Thyroid abscess is an uncommon infectious pathology. The thyroid is highly resistant to infection due to high iodine content, capsular encasement, and rich vascularity. Acute suppurative thyroiditis represents <1% of thyroid diseases that could potentially become a life-threatening endocrine emergency. A 48-year-old woman with AIDS presented with 3 days of fever, tender neck swelling, and methicillin-resistant Staphylococcus aureus bacteremia. Apart from leukocytosis, initial laboratory values including thyroid function tests were normal. The initial plain computed tomography scan of the neck and ultrasound scan of the neck were inconclusive as well. By day 4, she worsened, and on repeat computed tomography scan of the neck with contrast, multiloculated abscesses in the thyroid and retro pharynx were seen, which needed emergent drainage. Acute suppurative thyroiditis, a rare disease, occurs in patients with either preexisting disorders of the thyroid or in the immunocompromised. The most common pathogen is Staphylococcus aureus. In our case, we highlight the fact that initial imaging may be negative in the early stages of acute suppurative thyroiditis and lead to an erroneous diagnosis of subacute thyroiditis. There are less than 5 cases of methicillin-resistant Staphylococcus aureus suppurative thyroiditis reported.
Water-clear cell adenoma (WCCA) of the parathyroid gland is an exceedingly rare neoplasm. To date, 17 cases have been reported in the literature, with only one of them being intrathyroidal. Here we report a case of a 34-year-old woman who presented for evaluation of a goiter and was found to have a thyroid nodule and abnormal thyroid function tests (TFT). Fine needle aspiration biopsy of the nodule revealed thyroid follicular cells without atypia and subsequent Afirma® Gene Expression Classifier (GEC) testing results were suspicious for malignancy. As a result, the patient underwent a right thyroid lobectomy and isthmusectomy. Histological sections revealed an intrathyroidal nodule consistent with a clear cell neoplasm of parathyroid origin. The histologic appearance together with the immune profile was diagnostic of WCCA, with diffuse positivity for GATA3, focal weak positivity for parathyroid hormone, and negativity for PAX8, thyroglobulin, TTF1, synaptophysin, chromogranin, and S100p. Our study focuses on the clinical presentation, current management strategies, and review of the available literature surrounding this rare diagnosis. The ultimate goal is to help endocrinologists and surgeons establish a foundational treatment plan for intrathyroidal clear cell tumor cases.
La infección por SARS-CoV-2 se ha convertido en un problema mundial de salud pública. Su presentación clínica es variada, desde benigna hasta un síndrome de distrés respiratorio agudo, afectación sistémica y fallo multiorgánico. La severidad del cuadro clínico depende de factores biológicos del virus y del huésped y de comorbilidades como la enfermedad renal. Además, la interacción entre el virus, la enzima convertidora de angiotensina 2 y la respuesta inmunológica exacerbada podría conducir al desarrollo de lesión renal aguda. Sin embargo, las implicaciones de la infección por SARS-CoV-2 sobre las células renales, las repercusiones pronósticas en los pacientes con enfermedad renal crónica y su efecto a largo plazo sobre la función renal no están del todo claras. El objetivo es revisar el papel del SARS-CoV-2 en la enfermedad renal aguda y crónica, y sus posibles mecanismos patogénicos en la afectación renal.Palabras clave. SARS-CoV-2. COVID-19. Enzima convertidora de angiotensina 2. Enfermedad renal crónica. Lesión renal aguda.
Background: Novel immune checkpoint proteins inhibitors, such cytotoxic T-lymphocyte antigen 4 (anti-CTLA-4) like ipilimumab could produce hypophysitis as a side effect with a prevalence between 0 to 10%. There are no guidelines in how to monitor patients receiving similar agents. We present a case that was follow up hormonally and developed hypophysitis. Clinical Case: A 63-year-old male presented in 2015 with severe frontal headache that lasted 4 days with no improvement with Ibuprofen and fatigue 5 days after receiving third dose of ipilimumab for metastatic malignant melanoma. He denied nausea, vomiting, visual symptoms. Magnetic resonance (MRI) demonstrated a diffuse pituitary enlargement. Laboratory results showed decreased hormones like: cortisol (0.5mcg/dl, n:4-22mcg/dl), freeT4 (0.36 ng/dl, n:0.8-1.8ng/dl), TSH (0.36 mIU/L, n:0.40-4.5mIU/L) prolactin (<1ng/ml, n 2-18 ng/ml), free testosterone (33.6 pg/ml, n:35-155pg/ml) and normal IGF-1 (62 ng/ml, n:41-279) consistent with panhypopituitarism in the setting of hypophysitis secondary to ipilimumab. Cortisol and thyroid hormones levels where checked before beginning ipilimumab and after receiving first dose and were within normal limits. After patient received the second dose, patient had an episode of colitis which lasted 10 days, which required prednisone 40 mg for 1 week and then it was tapered for another 2 weeks. At that point cortisol was checked which was normal (9.9 mcg/l n:4-22mcg/dl), however patient was on steroids. Patient received third dose of ipilimumab and then he developed severe headache and was diagnosed with hypophysitis. Patient was started on dexamethasone high doses, which was tapper down and switched to hydrocortisone 20 mg am and 10 at pm and was started on levothyroxine 137 mcg daily. Two months after diagnosis an MRI was repeat which did not show any pituitary enlargement, however patient had persistent panhypopituitarism on laboratory results. Four months after diagnosis was started on testosterone replacement therapy. Last visit was in 2018 patient was without fatigue, he is on hydrocortisone 15mg am, 10mg pm, levothyroxine 175 mcg, and testosterone gel every day. His cortisol is decreased (1 mcg/dl , n:4-22mcg/dl), IGF-1 now is low (37 ng/ml n:41-279), prolactin is decrease (1.3 ng/ml, n 2-18 ng/ml), free T4 normal on replacement (1.1 ng/dl, n:0.8-1.8ng/dl), normal free testosterone on replacement (57.6 pg/ml, n:35-155pg/ml). Conclusion: endocrinopathies are seen up to 10% in patients on CTLA-4 , therefore awareness of more serious deficits like hypophysitis should need to be promptly recognized and follow up is recommended, like we are implementing this approach in our institution.
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