Thyroid dysfunction in pregnancy: definition of TSH cut-off should precede the decision of screening in low-risk pregnant women.

OBJECTIVE: To evaluate the frequency of elevated TSH in pregnant women of low risk for thyroid dysfunction. SUBJECTS AND METHODS: TSH was measured in 838 pregnant women during the first trimester of gestation (from 6 to 14 weeks, median 9 weeks) and who were considered to be of low risk for thyroid dysfunction because they did not meet any of the following criteria: known or clinically suspected thyroid disease; history of head and neck radiotherapy; personal history of autoimmune diseases; family history of thyroid disease; history of abortion or prematurity. RESULTS: The frequency of elevated TSH was 0.25%, 1.2% and 5.5% at cut-off values of 4, 3 and 2.5?mIU/l, respectively. These rates increase to 1.43%, 2.4% and 6.2% if cases of TSH> 2 mIU/l with TPOAb are included. TSH was undetectable in 18 women (2.1%), but only six (0.71%) had elevated T4. CONCLUSIONS: The definition of a TSH cut-off that defines subclinical hypothyroidism (SCH) should precede the decision of screening pregnant women without any risk factors for thyroid dysfunction.

Biochemical acromegaly in patients with prolactinoma during treatment with dopaminergic agonists.

OBJECTIVE: To evaluate the frequency of subclinical acromegaly (in the absence of clinical phenotype but biochemically uncontrolled) in patients with prolactinoma during treatment with dopaminergic agonists. SUBJECTS AND METHODS: One hundred twenty one patients without a phenotype suggestive of acromegaly were studied. RESULTS: Initially, the laboratory diagnosis of acromegaly was unequivocal (elevated IGF-1 for gender and age with nadir GH > 1 µg/L) in two patients, and likely (elevated IGF-1 with nadir GH > cut-off but < 1 µg/L) in another patient. In two other patients, this diagnosis was possible (normal IGF-1 with nadir GH > 1 µg/L). Repetition of the tests 6 months after withdrawal of the dopaminergic agonist confirmed the diagnosis of subclinical acromegaly (elevated IGF-1 for gender and age with nadir GH > 1 µg/L) in these 5 patients. False-positive results were excluded in all cases. CONCLUSION: In patients with prolactinomas, acromegaly should be investigated not only in cases with a clinical phenotype.

Biochemical acromegaly in patients with prolactinoma during treatment with dopaminergic agonists / Acromegalia bioquímica em pacientes com prolactinoma em tratamento com agonistas dopaminérgicos

OBJECTIVE: To evaluate the frequency of subclinical acromegaly (in the absence of clinical phenotype but biochemically uncontrolled) in patients with prolactinoma during treatment with dopaminergic agonists. SUBJECTS AND METHODS: One hundred twenty one patients without a phenotype suggestive of acromegaly were studied. RESULTS: Initially, the laboratory diagnosis of acromegaly was unequivocal (elevated IGF-1 for gender and age with nadir GH > 1 μg/L) in two patients, and likely (elevated IGF-1 with nadir GH > cut-off but < 1 μg/L) in another patient. In two other patients, this diagnosis was possible (normal IGF-1 with nadir GH > 1 μg/L). Repetition of the tests 6 months after withdrawal of the dopaminergic agonist confirmed the diagnosis of subclinical acromegaly (elevated IGF-1 for gender and age with nadir GH > 1 μg/L) in these 5 patients. False-positive results were excluded in all cases. CONCLUSION: In patients with prolactinomas, acromegaly should be investigated not only in cases with a clinical phenotype.

OBJETIVO: Avaliar a frequência de acromegalia subclínica (na ausência de fenótipo clínico, mas bioquimicamente não controlada) em pacientes com prolactinoma em tratamento com agonistas dopaminérgicos. SUJEITOS E MÉTODOS: Cento e vinte e um pacientes sem fenótipo de acromegalia foram estudados. RESULTADOS: Inicialmente, o diagnóstico laboratorial de acromegalia foi inequívoco (IGF-1 elevado para sexo e idade com nadir do GH > 1 μg/L) em dois pacientes, e provável (IGF-1 elevado com nadir do GH > valor de corte ensaio-específico mas < 1 μg/L) em outro paciente. Em outros dois, esse diagnóstico foi possível (IGF-1 normal com nadir do GH > 1 μg/L). A repetição dos testes seis meses após a suspensão dos agonistas dopaminérgicos confirmou o diagnóstico de acromegalia subclínica (IGF-1 elevado para sexo e idade com nadir do GH > 1 μg/L) em cinco desses pacientes. Os resultados falso-positivos foram excluídos em todos os casos. CONCLUSÃO: Em pacientes com prolactinomas, a acromegalia deveria ser investigada não apenas nos casos com fenótipo clínico.

Ultrasonographic characteristics as a criterion for repeat cytology in benign thyroid nodules.

OBJECTIVE: To report the results of repeat fine-needle aspiration cytology (FNAC) in thyroid nodules with an initial benign cytological diagnosis that grow during follow-up and/or present suspicious ultrasonographic characteristics. SUBJECTS AND METHODS: The sample consisted of 456 patients with 895 nodules. FNAC was repeated after 12 to 18 months in the case of nodules with suspicious ultrasonographic characteristics, irrespective of growth, and when the nodules showed significant growth. RESULTS: Among the 895 nodules examined, 102 (11.4%) presented suspicious ultrasonographic characteristics. The second FNAC revealed malignancy in 18 (17.6%) nodules, including 20% (2/10) of those showing growth and 17.4% (16/92) that did not. Seventy-six (9.6%) of 793 nodules without suspicious characteristics presented growth. Only one case (1.3%) of malignancy was diagnosed by repeat FNAC. CONCLUSIONS: The study suggests ultrasonographic characteristics rather than growth as a criterion for repeat FNAC in the case of nodules with an initial benign cytological diagnosis.

Contribution of scintigraphy and ultrasonography to the prediction of malignancy in thyroid nodules with indeterminate cytology.

OBJECTIVE: To evaluate the contribution of (131)I scintigraphy and ultrasonography to the prediction of malignancy in thyroid nodules with indeterminate cytology in euthyroid patients. SUBJECTS AND METHODS: The sample consisted of 102 patients with thyroid nodules, submitted to FNAC and presenting an indeterminate cytological diagnosis (follicular neoplasm). RESULTS: Malignancy was observed in 19/25 (76%) nodules with suspicious ultrasonographic characteristics versus 5/77 (6.5%) without suspicious findings. When (131)I scintigraphy showed a cold or hot nodule, the chance of malignancy was 38.5% and 2.5%, respectively. This exam was inconclusive in 10% of the patients. CONCLUSIONS: Surgery is indicated when a thyroid nodule with indeterminate cytology exhibits suspicious ultrasonographic characteristics. Otherwise, (131)I scintigraphy can exclude thyroidectomy when reveals uptake in the nodule, which is observed in half the cases.

Ultrasonographic characteristics as a criterion for repeat cytology in benign thyroid nodules / Características ultrassonográficas como critério para repetição da citologia em nódulos tireoidianos benignos

OBJECTIVE: To report the results of repeat fine-needle aspiration cytology (FNAC) in thyroid nodules with an initial benign cytological diagnosis that grow during follow-up and/or present suspicious ultrasonographic characteristics. SUBJECTS AND METHODS: The sample consisted of 456 patients with 895 nodules. FNAC was repeated after 12 to 18 months in the case of nodules with suspicious ultrasonographic characteristics, irrespective of growth, and when the nodules showed significant growth. RESULTS: Among the 895 nodules examined, 102 (11.4 percent) presented suspicious ultrasonographic characteristics. The second FNAC revealed malignancy in 18 (17.6 percent) nodules, including 20 percent (2/10) of those showing growth and 17.4 percent (16/92) that did not. Seventy-six (9.6 percent) of 793 nodules without suspicious characteristics presented growth. Only one case (1.3 percent) of malignancy was diagnosed by repeat FNAC. CONCLUSIONS: The study suggests ultrasonographic characteristics rather than growth as a criterion for repeat FNAC in the case of nodules with an initial benign cytological diagnosis.

OBJETIVO: Relatar os resultados da repetição da punção aspirativa com agulha fina (PAAF) em nódulos tireoidianos com diagnóstico citológico inicial benigno que apresentam crescimento durante o acompanhamento e/ou características ultrassonográficas suspeitas. SUJEITOS E MÉTODOS: A amostra consistiu de 456 pacientes com 895 nódulos. A PAAF foi repetida após 12 a 18 meses nos nódulos com características suspeitas, independente de crescimento, e quando apresentaram crescimento significativo. RESULTADOS: Entre os 895 nódulos avaliados, 102 (11,4 por cento) apresentavam características ultrassonográficas suspeitas. A segunda PAAF revelou malignidade em 18 nódulos (17,6 por cento), incluindo 20 por cento (2/10) naqueles com crescimento e 17,4 por cento (16/92) naqueles sem crescimento. De 793 nódulos sem características suspeitas, 76 (9,6 por cento) apresentaram crescimento. Somente um caso (1,3 por cento) de malignidade foi diagnosticado pela repetição da PAAF. CONCLUSÕES: O estudo sugere características ultrassonográficas mais que crescimento como critério para repetição da PAAF em nódulos com diagnóstico citológico inicial benigno.

Contribution of scintigraphy and ultrasonography to the prediction of malignancy in thyroid nodules with indeterminate cytology / Contribuição da cintilografia e ultrassonografia para a predição de malignidade em nódulos tireoidianos com citologia indeterminada

OBJECTIVE: To evaluate the contribution of 131I scintigraphy and ultrasonography to the prediction of malignancy in thyroid nodules with indeterminate cytology in euthyroid patients. SUBJECTS AND METHODS: The sample consisted of 102 patients with thyroid nodules, submitted to FNAC and presenting an indeterminate cytological diagnosis (follicular neoplasm). RESULTS: Malignancy was observed in 19/25 (76 percent) nodules with suspicious ultrasonographic characteristics versus 5/77 (6.5 percent) without suspicious findings. When 131I scintigraphy showed a cold or hot nodule, the chance of malignancy was 38.5 percent and 2.5 percent, respectively. This exam was inconclusive in 10 percent of the patients. CONCLUSIONS: Surgery is indicated when a thyroid nodule with indeterminate cytology exhibits suspicious ultrasonographic characteristics. Otherwise, 131I scintigraphy can exclude thyroidectomy when reveals uptake in the nodule, which is observed in half the cases.

OBJETIVO: Avaliar a contribuição da cintilografia com 131I e da ultrassonografia na predição de malignidade em nódulos tireoidianos com citologia indeterminada em pacientes eutireoidianos. SUJEITOS E MÉTODOS: A amostra foi composta por 102 pacientes com nódulos tireoidianos submetidos à punção aspirativa com agulha fina (PAAF), apresentando citologia indeterminada (neoplasia folicular). RESULTADOS: Malignidade foi encontrada em 19/25 (76 por cento) nódulos suspeitos na ultrassonografia versus 5/77 (6,5 por cento) naqueles sem características suspeitas. Quando a cintilografia com 131I mostrou nódulo hipo- ou hipercaptante, a chance de malignidade foi 38,5 por cento e 2,5 por cento, respectivamente, e em 10 por cento dos pacientes esse exame foi inconclusivo. CONCLUSÕES: Cirurgia está indicada quando um nódulo tireoidiano com citologia indeterminada exibe características ultrassonográficas suspeitas. Quando não as exibe, a cintilografia com 131I pode dispensar a tireoidectomia se revelar captação correspondente ao nódulo, o que ocorre em metade dos casos.

Low false-negative rate of cytology in thyroid nodules ¡Ý 4 cm / Baixa taxa de falso-negativo da citologia em n¨®dulos tireoidianos ¡Ý 4 cm

OBJECTIVE: To report the results of cytology and histology obtained for a series of systematically resected thyroid nodules > 4 cm. METHODS: A group of 151 patients with thyroid nodules > 4 cm was submitted to surgery despite the cytology result. RESULTS: Malignancy was confirmed histologically in 22.5 percent of the patients. Excluding cases of insufficient material, cytology was benign in only 3/31 carcinomas (90.3 percent sensitivity). The frequency of malignancy was 35 percent among nodules with indeterminate cytology (follicular neoplasm), and there was a predominance (77 percent) of papillary carcinoma. The negative predictive value of benign cytology was 96.4 percent. CONCLUSIONS: The false-negative rate of cytology in thyroid nodules > 4 cm does not justify systematic resection of these nodules in asymptomatic patients with benign cytology.

OBJETIVO: Reportar os resultados da citologia e da histologia em uma s¨¦rie de n¨®dulos tireoidianos > 4 cm sistematicamente ressecados. MÉTODOS: Foram submetidos ¨¤ cirurgia 151 pacientes com n¨®dulo tireoidiano > 4 cm, a despeito do resultado da citologia. Apenas a histologia referente a este n¨®dulo foi considerada nos resultados. RESULTADOS: Malignidade foi confirmada histologicamente em 22,5 por cento dos pacientes. Excluindo os casos com material insuficiente, a citologia foi benigna somente em 3/31 carcinomas (sensibilidade 90,3 por cento). A frequ¨ºncia de malignidade foi de 35 por cento nos n¨®dulos com citologia indeterminada (neoplasia folicular), predominando o carcinoma papil¨ªfero (77 por cento). O valor preditivo negativo da citologia benigna foi 96,4 por cento. CONCLUSÕES: A taxa de falso-negativo da citologia em n¨®dulos tireoidianos > 4 cm não justifica a ressecção sistem¨¢tica destes em pacientes assintom¨¢ticos com citologia benigna.

Area under the curve of TSH after levothyroxine withdrawal versus administration of recombinant human TSH (rhTSH): possible implications for tumor growth.

OBJECTIVE: The levothyroxine withdrawal (L-T4) for some weeks results in prolonged exposure to elevated TSH. In contrast, administration of recombinant human TSH (rhTSH) promotes a short period of hyperthyrotropinemia. The objective of this study was to compare the area under the curve (AUC) of TSH obtained after L-T4 withdrawal versus administration of rhTSH. METHODS: Thirty patients received 0.9 mg rhTSH for two consecutive days, and 64 were prepared by L-T4 withdrawal for four weeks, with the latter being reintroduced 48 hour after 131I. Measurement of TSH were performed before the first rhTSH ampoule; immediately before and seven and 14 days after 131I; before L-T4 withdrawal; and, weekly, up to two months after 131I. RESULTS: The AUC obtained after rhTSH was 4.6 times smaller than that obtained after L-T4 withdrawal (532 versus 2,423 mIU/L per day). It should be emphasized that, on average, in the latter group, 58.5% of the AUC corresponded to the period after reintroduction of hormone therapy. CONCLUSIONS: Surprising difference in the TSH AUC was demonstrated between rhTSH administration versus L-T4 withdrawal.

Area under the curve of TSH after levothyroxine withdrawal versus administration of recombinant human TSH (rhTSH): possible implications for tumor growth / Área sob a curva de TSH após suspensão da levotiroxina versus administração do TSH recombinante humano: possíveis implicações no crescimento tumoral

OBJECTIVE: The levothyroxine withdrawal (L-T4) for some weeks results in prolonged exposure to elevated TSH. In contrast, administration of recombinant human TSH (rhTSH) promotes a short period of hyperthyrotropinemia. The objective of this study was to compare the area under the curve (AUC) of TSH obtained after L-T4 withdrawal versus administration of rhTSH. METHODS: Thirty patients received 0.9 mg rhTSH for two consecutive days, and 64 were prepared by L-T4 withdrawal for four weeks, with the latter being reintroduced 48 hour after 131I. Measurement of TSH were performed before the first rhTSH ampoule; immediately before and seven and 14 days after 131I; before L-T4 withdrawal; and, weekly, up to two months after 131I. RESULTS: The AUC obtained after rhTSH was 4.6 times smaller than that obtained after L-T4 withdrawal (532 versus 2,423 mIU/L per day). It should be emphasized that, on average, in the latter group, 58.5 percent of the AUC corresponded to the period after reintroduction of hormone therapy. CONCLUSIONS: Surprising difference in the TSH AUC was demonstrated between rhTSH administration versus L-T4 withdrawal.

OBJETIVO: A suspensão de levotiroxina (L-T4) por algumas semanas resulta em exposição prolongada ao TSH elevado. Em contraste, a administração do TSH recombinante (rhTSH) promove um curto período de hipertirotropinemia. O objetivo deste estudo foi comparar a área sob a curva (do inglês "area under the curve", AUC) do TSH obtida após suspensão da L-T4 versus a administração do rhTSH. MÉTODOS: Trinta pacientes receberam 0,9 mg de rhTSH por dois dias consecutivos, e 64 foram preparados com suspensão da L-T4 por quatro semanas, com reintrodução dessa terapia 48 horas após o radioiodo. As medidas de TSH foram realizadas antes da primeira ampola de rhTSH; imediatamente antes e sete e 14 dias após o 131I; antes da suspensão da L-T4; e, semanalmente, até dois meses após o 131I. RESULTADOS: A AUC do TSH obtida após rhTSH foi 4,6 vezes menor do que a alcançada após suspensão da L-T4 (532 versus 2.423 mUI/L ao dia). Enfatiza-se que, em média, no último grupo, 58,5 por cento da AUC correspondeu ao período após a reintrodução da terapia hormonal. CONCLUSÕES: Surpreendente diferença na AUC do TSH foi demonstrada entre a administração do rhTSH versus suspensão da L-T4.

Tumor-induced osteomalacia: a case report.

Tumor-induced osteomalacia (TIO) is a rare paraneoplasic syndrome with overproduction of fibroblast growth factor 23 as a phosphaturic agent, leading to chronic hyperphosphaturia and hypophosphatemia, associated with inappropriately normal or low levels of 1,25-dihydroxyvitamin D. Diagnosis of this disease is often challenging. The following case report described a middle-aged man with symptoms of bone pain and severe muscle weakness, who was found to have TIO. The tumor responsible for the symptoms was localized on his thigh and its resection resulted in normalization of blood chemistry and complaints. Subsequent microscopic examination revealed a phosphaturic mesenchymal tumor, mixed connective tissue type. The authors reinforce the importance of recognition of this disease, as severe disability and even death can be avoided with the surgical removal of the causative tumor.

Tumor-induced osteomalacia: a case report / Osteomalácia induzida por tumor: relato de caso

Tumor-induced osteomalacia (TIO) is a rare paraneoplasic syndrome with overproduction of fibroblast growth factor 23 as a phosphaturic agent, leading to chronic hyperphosphaturia and hypophosphatemia, associated with inappropriately normal or low levels of 1,25-dihydroxyvitamin D. Diagnosis of this disease is often challenging. The following case report described a middle-aged man with symptoms of bone pain and severe muscle weakness, who was found to have TIO. The tumor responsible for the symptoms was localized on his thigh and its resection resulted in normalization of blood chemistry and complaints. Subsequent microscopic examination revealed a phosphaturic mesenchymal tumor, mixed connective tissue type. The authors reinforce the importance of recognition of this disease, as severe disability and even death can be avoided with the surgical removal of the causative tumor.

Osteomalácia induzida por tumor (OIT) é uma síndrome paraneoplásica rara, causada por hiperprodução do agente fosfatúrico, levando a hipofosfatemia e hiperfosfatúria crônicas, associadas a níveis reduzidos ou inapropriadamente normais de 1,25-dihidroxivitamina D. O diagnóstico dessa doença é, geralmente, desafiador. O relato de caso aqui apresentado descreveu um homem de meia-idade, com quadro inicial de dor óssea, fraqueza muscular extrema e hipofosfatemia, com diagnóstico tardio de OIT. O tumor responsável pelos sintomas foi localizado em membro inferior, e sua exérese resultou em normalização das alterações bioquímicas e dos sintomas. O exame microscópico da lesão revelou tumor mesenquimal fosfatúrico, tecido conectivo misto. Os autores reforçam a importância do reconhecimento dessa entidade, uma vez que a remoção do tumor responsável pelos sintomas pode evitar sérias complicações ou mesmo a morte.

Low false-negative rate of cytology in thyroid nodules >or= 4 cm.

OBJECTIVE: To report the results of cytology and histology obtained for a series of systematically resected thyroid nodules >or= 4 cm. METHODS: A group of 151 patients with thyroid nodules >or= 4 cm was submitted to surgery despite the cytology result. RESULTS: Malignancy was confirmed histologically in 22.5% of the patients. Excluding cases of insufficient material, cytology was benign in only 3/31 carcinomas (90.3% sensitivity). The frequency of malignancy was 35% among nodules with indeterminate cytology (follicular neoplasm), and there was a predominance (77%) of papillary carcinoma. The negative predictive value of benign cytology was 96.4%. CONCLUSIONS: The false-negative rate of cytology in thyroid nodules >or= 4 cm does not justify systematic resection of these nodules in asymptomatic patients with benign cytology.

Preparation with recombinant human thyroid-stimulating hormone for thyroid remnant ablation with 131I is associated with lowered radiotoxicity.

UNLABELLED: Preparation with recombinant human thyroid-stimulating hormone (rhTSH) for thyroid remnant ablation results in lower extrathyroidal radiation than does hypothyroidism. The objective of this prospective study was to compare the damage caused by 131I (3.7 GBq) when these 2 preparations are used. METHODS: Ninety-four consecutive patients who underwent total thyroidectomy and remnant ablation with 3.7 GBq of 131I were studied. Thirty patients (group A) received rhTSH, and 64 (group B) were prepared by levothyroxine withdrawal. Damage to salivary glands, ovaries, and testes; hematologic damage; and oxidative injury were evaluated by measurement of serum amylase, follicle-stimulating hormone (FSH), complete blood count, and plasma 8-epi-PGF2alpha before and after radioiodine. The 2 groups were similar in sex, age, and the results of baseline assessment. RESULTS: The rate of successful ablation (stimulated thyroglobulin level < 1 ng/mL and negative findings on neck ultrasonography) was 90% in group A and 80% in group B. Considering only patients with a preablation thyroglobulin level greater than 1 ng/mL, these rates were 80% and 70.6%, respectively. Only 1 patient (3.3%) reported transient headaches with rhTSH. Elevated FSH levels after therapy were observed in 4 of 9 (44%) men in group A versus 16 of 18 (89%) in group B (P < 0.03), with a mean increase of 105% versus 236% (P < 0.001), respectively. In women, elevated FSH was observed in 1 of 13 (7.7%) patients in group A versus 6 of 30 (20%) in group B (P = 0.4), with a mean increase of 65% versus 125% (P < 0.001). Thrombocytopenia or neutropenia occurred in 2 of 28 (7%) patients in group A versus 12 of 56 (21.4%) in group B (P = 0.1), with a mean decrease of 20% versus 45% and 25% versus 52% (P < 0.01) for neutrophils and platelets, respectively. Hyperamylasemia and symptoms of acute sialoadenitis occurred in 11 of 30 (36.6%) versus 48 of 60 (80%) (P < 0.001) and in 9 of 30 (30%) versus 35 of 60 (58.3%) (P = 0.01), respectively. 8-Epi-PGF2alpha was found to be elevated after 131I in 14 of 25 (56%) patients in group A versus 45 of 45 (100%) in group B (P < 0.001), with a mean increase of 60% versus 125% (P < 0.001). CONCLUSION: The lower radiotoxicity with rhTSH, suggested in dosimetry studies, was confirmed in the present prospective investigation, and this advantage occurred without compromising the efficacy of treatment.

Infusão de insulina subcutânea contínua em gestante com diabetes tipo 1: relato de caso e revisão da literatura / Continuous subcutaneous insulin infusion in type 1 diabetic during pregnancy: case report and literature review

A gestação em portadoras de diabetes tipo 1 é alvo de múltiplas tentativas para o bom controle glicêmico desde o período pré-concepcional, com a terapia com infusão de insulina subcutânea contínua apresentando opção terapêutica adicional na tentativa de alcançar as metas glicêmicas. Apresentamos o caso de uma paciente com diabetes tipo 1, não controlada com múltiplas injeções diárias, cuja instalação da bomba de insulina ocorreu durante o segundo trimestre de gestação, com sucesso terapêutico.

The type 1 diabetic patient pregnancy is subjected to various attempts to obtain good glycemic control, since the pre-conception period throughout the gestation. Continuous subcutaneous insulin infusion (CSII) is a therapeutic tool to achieve the glycemic targets. Here it is presented the case of a Type 1 diabetic woman, who was not under multiple insulin daily injections therapy, and whose insulin therapy started on CSII during the second trimester of gestation, obtaining successful therapeutic outcome.

Cetoacidose diabética associada com síndrome de Guillain-Barré: relato de caso / Diabetes ketoacidosis associated with Guillan-Barré syndrome

A síndrome de Guillain-Barré (GBS) é uma desordem causada por exacerbada resposta imune aos processos infecciosos. O diabetes melito (DM) não é reconhecido como uma causa desta polirradiculopatia inflamatória, com poucos casos relatados na literatura sobre tal associação. Apresentamos um caso de uma paciente do sexo feminino, 44 anos, admitida com história recente de poliúria, polidipsia, perda de peso e astenia, glicemia de 562 mg/dL, em cetoacidose, sem foco infeccioso. Posteriormente desenvolveu quadro de polirradiculopatia, insuficiência respiratória e alteração liquórica compondo o quadro de GBS. No presente relato, a paciente recuperou-se plenamente do déficit neurológico, assim como da hiperglicemia, configurando quadro de diabetes tipo 2, com tendência à cetoacidose, evoluindo sem insulino-dependência.

Guillain-Barré syndrome (GBS) is a disorder caused by exaggerated immune response to infectious process. Diabetes Melito (DM) is not recognized as one cause of this inflammatory polyradiculoneuropathy with just a few cases of this association been described in the literature so far. We report here the case of a 44 years-old female patient admitted with a history of polyuria, polydipsia, weight loss, asthenia, hyperglycemia (562 mg/dL) and ketoacidosis without any infectious focus. The patient progressed with poliradiculopathy, respiratory insufficiency and liquoric alteration completing the picture of Guillain-Barré syndrome. The patient fully recovered from the neurologic deficit and then stopped with insulin therapy.

[Contribution of computed tomography in patients with lung metastases of differentiated thyroid carcinoma not apparent on plain radiography who were treated with radioiodine]. / Contribuição da tomografia computadorizada em pacientes com metástases pulmonares de carcinoma diferenciado de tireóide não-aparentes na radiografia e tratados com radioiodo.

Computed tomography (CT or CAT Scan) of the chest is more sensitive than radiography in the detection of lung metastases of differentiated thyroid cancer (DTC), but little information is available regarding the aggregated value of this method. The present study evaluated the response of patients with lung metastases of DTC not apparent on radiography to treatment with 131I and the value of CT in these cases. Twenty-five patients with lung metastases not apparent on radiography, who initially received 100-200 mCi I151, were evaluated and those presenting pulmonary uptake on post-therapy WBS were submitted to a new treatment after 6 to 12 months, and so on. The chance of detection of pulmonary uptake on post-therapy WBS did not differ between patients with negative and positive CT (100% versus 91.5%). Mean serum Tg levels were higher in patients with positive CT (108 ng/ml versus 52 ng/ml). Negative post-therapy WBS was achieved in 82% of patients with positive CT and in 92.3% with negative CT and the cumulative I131 activity necessary to achieve this outcome did not differ between the two groups (mean=300 mCi). Stimulated Tg was undetectable in 47% of patients with negative CT at the end of treatment, but in none of the patients whose CT continued to be positive. In patients with elevated Tg, the CT result apparently did not change the indication of therapy or the I131 activity to be administered. In cases with lung metastases, the persistence of micronodules on CT was associated with the persistence of detectable Tg in patients presenting negative post-therapy WBS.

Diabetes auto-imune latente do adulto ou diabetes melito tipo 2 magro? / Latent autoimmune diabetes of adult or slim type 2 diabetes mellitus?

A prevalência do diabetes auto-imune latente do adulto (LADA) varia em virtude da população estudada, dos critérios usados e dos anticorpos avaliados. Em 256 pacientes com menos de 25 anos, encontramos 26 (10,2 por cento) com anticorpos anti-GAD (GADA) positivos, dos quais 16 (6,3 por cento) evoluíram sem necessidade de insulina inicialmente. Embora exista controvérsias, sugere-se como critérios diagnósticos de LADA: idade entre 25 e 65 anos; ausência de cetoacidose ou hiperglicemia sintomática no diagnóstico ou imediatamente após, sem necessidade de insulina por 6 a 12 meses; e presença de auto-anticorpos (especialmente GADA). A auto-imunidade e a resistência insulínica coexistem no LADA, e a contribuição desses fatores parece estar refletida nos títulos de GADA. Um subgrupo similar aos diabéticos tipo 2, fenotipicamente e na progressão para necessidade de insulina, parece ser melhor identificado pela presença de baixos títulos de GADA, sobretudo isolados. Por outro lado, indivíduos com altos títulos de GADA e múltiplos anticorpos apresentam fenótipo mais próximo do diabetes melito do tipo 1 (DM1) clássico e são de maior risco para falência prematura das células-beta. Comparados aos diabéticos GADA-negativos, pacientes com LADA apresentam maior prevalência de outros auto-anticorpos (anti-TPO, anti-21-hidroxilase e associados à doença celíaca) e maior freqüência de genótipos e haplótipos de risco para DM1. Pacientes com altos títulos de GADA podem ser beneficiados, retardando a falência das células-beta, com a insulinização precoce e evitando-se o uso de sulfoniluréias. Em oposição, pacientes com baixos títulos de GADA aparentemente não teriam prejuízos em serem conduzidos da mesma forma que pacientes portadores de diabetes melito tipo 2 (DM2) (GADA-negativos).

The prevalence of latent autoimmune diabetes of the adult (LADA) varies according to the population studied, criteria used and antibodies analyzed. In a series of 256 patients > 25 years, we found that 26 (10.2 percent) were anti-GAD antibody (GADA) positive and 16 of them (6.3 percent) progressed without initial insulin requirement. Although controversy exists, the following diagnostic criteria for LADA are suggested: age between 25 and 65 years; absence of ketoacidosis or symptomatic hyperglycemia at diagnosis or immediately thereafter, without insulin requirement for 6-12 months; and presence of autoantibodies (especially GADA). Autoimmunity and insulin resistance coexist in LADA and the contribution of these factors seems to be reflected in GADA titers. A subgroup, which is phenotypically and in terms of insulin requirement similar to type 2 diabetic patients, seems to be better identified based on the presence of low GADA titers, especially when these antibodies are present alone. On the other hand, subjects with high GADA titers and multiple antibodies show a phenotype close to that of classical DM 1 and are at a higher risk of premature beta-cell failure. Compared to GADA-negative diabetics, patients with LADA present a higher prevalence of other autoantibodies (anti-TPO, anti-21-hydroxylase and antibodies associated with celiac disease) and a higher frequency of genotypes and haplotypes indicating a risk for DM 1. Patients with high GADA titers may benefit from early insulinization and avoiding the use of sulfonylureas, delaying beta-cell failure. In contrast, patients with low GADA titers do not seem to have any disadvantage when managed as type 2 diabetic patients (GADA negative).