Ultrasonographic findings of papillary thyroid carcinoma with Hashimoto's thyroiditis.

OBJECTIVE: Papillary thyroid carcinoma (PTC) sometimes occurs with Hashimoto's thyroiditis (HT). It is often difficult to differentiate between benign and malignant nodules in HT because HT varies greatly on ultrasonography. We aimed to characterize the ultrasonographic features of PTC with HT. PATIENTS AND METHODS: In this retrospective study, 2167 patient records (1897 women and 270 men) were examined for ultrasonographic features and thyroid autoantibodies between 1998 and 2002 at our university. Patients with Graves' disease, positive TSH receptor autoantibody (TRAb) or thyroid-stimulating antibody (TSAb) were excluded. PTC was diagnosed by pathological examination. RESULTS: Of the 1644 patients who were autoantibody negative (MCHA, TGHA, TgAb, TPOAb), 54 (3.3%) had PTC, while 29 (5.5%) of the 523 patients who were autoantibody positive had PTC. On ultrasonography, the frequency of dense calcification in patients with HT was significantly higher (P=0.0064) and frequency of psammoma bodies was less than PTC patients without HT (P<0.0001). On the other hand, PTC with HT had more irregular shapes and ill-defined edges of the borders with less hypoechogenecity and calcification than PTC without HT, but the difference was not significant. CONCLUSION: The frequency of psammoma bodies in PTC with HT was less, while dense calcifications were greater than in those of PTC without HT. Any type of ultrasonographic calcification features may represent a risk for PTC.

Preclinical Cushing's disease characterized by massive adrenal hyperplasia and hormonal changes after three years of metyrapone therapy.

A 66-year-old woman had massive bilateral adrenal macronodular hyperplasia, found incidentally on an abdominal ultrasonogram. Her plasma ACTH and serum cortisol levels were normal, but they were not suppressed by low-dose dexamethasone. The patient did not exhibit any typical signs or symptoms of Cushing's disease. MRI showed no evidence of a tumor in the pituitary gland. A diagnosis of preclinical Cushing's disease was made, and she was treated with 11-hydroxylase inhibitor metyrapone. As the dose of metyrapone was increased, plasma ACTH levels gradually increased. After three years of treatment, she developed moon-face. Her plasma ACTH and serum cortisol concentrations were at their highest levels. A pituitary microadenoma was detected by MRI, whose source of ACTH was demonstrated by the definite step-up of central/peripheral ratio of ACTH obtained by cavernous sinus sampling. Overt Cushing's disease was diagnosed, and a pituitary tumor was removed by transsphenoidal surgery. In conclusion, the clinically and endocrinologically overt Cushing's disease characterized by macronodular adrenal hyperplasia was converted from a preclinical form. This case offers some insight into the clinical and biological features of preclinical Cushing's disease.

A man with interstitial pneumonia due to propylthiouracil.

A 50-year-old Japanese man with Grave's disease had been taking propylthiouracil (PTU) for 10 years prior to the diagnosis of pneumonia. He noticed dyspnea on exertion and had a dry cough for at least 2 years and then suddenly developed high fever and dyspnea at rest. Clinical symptoms, chest radiographs, chest computed tomography and lung function revealed interstitial pneumonia. The symptoms were completely resolved after withdrawal of PTU, and consequently he was diagnosed with PTU-induced interstitial pneumonia. He also showed moderate myeloperoxidase (MPO)- antineutrophil cytoplasmic antibody (ANCA) positivity without any signs of vasculitis before as well as after PTU withdrawal. Although PTU-induced interstitial pneumonia is quite rare, with only 3 cases, including the present patient, so far reported, respiratory involvement should be considered in patients treated with PTU.

Osteoporosis is more prevalent in adrenal than in pituitary Cushing's syndrome.

Osteoporosis is the most common complication of Cushing's syndrome. We retrospectively examined the prevalence and risk factors for osteoporosis in 42 female patients with Cushing's syndrome. Osteoporosis and atraumatic fractures were assessed by bone mineral density of the lumbar vertebral spine (L2-L4) using dual energy X-ray absorptiometry (DXA) and X-ray examination. The prevalence of osteoporosis and fracture were 54.8% and 21.4%, respectively. The prevalence of osteoporosis (69.6% vs. 37.8%) and atraumatic bone fracture (26.1% vs. 15.8%) were significantly higher in patients with adrenal Cushing's than in those with pituitary Cushing's. AP and lateral BMD was significantly higher in patients with pituitary origin than in those with adrenal origin. Among several variables examined by multiple logistic regression, the etiology of Cushing's syndrome (adrenal vs. pituitary origin) was a significant factor affecting the prevalence of osteoporosis. Neither age, body mass index, duration of amenorrhea, nor extent of hypercortisolism were significant factors in this analysis. Plasma DHEA-S and urinary 17-KS excretion were significantly higher in pituitary Cushing's than in adrenal Cushing's. The present study shows that the prevalence of osteoporosis in patients with Cushing's syndrome is influenced by its etiology. A factor associated with pituitary Cushing's syndrome, such as adrenal androgen, may protect these patients from glucocorticoid-induced osteoporosis.