How to evaluate an enlarged thyroid?
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Age Factors↗
Biomedical subjects
M D Whitaker
Publications and source records attributed to M D Whitaker.
When a thyroid abnormality is palpable. What it means and what you should do.
Clinicians faced with a palpable thyroid abnormality should ascertain whether there is evidence of thyroid dysfunction, concern for malignancy, and symptoms of obstruction. In the vast majority of cases, laboratory assessment of the thyroid with an sTSH assay establishes the presence or absence of thyroid dysfunction. In a nodular thyroid gland, fine-needle aspiration biopsy is the method of choice for determining whether malignancy is present. In a large goiter, the presence of obstructive symptoms or findings may be a clear indication that surgery is needed. The absence of these findings may warrant simple observation.
Airway Obstruction↗
Successful pregnancy in a woman with lipoatrophic diabetes mellitus. A case report.
BACKGROUND: Lipoatrophic diabetes mellitus is a rare insulin-resistance syndrome. A successful pregnancy occurred in a woman with lipoatrophic diabetes with no antepartum or intrapartum complications except hypertriglyceridemia, treated with gemfibrozil. CASE: A 29-year-old primigravida had lipoatrophic diabetes most consistent with congenital partial lipodystrophy (Kobberling-Dunnigan syndrome). The antenatal course was remarkable only for a midtrimester rise in serum triglycerides. The patient underwent oxytocin induction and an uncomplicated vaginal delivery. CONCLUSION: This case demonstrates that women with lipoatrophic diabetes who are otherwise healthy should not be discouraged from trying to conceive. Blood lipids should be checked periodically and hypertriglyceridemia treated to prevent pancreatitis. Gemfibrozil was used in this patient without apparent adverse effects.
Adult↗
Why different forms of testosterone?
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Female↗
Treatment of established postmenopausal osteoporosis with raloxifene: a randomized trial.
Raloxifene is a selective estrogen receptor modulator that in experimental animals acts as an estrogen receptor antagonist in breast and endometrium but as an estrogen receptor agonist in the skeletal and cardiovascular systems. We conducted a 1-year prospective, randomized, double-blind trial in 143 postmenopausal osteoporotic women (mean +/- SD age, 68.4+/-5.0 years) with at least one prevalent vertebral fractures and low bone mineral density (BMD), comparing groups receiving raloxifene at 60 mg/day (RLX60) or 120 mg/day (RLX120) and a control group receiving supplements of 750 mg/day of calcium and 400 IU/day of vitamin D. There were no differences among groups in the occurrence of uterine bleeding, thrombophlebitis, breast abnormalities, or increased endometrial thickness (assessed by ultrasonography). As compared with controls, the changes in values over 1 year for RLX60 and RLX120, respectively, were significant for serum bone alkaline phosphatase (-14.9%, -8.87%), serum osteocalcin (-20.7%, -17.0%), and urinary C-telopeptide fragment of type I collagen/creatinine (-24.9%, -30.8%), markers of bone turnover; for serum total cholesterol (-7.0% for RLX60) and low density lipoprotein cholesterol (LDL) (-11.4% for RLX60) and for the LDL/HDL cholesterol ratio (-13.2%, -8.3%). BMD increased significantly in the total hip (1.66% for RLX60) and ultradistal radius (2.92%, 2.50%). There were nonsignificant trends toward increases over controls in BMD for lumbar spine, total body, and total hip (for RLX120). Using a >15% cutoff definition, raloxifene had no effect on incident fractures, but using a >30% cutoff, there was a dose-related reduction (p = 0.047). We conclude that raloxifene therapy is well tolerated, reduces serum lipids, and does not stimulate the uterus or breasts. It has beneficial effects on bone, although, under the conditions of this study, these appear to be of a smaller magnitude than have been reported with estrogen therapy.
Aged↗
Pamidronate: an unrecognized problem in gastrointestinal tolerability.
Pamidronate (aminohydroxypropylidine bisphosphonate, APD) is an effective agent for treatment of Paget's disease of bone, and it has also been thought to be effective for treatment of osteoporosis. We desired to study a newer, time-release preparation of pamidronate, and carried out a placebo-controlled, double-masked study of postmenopausal osteoporosis. The original formulation was in a rapidly dissolving gelatin capsule. We encountered four episodes of esophagitis in 49 enrolled patients. We therefore discontinued treatment with this preparation and later began the study again using a standard tablet preparation. We encountered an additional case of erosive esophagitis in 1 patient of 40 receiving this tablet preparation. No patient was receiving concomitant medication which could cause esophagitis. Two of the patients gave a past history of hiatal hernia and 1 gave a history of gastric ulcer 27 years previously. The diagnosis of esophagitis was confirmed in all cases by endoscopy. Healing of the esophagitis promptly ensued after discontinuation of the pamidronate and the use of antacid medication.
Aged↗
Thoracoscopic excision of a peripheral corticotropin-secreting pulmonary carcinoid tumor.
Bronchial carcinoid tumors are rare neuroendocrine neoplasms that arise from the Kulchitsky cells of the bronchial epithelium. These tumors can manifest as central carcinoid tumors, pulmonary carcinoid tumorlets, or peripheral carcinoid tumors. Occasionally, the peripheral carcinoid tumors produce corticotropin and result in Cushing's syndrome. Herein we report the first case of Cushing's syndrome associated with a peripheral pulmonary carcinoid tumor that was excised by video-assisted thoracoscopy. After excision, the patient had complete remission. Video-assisted thoracoscopy may be ideal for resecting a peripheral pulmonary carcinoid, especially in patients with debilitation but no evidence of metastasis.
Adrenocorticotropic Hormone↗
Congenital gigantism due to growth hormone-releasing hormone excess and pituitary hyperplasia with adenomatous transformation.
The cause of gigantism in most patients is a GH-secreting pituitary tumor. In this report, a case of congenital gigantism due to probable central hypersection of GH-releasing hormone (GHRH) is described. Normal at birth (4.4 kg; 53 cm), our 7-yr-old male patient grew progressively thereafter to attain a height of 182 cm and a weight of 99.4 kg at the time of our evaluation. The markedly increased baseline plasma levels of GH (730 micrograms/L) did not suppress during a standard 3-h oral glucose tolerance test, but did increase 54% after iv infusion of GHRH. Baseline plasma levels of insulin-like growth factor-I, PRL, and immunoreactive GHRH were also markedly increased. Computed imaging of the head showed a large, partially cystic sellar and suprasellar mass. Extensive imaging studies did not localize a potential source of GHRH. Preoperative treatment with octreotide and bromocriptine for 4 months resulted in a 25% reduction of suprasellar tissue mass. The pituitary tissue removed at transsphenoidal and transfrontal operations showed massive somatotroph, lactotroph, and mammosomatotroph hyperplasia. Areas of GH- and PRL-secreting cell adenomatous transformation were also evident. No histological or immunohistochemical evidence of a pituitary source of GHRH was found. The peripheral plasma immunoreactive GHRH concentration remained unaffected by pharmacological and surgical interventions. We suspect that a congenital hypothalamic regulatory defect may be responsible for the GHRH excess in this case.
Adenoma↗
Case report 653: Arthritis of the wrist due to Mycobacterium avium-intracellulare.
We present a case of arthritis of the wrist in an elderly man due to Mycobacterium avium-intracellulare. Prior steroid injections and a surgical procedure on the affected wrist were predisposing risk factors for subsequent mycobacterial involvement of the skeleton. Radiographs demonstrated findings characteristic of tuberculous arthritis: particularly, osteopenia with marginal erosions and diffuse lytic lesions involving the carpals, proximal metacarpals, and distal ends of the radius and ulna. MR scans showed soft-tissue involvement and extensive marrow replacement consistent with infection. It is to be reemphasized that the clinical and radiological findings in this case are very often indistinguishable from TB. The diagnosis depends on the results of tissue culture. Since radiologists are likely to be involved increasingly in interpreting images of immunocompromised patients afflicted with a variety of both typical and atypical infections, it is important occasionally to report rare infections such as that described herein.
Aged↗
Resection of select mediastinal parathyroid adenomas through an anterior mediastinotomy.
Two patients who had undergone thorough surgical exploration of the neck were found to have adenomas of fifth parathyroid glands within the mediastinum. After localization with computed tomographic scanning or thallium-technetium imaging, or both, these tumors were resected through a parasternal approach (anterior mediastinotomy); thus, median sternotomy was obviated. This approach has not been described previously for the removal of mediastinal parathyroid tumors.
Adenoma↗
Insulinoma in a patient with annular pancreas.
Intraoperative ultrasonography has facilitated the localization of insulinomas. In this report, we describe a patient who was found to have an insulinoma in association with an annular pancreas. Because such tumors can be in close approximation to major pancreatic ductal structures, intraoperative ultrasonography can be useful for not only localizing the lesion but also delineating the related anatomic features. Although the optimal management of an asymptomatic annular pancreas has not been determined, our patient had no evidence of chronic pancreatitis and no narrowing of the duodenal lumen; therefore, no bowel bypass procedure was done.
Adenoma, Islet Cell↗
Diagnosis of corticotropin-producing bronchial carcinoid tumors causing Cushing's syndrome.
Cushing's syndrome due to ectopic production of adrenocorticotropic hormone (corticotropin) has been recognized for many years. Traditionally, clinicians have thought that most cases were due to lung carcinomas and that the clinical manifestations differed from those for pituitary-dependent Cushing's syndrome. We report two cases of corticotropin-producing bronchial carcinoid tumors that were clinically and biochemically indistinguishable from pituitary-dependent Cushing's syndrome. Review of the literature revealed that bronchial carcinoid tumors are the most common cause of Cushing's syndrome due to ectopic secretion of corticotropin. On biochemical and anatomic studies, they are frequently indistinguishable from pituitary-dependent Cushing's syndrome and thus may be difficult to diagnose. Inferior petrosal sinus sampling for corticotropin and computerized imaging of the chest may be the best aids in making the diagnosis.
ACTH Syndrome, Ectopic↗
The pituitary gland in the Laurence-Moon syndrome.
The apparent hypogonadism in patients with the Laurence-Moon syndrome has been variably attributed to unresponsiveness of target organs to gonadal hormones, primary end-organ failure, hypothalamic dysfunction, or pituitary failure. We report the first immunocytologic study of the pituitary gland in this rare disorder. No morphologic abnormalities were noted. The numbers and immunoreactivities of adenohypophyseal cell types were normal. No microscopic abnormalities were evident in the hypothalamus and target organs. The results of our study are consistent with recent biochemical data that suggest that pituitary function is normal in patients with this syndrome.
Adolescent↗
Prolactin cell carcinoma of the pituitary. Clinicopathologic, immunohistochemical, and ultrastructural study of a case with cranial and extracranial metastases.
A patient with a primary adenohypophyseal neoplasm who had a long course marked by multiple surgical resections, radiation therapy, and high-dose dopamine agonist therapy developed local invasion as well as cranial and extracranial osseous metastatic lesions. The serum prolactin levels were greatly elevated, and immunohistochemical studies demonstrated prolactin in the cytoplasm of primary and metastatic tumor cells. Ultrastructural features of lactotrophic differentiation, including misplaced granule exocytosis, were observed. This is the third reported case of prolactin cell carcinoma that metastasized despite high-dose dopamine agonist therapy. Analysis of the patient's serum prolactin showed no abnormality in the chromatographic profile of biologic activity.
Biological Assay↗
The hypothalamus and pituitary in cerebral gigantism. A clinicopathologic and immunocytochemical study.
Cerebral gigantism, or Sotos' disease, is a rare disorder of unknown cause characterized by the early onset of excessive growth, acromegalic features, and some degree of mental retardation. Although several endocrinologic abnormalities have been described in such patients, none has been specific or sufficient to explain the clinical features. Our report of the endocrinologic and pathologic aspects in a young woman with Sotos' disease includes the first microanatomic study of the hypothalamus and immunocytochemical examination of the pituitary gland in this disorder.
Autopsy↗
Gonadotrophin-secreting pituitary tumour: report and review.
A 34-year-old male with a pituitary adenoma was investigated and demonstrated to have hypersecretion of both gonadotrophins in the basal state. Immunocytochemical staining and electron microscopic examination were positive for tumour cells secreting FSH and LH. Presenting symptoms included visual disturbances, loss of libido, impotence, cold intolerance, frontal headaches, change in skin pigmentation and excessive weight gain. The patient denied alteration in hair distribution, had no acral features, galactorrhoea or gynaecomastia. Surgical extirpation resulted in complete amelioration of his symptoms over a three year follow-up period. Basal and stimulated pituitary function testing results returned to normal post-operatively. A review of the literature documents six other cases of pituitary tumour secreting both LH and FSH in the basal state. More commonly, the pituitary adenoma secretes FSH only. The literature is reviewed with regard to both types of tumour.
Adenoma↗
Demonstration of biological activity of prolactin molecular weight variants in human sera.
Three immunoreactive forms of PRL, separated by Sephadex G-100 column chromatography, were identified in serum samples from 10 normal subjects and 7 patients with PRL-secreting pituitary tumors. Fractions eluted from the column were assayed for bioactivity by using a sensitive bioassay with the Nb2 cell line. Three molecular weight variants of PRL were identified in normal subjects. In samples from 9 of the 10 normal subjects, 80.1 +/- 3.6% (mean +/- SEM) of the total bioactivity eluted in a peak corresponding to a PRL monomer (peak III) with a mol wt of approximately 24,000, 18.3 +/- 3.7% eluted in a peak with a mol wt of approximately 56,000 (peak II), and 1.6 +/- 1.1% of the biological activity was in the void volume (peak I). In the 10th normal sample, 65% of the total bioactivity was in the void volume (peak I), 31% was in peak III, and 4% was in peak II. Samples from the patients had 3.6 +/- 0.7% of the total bioactivity in peak I, 9.3 +/- 1.0% in peak II, and 87.0 +/- 1.1% in peak III, percentages not significantly different from normal. For comparison with bioassay, RIA measurement of PRL was performed on all fractions of six samples (three normal subjects and three tumor patients). Good correlation was found between RIA and bioassay measurements under each of the three peaks identified. We conclude that 1) in sera from normal subjects, three molecular weight variants of PRL have biological activity; 2) in patients with PRL-secreting tumors, secretion of biologically active PRL molecular weight variants is not proportionately different from that in normal subjects; and 3) the results of the Nb2 PRL bioassay correlate well with PRL levels determined by RIA for each of three molecular weight variants identified.
Adenoma↗
Idiopathic, sustained, inappropriate secretion of ADH with associated hypertension and thirst.
A 15 year old girl presented with excessive thirst and hypertension (170/110 mm Hg). Biochemical investigations revealed serum sodium 118 meq/liter, serum osmolality 238 mosmol/liter, urine sodium 90 meq/liter, urine osmolality 700 mosmol/liter, persistenly elevated serum antidiuretic hormone (ADH) levels (5.8 to 11.9 pg/ml) and no obvious cause for the hypertension. The hypertension is, at least in part, volume-related, diminishing with fluid restriction. Features of gross water intoxication (e.g., confusion, coma) have not occurred. The etiology of the inappropriate secretion of ADH is not obvious but is not thought to be due to "resetting of osmoreceptors" as evidenced by failure to maximally dilute urine following a water load test and persistently elevated serum ADH levels. A similar patient described by Epstein and associates in 1962 is presently well with persistent features of inappropriate secretion of ADH.
Adolescent↗