Unmasking the Diagnosis of Acromegaly

The diagnosis of acromegaly is still a difficult task, as the disease has a slow onset and progression, and some of its symptoms may resemble those of other common conditions. Delays in diagnosis are common. Moreover, due to the continuous requirement for mask-wearing in many healthcare settings to prevent the spread of COVID-19, it is crucial to conduct a comprehensive examination of each patient without a face mask.Copyright © The Author(s). 2022.

Reactivation of Surgical Campaigns after the Covid Pandemic: Surgeons in Action with Hernia International Foundations in 2022

Aim: The Cirujanos en Accion and Hernia International foundations carried out their own and collaborative surgical campaigns in developing countries. In 2020 and 2021 the programme had to be suspended due to Covid. In 2022 we restarted our actions, analysed the difficulties of reactivation and described the campaigns that had been carried out and those that had to be delayed. Material/ Methods: We describe the 9 campaigns of Surgeons in Action, our own and in collaboration with Hernia International and our own campaign to the region of Naborno Karabakh, planned for September and cancelled 24 hours before departure due to the resurgence of armed conflict. An analysis is made of volunteers, places, type (adults or children or mixed), collaborations with other foundations, patients operated and procedures done according to pathologies, integration with local staff with exchange of knowledge. Result(s): Made in 8 countries (Benin, Camerun, Gambia (2), Kenya, Liberia, Mozambique, Tanzania, Sierra Leone) and postponed in one country, the Naborno Karabakh region of Armenia. 85 volunteers (25 general and 10 paediatric surgeons, 19 anaesthetists, 3 intensivists, 23 nurses, 5 audiovisuals);local staff;1144 patients (473 children, 671 adults), 1325 procedures for various pathologies (hernias, goitres, hydroceles, undescendend testis, soft tissue tumours, etc.) Conclusion(s): 9 campaigns have been carried out successfully and new locations have been opened with a good projection for the coming years, and we have experienced difficulties with the cancellation of a mega-campaign in an area with geopolitical conflicts - to be taken into account in the future.

Subacute thyroiditis and thyrotoxicosis after SARS-CoV-2 vaccine: report of 2 cases / Tiroiditis subaguda y tirotoxicosis posterior a vacuna contra SARS-CoV-2: reporte de 2 casos

La enfermedad por coronavirus SARS-CoV-2 que surgió en el año 2019 (COVID-19), ha obligado al rápido desarrollo de vacunas para prevenir su propagación e intentar controlar la pandemia. Dentro de las vacunas desarrolladas, las primeras en ser aprobadas con una tecnología nueva en el campo de la vacunación, fueron las vacunas basadas en ARNm (ácido ribonucleico mensajero), que lograron tasas de efectividad cercanas al 95 % para la prevención de la enfermedad COVID-19 grave. Los eventos adversos comunes son reacciones locales leves, pero ha habido varios informes de pacientes que desarrollaron tiroiditis subaguda y disfunción tiroidea después de recibir la vacuna contra SARS-CoV-2. Este artículo presenta dos casos de tiroiditis subaguda poco después de recibir la vacuna contra COVID-19

The SARS-CoV-2 coronavirus disease which emerged in 2019 (COVID-19), has forced the rapid development of vaccines to prevent the spread of infection and attempt to control the pandemic. Among the vaccines developed, one of the first to be approved with a new technology in the field of vaccination, was the mRNA (messenger ribonucleic acid) vaccine, with rates of effectiveness close to 95% for the prevention of severe COVID-19 disease. Common adverse events are mild local reactions, but there have been some reports of patients developing sub-acute thyroiditis and thyroid dysfunction after receiving the SARS-CoV-2 vaccine. This article presents two case reports of subacute thyroiditis shortly after receiving the COVID-19 vaccine

A Case of Primary Biliary Cirrhosis With New Onset Hyperthyroidism and Supratherapeutic INR

Introduction: Hyperthyroidism is known to increase catabolism of vitamin-K-dependent clotting factors (II, VII, IX, X) and increase the response of vitamin K antagonists, usually warfarin. Primary biliary cirrhosis (PBC) has been associated with thyroid dysfunction (TD), especially with autoimmune thyroid disease. In the below case, a patient with known PBC on warfarin is found to have severely elevated INR related to new-onset hyperthyroidism with clinical consequences of hemorrhage including upper GI bleed. Case Description/Methods: A 64-year-old female with PBC and antiphospholipid antibody syndrome on warfarin was admitted for hemorrhagic epiglottitis requiring emergency intubation and supratherapeutic INR. Her PBC was diagnosed as stage II on biopsy 23 years ago and has remained clinically stable on ursodiol therapy. On presentation, the patient was tachycardic, tachypneic, and had O2 saturations <90% on HFNC prior to intubation. Physical exam significant for larger goiter with diffuse upper airway swelling. She was admitted and found to have COVID-19 infection, INR .16.0 and PT>200.0 (limit of lab), WBC of 22.8, and lactate of 2.5. LFTs WNL aside from albumin of 2.0. TSH was <0.0017 (limit of lab) and free T4 of 3.4, free T3 of 5.3. TSH receptor antibody (TRAB) and thyroid stimulating immunoglobulin (TSI) levels were normal. Her last TSH was normal a year ago. CTA chest found a 5.7cm heterogeneous, partially calcified superior mediastinal mass consistent with multinodular thyroid goiter. Patient was initially given prothrombin complex concentrate and vitamin K with correction of INR over the following few days. She was extubated and started on methimazole. During the hospital course, she was found to have coffee ground emesis for which an EGD was done with findings of non-bleeding gastric ulcer (Forrest Class IIc) and LA Grade D esophagitis with adherent clot and bleeding for which hemostatic spray was applied. Patient was discharged a few days later following resumption of warfarin and on pantoprazole and methimazole. Discussion(s): The above case demonstrates a rare case of PBC and new-onset hyperthyroidism due to multinodular thyroid goiter causing significantly elevated INR in the setting of warfarin use with hospital course complicated by GI bleed. PBC is associated with TD - hyperthyroidism, hypothyroidism, and thyroid cancer. Hyperthyroidism is less commonly associated with PBC compared to other TDs but should be considered especially with a finding of elevated INR.

Thyroiditis Post COVID-19 mRNA Booster Dose Vaccination

Introduction: SARS-CoV-2 vaccines have been associated with thyroid dysfunction including thyroiditis and Graves' disease. We report a patient who developed thyrotoxicosis secondary to thyroiditis after COVID-19 mRNA booster dose vaccination. Case Description: A 74-year-old man with no known personal or family history of thyroid disorders went to his primary care physician with symptoms of palpitations. Of note, he had the first booster (third dose) of the Pfizer/BioNTech vaccine about 1 week before. He did not recall any similar symptoms after the first two doses of the same vaccine. There were no other symptoms of thyrotoxicosis such as hand tremors, weight loss or mood change. There was no family history of thyroid disorders. He was not on any medications such as amiodarone and was not taking any herbal supplements. He did not have any symptoms of upper respiratory tract infection. There was no neck pain. Physical examination was unremarkable with no goiter or thyroid eye manifestations. Thyroid function: free T4 elevated at 46.7 pmol/L (11.5-22.7) and TSH suppressed at 0.01 mIU/L (0.5-4.5). Thyroid stimulating immunoglobulin was positive at 200% (50-179). He was initially started on carbimazole 15mg daily. However, the patient became rapidly hypothyroid despite dose reduction and subsequent discontinuation of carbimazole with free T4 of 8 pmol/L and TSH of 36.4 mIU/L. An ultrasound of the thyroid gland showed vascularity with no discrete nodules. No thyroid uptake scan was done. The diagnosis was revised to thyroiditis post vaccination. Hypothyroidism persisted despite discontinuation of carbimazole before recovery 8 months later. Patient was well and did not require any thyroxine supplementation. Discussion(s): It is postulated that COVID-19 vaccines triggered thyroiditis via an autoimmune inflammatory syndrome caused by the vaccine adjuvants. A high index of suspicion is necessary and a thyroid uptake scan may be useful in making the diagnosis. Thyroiditis is a self-limiting condition and recognising it is important as no specific thyroid treatment is necessary in most patients. Patients should not be deterred from subsequent vaccination as COVID-19 infection has higher mortality risk than thyroiditis.Copyright © 2023

Validity and reliability of the fear of COVID-19 scale (FCV-19) in Turkish pregnant women Turkish version of COVID-19 fear scale (FCV-19) in Turkish pregnant women

Aim: The emergence of coronavirus disease 2019 (COVID-19) has not only create international concern, but also caused panic, fear, and an increase in mental health problems among individuals. Fear of COVID-19 Scale (FCV-19S), developed by Ahorsu, was previously reported as a valid psychometric instrument for the assessment of COVID-19 fear among individuals. Validation of the scale among other high-risk groups like pregnant women may help obstetricians develop better coping skills during the pandemic. Material(s) and Method(s): This cross-sectional methodological study included 277 pregnant women admitted for routine follow-up at the outpatient obstetrics clinic of Liv Ankara Hospital, Turkey. Participants were asked to complete the Turkish version of the Hospital Anxiety and Depression Scale (HADS) and FCV-19S. Statistical analysis was performed using SPSS 25 software. Result(s): The mean FCV-19S score was 19.2+/-5.7 (range: 7-35). Cronbach's alpha for internal consistency evaluating the reliability of FCV-19S, was 0.857, revealing a satisfactory internal consistency. According to the correlation matrix analysis, all items of FCV-19S showed positive and strong correlations with total FCV-19S scores (p<0.001), and positive and moderate correlations with HADS scores (p<0.001). Discussion(s): Turkish version of FCV-19S is a valid and reliable clinical tool to assess the anxiety of pregnant women during the COVID-19 pandemic in Turkey.Copyright © 2023, Derman Medical Publishing. All rights reserved.

[Surgical treatment of a patient with stage v multinodular toxic goiter, severe thyrotoxicosis, strangulation syndrome and severe comorbidities]. / Khirurgicheskoe lechenie patsientki s mnogouzlovym toksicheskim zobom V stepeni, tireotoksikozom tyazheloi stepeni, kompressionnym sindromom i tyazhelymi soputstvuyushchimi zabolevaniyami.

The authors describe thyroidectomy in a patient with multinodular toxic goiter stage V, severe thyrotoxicosis complicated by thyro-cardiac disease, strangulation syndrome and severe comorbidities. Nodular euthyroid goiter was first diagnosed in 1992, and resection of the right thyroid lobe was performed. Progressive enlargement of thyroid gland and thyrotoxicosis occurred after coronavirus infection in February, 2020. Along with progression of thyrotoxicosis and strangulation of cervical organs, the patient suffered from portal vein thrombosis, pulmonary embolism. Myeloproliferative disease with essential thrombocythemia was also diagnosed. Volume of the right and left thyroid lobes was 69 and 101.3 cm3, respectively. X-ray examination of the esophagus revealed narrowing at C6 level up to 5-8 mm. Surgery time was 2 hours, dimension of removed right thyroid lobe - 10.0×7.5×6.5 cm, left thyroid lobe - 11.0×6.5×5.5 cm, total weight - 348 g. The patient was discharged in 6 days after surgery.

Post COVID Thyroiditis as Documented on Tc-99m Pertechnetate Thyroid Scan

Aim/Introduction: The etiology of SAT (subacute thyroiditis) is presumed to be usually viral (most commonly associated viruses include enterovirus, coxsackievirus, mumps, measles, and adenovirus). In this pandemic era, prevalence of SAT associated with the COVID 19 seems to be increasing either during or after the course of disease, characterized by neck pain or discomfort, goiter and transient hyperthyroidism. However, this is usually missed due to the wide spectrum of COVID syndrome, and a simple thyroid scan can be instrumental in diagnosing related thyroiditis. Material(s) and Method(s): We report 3 (1 male, 2 females) cases of thyroiditis detected using Tc99m pertechnetate scan. Thyroid scan was done 20 minutes after injection of 5 milicuries (170 MBq) of Tc99m pertechnetate and planar images were acquired. Result(s): 3 (1 male, 2 females) cases of thyroiditis detected using Tc99m pertechnetate scan. Mean age was 36.3 years. Symptoms such as goiter (n=1), neck pain and tenderness (n=2), weakness and fatiguability (n=3), palpitations (n=2), heat intolerance (n=1), restlessness (n=2) were observed along with raised T3, T4 hormone levels and suppressed TSH, 3-4 months after COVID infection (mean duration 3.3 months). Other possible causes of thyroiditis and drug interference were ruled out. Thyroid scan images revealed faint or absent tracer uptake in thyroid gland. Conclusion(s): The affinity of SARS-Cov-2 to the thyroid gland has been presumed via the ACE2 receptors which are more prevalent in thyroid cells than lung cells. Inflammatory response and apoptosis is another proposed factor. Ultrasound will show a normal or enlarged thyroid but typically, diffusely, or focally hypoechogenic, and the color Doppler sonography will demonstrate low flow but thyroid scan is easier to perform, is less user dependent and carries more diagnostic value. COVID related thyroiditis can present months after infection and is a part of long COVID syndrome. Possibility of post immunization also exists. Thyroid scan can be widely used in these scenarios.

NSAIDs in COVID-19, friend or foe?

At the beginning of COVID-19 pandemic the use of NSAIDS was avoided. This was because the previous studies suggesting that NSAIDs may be linked to an increased risk of lower respiratory tract infection consequences. Later on studies involved the patients who used NSAIDs for some chronic conditions and showed no additional harm among these patients. Then many studied assessed the benefit of using NSAIDs in COVID-19 patients for management of pain and fever and showed no additional risk among these patients.

DISSEMINATED INVASIVE ASPERGILLUS MASQUERADING AS AMIODARONE-INDUCED THYROTOXICOSIS

SESSION TITLE: Rare Pulmonary Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Aspergillus is a group of opportunistic endemic fungal species that causes pathology within the respiratory tract and sinuses of individuals with predisposing factors, such as immunosuppression. While less frequently discussed, aspergillosis thyroiditis represents the most common fungal thyroiditis. We present a case of this condition that was misdiagnosed as amiodarone induced thyrotoxicosis. CASE PRESENTATION: A 54-year-old male was evaluated in outpatient pulmonary clinic after a chest CT revealed new upper lobe mass-like pleural based infiltrates with accompanying symptoms of dyspnea on exertion and fevers. His medical history was significant for orthotopic heart transplant 6 months ago due to a combination of non-ischemic cardiomyopathy with further decompensation from COVID-19 infection. After transplant, he was diagnosed with thyrotoxicosis secondary to amiodarone that was being treated with prednisone and methimazole. Given the concern for infection on imaging, he was admitted to the hospital and underwent urgent bronchoscopic evaluation. During the procedure, he was noted to have severe extrinsic tracheal compression. His neck imaging was consistent with a nodular goiter. The BAL revealed Aspergillosis fumigatus and he was subsequently treated with isavuconazium. Given the compression on the trachea and persistent dyspnea, the decision was to pursue total thyroidectomy. Surgery occurred 2 months after treatment was initiated for the Aspergillosis and with improvement on serial chest CTs. Pathologic examination of the thyroid tissue revealed extensive invasive aspergillus with abscesses involving both lobes. DISCUSSION: Aspergillus infection leading to disseminated disease typically occurs in individuals that have a compromised immune system such as seen in malignancy, solid organ transplant, chronic steroid use, and poorly controlled diabetes mellitus. Recently, it has been cited that up to 15% of hospitalized COVID-19 patients requiring intensive care develop aspergillus infection. After initial aspergillosis infection has been established, the thyroid gland is a site for dissemination due to its rich vascular supply. In addition, due to the angioinvasive properties of the pathogen, the fungus can breakdown tissue planes and easily travel from its site of origin. Thereby a primary infection in the respiratory tract can lead to dissemination to the neck structures due to its proximity. When thyroid invasion occurs, the common complaints are neck pain and swelling. Thyroid laboratory findings encompass the full spectrum including hyperthyroidism, hypothyroidism, and euthyroid. Given these non-specific findings, clinicians need to be conscious of this disease entity. CONCLUSIONS: In patients with immunocompromising conditions, findings of neck pain, swelling, and abnormal thyroid laboratory values should broaden the differential for clinicians to include aspergillosis thyroiditis. Reference #1: Alvi, Madiha M et al. "Aspergillus thyroiditis: a complication of respiratory tract infection in an immunocompromised patient.” Case reports in endocrinology vol. 2013 (2013): 741041. doi:10.1155/2013/741041 Reference #2: Marui, Suemi, et al. "Suppurative thyroiditis due to aspergillosis: a case report.” Journal of Medical Case Reports 8.1 (2014): 1-3. Reference #3: Kuehn, Bridget M. "Aspergillosis Is Common Among COVID-19 Patients in the ICU.” JAMA 326.16 (2021): 1573-1573. DISCLOSURES: No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Consulting fee Removed 04/03/2022 by A. Whitney Brown No relevant relationships by Kristen Bussa Advisory Committee Member relationship with Boehringer Ingelheim Please note: 2019-2021 Added 04/03/2022 by Christopher King, value=Consulting f e Advisory Committee Member relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-22 Added 04/03/2022 by Christopher King, value=Consulting fee No relevant relationships by Haresh Mani No relevant relationships by Mary Beth Maydosz No relevant relationships by Alan Nyquist No relevant relationships by Anju Singhal No relevant relationships by Amy Thatcher

THE UNPREDICTABILITY OF LABILE BP: AFFERENT BAROREFLEX FAILURE IN A CRITICAL PATIENT WITH MULTIPLE THYROID SURGERIES AND COVID-19 INFECTION

SESSION TITLE: Cardiovascular Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: The carotid sinus-arterial baroreflex is essential in maintaining blood pressure (BP) regulation. Afferent baroreflex failure (ABF) can present with labile changes in BP within seconds and can be secondary to neck surgery or radiation (RT). The prevalence and etiology of this condition remain unknown, and management of BP can be challenging. We present here the first case, to our knowledge, of ABF precipitated by thyroidectomy, in a patient (pt) with active COVID-19 pneumonia (PNA), causing difficult control of severely labile BP in a critical care unit. CASE PRESENTATION: A 74-year-old female with a history of COPD and a thyroid mass s/p an open left hemithyroidectomy & isthmusectomy, partial right thyroidectomy with drain placement who presented with dyspnea and hypoxia with COVID-19 PNA and superimposed bacterial PNA. She was immediately intubated and admitted to the ICU. Due to improved alertness and breathing, an extubation trial was done on day 2 but was unsuccessful due to a neck mass compressing the trachea, and during extubation, the pt began to develop stridor, desaturate, and was reintubated. CT head and neck showed a markedly enlarged thyroid with left tracheal deviation and the pt underwent complete thyroidectomy the following day. On the 4th day following surgery, the pt desaturated on PRVC and CXR showed new consolidation, and the PNA panel was positive for K. pneumoniae. The pt's BP began to fluctuate from the 80's/40's - 260's/190's. Titrating pressors were not effective in controlling her volatile BP. Clonidine was started to control hypertensive urgencies, but severe subsequent hypotensive episodes made it difficult to continue. A trial of Fentanyl drip did not add a benefit either. Adequate BP control was finally achieved through administering Clonidine only when SBP reached above 180mmHg and Midodrine when SBP reached below 80mmHg. DISCUSSION: Blood pressure changes can be sensed by carotid sinus stretch receptors. ABF can manifest secondary to carotid sinus nerve damage following neck surgery or radiation. The diagnosis of ABF remains ill-defined;with limited research available to guide definitive management. Critically ill patients with poor prognosis have demonstrated higher ACTH levels with a longer cortisol release, with elevated IL-8 and IL-6 concentrations, concluding potential destructive pituitary-adrenal axis response in the setting of inflammation. IL-6 in particular can manifest following hypoxic conditions. In certain cases of POTS and AD in COVID-19, there has been an improvement of symptoms with the use of B-blockers, fludrocortisone, midodrine, methyldopa, and clonidine. CONCLUSIONS: Additional research with a multidisciplinary approach is warranted to fully optimize the treatment of ABF in patients with neck surgery and or inflammatory conditions such as COVID-19. Reference #1: Biaggioni I, Shibao CA, Jordan J. Evaluation and Diagnosis of Afferent Baroreflex Failure. Hypertension. 2022 Jan;79(1):57-9. Reference #2: Dimopoulou I, Alevizopoulou P, Dafni U, Orfanos S, Livaditi O, Tzanela M, Kotanidou A, Souvatzoglou E, Kopterides P, Mavrou I, Thalassinos N. Pituitary-adrenal responses to human corticotropin-releasing hormone in critically ill patients. Intensive care medicine. 2007 Mar;33(3):454-9. Reference #3: Dani M, Dirksen A, Taraborrelli P, Torocastro M, Panagopoulos D, Sutton R, Lim PB. Autonomic dysfunction in 'long COVID': rationale, physiology and management strategies. Clinical Medicine. 2021 Jan;21(1):e63. DISCLOSURES: No relevant relationships by Wadah Akroush No relevant relationships by Shady Geris No relevant relationships by Brooke Kania No relevant relationships by Anas Mahmoud No relevant relationships by Rajapriya Manickam

SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARSCoV- 2) VACCINE-INDUCED THYROID DYSFUNCTION: A TALE OF TWO PATIENTS

Introduction SARS-CoV-2 vaccine has been the main pillar in battling the coronavirus disease 2019 (COVID-19) pandemic. However, the current vast scale of SARS-CoV-2 vaccination programme has led to inevitable reports of various adverse reactions, one of which include thyroid dysfunction. CASES We describe two patients who manifested hyperthyroidism following BNT162b2 mRNA-based COVID-19 vaccine boosters. Patient 1, a previously euthyroid 46-year-old female, has an eight-year history of type 1 diabetes mellitus. She developed palpitations of increasing severity about two weeks after her COVID-19 booster vaccine on 20th January 2022. She had weight loss of 4 kg and experienced menstrual irregularities in the subsequent three months. Examination revealed tachycardia (112 beats per minute, regular) and bilateral fine tremors of the hands. There was no goitre or neck tenderness. Blood investigations showed overt hyperthyroidism with positive thyroid autoantibodies, consistent with Graves' disease. Treatment with carbimazole led to marked symptomatic improvement. Patient 2, a 38-year-old female with a six-year history of Hashimoto thyroiditis, was clinically and biochemically euthyroid while taking levothyroxine 100 mcg daily prior to her COVID-19 booster vaccine on 5th January 2022. Five weeks following the vaccine, her thyroid function test during her endocrine clinic appointment showed overt hyperthyroidism, which was confirmed by a second blood sample ten days later. There was neither a change in levothyroxine dose nor any additional supplement intake. She was otherwise asymptomatic. Levothyroxine was then withheld. She regained her baseline hypothyroid state two weeks later, during which levothyroxine was resumed. Conclusion SARS-CoV-2 vaccine-induced thyroid dysfunction can affect both euthyroid and hypothyroid patients. A history of recent COVID-19 vaccination should be included in the clinical evaluation of a newly diagnosed hyperthyroid patient or unexplained hyperthyroidism in a long-standing hypothyroid patient.

NEW ONSET GRAVES' DISEASE AFTER SARS-CoV-2 VACCINATION

Introduction There is an increasing number of reports of thyroid dysfunction after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. We would like to report a case of new onset Graves' disease following vaccination with the adenovirus-vectored Vaxzevria (Oxford-AstraZeneca). METHODOLOGY A 29-year-old female with no prior history of endocrine or autoimmune diseases, presented with a week of palpitations, heat intolerance and excessive sweating three days after her second dose of Vaxzevria. She did not experience these symptoms after her first dose which she received two months earlier. Her father and sister have Graves' disease. She had a diffuse goiter with no orbitopathy. Thyroid Stimulating Hormone (TSH) was <0.01 mIU/L (normal range: 0.27-4.2) with a markedly elevated free T4 of >100 pmol/L (normal range: 12-22). TSH receptor antibody was positive at >40.00 IU/L (Normal range: <1.75). Ultrasonography revealed a hypervascular, diffusely enlarged goiter. She was started on oral carbimazole and propranolol. Five months later, her free T4 had normalized at 18 pmol/L though her TSH was still undetectable. To date, she remains hesitant for her booster dose. Results SARS-CoV-2 infection and vaccination have been associated with subacute thyroiditis and autoimmune thyroid disease. While there are reports of new onset Graves' disease after mRNA and adenovirus-vectored vaccines, it has not been associated with inactivated virus vaccines. The current prevailing theory is that the adjuvants in the vaccines can trigger an autoimmune event, also called 'autoimmune/ inflammatory syndrome induced by adjuvants' (ASIA). Conclusion Physicians need to be aware of thyroid dysfunction after SARS-CoV-2 vaccination, especially in those with a strong family history of autoimmune disease. Nevertheless, it is also important to note that the benefit of vaccination far outweighs this uncommon potential risk. More studies are required to establish a causal relationship.

A case of Post-COVID-19 thyrotoxicosis and a cavalcade of complications

Thyroid dysfunction has been reported following COVID-19 infection in the recent past. A 50 year old hypertensive female with no previous thyroid illness, developed features of thyrotoxicosis two weeks after a COVID-19 infection. There was no thyromegaly, neck pain or fever and her ESR was 15 mm/hour. She was initiated on propranolol and methimazole in an outside hospital. Ten days later, she presented to our hospital with fever, sore throat, cough and breathing difficulty. On evaluation she was found to be in neutropenic sepsis (WBC -820 cells/mm3, ANC-6 cells/mm3). Evaluation of thyroid functions showed: TSH- <0.00025 IU/ml, free T3 - 4.17 pg/ml, free T4- 3.59 ng/ml and Thyroid Receptor Antibody Levels (TRAb)- 2.53 IU/L. Following treatment with colony stimulating factors and antibiotics she recovered. The patient was commenced on lithium bicarbonate and cholestyramine, along with propranolol. On follow up in the OPD she is euthyroid with free T4 1.43 ng/ml (normal) levels. Post COVID-19 thyrotoxicosis in this case is likely due to Graves' disease. Thyrotoxicosis following COVID-19 is now being recognised and is possibly due to infection induced molecular mimicry with activation of immune pathways causing autoimmune disorders.

Surgical correction of a percutaneous dilatational tracheostomy: A case report.

INTRODUCTION AND IMPORTANCE: Percutaneous dilatational tracheostomy (PDT) has become a routine procedure in intensive care, because of its multiple advantages over surgical tracheostomy (ST). CASE PRESENTATION: We present the case of a 72-year-old patient with SARS-CoV-2 pneumonia, who received a PDT in the 6th tracheal ring with a lateral puncture of the trachea. This atypical placement of tracheostomy was due to a massive left-pronounced goiter, causing a tracheal shift to the right. To avoid dislocation of the tracheal cannula and prevent recurrent bleeding, surgical revision was decided. After left hemithyroidectomy, oral intubation was temporarily necessary, in order to remove the old tracheostomy. Then suturing of the left lateral tracheal defect and standard ST in the 2nd tracheal cartilage was performed. The patient was successfully weaned and decannulated and his swallowing function remained intact. CLINICAL DISCUSSION: In our case left hemithyroidectomy was necessary, in order to enable an optimal surgical tracheostomy in the 2nd tracheal cartilage. Because mechanical ventilation was carried out proximal to the large tracheal defect after PCT, a secondary closing approach was not an option. The endotracheal cuff was placed above the defect, in order to prevent acute or chronic intraluminal pressure trauma. Postoperative x-ray and bronchoscopy insured the sufficient sealing of the tracheal suturing. CONCLUSION: We describe an unusual placement of percutaneous dilatational tracheostomy through a thyroid goiter and our approach to perform a correction surgical tracheostomy.

Severe osteoporosis: Pandemic pick ups

Objective: During COVID-19 pandemic, the access to skeleton investigations for osteoporosis was in many cases postponed, thus consequences on fracture risk (FR) might be expected in terms of not continuing the antiosteoporotic medication or not initiating it if needed. Reduced physical activity might reduce the risk of fall, on one hand, but associated sarcopenia and inhibition of bone formation due to lack of physical exercise increase the FR, on the other hand (1-5). This is a case report of a female with severe osteoporosis who delayed the presentation for diagnostic during first 15 months of pandemic. Case report: This is a 73-year-old female, known with a history of osteoporosis since 2005. She also associates FR: chronic therapy with different SSRIs for depression, multinodular goiter-related hyperthyroidism (which was treated with radioiodine therapy). She has chronic therapy for arteria hypertension, hyperlipemia and hiatal hernia. At diagnostic, after initial lumbar T-score=-3.5 SD, she refused therapy until 2015 (when T-score decreased to -4 SD), thus she began therapy with intravenous ibandronate until 2017 when she experienced a vertebral fracture and daily 20 μg of teriparatide was initiated, starting from a DXA-BMD of 0.783 g/cm2, T-score of 3.1 SD. After 8 months, the treatment was stopped because of her lack of compliance, so she continued with annual zolendronic acid 5 mg until of T-score of -2.6 SD, BMD=0.856 g/cm2. In March 2020, when lockdown pandemic were initiated, she had to come to reassessment, but delayed it, and refused medication based on telemedicine recommendations, except for daily 1000 UI vitamin D. 14 months later, central DXA showed lumbar L1-3 BMD of 0.824 g/cm2, T-score of -2.9 SD, Z-score of -0.7 SD, hip BMD of 0.682 g/cm2, T-score of -2.6 SD, Z-score of -0.4 SD;25-hydroxyvitamin D of 29 ng/mL, PTH of 55 pg/mL, suppressed CrossLaps of 0.287 ng/mL (normal: 0.33-0.782 ng/mL), osteocalcin of 17 ng/mL (normal: 15-46 ng/ mL), P1NP of 27 pg/mL (normal: 15-45 pg/mL);an additional T4 thoracic fracture. Zolendronic acid was further recommended. Conclusion: During pandemic lockdown, the usual serial assays and decision of therapy were less adequate based on telemedicine.

Global vision and clinical reasoning in complexity: An endangered competency in Internal Medicine in the CoViD era. Case series in an Internal Medicine unit CoViD-free

Background: During SARS-CoV-2 pandemic management of internist patient is even more complex: hospital acquired infection, resources devolved to CoViD-19, round visit with PPE, minor interrelation, post-CoViD patients. Presentation of the case series: 1. A 75-year old man had dysphagia, fever, low back pain, shoulder pain. Anamnesis: CoViD pneumonia (P/F143, TTS18/20), goiter, bladder neoplasm, T2DM. CT showed pneumomediastinum, pneumotorax, iliopsoas haematoma. He underwent broad spectrum antibiotic, arthrocentesis, culture tests. We concluded for pneumomediastinum due to CoViD-19 pneumonia, MSSA sepsis, septic arthritis, dysphagia due to goiter and pneumomediastinum, UTI. He is transferred to OSCO (surgery delayed) - 2. A 72-year old woman presented respiratory failure, fever, bacterial pneumonia. Anamnesis: stroke at age 50, APS diagnosis, AOCP, kidney failure. We performed antibiotics. Near to discharge, she had profuse haematemesis due to acute esophageal necrosis. She underwent PPI infusion and tests for risk factors and triggers (as APS or neoplasm). - 3. A 45-year old man had severe sepsis and intestinal obstruction. Anamnesis: paraplegia, previous intestinal obstruction. He underwent antibiotics, rehydration, NGT. Colonoscopy and gastrografin enema ruled out stenosis, but occlusion persisted. After collegial discussion surgical approach was proposed, but the patient had unfavorable outcome due to CoViD-19 infection. Discussion: These cases share high level of complexity: need of subintensive care, difficult management of patients' need. Clinical judgment, assessment of EBM priorities are essentials, underestimated skills.

De Quervain's subacute thyroiditis: An illustrious unknown

Background: De Quervain's thyroiditis (SATdQ), also known as subacute granulomatous thyroiditis, is a self-limiting disorder. The symptoms are hyperthyroidism and hypothyroidism. In addition, patients may suffer from painful dysphagia, thyroid pain confused with pharyngodynia, and systemic symptoms like fever, hepatic cytolysis, and an elevated erythrocyte sedimentation rate. Description of the case: We report a case of an adult age 66 admitted to Hospital for a 50-day fever above 38, for which he had a blood test, chest x-ray, all negative. He also took antibiotic therapy and steroid therapy without benefit. When he is hospitalized?, he reports headache and joint pain. He performed blood test, echocardiography, abdominal ultrasound, chest CT and CT abdomen with contrast medium, procalcitonin, blood cultures, urine culture, quantiferon test. The patient performed a nasopharyngeal swab for detection of SARS-CoV-2 with a negative result. The cultures were all negative. He had a high value of erythrocyte sedimentation rate, the patient presented a hyperthyroid hormonal pattern and the absence of antithyroid antibodies. The thyroid ultrasound and thyroid scintigraphy were compatible with De Quervain's thyroiditis. The treatment with cortisone/beta-blockers led to a progressive improvement. Conclusions: An infrequent atypical SATdQ manifests itself with a fever of unknown origin and can be suspected with scintigraphy. It is essential to differentiate SATdQ from other thyrotoxicoses such as diffuse toxic goiter or Graves' disease and not confuse it with otitis and pharyngitis.

Thyroid cancer surgery during the coronavirus disease 2019 pandemic: perioperative management and oncological and anatomical considerations.

The coronavirus disease 2019 (COVID-19) pandemic has changed many aspects of our everyday lives and medical practice, including oncology treatment; thyroid cancer surgery is not an exception. The reported number of fine-needle aspirations performed during the first semester of 2020 was significantly reduced. Poorly differentiated, medullary and anaplastic thyroid tumors are considered important indications for immediate surgical intervention. By contrast, most well-differentiated carcinomas present slow growth, and thus surgery can be deferred for a short period of time during which patients are under active surveillance. Thyroid surgeries have decreased during the COVID-19 pandemic. Furthermore, prior to any intervention, negative COVID-19 status - with the use of a nasopharyngeal swab and reverse transcription PCR assay as the gold standard and chest CT scan as a complementary modality in some cases - must be confirmed to achieve a COVID-free pathway. Thorough preoperative assessment regarding both oncological and anatomical aspects should be performed to identify optimal timing for safe management.

The value of 1.5T MRI in the evaluation of vocal fold mobility in patients with goiter.

The laryngoscopic examination remains the gold standard in the perioperative evaluation of the mobility of the vocal folds in patients with goiter. During the COVID-19 pandemic, many medical procedures, including laryngoscopy are optimized in terms of epidemiological safety. Therefore, it seems deeply justified to implement methods like i.e. ultrasound or MRI which can provide the diagnostic information usually obtained via laryngoscopic examination. AIM OF THE STUDY: To determine the value of dynamic MRI examination in the 1.5 T field in the assessment of the mobility of vocal folds in patients with goiter compared to healthy people and in relation to ultrasound examinations and routine laryngoscopy. MATERIALS AND METHODS: 35 healthy volunteers and 44 patients with goiter were subjected to videolaryngoscopy, dynamic examinations of the vocal folds during respiration and phonation using ultrasound and the MRI sequences: generic gradient echo (GRE) and true fast imaging with steady-state precession (TRUFI). The qualitative and quantitative data were analyzed, i.e. the angles of deviation from the midline of the vocal folds and the area of the right and left rima glottidis compartments. RESULTS: No statistically significant differences were found between the groups of healthy volunteers and patients with goiter in the values of the angles of deviation of the vocal folds with the use of ultrasound and two MRI dynamic sequences - GRE and TRUFI. There were also no statistically significant differences in the areas of the rima glottidis compartments between these two groups with the use of two MRI dynamic sequences - GRE and TRUFI. Among the analyzed parameters, the maximum size of each rima glottidis compartment was the only one to show features of sexual dimorphism and was significantly higher in men (GRE p < 0.001 and TRUFI p = 0.001). There was no correlation between the size of the minimum and maximum rima glottidis compartment and the total volume of the thyroid lobes in patients with goiter for the GRE and TRUFI sequences. CONCLUSIONS: MRI is a promising tool for the objective assessment of the mobility of the vocal folds in patients with goiter, as well as for the qualification for treatment and monitoring its effects. It is particularly important during an epidemiological emergency due to its safety compared to laryngoscopy. The presence of the goiter and its volume do not limit the possibility of performing dynamic imaging studies of the vocal folds and do not affect the surface area of the glottis.