Thyroid cancer & sarcoidosis.

UNLABELLED: The association of thyroid cancer and SA has been previously described in individual case reports. We are describing 4 patients with co-existence of papillary thyroid cancer (PTC) and SA who presented a diagnostic and management challenge. PATIENTS: One patient (Patient 1) with known history of SA was referred for thyroid nodules and cervical adenopathies; Fine needle aspiration (FNA) showed PTC.  At surgery, he was found to have non-necrotizing granulomatous inflammation (NNGI) in lymph nodes in addition to PTC. Another patient (Patient 2) with known history of PTC presented with a palpable LN.  FNA showed NNGI.  She was subsequently found to have diffuse lymphadenopathies from SA. A third patient (Patient 3) who was totally asymptomatic, without history of PTC or SA, presented with a right thyroid nodule and a right lateral neck adenopathy both of which were positive for PTC. Pathology showed extensive NNGI and PTC in 4 LNs. Subsequent work up revealed diffuse lymphadenopahies throughout the body on positron-emitting tomography/computed tomography with elevated serum angiotensin converting enzyme level.  The last patient (Patient 4) who did not have any history of SA or PTC presented with systemic symptoms. Work up revealed a large goiter with substernal extension that required a thyroidectomy.  At surgery, suspicious adenopathies were resected and were found to contain NNGI.  The thyroid specimen contained PTC. CONCLUSION: Clinicians should be wary of this association/co-existence of SA and PTC to avoid mismanagement of neck lymphadenopathies in patients with current or history of SA. Although 4% of thyroid cancers may induce a sarcoid reaction in the thyroid gland, SA as a disease may coexist with PTC although causality remains uncertain. Being aware of this association is important in the differential diagnosis of a thyroid mass and/or a LN in a patient with SA. Therefore, patients with known SA who are found to have cervical adenopathies or thyroid nodules should have a thorough work up.

Glycemic control with use of insulin glargine after cardiothoracic surgery: a retrospective study.

OBJECTIVE: Perioperative glycemic control in critically ill cardiothoracic surgery patients may improve postsurgical outcomes. The objective of the study was to compare outcomes before and after the implementation of a protocol using subcutaneous (SC) glargine at transition from intravenous insulin infusion (IVII). METHODS: In August 2006, the Cleveland Clinic began using glargine and supplemental rapid-acting sliding scale insulin (SSI) at transition from IVII (glargine-SSI group). Before August 2006, only supplemental insulin was used (SSI-only group). The primary outcome was first blood glucose (BG1) after discontinuation of IVII. Secondary outcomes included the absolute difference between the last glucose before discontinuation of IVII (BG0) and BG1, mean glucose in the first 24 hours after discontinuation of IVII (BG24), need for SSI, and hypoglycemia. RESULTS: Mean BG0, BG1, and BG24, and the difference between BG1 and BG0 and between BG24 and BG0 were not significantly different between groups. Diabetes mellitus (DM) patients who had received glargine had a lower mean difference between BG1 and BG0 and a lower mean BG24 than those who had not received glargine (14.6 mg/dL vs. 33.1 mg/dL; P = .20, and 163.8 mg/dL vs. 177.9 mg/dL; P = .29, respectively). A higher proportion of DM patients needed SSI than did non-DM patients (82% vs. 36%; P<.001). CONCLUSION: Glargine administered at the cessation of IVII enabled less SSI coverage in diabetic patients subsequent to transition from IVII. However, there was no significant difference in BG control between the glargine-SSI and SSI-only groups. Prospective studies involving more patients are needed to show possible clinically significant benefits of this intervention.

Recurrent granulomatous mastitis mimicking inflammatory breast cancer.

Granulomatous mastitis (GM) is an uncommon benign breast lesion. Diagnosis is a matter of exclusion from other inflammatory, infectious and granulomatous aetiologies. Here, we presented an atypical GM case, which had clinical and radiologic features overlapping with inflammatory breast cancer (IBC). The disease had multiple recurrences. The patient is a 40-year-old Caucasian woman with a sudden onset of left breast swelling accompanied by diffuse skin redness, especially of the subareolar region and malodorous yellow nipple discharge from the left nipple. The disease progressed on antibiotic treatment and recurred after local resection. A similar lesion developed even after bilateral mastectomy. GM may show clinical/radiologic features suggestive of IBC. Multiple recurrences can be occasionally encountered. GM after recurrence could be much more alarming clinically. Pathology confirmation is the key for accurate diagnosis and a multidisciplinary approach is important to rule out IBC.