Hypercalcemic Crisis Due to a Giant Intrathyroidal Parathyroid Adenoma, with Postsurgical Severe Hypocalcemia and Hungry Bone Syndrome: A Case Report.

BACKGROUND: Parathyroid adenoma is the most common cause of hypercalcemia and rarely leads to a hypercalcemic crisis, which is an unusual endocrine emergency that requires timely surgical excision. CASE PRESENTATION: A 67-year-old male was admitted to the ER of the Euroclinic Hospital, Athens, Greece, because of elevated calcium levels and a palpable right-sided neck mass, which were accompanied by symptoms of nausea, drowsiness, and weakness for six months that increased prior to our evaluation. A gradual creatinine elevation and decreasing mental state were observed as well. The initial laboratory investigation identified severely elevated serum calcium (3.6 mmol/L) levels consistent with a hypercalcemic crisis (HC) and parathyroid hormone PTH (47.6 pmol/L) due to primary hyperparathyroidism. Neck ultrasonography (USG) identified a large, well-shaped cystic mass in the right thyroid lobe. With a serum calcium concentration of 19.5 mg/dL and a PTH of 225.3 pmol/L, the patient underwent partial parathyroidectomy and total thyroidectomy, which decreased serum calcium and PTH to 2.5 mmol/L and 1.93 pmol/L, respectively. Histology revealed a giant intrathyroidal cystic parathyroid adenoma, which was responsible for the hypercalcemic crisis. Postoperatively, the patient developed severe biochemical and clinical hypocalcemia, with calcium concentrations as low as 1.65 mmol/L, consistent with hungry bone syndrome (HBS), which was treated with high doses of intravenous calcium gluconate and oral alfacalcidol, and a slow recovery of serum calcium. After discharge, parathyroid function recovered, and symptomatology resolved entirely in more than one month. DISCUSSION/CONCLUSIONS: We present a case involving an exceptionally large intrathyroidal parathyroid adenoma that is characterized by clinical manifestations that mimic malignancy. The identification and treatment of such tumors is challenging and requires careful preoperative evaluation and postoperative care for the risk of hungry bone syndrome.

Increased alpha-subunit response coexist with increased TSH response to TRH test in healthy individuals.

OBJECTIVE: The alpha-subunit (Alpha-SU) response to TRH was studied to examine the response of alpha-SU under TRH stimulation in normal situation. METHODS: Thirty seven healthy individuals were included in the study. They were divided into two groups according to the data taken: A with TSH equal or more than seven fold the basal values (0: 3.14+/-1.2 microU/ml., 30 after TRH: 20.22+/-4.6 microU/ml) and B with TSH 2 to 6 fold the basal values (0: 0.5+/-0.1 microU/ml., 30 after TRH: 2.9+/-0.5 microU/ml). Both groups exhibited similar FT3 and FT4 levels. RESULTS: In group A, prolactin displayed a 3 fold increase from the basal values, whereas alpha-SU increased 4 fold with a difference being statistically significant (p<0.001). In contrast, in group B individuals neither prolactin nor alpha-SU exhibited any significant difference from the basal values. CONCLUSION: The expression of alpha-SU upon TRH stimulation is dependent on the TSH basal values.

Thyroid abscess due to a mixed anaerobic infection with Fusobacterium mortiferum.

A rare case of a thyroid abscess due to mixed anaerobic flora containing Fusobacterium mortiferum in an immunocompetent patient is described. The patient was successfully treated with immediate surgical intervention and appropriate antimicrobial agents.

The use of recombinant human thyrotropin (Thyrogen) in the diagnosis and treatment of thyroid cancer.

The introduction of human recombinant thyrotropin (rhTSH/Thyrogen) into the diagnosis of thyroid cancer has substantially ameliorated the patient's quality of life through the avoidance of debilitating hypothyroidism. With the aim of updating the use of Thyrogen, we report 7 cases which were treated with Thyrogen for diagnostic or therapeutic purposes. All 7 patients were thyroidectomised and radioiodine ablated and all had detectable [> 1 ng/ml] basal serum thyroglobulin (b-Tg) levels. Thyrogen stimulation resulted in a rise of Tg (s-Tg) in all patients. Five patients had negative whole body scanning (WBS) and no clinical or radiological signs of disease. Two patients with a b-Tg value of 5 ng/ml and 11 ng/ml, respectively showed a s-Tg of 17 ng/ml and 84 ng/ml, respectively, whereas WBS was negative. Both of these patients received 100 mCi (3700 MBq) 131I. Owo patients had a positive Tg and positive WBS with skull, lung and hepatic metastases and received 150 131I after preparation with Thyrogen. Six months later one of these patients was free of disease and the other will be evaluated during the coming months. In conclusion, Thyrogen emerges as a reliable and safe agent for the diagnosis of thyroid cancer. Furthermore, it appears that Thyrogen could be used in the treatment of metastases as an alternative to thyroid hormone withdrawal.

Differentiated thyroid cancer in Greece: 1963-2000. Relation to demographic and environmental factors.

Thyroid cancer (TC) is a relatively rare neoplasia, accounting for 0.35%-0.38% of total deaths due to cancer in Greece. Environmental/nutritional factors are considered to play a role in its pathogenesis. The aim of this retrospective review of patients' histories from three of the largest specialized centers in southern Greece, from 1963 to 2000, was to assess associations of differentiated TC (DTC) with demographic and environmental factors. The total number of DTC cases was 610 (119 men or 19.5%, and 491 women or 80.5%), of which 442 cases (72%) were papillary DTCs (pure papillary type: 54.5% and mixed papillary-follicular type: 45.5%), 90 cases (15%) were of the pure follicular type, while 78 cases (13%) were classified as suspicious lesions, requiring follow-up, but not definitively carcinomas. The mean age (+/-SD) at diagnosis for all groups was 42.3+/-1.3 years. Fifty percent of the patients were living in Athens at the time of diagnosis. The diagnosis was delayed in patients living in villages compared to those living in cities (mean age +/-SD): 43.7+/-14.1 years and 40.9+/-13.8 years, respectively; p<0.05, t-test). Patients who were born in iodine-sufficient areas (n=162/193, 84%; X(2)=5.09, P=0.02) had papillary carcinoma more frequently compared to patients who were born in previously iodine-deficient areas (n=159/214, 74%). During the observation period (1963-2000) there appeared to be three different trends in the incidence of newly diagnosed cases: a random variation during the first nine years and a steady increase during the second two decades (starting before the Chernobyl nuclear accident) followed by a significant decline during the last few years. We suggest that the observed variations in the incidence of DTC could be related to the availability of diagnostic tools as well as to increased awareness.

Proopiomelanocortin mrna expression by small cell bladder carcinoma associated with cushing's syndrome: diagnostic contribution of in situ hybridization.

A case of ectopic ACTH secretion by primary small-cell carcinoma of the urinary bladder is described. The patient, a 38-year-old woman, presented with Cushing's syndrome. Although immunocytochemistry of the tumor for ACTH and corticotropin-releasing factor yielded negative results, in situ hybridization demonstrated a conclusive signal for proopiomelanocortin messenger RNA. This case report shows the value of in situ hybridization in diagnostic pathology.