poses difficult diagnostic and therapeutic problems. Both diseases, however, may have a profound influence on calcium metabolism. The resulting disturbances in thyrotoxicosis may simulate hyperparathyroidism. Contrariwise, the diagnosis of an associated parathyroid adenoma may be missed, or unnecessarily delayed because hypercalcemia is known to occur in hyperthyroidism. The coexistence of thyroiditis and thyroid nodules with parathyroid disorders is also known. Graves� disease (GD) and primary hyperparathyroidism (PHPT) are two common endocrine disorders. However the co- occurrence of hyperthyroidism and primary hyperparathyroidism (PHPT) is rare. However, the link between the two disorders remains unclarified. Hypercalcemia in Graves' hyperthyroidism should warrant a thorough investigation for concomitant primary hyperparathyroidism. Concomitant thyroid nodular disease and hyperparathyroidism (PHPT) disease has been also documented. PHPT is also reported in patients with thyroid malignancy. We hereby report a rare case of a patient who presented with coexistence of Hyperparathyroidism and Multinodular Goiter with Hashimotos Thyroiditis and Hyperthyroidism.

Bocio multinodular ectópico submandibular: a propósito de un caso y revisión de la literatura / Submandibular ectopic multinodular goiter: case report and literature review

Resumen El tiroides ectópico es una alteración congénita infrecuente que presenta una prevalencia entre 1/100.000-1/300.000. En el 90% de los casos se encuentra en la línea media cervical, siendo los casos de tiroides ectópico cervical lateral muy infrecuentes. Presentamos el caso de una paciente de 44 años que consultó por presentar una tumoración submandibular izquierda de más de seis meses de evolución. Las pruebas de imagen (ecografía, tomografía computarizada y gammagrafía) sugirieron un bocio ectópico multinodular; la punción aspiración con aguja fina (PAAF) informó de tejido tiroideo sin atipias (Bethesda II) y el estudio sanguíneo de hormonas tiroideas fue normal, orientando finalmente el caso como un bocio multinodular ectópico submandibular eutiroideo. Ante la ausencia de síntomas y signos sugerentes de malignidad, en conjunto con una PAAF con características de benignidad, se decidió realizar seguimiento. En el momento que presentó clínica por efecto masa se decidió realizar la exéresis de la lesión, que confirmó el diagnóstico de bocio multinodular ectópico. Los casos descritos en la literatura de bocio multinodular ectópico submandibular como único tejido tiroideo funcionante son excepcionales. El tiroides ectópico se debe considerar en el diagnóstico diferencial de una masa submandibular. Aunque actualmente no existe un consenso en relación con el manejo de dicha patología, el crecimiento de la masa puede contribuir a la decisión de una exéresis completa del tiroides ectópico, aun tratándose del único tejido tiroideo funcionante.

Abstract Ectopic thyroid is an uncommon congenital disorder with a prevalence between 1/100,000-1/300,000. In 90% of cases, it is placed in cervical midline, being the cases of lateral cervical ectopic thyroid very infrequent. We present the case of a 44-year-old female patient who had a left submandibular mass during more than six months. Imaging tests (ultrasound, computed tomography and scintigraphy) suggested a multinodular ectopic goiter; fine needle aspiration (FNA) reported thyroid tissue without atypia (Bethesda II) and the thyroid hormone blood tests were normal, finally orienting the case as a euthyroid submandibular ectopic multinodular goiter. In the absence of symptoms and signs suggestive of malignancy, together with an FNA with benign characteristics, it was decided to follow up. When the patient presented clinical symptoms due to mass effect, it was decided to perform excision of the lesion, which confirmed the diagnosis of ectopic multinodular goiter. There are very few cases described in the literature of submandibular ectopic multinodular goiter as the only functioning thyroid tissue. Ectopic thyroid should be considered in the differential diagnosis of a submandibular mass. Although there is currently no consensus on the management of this pathology, the growth of the mass may contribute to the decision of a complete excision of the ectopic thyroid, even if it is the only functioning thyroid tissue.

Multinodular goitre: a clinicopathological study from Kerala

Background: Multinodular goiter (MNG) occurs due to repeated hyperstimulation of thyroid gland due to iodine deficiency, goitrogens, antithyroid drugs and genetic defects. MNG can have different complications which include treacheal compression, retrosternal extension, malignancy and secondary thyrotoxicosis. The aim of the work was to study the clinical features and histopathology of MN in patients admitted for thyroidectomy in surgical wards of a tertiary care hospital in north Kerala.Methods: A prospective hospital based observational study in the patients in surgical wards of a tertiary care hospital in north Kerala from April 2011 to March 2012. The clinical data of patients who are subjected to thyroidectomy for MNG (clinical and fine needle aspiration cytology diagnosis) were included in this study. Patients undergoing completion thyroidectomy for recurrence or malignancy were excluded from this study.Results: MNG is more common in females. Female to male ratio 24:1 Majority are in the age group of 30-50 years (64%) with a mean age of 41 years. 38% (38 cases) had pressure symptoms in the form of dysphagia or dyspnea. Secondary thyrotoxicosis seen in 17% (17 cases). Fine needle aspiration cytology (FNAC) is not an error-proof investigation in MNG. 14 % of our patients had malignancy inspite of being reported as benign in FNAC. Among the malignancies papillary carcinoma thyroid was found to be most common accounting for 12% of cases (12/100) followed by follicular carcinoma.Conclusions: FNAC is not an error proof investigation in MNG. Incidental thyroid cancer in MNG is about 14 % with papillary carcinoma thyroid being the commonest.

La cirugía en el tratamiento de la crisis tirotóxica / Surgery for the Treatment of Thyrotoxic Crisis

RESUMEN La crisis tirotóxica es una complicación de la tirotoxicosis mal tratada y se asocia con una elevada mortalidad. Requiere tratamiento médico urgente en unidades de cuidados intensivos. Mujer de 42 años, con antecedentes personales de hipertensión arterial y nódulo tiroideo hiperfuncionante desde hace 18 años, con abandono del tratamiento médico hace dos años, que acude a urgencias con disnea paroxística nocturna, taquicardia, hipertensión arterial, gran bocio y anasarca. Ingresa en la unidad de cuidados intensivos con diagnóstico de crisis tirotóxica e inicia el tratamiento médico con medidas de soporte precisas, la que incluye intubación orotraqueal. Debido a la dificultad de manejo clínico y respiratorio de la paciente, se decide realizar tratamiento quirúrgico urgente. Se practica una tiroidectomía total de bocio multinodular parcialmente intratorácico y una traqueostomía preventiva. El resultado de anatomía patológica fue: bocio multinodular tóxico. La paciente fue dada de alta con función tiroidea normal, cierre de traqueostomía y buena fonación, tras mes y medio de hospitalización. A pesar de que un tratamiento médico conservador es el adecuado de la tirotoxicosis, los síntomas y signos sistémicos de la crisis tirotóxica y sus manifestaciones órgano-específicas, asociados a una persistente dificultad respiratoria por síntomas compresivos derivados del gran bocio, se consideró que la tiroidectomía urgente en este caso estaba indicada, dato que se corroboró ante la buena evolución posoperatoria. El tratamiento de la tirotoxicosis es fundamentalmente clínico, sin embargo, la cirugía puede ser útil ante la dificultad en el manejo clínico(AU)

Abstract The thyrotoxic crisis is a complication of poorly treated thyrotoxicosis and is associated with high mortality. This condition requires urgent medical treatment in intensive care units. A 42-year-old woman, with a personal history of high blood pressure, hyperfunctioning thyroid nodule for 18 years, and abandonment of medical treatment since two years ago, presented to the emergency department with paroxysmal nocturnal dyspnea, tachycardia, high blood pressure, large goiter, and anasarca. She was admitted into the intensive care unit with a diagnosis of thyrotoxic crisis and started to receive medical treatment under precise support measures, including orotracheal intubation. Due to the patient's difficult clinical and respiratory management, it was decided to perform urgent surgical treatment. She was performed a total thyroidectomy of partial intrathoracic multinodular goiter and a preventive tracheostomy. The result of pathological anatomy was toxic multinodular goiter. The patient was discharged with normal thyroid function, tracheostomy closure, and good phonation, after a month and a half of hospitalization. Despite the fact that conservative medical treatment is the adequate one for thyrotoxicosis, the systemic symptoms and signs of the thyrotoxic crisis, and its organ-specific manifestations, associated with persistent respiratory distress due to compression symptoms derived from large goiter, urgent thyroidectomy needed to be indicated in this case, a fact corroborated after good postoperative evolution. The treatment of thyrotoxicosis is fundamentally clinical; however, surgery can be useful given the difficulty in clinical management(AU)

Bocio multinodular tóxico por intoxicación con monóxido de carbono / Toxic multinodular goiter due to poisoning by carbon monoxide

RESUMEN Paciente masculino de 53 años con antecedentes de alergia, trabajador artesanal que realiza serigrafías, con alta exposición a productos químicos que, al someterse a altas temperaturas desprenden gran cantidad de vapor. Acude a consulta refiriendo que desde aproximadamente 2 meses antes presenta decaimiento con calambres musculares, palpitaciones, enrojecimiento de la cara y, aumento de tamaño de la glándula tiroides. Se diagnostica un bocio multinodular tóxico, por cifras hormonales elevadas. Se realiza ultrasonido de tiroides que informa bocio multinodular, una biopsia por aspiración con aguja fina, con atipia de significado incierto, y lesión folicular del tiroides. Se separa de su centro de trabajo y se logra revertir la sintomatología a los 15 días del tratamiento. Frecuentemente aparecen enfermedades asociadas a intoxicaciones por químicos y medicamentos, donde la presencia de hipertiroidismo no es habitual. Se requiere una anamnesis exhaustiva y exámenes complementarios específicos para un diagnóstico y tratamiento adecuados(AU)

ABSTRACT 53 years old male patient with a history of allergy; he works as a craft worker (producing serigraphs) very exposed to chemicals, which when subjected to high temperatures emit large amount of steam. The patient attends to the consultation referring that from approximately 2 months before he has been presenting weakness with muscle cramps, palpitations, flushing of the face and, increase in the size of the thyroid glands. It is diagnosed by the high hormonal figures a toxic multinodular goiter. Thyroid ultrasound is performed that shows multinodular goiter; it is also conducted a biopsy by fine-needle aspiration resulting in atypia of uncertain significance, and follicular lesion of the thyroid. The patient was separated from his workplace and there were reversed the symptoms after 15 days of treatment. Frequently appear diseases associated to poisonings caused by chemicals and medicines, where the presence of hyperthyroidism is not usual. It requires a comprehensive anamnesis and complementary tests that are specific for a proper diagnosis and treatment(AU)

Preoperatively undiagnosed papillary thyroid carcinoma in patients thyroidectomized for benign multinodular goiter

ABSTRACT Objective Incidental thyroid cancers (ITCs) are often microcarcinomas; among them, the most frequent histotype is the papillary one. The purpose of this study was to evaluate the rate of papillary thyroid cancer (PTC) in patients thyroidectomized for benign multinodular goiter. Subject and methods We retrospectively evaluated the histological incidence of PTC in 207 consecutive patients who, in a 1-year period, underwent thyroidectomy for benign multinodular goiter. All patients came from an iodine-deficient area (Orleans, France) with three nuclear power stations located in the neighboring areas of the county town. Results Overall, 25 thyroids (12.1%) harbored 37 PTC, of which 31 were microcarcinomas. In these 25 PTC patients, mean age was 55 ± 10 years (range 30-75), female:male ratio 20:5 (4:1). In 10 patients (40% of 25 and 4.8% of 207), PTCs were bilateral, and in 7 (2 with microPTCs) the thyroid capsule was infiltrated. These 7 patients underwent central and lateral cervical lymph node dissections, which revealed lymph node metastases in one and two cases, respectively. Radioiodine treatment was performed in 7 cases. Neither mortality nor transient and permanent nerve injuries were observed. Four (16%) transient hypocalcaemias occurred as early complications. At last follow-up visit (mean length of follow-up 17.2 ± 3.4 months), all patients were doing well and free of any clinical local recurrence or distant metastases. Conclusion With a 12% risk that multinodular goiter harbors preoperatively unsuspected PTCs, which can have already infiltrated the capsule and that can be accompanied by PTC foci contralaterally, an adequate surgical approach has to be considered.

Diagnostic utility of FNAC in thyroid lesions and their histological correlation – A case study

Fine needle aspiration of thyroid lesions forms the first diagnostic tool in the preoperative evaluation of thyroid lesions. Thyroid diseases are important as these are curable with medical as well as surgical treatment. Enlargement of thyroid called as goiter is the most common manifestation of thyroid diseases. FNAC forms an important role to determine the nature of thyroid lesion whether benign or malignant. It is simple, safe, accurate and cost effective method. This was a prospective and descriptive study done for the period of 2 years from January 2016 to December 2017 in the Department of Pathology at our tertiary care hospital. A total of 100 patients with thyroid lesions came for FNAC, out of which 50 cases were received for histopathological correlation. There were 39 cases of benign thyroid lesions out of which multinodular goiter were the commonest. Papillary carcinoma was the most common malignant lesion amongst 11 cases. Benign lesions presented in younger age group (20-40 years) whereas malignant lesions had bimodal presentation (20-40 years and 40-60 years). Hereby I have analyzed different types of thyroid lesions in different age groups based on cytological evaluation followed by its histopathological confirmation.

Cáncer papilar en bocio multinodular gigante / Papillary cancer in giant multinodular bocio

Resumen Se comunica el caso de una paciente de 71 años de edad con antecedente tabáquico, ingresada por padecer infecciones recurrentes. Tenía aumento de volumen del hemicuello izquierdo con nódulo de 4 cm de diámetro de 15 años de evolución hasta llegar a dimensiones de 20 x 15 cm. Se resecó de manera completa, excepto por su infiltración a la tráquea que quedó como remanente. El diagnóstico histopatológico fue: carcinoma papilar de tiroides infiltrante a la tráquea. En relación con este caso, se recomienda no dejar a libre evolución porque la incidencia del carcinoma papilar de tiroides asociado con bocio multinodular es similar a la encontrada en nódulos fríos solitarios, por lo que se recomienda actuar de manera temprana con cirugía.

Abstract This paper reports the case of a 71-year-old female with a history of tobacco addiction who presented with recurrent infections. She had an increase of volume of left neck with nodule of 4 cm of diameter of 15 years of evolution until arriving at dimensions of 20 x 15 cm. It was completely dry except for its infiltration into the trachea that remained as a remnant. The histopathological diagnosis was: papillary carcinoma of the thyroid infiltrating to trachea. Regarding this case, it is recommended not to leave free evolution, since the incidence of papillary thyroid carcinoma associated with multinodular goiter is similar to that found in solitary cold nodules, which is why it is recommended to act early with surgery.

Expression of Pendrin gene (SLC26A4) and protein in multinodular goiter / 中华内分泌外科杂志

Objective To explore the expression of the Pendrin gene (SLC26A4) and protein in multinodular goiter.Methods Thyroid tissues were obtained from 40 multinodular goiter patients undergoing surgery while the control group were obtained from 40 nomal thyroid tissues.RT-PCR was used to test SLC26A4 gene while western blot and immunohistochemistry were used to test Pendrin protein expression and distribution.Results SLC26A4 mRNA expression in multinodular goiter tissue was significantly increased in comparison with normal nodular tissues (t=2.663,P=0.011).Pendrin protein expression in multinodular goiter group was higher than that in normal tissue (t=2.286,P=0.026).The immunohistochemistry results showed that the Pendrin protein in multinodular goiter was mainly located in cytoplasm.There was positive expression in 24 patients (60％) in multinodular goiter group,while it was in 14 patients (35％) in the normal control group.The difference was significant (X2=5.013,P=0.025).Pendrin protein mainly expressed in cytoplasm in multinodular goiter tissue while it was mainly in cytomembrane in the normal control group.Conclusion SLC26A4 mRNA and its coding protein Pendrin expression are increased in multinodular goiter group,and mainly located in cytoplasm,indicating that iodide transporter function may be damaged when multinodular goiter occurs.

Successful reduction in thyroid and nodule volumes in large solitary and multinodular goiters with serial 131 iodine therapy

Introduction@#131Iodine therapy is effective in nodular nontoxic goiter with enhanced effects using recombinant thyroid stimulating hormone (rTSH). The eventual fibrosis of the thyroid tissue and blood vessels ligates the vascular supply of the nodule. The study aims to show the successful reduction of thyroid and nodule volumes in large solitary and multinodular goiters using serial low dose 131iodine therapy (10mCi) at three to six months interval.@*Methods@#A retrospective analytical study was done from January 2010 to December 2012 and included twenty three patients with enlarged solitary and multinodular (nodule/s ≥2cm) non-toxic goiter (females: age range 35-65yrs) given serial 131iodine therapy (eight to10mCi) at three to six-month interval. Before each course, serum thyroid stimulating hormone (TSH) was done to document hypothyroidism while thyroid gland and nodule sizes were monitored by ultrasonographic measurements serially with each 131iodine therapy. Relief of compressive symptoms was monitored on follow-up at clinic.@*Results@#Thyroid size reduced by 38-40% from baseline after first radioactive iodine (RAI) and by 33-39% after the second RAI. Thyroid nodules reduced by 63-69% and 11-25% serially. Significant reduction was noted after the first RAI. One subject underwent third RAI with 80-85% overall reduction in nodule size. All patients developed post-RAI hypothyroidism and overall had greater than 50% increase in levothyroxine replacement dose after the last RAI. Significant relief of compressive symptoms was noted by 91% post-therapy. Four thyroid nodules disappeared which resulted in reduced total number of thyroid nodules from 29 to 25 nodules post serial RAI.@*Conclusion@#Serial 131iodine therapy proved to have thyroid and nodule size reduction by more than 70% in this study. Among patients who do not consent or have contraindications to surgery, serial 131iodine therapy may be considered a safe and effective non-surgical alternative.

Histological study of adenomatous goitre.

Background & objectives: Multinodular goitre is probably the most common endocrine problem in the world today. Neither a well formulated nor a simple procedure is available for the management of MNG, hence the need for the present study. The aim was to study the various modes of presentation, the distribution with respect to age and sex and the usefulness of histological evaluation. Methods: This was a retrospective study of 100 cases of thyroid lesions during the period of April 2009 to October 2010. Results: Adenomatous goiter was found to be the commonest lesion with a frequency of 52 cases (52%).Most of the patients were female accounting for 90.39%. Most of the cases (53.85%) were noted in 21-40 years age group. Commonest presentation was swelling in front of the neck noted in 98% of cases. Conclusion: Commonest histological observation in the present study was adenomatous goitre in 52%. Majority of the patients were females with a M:F ratio of 1:9.4, with the commonest age group being 31-40 yrs. Almost all patients presented with swelling in front of the neck, with other complaints being that of pain, discomfort, dysphagia, dyspnoea and features of hyperthyroidism.

Total and Near-total Thyroidectomy is Better Than Subtotal Thyroidecomy for the Treatment of Bilateral Bening Multinodular Goiter; A Prospective Analysis.

Objective: To analyze the safety and effectiveness of total thyroidectomy in the surgical management of bilateral benign multinodular goiter. Materials and Methods: A prospective review of patients with bilateral benign multinodular goiter undergoing subtotal thyroidectomy (Group 1), and near-total thyroidectomy and total thyroidectomy (Group 2) during 5-year period was undertaken. Patients’ demographics, indications for surgery, type of operation performed, final histological diagnosis and complications were recorded. Transient and permanent complications regarding hypoparathyroidism and recurrent laryngeal nerve paralysis were analyzed for each surgical procedure. Results: Out of a total of 207 patients, recurrence of benign multinodular goiter was recorded in 27 (30%) cases in group 1 while there was no recurrence in group 2 (p < 0.01). Completion thyroidectomies were performed in 31 (34%) patients in group 1 whereas none was required in group 2 (p < 0.01). Incidental thyroid malignancy was found to be 18% (n= 38/207) in this study which necessitated completion thyroidectomy in group 1 patients. Permanent hypoparathyroidism was documented in 4(4%) and 3(1.8%) and transient hypoparathyroidism in 5 (6%) and 4 (2.8%) cases in groups 1 and 2, respectively; p value not significant. Permanent hypoparathyroidism and transient RLN palsy were recorded in 9 (29%) and 8 (25%) patients, respectively in those patients who underwent second thyroid surgery (P < 0.05). Conclusion: Total or near-total thyroidectomy is effective and safe for the surgical treatment of bilateral multinodular goiter to prevent recurrence and to eliminate the need for completion thyroidectomy in case of final diagnosis of incidental thyroid malignancy.

Giant Multinodular Goiter, Mimicking a Direct Invasion from the Malignant Thyroid Neoplasm: A Case Report / 대한갑상선학회지

Multinodular goiter (MNG) is one of the benign thyroid neoplasm and nodular hyperplasia is the most common pathologic type. MNG could be misdiagnosed as a malignancy because of its characteristic, which is its growing tendency. A-70-year-old female was referred to our clinic from endocrinology, with the huge and recently rapid growing thyroid mass. We performed the neck sonography, its guided fine needle aspiration cytology (FNAC), neck CT and MRI. She was presumed as the malignant thyroid neoplasm except papillary carcinoma. The right completion thyroidectomy and anterior compartment neck dissection had been done and the nodular hyperplasia was diagnosed finally. We learned a valuable lesson from this case in the following. Even if the malignancy is strongly suggested in the radiology and clinically, more careful consideration in determining the surgical method and its extent is mandatory.

Giant Multinodular Goiter, Mimicking a Direct Invasion from the Malignant Thyroid Neoplasm: A Case Report / 대한갑상선학회지

Multinodular goiter (MNG) is one of the benign thyroid neoplasm and nodular hyperplasia is the most common pathologic type. MNG could be misdiagnosed as a malignancy because of its characteristic, which is its growing tendency. A-70-year-old female was referred to our clinic from endocrinology, with the huge and recently rapid growing thyroid mass. We performed the neck sonography, its guided fine needle aspiration cytology (FNAC), neck CT and MRI. She was presumed as the malignant thyroid neoplasm except papillary carcinoma. The right completion thyroidectomy and anterior compartment neck dissection had been done and the nodular hyperplasia was diagnosed finally. We learned a valuable lesson from this case in the following. Even if the malignancy is strongly suggested in the radiology and clinically, more careful consideration in determining the surgical method and its extent is mandatory.

Radioiodine plus recombinant human thyrotropin do not cause acute airway compression and are effective in reducing multinodular goiter

Recombinant human thyrotropin (rhTSH) reduces the activity of radioiodine required to treat multinodular goiter (MNG), but acute airway compression can be a life-threatening complication. In this prospective, randomized, double-blind, placebo-controlled study, we assessed the efficacy and safety (including airway compression) of different doses of rhTSH associated with a fixed activity of 131I for treating MNG. Euthyroid patients with MNG (69.3 ± 62.0 mL, 20 females, 2 males, 64 ± 7 years) received 0.1 mg (group I, N = 8) or 0.01 mg (group II, N = 6) rhTSH or placebo (group III, N = 8), 24 h before 1.11 GBq 131I. Radioactive iodine uptake was determined at baseline and 24 h after rhTSH and thyroid volume (TV, baseline and 6 and 12 months after treatment) and tracheal cross-sectional area (TCA, baseline and 2, 7, 180, and 360 days after rhTSH) were determined by magnetic resonance; antithyroid antibodies and thyroid hormones were determined at frequent intervals. After 6 months, TV decreased significantly in groups I (28.5 ± 17.6 percent) and II (21.6 ± 17.8 percent), but not in group III (2.7 ± 15.3 percent). After 12 months, TV decreased significantly in groups I (36.7 ± 18.1 percent) and II (37.4 ± 27.1 percent), but not in group III (19.0 ± 24.3 percent). No significant changes in TCA were observed. T3 and free T4 increased transiently during the first month. After 12 months, 7 patients were hypothyroid (N = 3 in group I and N = 2 in groups II and III). rhTSH plus a 1.11-GBq fixed 131I activity did not cause acute or chronic changes in TCA. After 6 and 12 months, TV reduction was more pronounced among patients treated with rhTSH plus 131I.

Percutaneous ethanol injection efficacy in benign thyroid nodules: a descriptive retrospective study

Background: In benign nodular thyroid diseases, percutaneous ethanol injection (PEI) has been introduced as an alternative to surgery for more than 10 years. Previous studies confirmed the safety and efficacy of PEI in reducing the size of thyroid nodules, including cystic thyroid. PEI can be performed as an out-patient procedure. Objective: To evaluate the efficacy and safety of PEI treatment for reducing the size of benign thyroid nodules. Material and methods: Descriptive retrospective study was made for patients with non-toxic thyroid nodules treated by PEI at Theptarin Hospital (Bangkok, Thailand) during a five year period (Jan 2002 and Dec 2006). The volume of nodules was measured using ultrasound technique before and after PEI treatment. Any complications were also recorded. In the present analysis, the nodules were classified into four groups: solid, cystic, mixed solid-cystic nodules, and multinodular goiters. Results: Of the 167 treated nodules in the study, initial nodule volume was 10.14 ± 12.32 mL, median number of injections was 5 times with total ethanol volume injected 0.99 ± 0.54 mL per mL nodule volume. Percentage volume reduction was 66.67 ± 32.19% at the median time of 14 months follow-up. Overall, 80% of treated nodules achieved ≥ 50% volume reduction. The mean volume reduction in this group was 79.61%. In the subgroup of solid thyroid nodule (65 nodules), the mean volume reduction was 58.73 ± 35.33%. In the subgroup of cystic thyroid (8 nodules), the mean volume reduction was 92.38 ± 6.57%. In the subgroup of mixed solid-cystic nodule (44 nodules), the mean volume reduction was 67.35 ± 35.18%. In the subgroup of multinodular goiters (50 nodules), the mean volume reduction was 72.27 ± 23.76%. Only two patients developed temporary vocal cord paresis. No permanent or serious complications were experienced. Conclusion: PEI proved to be a safe and effective therapeutic procedure for patients with benign thyroid nodules. Recurrent thyroid cysts could be also managed with this treatment.

Aspectos patogênicos e clínicos do bócio multinodular / Pathogenic and clinical aspects of multinodular goiter

O bócio multinodular (BMN) é definido como um aumento da glândula tireóide secundário à proliferação multifocal de tireócitos e caracteriza-se pela heterogeneidade no crescimento e função das células foliculares. O BMN é considerado uma neoplasia benigna da tireóide. É uma doença comum, com aumento da prevalência em áreas com deficiência de iodo, sendo este o principal fator etiológico ambiental. A patogênese desta disfunção tireoidiana ainda não está inteiramente elucidada. Nesta revisão serão abordados os principais mecanismos envolvidos na patogênese, seguidos das implicações clínicas dessa patologia.

Multinodular goiter (MNG) is defined as an enlargement of the thyroid gland that is characterized by heterogeneity in growth and function of thyroid follicular cells. MNG is now considered a true thyroid neoplasm. It is a common disease, with higher prevalences in iodine deficiency areas. Iodine deficiency is the main environmental etiologic factor for MNG. The pathogenesis of multinodular goiter is not yet fully clarified. The purpose of this review is to summarize the current knowledge of MNG with respect to the pathology, etiologic and clinical characteristics.

Hyperthyroid Graves’ disease after radioiodine therapy for non-toxic multinodular goiter

Background: Radioiodine treatment has been used to reduce the size of euthyroid multinodular goiter (MNG) as an alternative to surgery. Postradioiodine Graves’ disease is a rare side effect which can occur several months after radioiodine treatment for non-toxic multinodular goiter. Objective: To report two patients who developed hyperthyroid Graves’ disease after radioiodine therapy for non-toxic multinodular goiter. Methods: We report the clinical and laboratory findings of Graves’ disease which occurred after radiotherapy. The literature was reviewed for the incidence and pathogenesis of Graves’ disease after radioiodine therapy. Results: The first case describes a 39-year-old woman presented with hyperthyroidism after repeated radioiodine therapy for non-multinodular goiter. The second case describes a 45-year-old woman who presented with hyperthyroidism after the first dose of radioiodine therapy for non-multinodular goiter. Graves’ disease was confirmed in both cases by the presence of thyrotropin receptor antibody (TRAb). Both patients respond well to methimazole. Conclusion: We demonstrate the rare occurrence of Graves’ disease as the side effect of radioiodine treatment for non-toxic multinodular goiter. They highlight the importance of recognizing patients with hyperthyroidism after radioiodine treatment as they could develop hyperthyroid Graves’ disease following this treatment.

Pseudoxantoma elástico con complicaciones tardías y asociaciones infrecuentes / Pseudoxanthoma elasticum with late complications and unusual associations

El pseudoxantoma elástico (PXE) es un trastorno hereditario poco común del tejido conectivo, que se caracteriza por lesiones cutáneas, oculares y cardiológicas originadas por fragmentación y calcificación de las fibras elásticas. La mayoría de casos se hereda con un patrón autosómico recesivo, y, en menos proporción, autosómico dominante. El propósito del presente reporte es dar a conocer un caso de pseudoxantoma elástico con complicaciones tardías y asociaciones infrecuentes, como son una ECV (enfermedad cerebro vascular) recidivante, abortos recurrentes, la presencia de un bocio multinodular unilateral derecho, fibromatosis uterina gigante no sintomática, hipertensión arterial, y un antecedente no bien clarificado con respecto a la presencia de diabetes mellitus.

Pseudoxanthoma elasticum (PXE) is connective tissue's rare inherited disorder, characterized by skin, eye and cardiac lesions, originated by fragmentation and calcification of elastic fibers. Most cases are inherited with an autosomal recessive pattern, and in a little proportion, with an autosomal dominant pattern. This paper has the purpose of reporting a case of pseudoxanthoma elasticum with late complications and unusual associations, such as recidivated stroke, recurrent aborts, right multinodular unilateral goiter, giant uterine fibromatosis, arterial hypertension, and an unclear antecedent of diabetes mellitus.

Effect of 30 mCi radioiodine on multinodular goiter previously treated with recombinant human thyroid-stimulating hormone

Recombinant human thyroid-stimulating hormone (rhTSH) enhances 131I uptake, permitting a decrease in radiation for the treatment of multinodular goiter (MNG). Our objective was to evaluate the safety and efficacy of a single 0.1-mg dose of rhTSH, followed by 30 mCi 131I, in patients with MNG. Seventeen patients (15 females, 59.0 ± 13.1 years), who had never been submitted to 131I therapy, received a single 0.1-mg injection of rhTSH followed by 30 mCi 131I on the next day. Mean basal thyroid volume measured by computed tomography was 106.1 ± 64.4 mL. 131I 24-h uptake, TSH, free-T4, T3, thyroglobulin, anti-thyroid antibodies, and thyroid volume were evaluated at regular intervals of 12 months. Mean 131I 24-h uptake increased from 18.1 ± 9.7 to 49.6 ± 13.4 percent (P < 0.001), a median 2.6-fold increase (1.2 to 9.2). Peak hormonal levels were 10.86 ± 5.44 mU/L for TSH (a median 15.5-fold increase), 1.80 ± 0.48 ng/dL for free-T4, 204.61 ± 58.37 ng/dL for T3, and a median of 557.0 ng/mL for thyroglobulin. The adverse effects observed were hyperthyroidism (17.6 percent), painful thyroiditis (29.4 percent) and hypothyroidism (52.9 percent). Thyroid volume was reduced by 34.3 ± 14.3 percent after 6 months (P < 0.001) and by 46.0 ± 14.6 percent after 1 year (P < 0.001). Treatment of MNG with a single 0.1-mg dose of rhTSH, followed by a fixed amount of radioactivity of 131I, leads to an efficacious decrease in thyroid volume for the majority of the patients, with a moderate incidence of non-serious and readily treatable adverse effects.