Clinical, biochemical & cytomorphologic study on Hashimoto’s thyroiditis.

Background & objectives: Despite, the extensive salt iodization programmes implemented in India, the prevalence of goiter has not reduced much in our country. The most frequent cause of hypothyroidism and goiter in iodine sufficient areas is Hashimoto’s thyroiditis (HT). This study records the clinical presentation, biochemical status, ultrasonographic picture and cytological appearance of this disease in a coastal endemic zone for goiter. Methods: Case records of patients with cytological diagnosis of HT were studied in detail, with reference to their symptoms, presence of goiter, thyroid function status, antibody levels and ultrasound picture. Detailed cytological study was conducted in selected patients. Results: A total of 144 patients with cytological proven HT/lymphocytic thyroiditis were studied. Ninety per cent of the patients were females and most of them presented within five years of onset of symptoms. Sixty eight per cent patients had diffuse goiter, 69 per cent were clinically euthyroid and 46 per cent were biochemically mildly hypothyroid. Antibody levels were elevated in 92.3 per cent cases. In majority of patients the sonographic picture showed heterogeneous echotexture with increased vascularity. Cytological changes were characteristic. Interpretation & conclusions: our study showed predominance of females in the study population in 21-40 yr age group with diffuse goiter. We suggest that in an endemic zone for goiter, all women of the child bearing age should be screened for HT.

Two cases of thyroid sarcoidosis presentation as painful, recurrent goiter in patients with Graves' disease / Dois casos de sarcoidose na tireoide com apresentação na forma de bócios recorrentes dolorosos em pacientes com doença de Graves

Sarcoidosis rarely involves the thyroid gland. Pain in the thyroid gland area was only sporadically reported in patients suffering from this disease. The aim of this paper is to report and discuss the cases of two female patients with Graves' disease who presented painful, rapidly growing, recurrent goiters (after strumectomy in their early adult lives). Invasive treatment was applied and sarcoidosis was revealed histologically. The first patient suffered from dysphagia and dyspnoea due to large goiter; skin lesions were present as well. Sarcoidosis was diagnosed in histological examination of the thyroid tissue specimens. Steroid treatment was ineffective; thus, the thyroid was removed. Two years later thyroid sarcoidosis recurred as a painful goiter and surgical treatment was applied once again. In the second case, thyroid ultrasound findings suggesting malignancy, and prompted the decision to perform thyroidectomy despite the fact that FNAB (fine needle aspiration biopsy) revealed cells indicative of a "granulomatous disease in the post-resection scar" and results of the thorax high-resolution computed tomography scan suggested pulmonary sarcoidosis. Pathological examination confirmed sarcoidosis. However, a papillary cancer focus was also found.

A sarcoidose raramente envolve a glândula tireoide, e apenas esporadicamente foi relatada dor na região da glândula em pacientes que sofrem dessa doença. O objetivo deste trabalho é relatar e discutir os casos de duas mulheres que apresentavam bócios dolorosos, de rápido crescimento e recorrentes (após tireoidectomia na adolescência). Foi usado um tratamento invasivo e a sarcoidose foi revelada pelos achados histológicos. A primeira paciente sofria de disfagia e dispneia em decorrência de um grande bócio; lesões cutâneas também estavam presentes. A sarcoidose foi diagnosticada em um exame histológico das amostras de tecido da tireoide. O tratamento com esteroides foi ineficaz; foi feita assim a ressecção da glândula. Dois anos depois, houve recidiva da sarcoidose da tireoide como um bócio doloroso, e o tratamento cirúrgico foi feito mais uma vez. No segundo caso, os resultados do ultrassom da tireoide sugeriam malignidade e levaram à decisão de se realizar a tireoidectomia, apesar de as células de PAAF indicarem uma doença granulomatosa na cicatriz pós-ressecção e os resultados da tomografia computadorizada de alta resolução de tórax sugerirem sarcoidose pulmonar. O exame histopatológico da glândula revelou sarcoidose. Entretanto, também foi encontrado um foco de câncer papilar.

Hemiagénesis tiroidea de lóbulo derecho: comunicación de un caso / Right thyroid hemiagenesis and microcarcinoma of the left lobe: report of one case

In congenital thyroid hemiagenesis, one of the thyroid lobes, usually the left one, does not develop. This condition is generally asymptomatic. We report a 47 years old female with a diffuse left goiter. An ultrasound detected the right lobe hemiagenesis. She was subjected to a subtotal thyroidectomy. The pathological study of the surgical piece disclosed the presence of an encapsulated papillary carcinoma, follicular variant with a diameter of 2 mm.

La hemiagénesis tiroidea es una anormalidad congénita inhabitual en la cual uno de los lóbulos de la tiroides no se desarrolla. Su prevalencia es desconocida, debido a que generalmente es asintomática. Damos cuenta del caso de una mujer de 47 años, con bocio difuso de predominio izquierdo, operada, con presencia de microcarcinoma papilar en el lóbulo remanente. La detección de la hemiagénesis tiroidea es usualmente casual durante el examen de la glándula tiroides por otras causas. Es más frecuente en mujeres que en hombres (3:1), y el lóbulo izquierdo suele estar más comprometido que el derecho. Este caso muestra la inhabitual hemiagénesis tiroidea derecha con presencia de microcarcinoma papilar latente.

Carcinoma thyroid in multi and uninodular goiter

To determine the frequency and profile of carcinoma in multi-nodular goiter and solitary thyroid nodule. Case series. Surgical Unit-I, Ward-3 of Jinnah Postgraduate Medical Center, Karachi, from January 1999 to January 2009. Cases with solitary thyroid nodules and multi-nodular goiter were included. Patients under 12 years of age, cystic benign lesion in solitary thyroid nodules or those multi-nodular goiters, which were not causing pressure symptoms, cosmetic problems or sign of malignancy were excluded. In solitary thyroid nodule, hemithyroidectomy was done and if histopathology examination revealed carcinoma thyroid then completion thyroidectomyw as done. In multi-nodular goiter sub-total thyroidectomy done. Results were described as frequency percentages and mean. Out of 379 patients of multi-nodular goiter only one patient was found to be papillary carcinoma [0.25%]. In 220 patients of solitary thyroid nodules, 93 patients were diagnosed as carcinoma of thyroid [42.27%]. Others diagnosed in solitary thyrid nodule were thyroid adenoma, colloid goiter, thyroiditis and multi-nodular goiter. The frequency of papillary carcinoma in 65.95% occurring females of 12-30 years of age and being multifocal in 6.45% follicular carcinoma in 23.49%, medullary carcinoma in 7.44%, analplastic carcinoma in 2.12% and lymphoma in 1.01%. Female were predominantly involved and papillary carcinoma was common in 12-30 years of age [7.63%] and follicular was common in 30-40 years of age [68.18%. 6.45% of papillary carcinoma was found to be multifocal in nature. Frequency of carcinoma of thyroid is very high in solitary thyroid nodule [42.27%], but markedly low in multi-nodular goiter. Papillary carcinoma is the most common variety, most of in younger female

Fetal euthyroid goiter.

We present a very unusual case of a baby born with antenatally diagnosed large neck swelling causing compression of trachea on imaging, who was euthyroid. There was no history of any thyroid disease in the mother and no history of exposure to known goitrogens. The goiter gradually reduced in size and baby’s thyroid function as well as neurodevelopment remained completely normal during follow-up.

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.

Naturaleza, severidad y situación actual de los desórdenes por deficiencia de yodo / Nature, severity and present situationof disorders caused by iodine defficiency

Objetivo: proporcionar información a los profesionales de la salud en relación con aspectos generales del yodo en el organismo, su función fisiológica, aspectos históricos y geoecológicos relacionados con su deficiencia, la panorámica mundial y nacional. Desarrollo: se realizó una revisión actualizada de la literatura nacional e internacional, con énfasis en la magnitud y severidad de la deficiencia de yodo, repercusión a la salud, situación mundial y nacional. Conclusiones: se evidencia la importancia del monitoreo sistemático del yodo en la sal, la excreción urinaria y las encuestas sobre el consumo de sal yodada, como indicadores apropiados para diagnosticar y monitorear la nutrición de yodo en las poblaciones y en la evaluación de programas.

Aim: to give information to the health professionals about general aspects of iodine in the organism, its physiological function, the historical and geoecological aspects related to its deficiency, and the world and national panorama. Development: an updated review of the national and international literature was made, emphasizing the magnitude and severity of this type of deficiency, its impact on health, and the world and national situation. Conclusions: it was evidenced the significance of the systematic monitoring of iodine in salt, the urinary excretion, and the surveys on iodized salt consumption, as suitable indicators to diagnose and control iodine nutrition in populations and in the evaluation of programs.

Paratiroidectomía total guiada por fluorescencia en el tratamiento del hiperparatiroidismo secundario: primeros casos en América / Parathyroidectomy guided by fluorescence in the treatment of hyperparathyroidism secondary

La fluorescencia con ácido 5-aminolevulínico (ALA) ha sido utilizada como un procedimiento novedoso para identificar a las glándulas paratiroides. En este trabajo se aplicó esta técnica para estudiar sus detalles. Se realizó un estudio experimental no aleatorizado, controlado, descriptivo, a tres pacientes con hiperparatiroidismo secundario por insuficiencia renal crónica. Se administró ALA vía oral exponiendo el comportamiento visceral cervical a la luz blanca y azul (380-440 nm); realizándose luego paratiroidectomía total con timectomía subtotal transcervical. Se intervinieron 3 pacientes, edad media 29.6 años (28-32), con hiperparatiroidismo secundario. Tiempo medio de insuficiencia renal 12 años (10-15), tiempo medio en diálisis 5.6 años (4-8). Hubo fluorescencia selectiva de 4 estructuras que correspondieron a las 4 glándulas paratiroides en los casos 1 y 3, representando una identificación del 100 por ciento, y de 3 estructuras en el caso 2 (identificación 75 por ciento). Los pacientes evolucionaron satisfactoriamente. Efectos adversos: emesis y reacción foto-cutánea, todos autolimitados. La detección de glándulas paratiroides con fluorescencia con ALA pareciera ser efectiva. Hacen falta estudios que evalúen la efectividad, costo-beneficio y otros usos del procedimiento.

Utilidad del bisturí bipolar con efecto de sellado de vasos en pacientes con patología tiroidea / Usefulness of bipolar effective sealing of vessels in patients with thyroid disease

Comparar el uso del bisturí con efecto de sellado de vasos (LigaSure precise®) con la Ligadura convencional de los vasos tiroideos y demostrar la reducción del tiempo y del sangrado operatorio en las tiroidectomías totales o subtotales de pacientes con patología tiroidea, estudio realizado en los Servicios de Cirugía II y III, del Hospital Domingo Luciani, Caracas. Se realizó un estudio descriptivo, prospectivo y comparativo desde agosto 2006 hasta agosto 2007, la selección de la muestra fue de tipo intencional no probabilístico (pacientes con patología tiroidea). Se operaron con técnica convencional 26 sujetos (muestra control) y con bisturí con efecto de sellado de vasos 21 sujetos (muestra de casos). La variación media del tiempo operatorio en el grupo LigaSure fue 80 ± 21 minutos y en el grupo con sutura convencional fue de 98 ± 26 minutos, diferencia estadísticamente significativa (p = 0,013). La media del sangrado intraoperatorio resultó de 55 ± 36cc (grupo LigaSure) y de 166 ± 93cc (grupo de suturas) igualmente estadísticamente significativas (p = 0,001). No hubo diferencias entre las complicaciones (hipocalcemia, disfonía), uso de drenes (látex, aspirativo cerrado). La patología más frecuente operada durante el estudio fue el bocio multinodular (61,7 por ciento) y en el 51 por ciento de los pacientes operados se realizó tiroidectomía total. El uso del bisturí con efecto de sellado de vasos (LigaSure precise®) es seguro en tiroidectomías, acorta el tiempo operatorio y disminuye el sangrado comparado con la técnica convencional. Patología tiroidea, Bisturí bipolar con sellado de vasos, Tiroidectomía, LigaSure®.

Les goitres benins en ORL. Aspects epidemiologiques et anatomocliniques : etudes de 97 cas

But : Analyse epidemiologique; clinique et anatomopathologique des goitres benins. Methodologie : Etude retrospective de janvier 2002 a decembre 2006 sur dossier de patients ayant consulte en ORL pour goitre. Les parametres suivant ont ete etudies : - interrogatoire : age; sexe; profession; residence; anciennete du goitre; motif de consultation ; - examen clinique precisant resultats palpation; classification OMS de 1962 du goitre ; - resultats de l'echographie ; - resultats du dosage de la TSH ultrasensible. Ont ete exclus tous les dossiers comportant une histologie suspecte et/ou maligne et les inflammations de la thyroide. Ainsi a-t-on retenu 97 dossiers sur 122. Resultats : Notre recrutement a ete marque par une forte proportion d'adulte jeune (classe d'age de 31 a 50 ans : 78 patients) et par une predominance feminine (sex-ratio; 17/80).Ces patients etaient plus souvent des femmes au foyer et residaient le plus souvent a Bamako. Ils etaient porteurs a 52 de goitre evoluant depuis plus de vingt ans et a 44 de plus de dix ans d'evolution. Deux signes principaux ont amenes les patients a consulter : les signes d'hyperthyroidie et la tumefaction cervicale disgracieuse. Le goitre etait de type 3 de l'OMS dans 68 des cas. Un aspect multi nodulaire clinique a ete vu chez 81 patients. A l'imagerie; nous avons note 10 de goitre isoechogene. L'examen anatomopathologie a plus souvent trouve des goitres de type macro folliculaire sur les pieces d'exerese. Ils etaient dans 20 des cas des goitres en activite. Conclusion : Le praticien ORL en pays d'endemie goitreuse se doit de connaitre tous les contours de la pathologie thyroidienne. Il ne doit jamais oublier non plus que la prise en charge efficiente doit etre multidisciplinaire (Endocrinologue; Radiologue; Anatomopathologiste; Anesthesiste Reanimateur)

Morphological evaluation of non neoplastic lesions of the thyroid gland

This study was conducted to see the frequency of non neoplastic lesions of thyroid glands in patients who underwent thyroid surgery at Mayo hospital, Lahore. It was a descriptive cross sectional study. It was a retrospective and prospective study commencing from Ist July 1999 to 30th June 2002 and was conducted at Pathology Department King Edward Medical University, Lahore. All thyroid samples submitted and reported at the Department of Pathology, King Edward Medical University, Lahore during a three year period commencing from Ist July 1999 to 30th June 2002 were included in this study. Out of the total number of 1136 thyroid surgical specimens, 855 specimens [75.26%] were shown to comprise of non-neoplastic lesions and were more common in females [77.2%] as compared to males [22.8%] giving a male to female ratio of 1:3.4. Regarding non neoplastic lesions maximum comprised of diffuse[74%] and multi nodular goiters [16%]. Others consisted of inflammatory conditions [5%], hyperplastic nodules[4%] and simple colloid filled cysts 1%. Inflammatory conditions included Hashimotos' thyroiditis [67.3%] deQuervain's thyroiditis [granulomatous thyroiditis] [16.3%], Lymphocytic thyroiditis [11.7%], and Riedel's thyroiditis[4.7%]. Non neoplastic thyroid lesions are more common than neoplastic lesions, especially in females. The frequency of diffuse colloid goiter was very high, while among inflammatory lesions Hashimotos' thyroiditis was the commonest lesion. Most of the cases of hypothyroidism were associated with iodine deficiency

Diagnosis of enlarged thyroid - an analysis of 250 cases

Thyroid enlargement is a common problem faced both by clinicians and histopathologists. In an effort to determine the incidence of its various causes in our population, 250 cases were analyzed. There was a marked female preponderance [M:F ratio 1:3.8]. Multinodular goiter was the commonest final diagnosis whereas 4 cases showed malignant thyroid neoplasms. Microscopic examination remained the golden path to the final diagnosis. The results as well as the relative efficacy of the various diagnostic modalities are discussed

Amyloid goitre: a case report.

Amyloid goitre is an exceedingly rare condition associated with a clinically apparent enlargement of the thyroid gland due to massive amyloid infiltration. We hereby report an additional case of this rare entity.

Valor de la determinación de anticuerpos antitiroideos plasmáticos para el diagnóstico de tiroiditis crónica autoinmune / Value of the determination of plasmatic antithyroid antibodies for the diagnosis of chronic autoimmune thyroiditis

Se valoró la eficacia de los métodos de detección de anticuerpos humorales empleados en el Instituto Nacional de Endocrinología para el diagnóstico de TCA. Se estudió un grupo de 100 pacientes con bocio y la sospecha clínica de que padecieran de TCA. A cada uno se le realizó una biopsia con aguja fina (BAF), que se tomó como la regla de oro del diagnóstico, determinación de anticuerpos plasmáticos antitiroglobulina por el método del TRC y antimicrosomales (AMS), para hacer una validación estadística de ambos métodos; sensibilidad, especificidad, valor predictivo para casos positivos, valor predictivo para casos negativos y el índice general de eficacia diagnóstica. Se hallaron 70 pacientes con resultados positivos de TCA por la BAF y 30, negativos. La sensibilidad de ambos métodos de detección de anticuerpos humorales fue pobre (45,7 (por ciento) para el AMS y 30 (por ciento) para el TRC). Aún aplicados los dos al mismo paciente no sobrepasó del 60 (por ciento). La especificidad fue mucho mejor para ambos métodos (73,3 (por ciento) para la AMS, 90 (por ciento) para el TRC y 70 (por ciento) para ambos métodos juntos). El valor predictivo para casos positivos fue bueno (80 (por ciento) para AMS, 87,5 (por ciento) para TRC y 82,3 (por ciento) para los métodos de conjunto) y el predictivo para casos negativos fue 36,3, 35,5 y 42,9 (por ciento), respectivamente. La eficacia general fue tan solo del 54 (por ciento) para el TRC, 48 (por ciento) para AMS y 63 (por ciento) para ambos métodos de conjunto. Se concluyó que estos métodos son útiles para reafirmar el diagnóstico cuando resultan positivos, pero de poca utilidad para asegurar que no se trata de esta afección cuando resultan negativos(AU)

The effectiveness of the humoral antibody detection methods used in the diagnosis of chronic autoimmune thyroiditis (CAT) in the National Institute of Endocrinology was assessed. A group of 100 patients with goitier and presenting with clinical suspicion of CAT was studied. A fine needle biopsy was performed on each of the patients, which was taken as the golden rule of the diagnosis and also the determination of plasmatic antithyroglobulin antibodies by the TCR method and the determination of antimicrosomal antibodies were made for statistically validating both methods, taking sensitivity, specificity, predictive value for positive cases, predictive value for negative cases and general index of diagnostic efficacy into consideration. Seventy patients were found positive and 30 negative for CAT by the FNB. The sensitivity of both methods of humoral antibodies was poor: 45.7 percent for AMS and 30 percent for TRC. Even the joint application of both methods to the same patient did not exceed 60 percent. Specificity was a much better indicator in both methods (73.3 percent for AMS, 90 percent for TRC and 70 percent for both applied together). The predictive value for positive cases was good (80 percent for AMS; 87.5 percent for TRC and 82.3 percent for both) and the predictive value for negative cases was 36.3, 35.5 and 42.9 percent respectively. The general efficacy was only 54 percent for TRC, 48 percent for AMS and 63 percent for both methods together. It was concluded that these procedures are useful to confirm the diagnosis when cases are positive, but they are rather useless to assure the non-existence of this affection when cases are negative(AU)

Dyshormonogenetic goitre with clear cell change resembling parathyroid adenoma--a case report.

Dyshormonogenesis is a rare cause of goitre. It is manifestation of mutation in genes controlling the proteins involved in synthesis of thyroid hormones. Though there is wide spectrum of biochemical and clinical presentation, pathological features are similar in all defects. Nonencapsulated nodules with minimal regressive changes and lack of lymphocytic infiltration are important diagnostic features. Clear cell change as seen in this case is common and needs to be differentiated from parathyroid adenoma. Hypercellularity with cellular atypia should not lead to misdiagnosis of malignancy.

Revisäo de 2.564 punçöes aspirativas de tireóide: ênfase em doenças näo-neoplásticas / Review of 2564 fine needle aspiration of thyroid: with emphasis on non-neoplastic disease

Mediante estudo retrospectivo, os autores revisaram 2.564 casos de punçäo aspirativa por agulha fina (PAAF) da glândula tireóide de pacientes do Hospital das Clínicas da Faculdade de Medicina de Botucatu-UNESP registrados entre 1989 e 1995. Foram observados 1.911 casos de diagnósticos näo-neoplásticos, 134 de neoplásticos e 519 de materiais inadequados ao dagnóstico citológico, sendo que, dentro do critério "näo-neoplástico", foram encontrados 1.244 diagnósticos de Bócio Colóide, 337 de Tireoidites e 323 de Doença de Graves. A PAAF mostrou ser um método diagnóstico útil também nas doenças tireóideas näo-neoplásticas, incluindo os processos difusos como as Tireoidites e a Doença de Graves

Conducta espectativa ante el bocio eutiroideo puberal / Spectative conduct before the puberal euthyroid goiter

Se siguió espectativamente a 25 niños con bocio eutiroideo en época puberal (23 hembras y 5 varones), mediante la realización de un estudio clínico bioquímico (TSH) semestral durante 1 año, con el objetivo de valorar la eficacia de esta conducta. No se encontraron afectaciones de la talla y la progresión de los estadios puberales de Tanner en estos pacientes sin tratamiento medicamentoso. No existió variación en tamaño del bocio, ni en el valor de la TSH que siempre fue bajo (<20 Mu/L) en los pacientes que no hicieron hipotiroidismo. En el seguimiento se detecto hipotiroidismo subclínico en 3 pacientes, lo cual sugiere que esta conducta sea útil, por cuanto permite captar el hipotiroidismo subclínico cuando la TSH sea mayor e igual 10 Mu/L y así comenzar tratamiento en estos pacientes, evitando un tratamiento innecesario y prolongado con hormonas tiroideas a todo paciente con bocio eutiroideo

Tiroidite de Hashimoto: correlaçäo clínico-citológica / Hashimoto thyroiditis: clinic-cytological correlation

Foram estudados 85 pacientes portadores de bócio com diagnóstico clínico-citológico de tiroídite de Hashimoto. Oitenta e um pacientes (95 por cento) eram do sexo feminino e 4 (15 por cento) do sexo masculino, com idade média de 40,4 + 14,6 anos, variando entre 11 a 88 anos. Cinco indivíduos (5,9 por cento) tinham idade menor que 20 anos e 4 deles (9,4 por cento) idade superior a 60 anos. Todos foram submetidos a citologia aspirativa de agulha fina de tiroide (CAAF) e os dados clínicos e exames complementares foram correlacionados com os achados citológicos. Notou-se diversidade de apresentaçao clínica e laboratorial da tiroidite de Hashimoto: o bócio era do tipo nodular em 55 por cento dos casos (cintilograficamente "frios" em 62 por cento e "mornos" em 38 por cento) e considerado difuso em 45 por cento. A funçao tiroidiana era norínal em 59 por cento, diminuída em 26 por cento e aumentada em 15 por cento. A pesquisa de anticorpos anti-microssomal (n=50) foi considerada positiva (1:400) em 72 por cento e negativa em 18 por cento dos pacienteç. O estudo citopatológico mostrou que pelo menos 3 critérios estavam sempre presentes na tiroidite de Hashimoto: infiltraçao linfo-histio-plasmocitária, esboço de folículos linfóides e colóide. Constatou-se que a CAAF é de grande auxílio no diagnóstico de tiroidite de Hashimoto, podendo, isoladamente, confirmar este diagnóstico em 83,5 por cento dos pacientes estudados. Nos casos em que os critérios citológicos sao apenas sugestivos, é importante a correlaçao com os dados clínicos, laboratoriais e cintilográficos para melhor definir o diagnóstico.