Bocio endotorácico / Endothoracic Goiter

Introducción: Un bocio se considera intratorácico cuando más de un 50 por ciento de la glándula tiroides está en el mediastino, o sea, por debajo del nivel del estrecho torácico superior. Se trata de una enfermedad poco frecuente que padece aproximadamente el 3 por ciento de los pobladores del mundo. La incidencia del bocio nodular ha disminuido debido a la ingestión en algunos países de sal yodada y alimentos ricos en yodo. Esta enfermedad alcanza alrededor del 10 por ciento de las masas mediastínicas. Objetivo: Presentar el caso de un paciente masculino, operado de bocio endotorácico en la provincia de Cienfuegos. Presentación de caso: Se presenta un paciente masculino, de 48 años de edad, que acude a consulta y refiere aumento de volumen del cuello en la región anterior, que se acompaña de decaimiento y en ocasiones disfagia tanto a los alimentos líquidos como a los sólidos. Además, refiere ligera disnea que tolera adecuadamente cuando realiza las actividades de la vida diaria. Por tratarse de una enfermedad poco frecuente, se considera de interés científico publicar el caso para conocimiento de los profesionales dedicados al estudio y tratamiento de las afecciones tiroideas. Conclusiones: El bocio endotorácico es una entidad poco frecuente y en todos los casos requiere de intervención quirúrgica(AU)

Introduction: A goiter is considered intrathoracic when more than 50 percent of the thyroid gland is in the mediastinum; in other words, below the level of the superior thoracic outlet. It is a rare disease that affects approximately 3 percent of the world's population. The incidence of nodular goiter has decreased due to the ingestion of iodized salt and iodine-rich foods in some countries. This disease accounts for about 10 percent of mediastinal masses. Objective: To present the case of a male patient operated on for endothoracic goiter in the province of Cienfuegos. Case presentation: The case is presented of a 48-year-old male patient who comes for consultation referring a volume increase in the anterior neck region, accompanied by decay and sometimes dysphagia to both liquid and solid food. In addition, he reports slight dyspnea that he tolerates adequately when performing daily living activities. Since this is a rare disease, it is considered of scientific interest to publish the case for the knowledge of professionals dedicated to studying and treating thyroid disorders. Conclusions: Endothoracic goiter is a rare entity and, in all cases, requires surgical intervention(AU)

Manejo del paciente con Hipertiroidismo en consulta externa de la Unidad Técnica de Endocrinología del Hospital Carlos Andrade Marín / Management of the patient with hyperthyroidism in the outpatient clinic of the Technical Unit of Endocrinology of the Endocrinology Technical Unit of the Carlos Andrade Marín Hospital

El hipertiroidismo es un trastorno caracterizado por el exceso de hormonas tiroideas. El déficit de yodo es un factor clave en dicha patología y en lugares con suficiencia del mismo se asocian a au-toinmunidad tiroidea. La prevalencia de hipertiroidismo mani-fiesto varía del 0,2% al 1,3% en áreas con suficiencia de yodo, sin embargo, esto puede variar en cada país por diferencias en umbrales de diagnóstico, sensibilidad de ensayo y población se-leccionada. Un reporte de The Third National Health and Nutri-tion Examination Survey (NHANES III) mostró que el hiperti-roidismo manifiesto se presenta en 0,7% de la población general e hipertiroidismo subclínico en el 1,7%1,2.En incidencia, la patología se asocia con la suplementación de yodo, con la mayor frecuencia en áreas de deficiencias, por au-mento de nódulos tiroideos en la población anciana, teniendo a regiones de áreas montañosas como América del Sur, África Central y suroeste de Asia dentro de este grupo. Un meta aná-lisis de estudios europeos mostró una incidencia general de 50 casos por 100000 personas/años1. En Ecuador, según los datos del Instituto Nacional de Estadísticas y Censos (INEC) del 2017, se reportaron 157 casos de hipertiroidismo, de los cuales la En-fermedad de Graves (EG) fue la causa más común, seguida por el bocio multinodular tóxico (BMNT) y finalmente el adenoma tóxico (AT) con una incidencia de 61 %, 24 % y 14 % respecti-vamente3.Los pacientes con esta patología tienen aumento de riesgo com-plicaciones cardiovasculares y mortalidad por todas las causas, siendo falla cardíaca uno de sus principales desenlaces, así el diagnóstico precoz evita estos eventos, principalmente en pobla-ción de edad avanzada.El presente protocolo se ha realizado para un correcto trata-miento de esta patología en el Hospital de Especialidades Carlos Andrade Marín (HECAM).

Hyperthyroidism is a disorder characterized by an excess of thyroid hormones. Iodine deficiency is a key factor in this pa-thology and in places with iodine deficiency it is associated with thyroid autoimmunity. The prevalence of overt hyperthyroidism varies from 0,2% to 1,3% in iodine-sufficient areas; however, this may vary from country to country due to differences in diag-nostic thresholds, assay sensitivity, and selected population. A report from The Third National Health and Nutrition Examina-tion Survey (NHANES III) showed that overt hyperthyroidism occurs in 0,7% of the general population and subclinical hyper-thyroidism in 1,7%1,2.In incidence, the pathology is associated with iodine supplemen-tation, with the highest frequency in areas of deficiencies, due to increased thyroid nodules in the elderly population, having regions of mountainous areas such as South America, Central Africa and Southwest Asia within this group. A meta-analysis of European studies showed an overall incidence of 50 cases per 100000 person/years1. In Ecuador, according to data from the National Institute of Statistics and Census (INEC) in 2017, 157 cases of hyperthyroidism were reported, of which, Graves' di-sease (GD) was the most common cause, followed by toxic mul-tinodular goiter (BMNT) and finally toxic adenoma (TA) with an incidence of 61 %, 24 % and 14 % respectively3.Patients with this pathology have an increased risk of cardiovas-cular complications and all-cause mortality, with heart failure being one of the main outcomes, so early diagnosis avoids these events, mainly in the elderly population.The present protocol has been carried out for the correct treat-ment of this pathology at the Carlos Andrade Marín Specialties Hospital (HECAM).

Mechanism Study on Chinese Medicine in Treatment of Nodular Goiter / 中国结合医学杂志

Nodular goiter has become increasingly prevalent in recent years. Clinically, there has been a burgeoning interest in nodular goiter due to the risk of progression to thyroid cancer. This review aims to provide a comprehensive summary of the mechanisms underlying the therapeutic effect of Chinese medicine (CM) in nodular goiter. Articles were systematically retrieved from databases, including PubMed, Web of Science and China National Knowledge Infrastructure. New evidence showed that CM exhibited multi-pathway and multi-target characteristics in the treatment of nodular goiter, involving hypothalamus-pituitary-thyroid axis, oxidative stress, blood rheology, cell proliferation, apoptosis, and autophagy, especially inhibition of cell proliferation and promotion of cell apoptosis, involving multiple signal pathways and a variety of cytokines. This review provides a scientific basis for the therapeutic use of CM against nodular goiter. Nonetheless, future studies are warranted to identify more regulatory genes and pathways to provide new approaches for the treatment of nodular goiter.

Subacute thyroiditis and rapidly developing goiter in a 16-year-old female: a case report / Tiroiditis Sub-aguda asociada a bocio nodular en una paciente de 16 años; reporte de un caso

Subacute thyroiditis (SAT) is an inflammatory disease of the thyroid gland with multiple etiologies and clinical features, often challenging to recognize. The classic presentation is the painful, granulomatous thyroiditis (DeQuervain's) characterized by diffuse swelling of the gland, usually preceded by an upper respiratory tract infection. A painless variant, also referred to as autoimmune subacute thyroiditis, has been documented and is strongly linked to postpartum state, reported following ~10% of pregnancies. It can be differentiated from the former by the presence of anti-thyroid antibodies, which classifies it as an autoimmune thyroiditis. Any spontaneous development of painful swelling of the thyroid gland warrants a complete work up that includes thyroid hormones, thyroid autoimmune panel, acute phase reactant titers, and, if available, imaging that may lead to the diagnosis of an inflammatory or infectious cause of thyroiditis.

Tiroiditis Subaguda, es una enfermedad inflamatoria de la glándula Tiroides que tiene muchas etiologías y características clínicas, y frecuentemente difícil de reconocer. La presentación clásica es: tiroiditis granu-lomatosa dolorosa caracterizada de hinchazón difusa de la glándula del Tiroides, usualmente precedida de una infección respiratoria de las vías áreas superior (como una infección viral). Existe una variante sin dolor, tam-bién referida como tiroiditis subaguda autoinmune, ha sido documentado y es muy ligada al estado postparto, en un 10% de los embarazos. La Tiroiditis postparto Puede ser diferenciada de la anterior por la presencia de anticuerpos lo que la clasifica como una tiroiditis auto-inmune. Cualquier desarrollo espontaneo de una hin-chazón dolorosa de la tiroides garantiza su evaluación de una manera formal, que incluye las hormonas del tiroides, panel tiroideo de autoinmunidad títulos de los factores que reaccionan agudamente, y si está disponible imágenes como una ultrasonografía que conlleva al di-agnóstico de una Tiroiditis inflamatoria o de origen in-feccioso.

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.

Bocio endotorácico en un adulto / Endothoracic goiter in an adult

Se presenta el caso clínico de un paciente de 48 años de edad, quien acudió a la consulta de Patología de Tiroides del Hospital Provincial Dr. Gustavo Aldereguía Lima de Cienfuegos, por presentar aumento de volumen del cuello en la región anterior, decaimiento, ocasionalmente disfagia y ligera disnea. Al examen físico se constató un tumor en la región anteroinferior y lateral derecha del cuello, movible, que se prolongaba hacia abajo a la parte superior del tórax. Se realizó hemitiroidectomía derecha con exéresis de la prolongación endotorácica. El paciente evolucionó favorablemente.

The case report of a 48 years patient is presented. He went to the Thyroid Pathology Service of Dr. Gustavo Aldereguía Lima Provincial Hospital from Cienfuegos, due to an increase of volume in the anterior region of the neck, weakness, occasionally deglutition disorders and light dyspnea. A tumor was verified in the anteroinferior and lateral right region of the neck, movable, that was prolonged downward to the superior part of the thorax when the physical exam was carried out. A right hemithyroidectomy was carried out with exeresis of the endothoracic extension. The patient had a favorable clinical course.

Perfil clínico e terapêutico dos pacientes com hipertireoidismo do ambulatório de endocrinologia de um hospital universitário do sul do Brasil / Perfil clínico e terapêutico dos pacientes com hipertireoidismo do ambulatório de endocrinologia de um hospital universitário do sul do BrasilClinical and therapeutic profile of patients with hyperthyroidism in an outpatient endocrine clinic at a university hospital in southern Brazil

.Introdução: O hipertireoidismo decorre da elevação sérica dos hormônios tireoidianos, secundária à hiperfunção da glândula tireoide, sendo as principais causas a Doença de Graves (DG) e os Bócios Nodulares Tóxicos (BNT). Objetivos: Avaliar o perfil clínico e modalidades terapêuticas aplicadas em pacientes com diagnóstico de hipertireoidismo acompanhados em um Hospital Universitário no Sul do Brasil. Métodos: Estudo observacional, transversal e descritivo, com inclusão de pacientes com diagnóstico de hipertireoidismo por DG e BNT; foram coletados dados epidemiológicos, clínicos, laboratoriais e de tratamento. Resultados: A maioria dos pacientes foi referenciada pela atenção primária e encontrava-se em uso prévio de droga antitireoidiana (DAT). A variável idade obteve diferença estatisticamente significativa entre as etiologias de DG e BNT; em ambas houve predomínio de incidência no sexo feminino. A DG apresentou maior frequência de sinais e sintomas de tireotoxicose, ao passo que o BNT mostrou mais sinais e sintomas de compressão. Houve remissão da doença em 23,2% dos pacientes com DG tratados com DAT; em 23,2% dos pacientes optou-se pela manutenção de metimazol em baixa dose por mais de 36 meses e em 16,1% foi realizado tratamento definitivo. No BNT foram preferidas terapias definitivas, principalmente a tireoidectomia, em 27,5% dos pacientes. Doses baixas de metimazol por mais de 36 meses foram utilizados também no BNT, em 22,5% dos pacientes. Conclusão: O hipertireoidismo é uma doença heterogênea, desde a clínica inicial até a terapêutica, entre suas etiologias mais prevalentes. Observou-se uma tendência de priorizar as terapias medicamentosas em longo prazo com baixas doses, tanto na DG quanto no BNT. (AU)

Perfil clínico e terapêutico dos pacientes com hipertireoidismo do ambulatório de endocrinologia de um hospital universitário do sul do BrasilClinical and therapeutic profile of patients with hyperthyroidism in an outpatient endocrine clinic at a university hospital in southern Brazil ARTIGO ORIGINALRafael Antonio Parabocz1, Renata Soares Carvalho1, Gianna Carla Alberti Schrut1, Ana Claudia Garabeli Cavalli Kluthcovsky1, Matheo Augusto Morandi Stumpf1Introduction: Hyperthyroidism results from the serum elevation of thyroid hormones, secondary to hyperfunction of the thyroid gland. The main causes are Graves' disease (DG) and Toxic Nodular Goiters (BNT). Objectives: Evaluate the clinical profile and therapeutic modalities applied in patients diagnosed with hyperthyroidism followed up at a University Hospital in Southern Brazil. Methods: Observational, cross-sectional and descriptive study, including patients diagnosed with hyperthyroidism by DG and BNT; epidemiological, clinical, laboratory and treatment data were collected. Results: Most patients were referred by primary care and had been using antithyroid drugs (DAT). The age variable obtained showed a statistically significant difference between the etiologies of DG and BNT; in both, there was a predominance of incidence in females. DG showed a higher frequency of signs and symptoms of thyrotoxicosis, while BNT showed more signs and symptoms of compression. There was remission of the disease in 23.2% of patients with DG treated with DAT; in 23.2% of the patients, low-dose methimazole was maintained for more than 36 months and in 16.1%, definitive treatment was performed. In BNT, definitive therapies were preferred, mainly thyroidectomy, in 27.5% of patients. Low doses of methimazole for more than 36 months were also used in BNT in 22.5% of patients. Conclusion: Hyperthyroidism is a heterogeneous disease, from initial clinic to therapy, among its most prevalent etiologies. There was a tendency to prioritize long-term drug therapies with low doses, both in DG and BNT. (AU)

Tiroidectomía y paratiroidectomía endoscópica transoral con abordaje vestibular(TOETVA TOEPVA): Experiencia inicial en el Hospital Universitario Austral / Transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach (TOETVA TOEPVA): intial experience in Hospital Universitario Austral

RESUMEN Antecedentes: la cervicotomía de Kocher ha sido el abordaje clásico para la cirugía tiroidea y paratiroidea. El aumento en la preocupación por la cicatriz cervical ha generado un interés creciente por disminuir su tamaño o trasladarla a lugares menos visibles. Anuwong publica 60 casos de TOETVA/TOEPVA en 2016, con resultados óptimos. Objetivos: comunicar la experiencia con la tiroidectomía y paratiroidectomía transoral endoscópica con abordaje vestibular en el Hospital Universitario Austral. Material y métodos: análisis retrospetivo, sobre base prospectiva, de 18 procedimientos, entre mayo de 2019 y marzo de 2020. Se realizaron 2 paratiroidectomías, 13 lobectomías, 4 tiroidectomías totales, una con linfadenectomía central; una paciente presentó 2 patologías (adenoma paratiroideo y nódulo tiroideo). Citología según Bethesda: categoría II: 7; indeterminada: 1 y categoría VI: 9. Resultados: 18 pacientes femeninas. Mediana de edad: 41 años. Media del tamaño nodular: 30 mm. Volumen glandular medio: 24 mL. Conversión: 1 caso. Promedio de tiempo quirúrgico: lobectomía, 260 minutos; tiroidectomía total, 262 minutos. Histología definitiva: carcinoma papilar, 11; bocio nodular, 6; adenoma paratiroideo, 2. Complicaciones: equimosis leve, 12 pacientes; hipoparatiroidismo transitorio, 1 caso; paresia recurrencial transitoria, 1 caso; hiposensibilidad mentoniana transitoria, 1 caso. Dos casos de tiroidectomía total por cáncer: tiroglobulina a las 6 semanas < 0,1 μUI/mL. Conclusiones: 1) Es un abordaje seguro y ofrece resultados cosméticos excelentes. 2) Puede implementarse con equipamiento endoscópico convencional, con curva de aprendizaje corta y escasa morbilidad. 3) Alternativa para el tratamiento del carcinoma papilar de bajo riesgo. 4) Es prioritario garantizar la seguridad del paciente.

ABSTRACT Background: Kocher's cervicotomy has been the classic approach for thyroid and parathyroid surgery. The greater concern about neck scarring has generated an increasing interest in reducing scar size or leaving the scar in less visible places. In 2016 Anuwong published 60 cases of TOETVA/TOEPVA with optimal outcomes. Objectives: The aim of this study is to report the initial experience with transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach in Hospital Universitario Austral. Material and methods: We conducted a retrospective analysis of 18 prospective procedures performed between May 2019 and March 2020. The procedures performed were 2 parathyroidectomies, 13 lobectomies, 4 total thyroidectomies, 1 with central lymph node dissection; one patient presented a parathyroid adenoma and a benign thyroid nodule. Cytology report according to the Bethesda system: category II in 7 cases, VI in 9 and indeterminate in 1. Results: 18 female patients. Median age: 41 years. Mean nodule size: 30 mm. Mean gland volume: 24 mL. Conversion. 1 case. Mean operative time: lobectomy, 260 minutes; total thyroidectomy, 262 minutes. Definite histology: papillary thyroid carcinoma,11; benign nodular goiter, 6; parathyroid adenoma, 2. Complications: mild ecchymosis, 12 patients; temporary hyperparathyroidism, 1 case; temporary recurrent laryngeal palsy, 1 case; temporary numbness of the mental region in 1 case. In the two cases undergoing total thyroidectomy due to cancer, thyroglobulin level 6 weeks after surgery was < 0.1 μIU/mL. Conclusions: 1) The transoral approach is a safe and feasible procedure that offers excellent cosmetic results. 2) It can be implemented using conventional endoscopic equipment, has a short learning curve and low morbidity rate. 3)It constitutes an alternative for the treatment of low-risk papillary thyroid carcinoma. 4) Patient's safety should be guaranteed.

Neoplasias foliculares del tiroides. Correlación citopatológica / Follicular thyroid neoplasia. Cytopathological correlations

RESUMEN Introducción: la citología con aguja fina se mantiene como el estudio fundamental ante un nódulo tiroideo, pero el diagnóstico de neoplasia folicular es aún su punto débil para definirlo. Se mantiene como conducta su extirpación quirúrgica para alcanzarlo. Objetivo: determinar la correlación citopatológica en las neoplasias foliculares del tiroides. Materiales y métodos: se realizó un estudio prospectivo y descriptivo que incluyó a 80 pacientes operados con diagnóstico citológico de neoplasia folicular del tiroides, en el Hospital "Comandante Faustino Pérez" de la ciudad de Matanzas, de marzo del 2012 a febrero del 2016. Se evaluaron las variables: edad, sexo, tamaño, localización, número de nódulos y diagnóstico histológico definitivo. Resultados: predominaron las lesiones benignas con 56 para el 70 % dentro de ellas, los bocios multinodulares con 33,75 % y los adenomas foliculares con el 31,25 %. Los tumores malignos ocuparon el 30 %. El carcinoma papilar, variedad folicular con 12 para el 15 %, seguido del carcinoma papilar clásico con 10 para el 12,50 %. Conclusiones: el porcentaje de malignidad de este estudio fue del 30 % con predominio del carcinoma papilar variedad folicular y el carcinoma papilar clásico. Entre las lesiones benignas predominaron los bocios multinodulares y los adenomas foliculares (AU).

ABSTRACT Introduction: fine needle cytology is still the main study against a thyroidal nodule, but the follicular neoplasia diagnosis is still its weak point to define it. The surgical removal keeps being used to reach it. Objective: to determine the cytopathological correlation in follicular thyroid neoplasia. Materials and methods: a prospective, descriptive study was carried out including 80 patient with diagnosis of follicular thyroid neoplasia in the Hospital "Comandante Faustino Pérez" of Matanzas, who underwent a surgery from March 2012 to February 2016. The assessed variables were age, sex, size, location, quantity of nodes and final histological diagnosis. Results: benign lesions predominated, with 56 for 70 %; among them, multinodular goiters with 33.75 % and follicular adenomas with 31.25 %. Malignant tumors were 30 %: papillary carcinoma, follicular variety with 12 for 15 %, followed by the classical papillary carcinoma with 10 for 12.50 % Conclusions: the malignity percent of this study was 30 % with the predominance of the papillary carcinoma, follicular variant and the classic papillary carcinoma. Multinodular goiters and follicular adenomas predominated among the benign lesions (AU).

Bocio Intratorácico / Intrathoracic goiter

El bocio intratorácico se define como aquel bocio que se encuentra parcial o totalmente en el mediastino; su incidencia está en relación con el bocio multinodular. Es asintomático entre el 20­30%. Su diagnóstico se hace por pruebas de imagen; su Gold estándar es la tomografía axial computarizada. El tratamiento más efectivo y recomendado es la cirugía, sobre todo para pacientes con síntomas opresivos o con sospecha de malignidad y bocios hiperfuncionantes en quienes el tratamiento farmacológico no fue exitoso. Se detalla el caso de una paciente de 59 años de edad, quien, con síntomas opresivos esternales, a quien se le diagnostica masa mediastínica, la cual se resuelve con indicación quirúrgica, siendo resolutiva para la paciente, con mejoras en la sintomatología y diagnostico de benignidad. (AU)

Intrathoracic goiter is defined as partially or totally in the mediastinum; its incidence is related to multinodular goiter. It is asymptomatic in 20-30%. Its diagnosis is made by imaging tests; the gold standard is computerized axial tomography. Treatment can be pharmacological with risk of recurrence; the most effective and recommended is surgery, especially for patients with oppressive symptoms or with suspected malignancy. We present the case of a 59-year-old patient with sternal oppressive symptoms, who is diagnosed with a mediastinal mass, which resolved by surgery, with improvements in symptoms and a diagnosis of benignity. (AU)

Hepatotoxicidade induzida por azatioprina em portadora da síndrome de Vogt-Koyanagi-Harada / Azathioprine-induced hepatotoxicity in a Vogt-Koyanagi-Harada syndrome patient

Este relato teve como objetivo apresentar um caso de hepatotoxicidade colestática induzida por azatioprina em portadora da síndrome de Vogt-Koyanagi-Harada. À admissão, apresentava icterícia +3/+4, acolia fecal e colúria, além de aumento de marcadores hepáticos, sendo compatível com síndrome colestática, cuja etiologia foi confirmada após exclusão de outras causas possíveis e retirada da azatioprina. A paciente evoluiu, após 1 semana de retirada do fármaco, com diurese livre de coloração menos escura e evacuação presente, sem acolia. Além disso, houve melhora nos exames que precederam a alta hospitalar

This report aimed at presenting a case of azathioprine-induced cholestatic hepatotoxicity in a patient with Vogt-Koyanagi-Harada syndrome. On admission, she presented with jaundice +3/+4, acholic feces, and choluria, as well as increased hepatic markers, all consistent with cholestatic syndrome, the etiology of which was confirmed after other possible causes were ruled out and azathioprine was discontinued. After 1 week of the drug discontinuation, the patient progressed with free diuresis of lighter color and defecation, with no acholia. In addition, tests performed before discharge were improved.

Thyroid gland changes in patients with acromegaly

ABSTRACT Objective Acromegaly is characterized by high neoplastic morbidity as a side effect of growth hormone (GH) hypersecretion. Increased incidence of goiter, thyroid carcinoma, and thyroid dysfunction is also reported. The aim of the present study was to find the prevalence of thyroid dysfunction and goiter in patients with acromegaly and determine its relationship to disease activity, disease duration, and the presence of secondary hypothyroidism. Subjects and methods In a cross-sectional study of the period 2008-2012 were included 146 patients with acromegaly (56 men, 90 women) of mean age 50.3 ± 12.4 years. Acromegaly disease activity and thyroid function were evaluated in all patients. Thyroid ultrasonography was performed to calculate thyroid volume and detect the presence of nodular goiter. Results Ninety-one patients were determined to have an active disease, and 55, a controlled disease. The mean thyroid volume in patients without previous thyroid surgery was 37.6 ± 38.8 mL. According to disease activity, thyroid volume was significantly higher in patients with active disease (38.5 ± 45.4 mL vs. 27.2 ± 18.4 mL, p = 0.036). A weak positive correlation was found between thyroid volume and insulin-like growth factor 1 (IGF-1) in the whole group and in females (R = 0.218; p = 0.013, and R = 0.238; p = 0.037, respectively). There was no significant correlation of thyroid volume with disease duration and GH level in the whole group and in both sexes. The patients with secondary hypothyroidism had twofold smaller thyroid volume, relative to the rest of the group. The prevalence of thyroid dysfunction was 39%, with a female to male percentage ratio of 1.73. Goiter was diagnosed in 87% of patients, including diffuse goiter (17.1%) and nodular (69.9%), with no significant difference between patients with active and controlled disease or the presence of secondary hypothyroidism. Conclusions Thyroid volume in patients with acromegaly depends on disease activity and the presence of secondary hypothyroidism as a complication. The increased prevalence of nodular goiter determines the need of regular ultrasound thyroid evaluation in the follow-up of patients with acromegaly. Arch Endocrinol Metab. 2020;64(3):269-75

Comportamiento quirúrgico de las patologías del tiroides / Surgical behavior of thyroid pathologies

RESUMEN Introducción: La enfermedad nodular tiroidea es motivo de consulta médica, la decisión quirúrgica viene marcada por la sospecha de malignidad, el aumento de tamaño, presencia de clínica compresiva, e incluso motivos estéticos. Objetivo: Describir las características clínicas y quirúrgicas, de los pacientes con patología tiroidea, operados en el hospital "Comandante Pinares". Métodos: Se realizó un estudio descriptivo, ambispectivo de los pacientes intervenidos quirúrgicamente del tiroides en el Hospital "Comandante Pinares", en el período comprendido desde enero 2014 a diciembre 2018. Se tomó una muestra de 85 pacientes que cumplieron los criterios de inclusión. Los datos fueron obtenidos de las historias clínicas en un formulario diseñado para la investigación. Se midieron variables demográficas, epidemiológicas, clínicas, paraclínicas y quirúrgicas utilizándose métodos estadísticos para variables cuantitativas y cualitativas. Resultados: Las afecciones quirúrgicas de tiroides fueron más frecuentes en el sexo femenino, entre 50 y 59 años, predominándose los nódulos benignos. La forma clínica más frecuente de presentación fue la nodular sólida y los nódulos malignos se presentaron mayormente en tumores menores de 2 cm. El diagnóstico definitivo según resultados de la biopsia por parafina mostró que la mayoría de las lesiones fueron benignas, predominándose el bocio nodular y en la biopsia aspirativa con aguja fina. El resultado más frecuente fue el negativo. La técnica quirúrgica más empleada fue la Tiroidectomía total en un tiempo. La mayoría de los pacientes no presentaron complicaciones. Conclusiones: El tratamiento de las afecciones quirúrgicas del tiroides muestra resultados satisfactorios, predominándose las afecciones en el sexo femenino, de etiología benigna(AU)

ABSTRACT Introduction: Nodular thyroid disease is a reason for medical consultation, the surgical decision is marked by the suspicion of malignancy, an increase in size, the presence of a compression symptoms, and even aesthetic reasons. Objective: To describe the clinical and surgical characteristics of patients with thyroid disease, operated at the "Comandante Pinares" hospital. Methods: A descriptive, ambispective study of patients undergoing thyroid surgery at the "Comandante Pinares" Hospital was performed in the period from January 2014 to December 2018. A sample was taken of 85 patients who met the inclusion criteria. Data was obtained from medical records in a form designed for research. Demographic, epidemiological, clinical, paraclinical and surgical variables were measured using statistical methods for quantitative and qualitative variables. Results: Surgical thyroid conditions were more frequent in females, between 50 and 59 years of age, with benign nodules prevailing. The most frequent clinical form of presentation was solid nodular, and malignant nodules appeared mainly in tumors smaller than 2 cm. The definitive diagnosis according to the results of the paraffin biopsy showed that the majority of the lesions were benign, with a predominance of nodular goiter and fine needle aspiration biopsy. The most frequent result was negative. The most widely used surgical technique was Total Thyroidectomy at one time. Most of the patients did not present complications. Conclusions: The treatment of surgical thyroid conditions shows satisfactory results, predominating the conditions in the female sex, of benign etiology(AU)

Bocio multinodular gigante. Revisión de la literatura a propósito de un caso / Giant multinodular goiter. Case report and literature review

Introducción. La patología tiroidea abarca desde procesos benignos hasta cánceres. El manejo médico-quirúrgico del bocio gigante implica la realización de estudios citológicos y de imagen. El objetivo de este artículo fue hacer una revisión de la literatura y presentar un caso atendido de bocio multinodular gigante. Métodos. En el presente artículo se revisa la literatura sobre el tema en cuestión a propósito del caso de una paciente de 54 años de edad, intervenida quirúrgicamente por bocio multinodular, con evolución satisfactoria.Resultados. Se interviene la paciente de manera electiva, realizando exéresis a un tiroides de 658 gramos, conservando los nervios laríngeos recurrentes y las glándulas paratiroides; se realizó una meticulosa hemos-tasia y se trasladó la paciente a la Unidad de Cuidados Intensivos. A los 3 días se retiraron ambos drenajes cervicales, y se dio alta hospitalaria definitiva a los 8 días. La biopsia por parafina corroboró el diagnóstico preoperatorio. Discusión. Las indicaciones de tratamiento quirúrgico del bocio incluyen: crecimiento rápido de la glándula, síntomas compresivos y sospecha de malignidad. Las complicaciones son mínimas cuando se realiza una técnica muy meticulosa.Conclusión. El bocio multinodular gigante es infrecuente, y en todos los casos, requiere de intervención quirúrgica

Introduction. Thyroid pathology ranges from benign processes to cancers. The medical-surgical management of the giant goiter involves performing cytological and imaging studies. The objective of this article was to review the literature and present a treated case of giant multinodular goiter.Methods. This article reviews the literature on the subject in question regarding the case of a 54-year-old female patient who underwent surgery for multinodular goiter, with satisfactory evolution.Results. The patient was intervened electively, excising a 658 gram thyroid, preserving the recurrent laryngeal nerves and the parathyroid glands. A meticulous hemostasis was performed and the patient was transferred to the Intensive Care Unit. After 3 days, both cervical drains were removed, and the patient was discharged after 8 days. The paraffin biopsy corroborated the preoperative diagnosis.Discussion. Indications for surgical treatment of goiter include: rapid gland growth, compressive symptoms, and suspected malignancy. Complications are minimal when a very meticulous technique is performed. Conclusion. Giant multinodular goiter is rare, and in all cases, requires surgical intervention

Resultados a corto plazo del tratamiento con 131I en el bocio multinodular: valor adicional de la estimulación previa con rhTSH / Short-term results of treatment with 131I in multinodular goiter: additional value of previus stimulation with Recombinant human thyrotropin

OBJETIVO: El yodo radiactivo (131I) es una opción terapeútica segura y eficaz cuando se utiliza solo o con la estimulación previa de TSH recombinante humana (rhTSH) en el tratamiento del bocio multinodular (BMN). En espera de ensayos clínicos que determinen la dosis óptima, demuestren seguridad y confirmen la eficacia, diferentes protocolos se utilizan para aplicar la dosis de 131I. Analizamos la respuesta al tratamiento con una dosis calculada por protocolo mixto (dosis fijas y cálculo por porcentaje de captación) en pacientes con BMN toxico y no toxico en nuestro hospital, en el periodo 2010-2013. MATERIALES Y MÉTODOS: Estudio prospectivo en pacientes con BMN no quirúrgico (BMNNQ) que requerían reducción del volumen glandular y/o tratamiento del hipertiroidismo. Se evaluaron 134 pacientes, 14 cumplieron con los criterios de inclusión (13mujeres) de edad media 71.08 años. Un grupo con BMN toxico, otro grupo con BMN no toxico, un tercer grupo con BMN no toxico estimulado con 0,1 mg de rhTSH previo a la dosis. Se evaluó, función tiroidea, captación tiroidea de 99ᵐTc, volumen tiroideo y síntomas compresivos. Se siguió a los pacientes durante 12 meses. RESULTADOS: Se aplicaron dosis entre 15 y 30 mCi de 131I. Remitió el hipertiroidismo en 6 de 7 pacientes. Hubo una reducción del volumen glandular (p<0.01).Los pacientes con estímulo de 0,1 mg rhTSH, aumentaron el porcentaje de captación de 99ᵐTc a las 24 h en un 32.43±10.61 permitiendo aplicar menor dosis de 131I. La tasa de aparición de hipotiroidismo fue de 7.41 por cada 100 pacientes.mes, mayor en pacientes con BMN toxico tratados con dosis bajas (p-=0.03). Hubo una mejoría subjetiva de la clínica compresiva en todos los pacientes. No hubo eventos adversos. CONCLUSIONES: Una dosis de 131I calculada por protocolo mixto es efectiva y segura para la reducción del volumen glandular y control del hipertiroidismo asociado. La estimulación con rhTSH logra el mismo efecto con una menor dosis administrada.

OBJECTIVE: Radioactive iodine (131I) is a safe and effective therapeutic option when used alone or with prior stimulation of recombinant human Thyrotropin (rhTSH) in the treatment of multinodular goiter (MNG). In absence of clinical trials that determine the optimal dose, demonstrate safety and confirm efficacy, different protocols are used to apply the dose of 131I. We analyze the response to treatment with a dose calculated by mixed protocol (fixed doses and calculation by percentage of uptake) in patients with toxic and non-toxic MNG in our hospital, in the period 2010-2013. MATERIALS AND METHODS: Prospective study in patients with non-surgical MNG that required glandular volume reduction and / or treatment of hyperthyroidism. 134 patients were evaluated, 14 met the inclusion criteria (13 women) of average age 71.08 years. One group with toxic MNG, another group with non-toxic MNG and a third with non-toxic multinodular goiter stimulated with 0.1 mg of rhTSH prior to the dose. Patients were followed for 12 months. Upon following, we assessed Thyroid function, 99ᵐTc thyroid uptake, thyroid volume and compressive symptoms. RESULTS: Doses between 15 and 30 mCi of 131I were applied. We observed hyperthyroidism remission in 6 of 7 patients. There was a reduction in glandular volume (p <0.01) considering all patients. Patients with a stimulus of 0.1 mg rhTSH, increased the percentage of uptake of 99ᵐTc at 24 h by 32.43 ± 10.61, allowing a lower dose of 131I to be applied. The rate of onset of hypothyroidism was 7.41 per 100 patients-month, and was higher in patients with toxic MNG treated with low doses (p = 0.03). There was a subjective improvement of the compression clinic in all patients. No adverse events were observed. CONCLUSIONS: A dose of 131I calculated by a mixed protocol is effective and safe for achieving glandular volume reduction and associated hyperthyroidism control. Stimulation with rhTSH produces the same effect with a lower administered dose.

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)

Association between metabolic syndrome and euthyroid nodular goiter: a case-control study / Asociación entre el síndrome metabólico y el bocio nodular eutiroideo: un estudio de casos y controles

Abstract Background: Metabolic syndrome is a cluster of metabolic abnormalities and abdominal obesity; its pathophysiologic basis, insulin resistance, has been shown to act as agent in thyroid cell proliferation. Few studies analyze the relationship between metabolic syndrome and thyroid nodular disease, with a substantial knowledge gap. Objective: Determine the association between metabolic syndrome and nodular thyroid disease in a region with adequate iodine intake. Methods: Case-control study. A total of 182 patients referred to radiology to undergo thyroid ultrasonography due to suspicion of thyroid disease. Cases had at least one thyroid nodule greater than 3 mm (n= 91). Controls did not have evidence of thyroid nodules (n= 91). Results: Bivariate analysis showed a significant association between metabolic syndrome and the presence of thyroid nodule (OR 2.56, 95% CI: 1.41-4.66, p <0.05). Low levels of HDL (OR 2.81, 95% CI: 1.54-5.12, p <0.05) and impaired fasting glucose (OR 2.05, 95%CI 1.10 to 3.78, p <0.05) were significantly associated with the presence of thyroid nodule, independent of the presence of metabolic syndrome. Multivariate analysis maintained the association between metabolic syndrome and thyroid nodule with an OR of 2.96 (95%CI 1.47 to 5.95, p <0.05); similarly, the associations of low levels of HDL (OR 2.77, 95%CI 1.44 to 5.3, p <0.05) and impaired fasting glucose (OR 2.23, 95%CI 1.14 to 4.34, p<0.05) with thyroid nodule remained significant. Conclusion: The thyroid nodular disease is associated with increased risk of metabolic syndrome, specifically decreased HDL and impaired fasting glucose levels were the factors that increased association was found.

Resumen Antecedentes: el síndrome metabólico es un conjunto de anormalidades metabólicas y obesidad abdominal; Se ha demostrado que su base fisiopatológica, la resistencia a la insulina, actúa como agente en la proliferación de las células tiroideas. Pocos estudios analizan la relación entre el síndrome metabólico y la enfermedad nodular tiroidea, con una brecha de conocimiento sustancial. Objetivo: determinar la asociación entre el síndrome metabólico y la enfermedad tiroidea nodular en una región con una ingesta adecuada de yodo. Métodos: estudio de casos y controles. Un total de 182 pacientes remitidos a radiología para someterse a una ecografía tiroidea debido a la sospecha de enfermedad tiroidea. Los casos tenían al menos un nódulo tiroideo mayor de 3 mm (n = 91). Los controles no tenían evidencia de nódulos tiroideos (n = 91). Resultados: El análisis bivariado mostró una asociación significativa entre el síndrome metabólico y la presencia de nódulo tiroideo (OR 2.56, IC 95%: 1.41-4.66, p <0.05). Los niveles bajos de HDL (OR 2.81, IC 95%: 1.54-5.12, p <0.05) y glucosa en ayunas alterada (OR 2.05, IC 95% 1.10 a 3.78, p <0.05) se asociaron significativamente con la presencia de nódulo tiroideo, independiente de la presencia de síndrome metabólico. El análisis multivariado mantuvo la asociación entre el síndrome metabólico y el nódulo tiroideo con un OR de 2.96 (IC 95% 1.47 a 5.95, p <0.05); de manera similar, las asociaciones de niveles bajos de HDL (OR 2.77, IC 95% 1.44 a 5.3, p <0.05) y glucosa en ayunas alterada (OR 2.23, IC 95% 1.14 a 4.34, p <0.05) con nódulo tiroideo permanecieron significativas. Conclusión: la enfermedad nodular tiroidea se asocia con un mayor riesgo de síndrome metabólico, específicamente la disminución de HDL y los niveles de glucosa en ayunas alterados fueron los factores que aumentaron la asociación.

Hipotireoidismo congênito como fator de risco para os transtornos do processamento auditivo central / Congenital hypothyroidism as a risk factor for central hearing process disorders

RESUMO Objetivo: Investigar a manifestação de sintomas do transtorno do processamento auditivo central em crianças com hipotireoidismo congênito. Métodos: Estudo de caráter exploratório, descritivo e transversal com 112 pacientes com hipotireoidismo congênito com idade ≥5 anos. Realizou-se entrevista com os pais/cuidadores no momento da espera da consulta médica. Portadores de outras afecções médicas foram excluídos. Como instrumento de pesquisa utilizou-se o protocolo estruturado de anamnese para avaliação do processamento auditivo rotineiramente empregado por audiologistas. A análise estatística utilizou o teste Qui-quadrado. Resultados: A distribuição por sexo foi semelhante (meninas: 53,3%). Os casos não-disgenesia constituíram a forma fenotípica mais prevalente para o hipotireoidismo congênito (88,4%), e verificou-se que 65,3% das crianças apresentavam algum episódio de níveis séricos irregulares de hormônio tireoestimulante. Dentre as manifestações mais frequentes dos sintomas do transtorno do processamento auditivo central, as queixas relaciondas às funções cognitivas auditivas, como: figura-fundo (83,0%), atenção auditiva (75,9%) e memória auditiva (33,0%) foram as mais evidentes. Reclamações relacionadas ao rendimento escolar foram reportadas em 62,3%. Conclusões: Os dados obtidos evidenciaram altas frequências de sintomas de defasagem nas funções cognitivas relacionadas ao processamento auditivo central, em especial na atenção auditiva, figura-fundo e memória auditiva nos portadores do hipotireoidismo congênito.

ABSTRACT Objective: To investigate the presence of central auditory processing disorder symptoms in children with congenital hypothyroidism. Methods: An exploratory, descriptive, cross-sectional study of 112 patients with congenital hypothyroidism aged ≥5 years old. An interview was held with the parents/caregivers at the time of the medical consultation. Patients with other medical conditions were excluded. As a research instrument, the structured protocol of anamnesis was used to evaluate the auditory processing routinely used by audiologists. For statistical analysis, the chi-square test was used. Results: Sex distribution was similar in both boys and girls (girls: 53.3%). The most prevalent phenotypic form of congenital hypothyroidism was no dysgenesis (88.4%), and 65.3% of the children had an episode of irregular serum thyroid-stimulating hormone (TSH) levels. Among the manifestations of the most frequent central auditory processing disorder symptoms, problems were reported with regard to cognitive functions, as they related to hearing, such as figure-background ability (83.0%), auditory attention (75.9%) and auditory memory (33.0%). Complaints related to school performance were reported in 62.3% of the cases. Conclusions: The data obtained show a high frequency of lag symptoms in cognitive functions related to central auditory processing, particularly with regard to auditory attention, figure-background ability and auditory memory in patients with congenital hypothyroidism.

High-intensity focused ultrasound ablation as a treatment for benign thyroid diseases: the present and future

High-intensity focused ultrasound (HIFU) is a promising ablation technique for benign thyroid nodules. Current evidence has found good short- to medium-term outcomes, similar to those of better-established ablation techniques such as radiofrequency and laser ablation. The fact that it does not require insertion of a needle into the target makes HIFU a truly non-invasive treatment. Although it is not without risks, its low risk profile makes it an attractive alternative to surgery. There is much room for future development, starting from expanding the current indications to enhancing energy delivery. Relapsed Graves disease and papillary microcarcinoma are diseases that can benefit from HIFU treatment. Its role in the mediation of immune responses and synergistic effects with immunotherapy are promising in the fight against metastatic cancers.