Barsienė, Lina

Introduction Hypothyroidism is associated with a spectrum of symptoms affecting almost all bodily functions. We present a case of severe hypothyroidism with multiple body cavity effusions, volvulus of sigma creating ileus. Case report: A 70 year old female was admitted to emergency department with dyspnea, and acute abdominal pain. Physical examination was notable for anasarca, abdominal fluid wave, lower extremity pitting edema, hypotension. She did not have any comorbidities. Anamnesis of hypothyroidism left unknown during admission. Diagnostic CT scan revealed a volvulus of sigma creating bowel obstruction. Ascites, bilateral pleural effusion, cardiac tamponade were also diagnosed. Sigmostoma was applied for decompression of ileus during urgent laparatomy. Pericardial, pleural and peritoneum drainage was performed. Antibiotics were started due to inflammation (CRP 120 mg/l). Abundant secretion from the peritoneum, pleura and pericardium continued. Polyserositis differential diagnostic tests were done: ANCA –negative, AntiDNA 25.2kU/l, albumine 23.2–16.3 (n–35–52) g/l, liquid from pleura, peritoneum and pericardium had no signs of cancer, tuberculosis. Thyroid function tests showed hypothyreosis: TSH 100 (0.4–3.6) mU/l, FT4 0.1 (9–21.07) pmol/l, FT3 1.17 (3.34–5.34) pmol/l, AntiTPO 63.73kU/l (0–3.2). Adrenal insufficiency was denied: ACTH 7.7 (3–14) pmol/l, morning cortisol 441 nmol/l. Ultrasound of the thyroid gland revealed small lobes and isthmus. Treatment with levothyroxine 50 μg/day was started, human albumin transfusions were applied. Expanded anamnesis revealed that patient had been on levothyroxine replacement but had defaulted treatment for 15 years. Following hospital course was uncomplicated with steadily rising dose of levothyroxine from 50 to 100 μg/day. After 26 days of treatment with levothyroxine TSH was still high (87.5 mIU/l), though FT4 reached 6.73 pmol/l. Abatement o[...].

Algoritmas (lot. algorismus

Introduction: Grave’s disease is frequently associated with cytopenia. Pancytopenia, however, is rare. Thyroid hormones have a direct effect on myocardial contractility and left ventricle (LV) diastolic function. Only less than 1% of the patients with hyperthyroidism develop cardiomyopathy with impaired left ventricular systolic function. Case: A 51-year old woman was admitted to the Hospital of Lithuanian University of Health Sciences, Kaunas clinics with 6 months history of tachycardia, bilateral leg oedema and progressive dyspnea. For 9 years, the patient was treated with Thiamasole for thyrotoxicosis. Physical examination demonstrated enlarged thyroid, pale skin, cyanotic lips. Both legs were swollen below the knee down to the feet. There was no endocrine ophthalmopathy. Cardiac auscultation revealed an irregular heartbeat with rate of 128 bpm. Laboratory tests: TSH <0.001 mIU/l (0.27–4.2), FT4 34.38 pmol/l (12–22), FT3 7.38 pmol/l (3.34–5.14), anti-TSH-R 180 U/l (<9), anti-TPO 307.4 kU/l (0–12), anti-Tg 12 kU/l (0–100). Pancytopenia was diagnosed by haemoglobin 60 g/l (135–169), neutrophils 1.30×109/l (1.8–7.4), platelets 64×109/l (166–308). An electrocardiogram showed atrial fibrillation with heart rate of 128 bpm. Thyroid ultrasonography revealed enlarged thyroid gland with bilateral hypoechogenic zones. Color Doppler showed a highly increased vascularisation. Chest X-ray showed hydrothorax (12.3 cm liquid in the right pleura). Therapeutic thoracocentesis was performed. 5.6 cm of free abdominal fluid were observed in the peritoneal cavity by abdominal US. A transthoracic echocardiogram (TTE) was performed after intensive treatment (after 1 month), when clinical symptoms regressed. TTE showed moderately reduced systolic LV function (ejection fraction 50%), normal LV diastolic function; mild pericardial effusion, moderate aortic regurgitation, expanded mitral valve ring and severe mitral reg[...].

Introduction Von Hippel–Lindau (VHL) disease is a rare disorder, characterized by the development of a variety of benign and malignant tumors. It is autosomal dominantly inherited disease that causes retinal or central nervous system hemangioblastomas, endolymphatic sac tumors, renal cell carcinomas, pancreatic cysts and tumors, pheochromocytoma and epididymal cystadenomas. The condition is associated with inactivation of a tumor suppression gene. Case The 31-year-old Caucasian male patient was consulted in the Hospital of Lithuanian University of Health Sciences, Kaunas clinics ophthalmology department because of the gradually decreasing vision with a right eye. Proliferative retinopathy and retinal hemangioma were diagnosed. VHL syndrome was suspected and abdominal computed tomography (CT) was performed. CT revealed masses in both adrenal glands and MIBG scintigraphy confirmed bilateral pheochromocytoma (PCC). Another diagnostic VHL sign - cysts in pancreas and kidney were also seen in CT. The patient had no clinical symptoms of PCC at that time. To confirm pheochromocytoma, the catecholamine blood test was done and five times elevated normetanephrine 5.65 pmol/l (0–1.037) and chromogranin A 177 mg/l (0–100) were detected. To exclude MEN 2 syndrome genetic test was done and no RET mutations were found. Diagnose of VHL was made based on clinical findings. The multidisciplinary team decided to remove left adrenal gland because the size of the left adrenal tumor was four times larger and in SPECT/CT it had more intensive radionuclide uptake. Histopathological examination revealed pheochromocytoma in 2.4!4!4.3 cm and 3.5!4!2.3 cm size masses with necrotic areas and on immunohistochemistry positive expression of chromogranin A. Catecholamine and chromogranin A levels decreased in one-year follow-up after the operation. Patient lost vision with a right eye because the hemangioblastoma of the retinae was inoperable

Introduction Lymphoma usually occurs within lymph nodes, but in rare cases, it arises from lymphocytes that are presented within the thyroid gland. Thyroid lymphoma is rare, representing less than 5% of thyroid malignancies and less than 2% of all lymphomas occurring outside of the lymph nodes and it is more likely to occur in people with Hashimoto’s thyroiditis. In this case we present a patient with Hashimoto’s thyroiditis (HT) and thyroid lymphoma (TL). Case 63 years women presented to the outpatients clinic with complains of fatigue, weakness of voice and enlargement of the neck. She has autoimmune thyroiditis (anti-TPO 53 kU/l) for 10 years. She has been taking Levothyroxin 50 mg per day for 5 years. Few weeks ago, she had noticed painless fast swelling left side of the neck and after 2 weeks the enlargement of the right side of the neck. Physical examination showed a large palpable mass on the both sides of the neck and an enlarged thyroid. Laboratory studies showed elevated sedimetation rate 34 mm/h (normal !13 mm/h), elevated anti-TPO antibodies 689kU/l (0–12) and anti-Tg 682 kU/l (0–100). Other laboratory measurements, including haemoglobin and leukocytes, thyroid hormones (FT4 15.22 pmol/l (12–22), TSH 0.72 mU/l (0.27– 4.2), anti-TSH-R 3U/l (!9)), calcitonin !0.42 pmol/l (0–2.8), were normal. In the thyroid ultrasound examination thyroid enlarged, hypoechoic, heterogeneous, in the left side pathological lymph nodes – suspicion of lymphoma or anaplastic carcinoma. Other radiological tests, including abdomen ultrasound, chest X-ray and mammography, evaluating the spread of oncological process, were normal. Core needle biopsy of the thyroid was taken and showed a Diffuse large B-cell lymphoma (DLBCL). PET-CT scan showed metabolically active lymphoproliferative process in the thyroid, in the lymph nodes of mediastinum, in the small intestine and in the mesenteric lymph nodes. The patient was di

Introduction Tumor-induced osteomalacia (TIO) or oncogenic hypophosphatemic osteomalacia (OHO) is a rare paraneoplastic syndrome characterized by renal phosphate wasting leading to hypophosphatemia and secondary osteomalacia. TIO was first described in 1947 by Robert McCance and only 500 of cases have been reported in literature since then, approximately 200 of cases during this decade. Case report In 2014, a 32-year-old female presented with waist pain, myalgia, muscle weakness. The patient felt unhealthy after second childbirth. In June 2015 MRI scan revealed bilateral acute sacroiliitis. Treatment with sulphasalazine, methylprednisolone, methotrexate and later with etanercept was started, but was ineffective. In May 2016 repeated MRI showed bilateral avascular femoral head necrosis of unknown origin. Plain radiography showed osteoporosis at thoracic, lumbar vertebrae, hip bone and femur, fracture of superior ramus of pubis, compressive fractures in Th8-Th9. Dual energy x ray absorptiometry (DXA) scans confirmed low bone mineral density at the spine 0.516 g/cm2 (Zscore K4.8), hip neck 0.507 g/cm2 (Z-score K2.9) and hip total 0.496 g/cm2 (Zscore K3.6). Other causes of secondary osteoporosis were excluded and the antiosteoporotic treatment with denosumab was started. The patient was first seen by an endocrinologist in October 2016 because of progressing symptoms. Biochemical evaluation revealed hypophosphatemia 0.3 mmol/l (n: 0.78–0.153) and low 24-h urine phosphorus excretion 8.78 mmol/24 h (n: 12.9–42.0). Hypophosphatemia was treated with phosphate supplements but where was no improvement. In September 2017 patient noticed a soft lump in the right groin. Right leg ultrasound and MRI revealed 1.5!1.8!2.0 cm size tumor between sartorius and adductor longus muscles. Whole-body MRI and bone scintigraphy showed no metastasis or other tumors. In October 2017 the whole-body scintigraphy with somatostatin analogues 99

Introduction Fine-needle aspiration (FNA) is the most accurate diagnostic approach for determining thyroid nodule malignancy. Most nodules are benign, therefore, only suspicious ones require FNA. In 2017 American College of Radiology proposed a scoring system – Thyroid Imaging, Reporting and Data System (TI-RADS) for identifying clinically significant malignancies. Whether a nodule requires FNA depends on various criteria, one of which is the size. The aim of this study was to determine whether size is an important factor in deciding the necessity for FNA. Methods A total of 288 ultrasound images of patients with thyroid nodules were analysed. The nodules were scored, measured and assigned to one of five TI-RADS levels (TR): TR1 – benign, TR2 – not suspicious, TR3 – mildly suspicious, TR4 – moderately suspicious, TR5 – highly suspicious. The results were compared with histology findings. Results 219/288 (76%) benign and 69/288 (24%) malignant thyroid nodules were verified histologically. Nodules were distributed as follows: TR1 – 17 (5.9%), TR2 – 27 (9.4%), TR3 – 72 (25.0%), TR4 – 126 (43.8%), TR5 – 46 (16.0%). The mean size of measured nodules was 2.05G1.02 cm. In categories TR1 and TR2 100% of nodules were benign according to FNA. In TR3 68/72 (94.4%) of nodules were benign and 4/72 (5.6%) malignant, 38/72 (52.7%) !2.5 cm in size and 34/72 (47.22%) – R2.5 cm. None of the malignant nodules in TR3 were R2.5 cm. Negative correlation (rs ZK0.298, PZ0.011) was found between size and malignancy. In TR4 93/126 (73.8%) of nodules were benign and 33/126 (26.2%) malignant, 59/126 (46.8%)!1.5 cm in size and 67/126 (53.2%) –R1.5 cm. Size of R1.5 cm had sensitivity of 39.39%, specificity of 41.94%, positive predictive value (PPV) of 19.40%, negative predictive value (NPV) of 66.10% and accuracy of 41.27%. No significant correlations between size and malignancy in TR4 were found. In TR5 14/46 (30.4%) of the nodules were benign and 32/46 (69.6%)

Kušingo sindromas, sukeltas antinksčių adenomos, yra reta endokrininė liga. Remiantis skirtingais literatūros šaltiniais, kortizolį gaminančios antinksčių adenomos nustatomos 0,6-1,4 paciento iš milijono [1,2]. Patologija ne tik reta, bet ankstyvų stadijų ir sunkiai diagnozuojama, kadangi Kušingo sindromui būdinga penkerių metų preklinikinė fazė, kurios metu matomi tik biocheminiai pokyčiai – patologinė hiperkortizolemija, be klinikinių simptomų [1]. Vėliau, ligai progresuojant, išryškėja tipiška Kušingo sindromo klinika ir ligos komplikacijos: širdies ir kraujagyslių ligos, kaulų mineralų tankio pokyčiai (osteopenija, osteoporozė), angliavandenių, lipidų apykaitos sutrikimai.