Thyroid tuberculosis with abnormal thyroid function--case report and review of the literature.

OBJECTIVE: To report an extremely rare case of thyroid tuberculosis (TT) with abnormal thyroid function and to review the related literature. METHODS: We present the patient's history, clinical findings, laboratory test results, imaging examinations, cytological data, management, and follow-up. In addition, we perform a review of the previously published cases of TT and give special attention to those with hypothyroidism. RESULTS: A 45-year-old Indian man presented to the outpatient clinic with neck swelling and respiratory and constitutional symptoms. Cervical ultrasound revealed a thyroid nodule and a necrotic right cervical adenopathy. Fine-needle aspiration cytology (FNAC) was performed and purulent material was removed from thyroid and lymph node. In both specimens, the culture was positive for Mycobacterium tuberculosis complex, and a cytological examination revealed epithelioid cell granulomas and necrosis. Mycobacterium tuberculosis complex was also identified by sputum culture. Antibiotic testing revealed sensitivity to all first-line drugs. A diagnosis of disseminated tuberculosis with thyroid and cervical lymph node involvement was made. Thyroid function was consistent with subclinical hyperthyroidism that subsequently evolved to hypothyroidism, requiring thyroid hormone replacement, and reflected tuberculous thyroiditis. Anti-tuberculosis drugs were started with good therapeutic response. CONCLUSION: TT is a rare condition and its association with thyroid function abnormalities is even rarer. To our knowledge this is the third report of hypothyroidism related to TT and the first to identify a period of hyperthyroidism preceding hypothyroidism. Despite its rarity, TT should be considered in the differential diagnosis of neck mass. FNAC is a useful procedure and thyroid function should be monitored.

[Prolactin and the laboratory]. / Prolactina e o laboratório.

Up to 95% of adult serum prolactin is monomeric prolactin with a molecular weight of 23 kDa. Macroprolactin is a prolactin-antibody complex of molecular weight greater than 100 kDa and constitutes less than 1% of circulating prolactin. In some cases, hyperprolactinemia is the result of elevated macroprolactin levels, misleading the medical approach to the patient. This may involve inappropriate and unnecessary imaging investigations and treatment, either medical or surgical. The screening of macroprolactin in all the hyperprolactinemic patients could be useful and necessary. Presently is facilitated by a simple and rapid laboratory test such as the polyethyleneglycol precipitation. Besides the macroprolactin, the hook effect is another laboratorial pitfall in the diagnosis of the hyperprolactinemia. It is characterized by the finding of falsely low levels of serum prolactin in patients with very high prolactin levels and big prolactinomas. The hook effect should be excluded in patients with prolactin levels less than 200 ng/mL and macroadenomas. It is identified by re-measuring the prolactin level after performing a serum dilution. In this article, we focus these two pitfalls in the laboratorial diagnosis of the hyperprolactinemia, remembering that they could occur and interfere with a correct approach of the patient.

[Inflammatory myopathy with an unusual evolution]. / Miopatia inflamatória com evolução menos comum.

Inflammatory myopathies are a heterogeneous group of conditions characterized by proximal muscle weakness, nonsuppurative inflammation of skeletal muscle, with elevated muscle enzyme levels and characteristic electromyography and muscle biopsy findings. The authors describe a clinical case of a young woman, admitted with a four day history of bilateral thigh myalgia. She was afebrile and without skin, mucosal or joint involvement. Thigh muscle palpation was painful. Complete blood count revealed leukopenia and thrombocytopenia. High levels of creatine kinase, serum aminotransferases and myoglobin were detected. Metabolic, toxic and drug-related causes were excluded as well as infectious diseases, malignant tumours and endocrine myopathies. Auto-antibodies for connective diseases were negative. Magnetic resonance imaging and electromyography of lower limbs were suggestive of inflammatory myopathy. Generalized muscle weakness and dysphagia were reported subsequently. Clinical and laboratorial improvement was seen after corticotherapy. Muscle biopsy revealed myopathy signs without inflammatory changes or vasculitis. After prednisolone reduction, presently without treatment, she remains asymptomatic with normal laboratorial findings. The authors emphasize in this case of inflammatory myopathy the unusual clinical and laboratory evolution and the importance of a cautious differential diagnosis.

[Thyroid adenolipoma]. / Adenolipoma da tiróide.

Thyroid adenolipomas or thyrolipomas are rare benign neoplasms composed of mature adipose tissue and glandular elements. The most common clinical manifestation is a slowly enlarging neck mass. If thyroid fine-needle aspiration biopsy discloses a mixed population of adipocytes and follicular cells, the possibility of an adenolipoma should be considered in the differential diagnosis. Complete surgical excision is curative and the prognosis is favorable. We report a case of a 61 year-old female, with a recent diagnosis of multinodular goitre. The diagnosis of adenolipoma was only possible after surgery, performed because of a suspicious fine-needle aspiration biopsy. We also briefly discuss the pathogenesis, clinic and diagnosis of this entity.