Tall cell papillary thyroid carcinoma metastatic to femur: evidence for thyroid hormone synthesis within the femur.

A 67-year old man with a 3-month history of left hip pain had a history of Graves disease, treated with 131I 20 years before admission, and papillary thyroid carcinoma, treated with cervical lymphadenopathy 9 years before admission. Removal of a 3.5- x 5-cm mass from the left femur revealed it to be a tall cell variant of papillary thyroid carcinoma. Removal of this mass resulted in his thyrotropin level increasing from 2 (presurgery) to 23 mIU/mL, whereas his thyroxine level simultaneously decreased from 5.79 (presurgery) to 2.29 microg/dL 12 days after surgery despite continuation of levothyroxine of 0.137 mg/day. On histological examination, the tall cell variant in the femur was producing abundant thyroglobulin. This first case of a metastatic papillary thyroid carcinoma in bone producing thyroid hormone to the extent that the patient became hypothyroid after removal of this metastasis illustrates that metastatic thyroid lesion(s) may produce significant amounts of thyroid hormone.

Teaching consultation psychiatry through computerized case simulation.

The PsyConsult Adventure Simulation program presents a case simulation of consultation in a general hospital. Exploring this computerized case helps trainees prepare for the complexities of consultation that they will face on the hospital wards. The simulation provides a distinctive approach, modeling the process of an actual consultation and allowing trainees to explore on their own initiative. It presents general techniques of psychiatric consultation as well as specifics of diagnosis and treatment. The program demonstrates the feasibility of using case simulation with a personal computer system as a supplement to bedside teaching of consultation psychiatry.