Successful Antifungal Combination Therapy and Surgical Approach for Aspergillus fumigatus Suppurative Thyroiditis Associated with Thyrotoxicosis and Review of Published Reports.

In immunocompromised patients, Aspergillus infections are important causes of morbidity and mortality. We describe a patient with cryoglobulinemic vasculitis who developed disseminated invasive aspergillosis with thyrotoxicosis caused by Aspergillus fumigatus. The diagnosis was based upon radiological, microbiological and pathological findings. The patient was treated successfully with voriconazole and caspofungin treatment followed by total thyroidectomy. We provide an overview of published reports on Aspergillus thyroiditis with an emphasis on therapeutic approaches.

Recurrent laryngeal nerve palsy and substernal goiter. An Italian multicenter study.

The aim of this retrospective multicenter study was to verify whether the substernal goiter and the type of surgical access could be risk factors for recurrent laryngeal nerve palsy during total thyroidectomy. Between 1999-2008, 14,993 patients underwent total thyroidectomy. Patients were divided into three groups: group A (control; n=14.200, 94.7%), cervical goiters treated through collar incision; group B (n=743, 5.0%) substernal goiters treated by cervical approach; group C (n=50, 0.3%) in which a manubriotomy was performed. Transient and permanent unilateral palsy occurred significantly more frequently in B+C vs. A (P≤.001) and in B vs. A (P≤.001). Transient bilateral palsy was significantly more frequent in B+C vs. A (P≤.043) and in C vs. A (P≤.016). Permanent bilateral palsy was significantly more frequent in B+C vs. A (P≤.041), and in B vs. A (P≤.037). Extension of the goiter into the mediastinum was associated to increased risk of recurrent nerve palsy during total thyroidectomy.

Efficacy of desmopressin as surgical prophylaxis in patients with acquired von Willebrand disease undergoing thyroid surgery.

Coagulation abnormalities may occur in patients with thyroid diseases. We report on 14 patients undergoing thyroid surgery for a thyroid disease with an alteration of coagulation parameters resembling von Willebrand disease. Subcutaneous desmopressin was first tested and then used successfully in these patients as surgical prophylaxis, with no side-effects or bleeding complications during or after surgery. This study highlights the need for coagulation studies in patients with thyroid diseases undergoing thyroid surgery. Subcutaneous desmopressin may be used in these patients in order to prevent a surgically related bleeding risk.

[Bilateral pheochromocytoma associated with duodeno-jejunal GIST in patient with von Recklinghausen disease: report of a clinical case]. / Feocromocitoma bilaterale associato a GIST duodeno-digiunale in paziente affetto da malattia di von Recklinghausen: presentazione di un caso clinico.

The authors present the case of a 60-year-old male patient suffering from von Recklinghausen's disease (neurofibromatosis type I, NF1) with bilateral pheochromocytoma and occasional intraoperative reports of duodenojejunal GIST (GastroIntestinal Stromal Tumour). Through a review of the literature the authors analyze the frequency and the features of bilateral pheochromocytoma and its rare histological variant, the so-called composite pheochromocytoma, characterized by the combination of pheochromocytoma and ganglioneuroma or ganglioneuro-blastoma. Bilaterality of pheochromocytoma is more frequent in patients with familiarity for pheochromocytoma without NF1. Composite pheochromocytoma accounts for about 3% of total pheochromocytomas. In addition, the authors summarize the present knowledge about gastrointestinal stromal tumours and investigate the possible association between them and NF1 or pheochromocytoma, concluding that any such association is purely casual, while confirming the well known, genetically determined association between NF1 and pheochromocytoma.

Intralymphocyte free magnesium in patients with primary aldosteronism: aldosterone and lymphocyte magnesium homeostasis.

It is known that hyperaldosteronism has been associated with magnesium deficiency, yet there are no data on the intracellular concentration of ionized magnesium ([Mg(2+)(i)]) in subjects with primary aldosteronism (PA). We measured intralymphocyte free magnesium ([Mg(2+)(i)]) and intralymphocyte free calcium ([Ca(2+)(i)]) in 16 patients with PA and 26 normotensive control subjects (NCs). [Mg(2+)(i)] and [Ca(2+)(i)] were also measured in blood lymphocytes incubated in vitro with aldosterone, according to a fluorimetric method. In subjects with PA, [Mg(2+)(i)] was significantly lower than that in NCs (mean+/-SD; PA 203+/-56 micromol/L, NCs 291+/-43 micromol/L, 95% confidence interval 57 to 119, P=0.001). In the patients, [Ca(2+)(i)] did not prove to be statistically different from that of NCs (mean+/-SD; PA 47.2+/-10.6 nmol/L, NCs 53.2+/-11 nmol/L). The lymphocytes exposed to the action of aldosterone showed a significant reduction in [Mg(2+)(i)] (n=15, NCs 271+/-28 micromol/L, aldosterone treatment 188+/-39 micromol/L, P=0.001, 95% confidence interval 57 to 108). The dose-effect curve of aldosterone on [Mg(2+)(i)] showed an EC(50) value of approximately 0.5 to 1 nmol/L aldosterone. The reduction in [Mg(2+)(i)] mediated by aldosterone is antagonized by the receptor inhibitor of aldosterone; it is inhibited by inhibitors of protein synthesis and is not measurable when the lymphocytes are incubated in an Na(+)-free medium. The data are consistent with the hypothesis that aldosterone affects the cellular homeostasis of magnesium, probably through modification of the activity of the Na(+)-Mg(2+) antiporter.

[Gastric neoplasia in pregnancy: report of a case]. / Neoplasia gastrica in gravidanza: case report.

CASE REPORT: Gastric cancer in a 29 years old pregnant woman. A total of 109 cases were collected in the whole from 1916 to 1988; to these, we add one new case of a 29 years old pregnant woman observed in 1993 in Verona University Surgical Sciences Department. DISCUSSION: Cancer of the digestive tract during pregnancy is really rare and has poor prognosis. The diagnosis during pregnancy is difficult because the symptoms are frequently masked by factors related to the normal first trimester in pregnancy. X-ray are often restricted. Gastroendoscopy is applied to pregnant women only when evident symptoms are present such as: severe anemia, jaundice and weight loss. The incidence of inoperable cases is elevated such as the mortality in the operated cases. The whole survival rate after three years is 21%. CONCLUSION: Gastric cancer in pregnancy has a poor prognosis. The possible reasons are: delayed detection, low differentiation degree, restricted therapeutic approach because of pregnancy, personal factors as the patients' desire for a child, religious, ethical considerations.

Heterogeneity of nuclear DNA pattern and its relationship with cell cycle activity parameters in multinodular goitre.

OBJECTIVE: Recent studies suggest that the malignancy rate in multinodular goitre is not significantly different from that observed in solitary nodules and that chromosomal aberrations are not infrequent in multinodular goitre. To further investigate this topic we determined the DNA pattern in multinodular goitres. DESIGN: DNA ploidy and cell cycle activity parameters were determined in multinodular goitres. PATIENTS: We evaluated 235 patients (185 female, 50 male, mean age 52 +/- 13 years), who had undergone thyroidectomy; 11 of them harboured occult differentiated microcarcinoma. MEASUREMENTS: DNA index (DI), coefficient of variation of G0/G1 phase (CV), percentage of cells in S phase (%S) and in G2+M phase (%G2-M) and proliferative index (PI = %S+%G2-M) were determined by flow cytometric analysis (FCM) in tissue samples taken from 3 different areas of the thyroid gland. RESULTS: Aneuploid DNA was found in 50 goitres without carcinoma (22.3%) and in 5 goitres with carcinoma (45.5%). The mean PI of euploid cells in the goitre without carcinoma was significantly higher in the goitres with an aneuploid component compared to the goitres without aneuploidy (10.8 +/- 1.3 SEM vs 6 +/- 0.32; P +/- 0.001). Also, the percentage difference between maximal and minimal PI found within each goitre (delta PI %) was higher in the former group (373 +/- 49 SEM vs 142 +/- 11.3; P < 0.0001). The PI was significantly higher in goitres with carcinoma compared to the goitres without carcinoma (12.9 +/- 3.2 SEM vs 7.07 +/- 0.40; P < 0.05). CONCLUSIONS: The findings of increased proliferation rate in goitres with an aneuploid or neoplastic component suggests that some factors involved in goitrogenesis could also be responsible for the development of chromosomal aberrations and/or for the selection of cellular clones endowed with high growth potential.

[Perforated diverticulum of the cecum: a difficult preoperative diagnosis]. / Diverticolo perforato del cieco: una diagnosi preoperatoria difficile.

A patient was admitted for a suspected appendicitis; occasionally, a roentgenogram of abdomen, an echography and a tomography: confirmed the suspect. At laparotomy a perforated diverticulum of cecum is suddenly reported: a segmentary resection of ascending colon is performed. Authors remark, according to literature, that preoperative diagnosis of perforated cecal diverticulum is difficult even today, in spite of diagnostic procedures.

An unusual case of adrenal failure due to isolated metastases of breast cancer.

We describe a patient affected by adrenal insufficiency due to metastases of breast cancer. Adrenal involvement became clinically evident 20 years after radical mastectomy and it was the only secondary localization of the tumor. There is still no evidence of other metastases after a two year follow-up. This case suggests that adrenal function evaluation should be included in periodical follow-ups of patients who underwent radical mastectomy for breast cancer.

[Complications of thyroidectomy: hemorrhage]. / Complicanze della tiroidectomia: l'emorragia.

The authors report their experience in haemorrhage after thyroid surgery. Haemorrhagic complications occurred in 5 cases in a series of 1803 sequential thyroidectomies (incidence: 0.27%). In particular, incidence was 1.9% after interventions for thyroid neoplasias (adenoma and carcinoma) and 0.18% after interventions for non-neoplastic thyroid pathology. Haemorrhage occurred always after "total" operations, even if monolateral. Causative and contributing factors, precautions and measures helpful in reducing the incidence and the potential dangerousness of haemorrhagic complications are discussed.

[Nuclear DNA in neoplastic pathology of the thyroid gland]. / Il DNA nucleare nella patologia neoplastica della tiroide.

We have analysed the nuclear DNA content in a series of 33 thyroid tumours (18 carcinomas and 15 adenomas) and, for comparison, in 189 nodular strumas and 17 tissue samples of normal thyroids, calculating cell cycle parameters and presence of aneuploid DNA. Cell suspensions were prepared for each of three tissue fragments taken for different areas of the surgical specimens. Cell subpopulations with aneuploid DNA content were present in 39% of carcinomas, 27% of adenomas, 20% of strumas, but were absent in the samples from normal thyroids. The presence of hyperdiploid DNA was much more frequent than that of hypodiploid DNA in all pathologic tissues. The mean proliferation index was 14.1 in the carcinomas, 6.6 in the adenomas, 7.1 in the strumas and 6.1 in normal thyroid tissues. The percent of histograms with a coefficient of variation of the G0-G1 peak greater than 5 was highest in the carcinomas (26%). The significance and implications of the reported data are discussed for the interpretation of thyroid neoplastic pathologies.