A RARE CASE OF A PATIENT WITH HYPERTHYROIDISM AFTER HYPOTHYROIDISM.

Primary hypothyroidism caused by an underlying autoimmune thyroiditis disease is very common in clinical practice, while one of the most commonly seen types of hyperthyroidism states is Graves' disease. In hypothyroidism, patients are thought to be lifelong treated with substitution therapy with the lacking levothyroxine hormone. Usually due to the started autoimmune process that progressively destroys the thyroid tissue, the doses of levothyroxine increase in a different period of time during the follow ups. Rarely, the doses need to be tapered down, and that is the exact moment when the physician should be suspicious of a possible conversion from a hypothyroid state to a hyperthyroid one. We describe a case of a woman who was diagnosed with hypothyroidism and treated with suitable doses of levothyroxine, and then gradually the levothyroxine doses were tapered and eventually discontinued because of the clinical and laboratory confirmed state of hyperthyroidism- requiring a treatment with thiamazole. To our knowledge, this case is one of rarest worldwide so far published cases that illustrate the shortest time interval between the diagnosis of hypothyroidism and its switch to a hyperthyroid state.

INSULINOMA OF THE TAIL OF THE PANCREAS - A CASE REPORT.

Insulinoma is a rare neuroendocrine functional tumor of the pancreas of unknown etiology which manifests itself through hypoglycemic symptoms which resolve by administering glycose. Common autonomic symptoms of insulinoma include diaphroresis, tremor, and palpitations, whereas neuroglycopenenic symptoms include confusion, behavioural changes, personality changes, visual disturbances, seizure, and coma. In most cases, these are benign solitary tumors of the pancreas, and in 5% of the cases they are associated with MEN1 syndrome. A characteristic of the diagnosis is the presence of hypoglycemia, and increased levels of C-peptide and insulin. Further radiological verification (non-invasive imaging procedures: computed tomography and magnetic resonance imaging; and invasive modalities, such as endoscopic ultrasonography and arterial stimulation venous sampling) of the tumor are required as well as its surgical extraction. We present a case of a middle-aged male with history of recurrent hypoglycemic episodes with vertigo, sweating, tremors, anxiety, fatigue, and loss of consciousness, all of which resolved after eating food. The diagnoses were confirmed after we performed non-invasive imaging procedure, such as Computed Tomography and Magnetic Resonance Imaging. The patient underwent successful resection of the tumor, and his symptoms showed complete resolution. Despite the low incidence of these tumors, they should be suspected, in cases where the patient presents with repetitive hypoglycemic episodes, with symptoms, which resolve after eating a meal. Timely diagnosis and adequate treatment in most cases equals to complete withdrawal of symptoms.