Endocrine case studies

Case 1

• A 40 y/o woman with onset of fatigue, sleep disturbance, palpitation, anxiety, night sweats and sore throat since 2 weeks ago

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• P/E: stable vital sign
• No proptosis, no tremor
• Thyroid: diffusely enlarged 2x normal, firm, Tender

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What is your DDX

• Hyperthyroidism
• (primary, secondary or tertiary)

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• Thyroiditis
• (infectious, autoimmune, granoulomatous)

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What is the next step in diagnosis?

• The thyroid function tests are as below:
• TSH: 0.004 (0.35-5.3)
• T4: 20 (4-12)
• T3: 340 (60-180 ng/ml)
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• Thyroid ultrasound: Diffusely enlarged gland with mildly heterogenous echotexture, no nodules

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What are the possible causes of low TSH?

• Hyperthyroidism
• Graves
• Toxic adenomas or autonomously functioning thyroid nodules
• Toxic Multinodulargoiter (TMNG)
• Thyroiditis
• Central Hypothyroidism
• Euthyroid Sick Syndrome
• Medications (steroids, sympathomimetics)
• Ingestion of excess exogenous thyroid hormone (most common)

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What are the clinical symptoms and signs of hyperthyroidism?

• Appetite change
• Exertional shortness of breath
• Fatigue
• Headache
• Heat intolerance
• Hyperactivity
• Irritability
• Menstrual disturbances
• Nervousness

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• Palpitations
• Pelvic and pectoral girdle muscle weakness
• Sleep disturbance
• Tremor
• Weakness
• Weight change

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Clinical signs of hyperthyroidism

• Goiter
• Hyperactivity
• Hyperreflexia
• Muscle weakness
• Stare and eyelid retraction
• Systolic hypertension

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• Tachycardia/
• Atrial arrhythmia
• Tremor
• Warm, moist, smooth skin

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What additional tests do you order to reach final diagnosis?

• Free T3, T4: Increased
• TSI: normal
• Thyroid scan and uptake: decreased uptake

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What is the final diagnosis?�

• Subacute thyroiditis (granulomatous thyroiditis or De Quervain thyroiditis)

What do you expect to see in histologic sections of thyroid of the patient?

• there is disruption of thyroid follicles with extravasations of colloid

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• granulomatous reaction with giant cells

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• Inflammatory infiltration

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What is the pathogenesis of patient disease?

• viral infection or a postviral inflammatory process

• NSAID and beta-blocker was started for the patient and symptoms improved. After 4 weeks patient’s lab data shows:
• TSH: 8.5 T4: 2
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• What’s happening now?
• hypothyroidism

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• Levothyroxine prescribed in follow up TSH normalized and Levothyroxine was weaned after 3 months with maintenance of normal thyroid levels thereafter

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Case #2

• 19 y/o female presents for general checkup complaining of fatigue and weight gain
• Physical exam: unremarkable except for a 2 cm nodule firm and slightly irregular in the right lobe of the thyroid. No palpable adenopathy
• TSH:1.1
• Free T4: 1.5

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What is your DDX?�

• Nodular goiter
• Follicular adenoma
• Thyroid carcinoma
• Papillary ca
• Follicular ca
• Medullary ca
• Anaplastic ca
• lymphoma

What should we do next?�

• Ultrasound:solid nodule on right 2.1 cm solid nodule on right 2.1 cm (hypoechoic with microcalcifications and increased vascularity, irregular margins)
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• Scan: cold nodule on right
• FNA: suspicious for papillary carcinoma
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FNA

• Provides the best means of evaluating a thyroid nodule.
• In patients with a solitary nodule it is the diagnostic procedure of choice

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• Most cases of MNG do not require biopsy unless there is concern for malignant potential

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• Dependent on availability of an experienced cytopathologist

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FNA findings of Papillary carcinoma

• Papillary clusters
• Nuclear atypia
• Intranuclear groove
• Intranuclear pseudoinclusion

• The patient referred to surgeon for thyroidectomy.
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• What do you see in histopathologic slides of the resected mass?

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• Papillary configuration
• Nuclear clearing
• Intranuclear inclusions (pseudoinclusions) or intranuclear grooves.
• Psammoma bodies

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