Tirotoxicosis por enfermedad trofoblástica gestacional: revisión a partir de 3 casos / Thyrotoxicosis due to gestational trophoblastic disease: clinical cases

La enfermedad trofoblástica gestacional (ETG) es una complicación del embarazo poco común. Corresponde a un espectro de lesiones proliferativas del tejido trofoblástico: Mola Hidatiforme (MH) en sus formas parcial y completa, Coriocarcinoma, Tumor Trofoblástico y Tumor Trofoblástico Epiteloide. Los distintos tipos de ETG presentan en común la hipersecreción de gonadotrofina coriónica humana (hCG). La hCG es una hormona glicoproteica con una estructura muy similar a la TSH, por lo cual puede estimular la función tiroidea en condiciones fisiológicas y en algunas condiciones patológicas. La ETG puede cursar con hipertiroidismo, el cual puede variar en intensidad, desde una presentación asintomática con alteración leve de hormonas tiroideas a un cuadro de hipertiroidismo manifiesto. Se presentan 3 casos clínicos de pacientes con ETG, específicamente MH que evolucionaron con tirotoxicosis transitoria. Los casos presentaron un cuadro leve de hipertiroidismo con pocos síntomas asociados. La taquicardia fue el único síntoma en la mayoría de los casos. En todas las pacientes las hormonas tiroideas se normalizaron después del tratamiento de la ETG. Conclusión: Se debe tener presente la posibilidad de hipertiroidismo en toda paciente con ETG. Un alto nivel de sospecha permitirá identificar a aquellas pacientes que cursen con hipertiroidismo, permitiendo así un diagnóstico y tratamiento oportuno.

Gestational trophoblastic disease (GTD) is a rare complication of pregnancy. GTD includes a group of proliferative lesions of trophoblastic tissue: partial and complete hydatidiform mole, choriocarcinoma, epithelioid trophoblastic tumor, and placental site trophoblastic tumor. The different types of GTD have in common the hypersecretion of human chorionic gonadotropin (hCG). HCG is a glycoprotein hormone with a similar structure to TSH. In physiological and pathological conditions hCG can stimulate thyroid function. GTD can present with hyperthyroidism, which can vary in intensity, from an asymptomatic presentation with mild alteration of thyroid hormones to a manifest hyperthyroidism. We present 3 clinical cases of patients with GTD thyrotoxicosis. All cases presented mild hyperthyroidism. Tachycardia was the only symptom in most cases. In all patients thyroid hormones return to normal after treatment of GTD. Conclusion: In patients with GTD the possibility of hyperthyroidism should be kept in mind. A high level of suspicion will allow to identifying patients with hyperthyroidism.

Hipertiroidismo en personas mayores de 65 años: serie de casos de un hospital universitario / Thyrotoxicosis in the elderly: case series report from a university hospital

Introducción: En Chile en las últimas décadas ha aumentado la población de personas mayores de 65 años. La tirotoxicosis en este grupo está asociada a complicaciones como fibrilación auricular (FA), insuficiencia cardiaca (ICC), osteoporosis y aumento de la mortalidad. En algunos casos puede presentarse con síntomas no específicos, cuadro conocido como hipertiroidismo apático. Objetivos: Evaluar las características clínicas de la tirotoxicosis en personas mayores. Método: Serie de casos retrospectiva. Se analizaron fichas clínicas de pacientes mayores de 65 años con el diagnóstico de tirotoxicosis controlados en nuestro centro entre enero de 2012 y mayo de 2018. Resultados: En el periodo estudiado 54 pacientes fueron diagnosticados de tirotoxicosis. Se excluyen 4 por datos incompletos. El 80% corresponden a mujeres. La mediana de edad fue 71 años (rango 65-94), sin diferencias por género (p=0,61). La etiología más frecuente fue enfermedad de Graves (EG) en 64%, seguido por bocio multinodular hiperfuncionante en 20%, adenoma tóxico en 10% y asociada a fármacos en 6%. De los pacientes con EG, 28% presentó orbitopatía distiroidea (OD) clínicamente evidente. Un 30% se diagnosticó en contexto de baja de peso, deterioro cognitivo o patología cardiovascular, sin presentar síntomas clásicos de hipertiroidismo. Un 16% presentó FA, 14% ICC y 6% fractura osteoporótica. El 28% fue diagnosticado durante una hospitalización o requirió ser hospitalizado durante los meses siguientes. Los mayores de 75 años presentan una mayor probabilidad de hipertiroidismo apático (OR 5,1, IC95% 1,15-22,7 p=0,01). Además, las complicaciones aumentan en mayores de 75 años, encontrándose en este grupo todos los casos de FA. Conclusiones: La etiología más común de tirotoxicosis fue la EG, a diferencia de lo reportado en otras poblaciones. Un número importante de pacientes debutó sin síntomas clásicos de hipertiroidismo, principalmente mayores de 75 años, por lo que se debe tener una alta sospecha en este grupo etario.

Introduction: Hyperthyroidism in the elderly can produce severe complications such as atrial fibrillation (AF), heart failure (CHF) and osteoporosis. In the elderly, thyrotoxicosis may have only nonspecific symptoms, known as apathetic hyperthyroidism. Objective: To evaluate the clinical characteristics of thyrotoxicosis in the elderly. Methods: Retrospective case series. We reviewed clinical records of patients with thyrotoxicosis older than 65 years, between January 2012 and March 2019. Results: During this period, 54 patients were diagnosed with thyrotoxicosis. Four patients were excluded due to incomplete data. 80% were women. The average age was 73 years (range 65-94), without age difference between gender (p=0,61). The most frequent etiology was Graves' disease in 64%. Hyperfunctioning multinodular goiter was confirmed in 20%, toxic adenoma in 10% and drug-associated in 6%. Twenty eight percent of Graves' disease patients had dysthyroid orbitopathy. Thirty percent presented as apathetic hyperthyroidism. Sixteen percent of the patients presented AF, 14% CHF, and 6% osteoporotic fracture. Twenty-eight percent were diagnosed during hospitalization or required hospitalization in the following months. Those older than 75 years had a greater probability of presenting apathetic hyperthyroidism (OR 5.1, 95% CI 1.15- 22.7 p=0.01). Complications increase in this age group, with all cases of AF. Conclusions: The most common etiology of thyrotoxicosis in this group was GD. This differs from other populations. A significant number of patients presented without classic symptoms of hyperthyroidism, especially in people older than 75 years. Special attention should be paid to atypical symptoms of hyperthyroidism in this group.

Incidentalomas endocrinos, más que una imagen / Endocrine incidentalomas, more than an image

Endocrine incidentalomas are nodular lesions located in endocrine glands, diagnosed serendipitously by different image techniques requested for non-endocrine reasons. They can be located in many sites, but this review describes those that compromise pituitary, adrenal and thyroid gland. The main diagnostic challenges of endocrine incidentalomas are discrimination between benign and malignant lesions, and their functional or non-functional endocrine activity. The relevance of adequate image interpretation and associated hormonal study is discussed. (AU)

Hipopituitarismo como debut de absceso hipofisiario / Hypopituitarism as debut of pituitary abscess

We present a case of a 20 years old woman who consults for amenorrhea and mild hyperprolactinemia. Within the functional study hypopituitarism was discover and MRI showed a cystic lesion with “ring” enhancement. Transsphenoidal resection was performed, showing purulent material. Cultures were positive for MSSA and Neisseria cinerea. Antibiotic treatment was started completing 21 days. She evolved without relapse but did not recovered pituitary function.

Asociación entre tiroiditis crónica y cáncer diferenciado de toroides: revisión de la literatura / Association beetwen chronic thyroiditis and differentiated cancer: literature review

Differentiated thyroid cancer (DTC) in the common endocrine malignancy. Its frequency increases with age and its have a female predominance. There is evidence that papillary thyroid cancer is increasing in recent years. It has been proposed that this increase is independent from the greater availability of diagnostic techniques, because is observed an increase in both small tumors like those of grater size and more advanced stage. The causes of this increase are unclear and several hypotheses have been raised, including within these possible factors the presence of chronic thyroiditis (CT). Among the reasons to make this association is the relationship described between inflammatory processes and the genesis of cancer as well as some descriptive studies that reports a high incidence of CT in patients with DTC. But the results of these studies are controversial and there are other reports in rejecting this association.

Disfunción suprarrenal en el paciente cirrótico, ¿síndrome hepatoadrenal o síndrome del “euadrenálico” enfermo? / Adrenal dysfunction in the cirrhotic patient, ¿hepatoadrenal syndrome or the non adrenal illness syndrome?

Adrenal insufficiency is a potentially lethal condition that is characterized by decreased production of glucocorticoids, mineralocorticoids and sex steroids. In normal conditions adrenocorticotropin and corticotrophin releasing hormone regulate cortisol production, but in critical illness other peptides and substances are produced that modulate the axis. In decompensated liver failure, there is a hemodynamic state similar to septic shock, even an increase in proinflammatory cytokines such as IL6 and TNF- alpha. In critically ill patients, a high proportion of adrenal insufficiency has been reported; therefore, some authors have argued that the same could happen in the cirrhotic patient, introducing the term hepatoadrenal syndrome. There are several reports of an increased frequency of adrenal insufficiency in the cirrhotic patient. However, these studies are heterogeneous in many aspects. There are differences in patient’s characteristics, in the criteria for the diagnosis of adrenal insufficiency, and in the laboratory tests used. Because over 90 percent of cortisol circulates bound to proteins, it is important to consider this issue in the diagnosis of adrenal insufficiency, especially in patients with hypoalbuminemia. Serum-free cortisol and salivary cortisol appear to be a good diagnostic method. Further studies need to be carried out in order to define the cut off points of these methods. These tests are not widely available.

La insuficiencia suprarrenal es una condición potencialmente letal, que se caracteriza por la disminución en la producción de glucocorticoides, mineralocorticoides y esteroides sexuales. Normalmente, la producción de cortisol es regulada por la adrenocorticotrofina y ésta por la hormona liberadora de corticotrofina, pero en estado de enfermedad, se producen otros péptidos y sustancias que modulan el eje. En la insuficiencia hepática descompensada, se produce un estado hemodinámico similar al shock séptico, incluso se produce un aumento de citoquinas proinflamatorias como IL6 y TNF- alfa. Como en el paciente crítico se ha reportado un gran porcentaje de insuficiencia adrenal, algunos autores han planteado que lo mismo podría ocurrir en el paciente cirrótico, introduciendo el término de síndrome hepatoadrenal. Varios autores han publicado que también existe un aumento en la frecuencia de insuficiencia adrenal en el paciente cirrótico. Sin embargo, en estos estudios la población analizada es heterogénea, se utilizan distintos criterios para definir insuficiencia adrenal y las pruebas de laboratorio utilizadas tienen limitaciones. Debido a que más del 90 por ciento del cortisol circula unido a proteínas, es importante considerar este factor para diagnóstico de la insuficiencia adrenal, especialmente en el paciente con hipoalbuminemia. En estos casos, el cortisol libre sérico parece ser junto al cortisol salival un buen método diagnóstico. Sin embargo, faltan estudios para definir los puntos de corte de estos exámenes y tienen la limitación que no están ampliamente disponibles.

Enfermedad de graves en asociación con miastenia gravis: presentación de un caso y revisión de la literatura / Myasthenia gravis with concomitant hyperthyroidism: report of one case

Myasthenia gravis and Graves disease are autoimmune diseases that can coexist in the same patient. We report a 18 years old female with a history of myasthenia gravis diagnosed at the age of six, treated with neostigmine and prednisone. She starts with palpitations, dyspnea, proximal muscle weakness and exophthalmos appearing seven months after the onset of symptoms. She was admitted to the hospital due to her decompensated hyperthyroidism. After admission, she develops a myasthenic crisis, that requires mechanical ventilation. Afterwards, the patient is subjected to a thymectomy and thyroidectomy with a good postoperative evolution.

Frecuencia de periodontitis en una muestra de diabéticos tipo 2 y no diabéticos de Santiago de Chile / Frequency of periodontitis in a sample of type 2 diabetics and non diabetics

Background: Periodontitis is highly prevalent in the general population and some diseases such as diabetes could favor its development, reaching a prevalence of over 60 percent. Aim: To evaluate the prevalence of periodontitis in a sample of DM2 patients and to compare it with non-diabetic subjects. Patients and Methods: We enrolled patients with DM2 and non-diabetic adult subjects. According to periodontal diagnosis, they were classified as healthy, having mild to moderate periodontitis and having severe periodontitis. Anthropometric assessment was performed and a fasting blood sample was obtained to measure blood glucose and lipid profile. In diabetics, HbA1c, creatinine, microalbuminuria, EKG and fundoscopy were evaluated. Results: We studied 62 patients with DM2, aged 55.2 +/- 9.4 years and with 4.7 +/- 4.6 years of diagnosis of diabetes and 65 non-diabetic subjects, aged 50 +/- 9.6 years. Among diabetics, HbA1c values were 7.85 +/- 2.3 percent. The proportion of periodontitis was significantly higher in DM2 than in non-diabetics (98 and 89 percent, p = 0.02). Mild to moderate and severe periodontitis was observed in 39 and 60 percent of diabetic patients, respectively. Among non-diabetics, 11 percent were healthy, 5 percent had gingivitis, 37 percent mild to moderate periodontitis and 48 percent had severe periodontitis. The frequency of chronic complications of diabetes was low, except for positive microalbuminuria, that was present in 42.6 percent of patients. Conclusions: We found a high prevalence of periodontitis in diabetic and no diabetic patients, but among the former, it was near to 100 percent. Periodontal examination should be considered as part of the evaluation of patients with type 2 diabetes.

Coexistencia de hiperparatiroidismo primario y carcinoma diferenciado del tiroides en tres casos clínicos / Coexistence of a primary hyperparathyroidism and a differentiated thyroid carcinoma: report of three cases

In 15 percent of patients with primary hyperparathyroidism subjected to parathyroid surgery, a coexistent differentiated thyroid carcinoma is found. We report three female patients aged 57, 53 and 57 years with a primary hyperparathyroidism and ultrasonographic thyroid nodules. During parathyroid surgery, a thyroidectomy was performed, confirming the presence of a differentiated thyroid carcinoma. Two patients had a microcarcinoma measuring 1 and 2 mm diameter and other had a follicular thyroid carcinoma, and parathyroid carcinom whose association with primary hyperparathyoidism is even more uncommon.

Hemibalismo invalidante transitorio como debut de diabetes mellitus / Transient hemiballism as the presenting symptom of diabetes mellitus: report of one case

Hemiballism is an uncommon neurological disorder characterized by uncontrollable movements of one lateral half of the body. We report a 56 years old male with a history of three weeks of polydipsia, polyuria and weight loss that, three days before consultation, started with hemiballism. A CAT scan without contrast showed a higher density in the lenticular nucleus and calcifications in caudate and lenticular nuclei. Diabetes was treated with regular insulin and hemiballism was controlled with neruoleptics. Ten days after admission a new CAT scan shows a partial regression of the lenticular lesion. After two months of follow up, the patient is asymptomatic.

Prolactinoma gigante de inicio en la adolescencia: a propósito de 2 casos clínicos / Report of two adolecents with giant prolactinomas

The prevalence of pituitary among adolescents is 0.1 per million and the most common type is prolactinoma. We report two adolescents with pituitary adenomas. A 15 years old female presenting with a progressive reduction of visual acuity, headache and galactorrhea. Magnetic resonanceshowed a sellar tumor with suprasellar expansion. She was subjected to transcraneal surgery and the pathological study of the piece disclosed a prolactinoma. A 23 years old male presenting with weight gain, headache and decreased visual acuity of the left eye. Magnetic resonance demonstrateda tumor with sellar and suprasellar involvement. He was subjected to transsphenoidal surgery and the pathological study of the surgical piece disclosed a prolactinoma.