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Ahmad Housin, Marc P Pusztaszeri, and Michael Tamilia

generalized weakness. His past medical history included treated hypertension, dyslipidemia, and benign prostatic hyperplasia. He also had a 40 pack-year history of cigarette smoking. He immigrated to Canada from Bangladesh in 2008 and his last travel was to

Open access

Ji Wei Yang and Jacques How

Lugol’s solution. Interestingly, our patient informed us that her brother and her sister-in-law, who live in another distant province of Canada, were independently also prescribed Lugol’s solution by their family physician for prolonged period for the

Open access

Gerald J M Tevaarwerk

concentrations and an elevated T 4 :T 3 ratio ( Table 1 ). Thyroid hormone measurements were carried out by LifeLabs Laboratory Services, 3680 Gilmore Way, Burnaby, BC, V5G 4V8, Canada, using a competitive immunoassay with direct chemiluminescent technology

Open access

Xin Feng and Gregory Kline

adrenal tumors ( 3 ). Prostate cancer is the most common cancer among Canadian men (excluding non-melanoma skin cancer) accounting for 21% of all new cancer cases in men in 2016 ( 4 ). Abiraterone has been used for the treatment of castration

Open access

Despoina Manousaki, Cheri Deal, Jean Jacques De Bruycker, Philippe Ovetchkine, Claude Mercier, and Nathalie Alos

fellowship from the Canadian Pediatric Endocrine Group. Patient consent We confirm that we have obtained written informed consent from the patient (and the patient's parents) for publication of the submitted article and accompanying images

Open access

S Hamidi, S Mottard, M J Berthiaume, J Doyon, M J Bégin, and L Bondaz

. References 1 Khan AA Hanley DA Rizzoli R Bollerslev J Young JE Rejnmark L Thakker R D’Amour P Paul T Van Uum S , et al . Primary hyperparathyroidism: review and recommendations on evaluation, diagnosis, and management. A Canadian and

Open access

Charlotte S Schömig, Marie-Ève Robinson, and Julia E von Oettingen

.9 (H) 22.9 (H) 92 10.3 – 58 297 36 (H) 184 4.9 – 11 34 (H) H, higher than normal range. Investigation On day 12, newborn screening, which in Quebec, Canada includes a TSH drawn after 24 h

Open access

Jill Pancer, Elliot Mitmaker, Oluyomi Ajise, Roger Tabah, and Jacques How

Summary

Multifocal papillary thyroid carcinoma (PTC) is common and the number of tumor foci rarely exceeds ten. The mechanism of multifocal disease is debated, with the two main hypotheses consisting of either intrathyroidal metastatic spread from a single tumor or independent multicentric tumorigenesis from distinct progenitor cells. We report the case of a 46-year-old woman who underwent total thyroidectomy and left central neck lymph node dissection after fine-needle aspiration of bilateral thyroid nodules that yielded cytological findings consistent with PTC. Final pathology of the surgical specimen showed an isthmic dominant 1.5 cm classical PTC and over 30 foci of microcarcinoma, which displayed decreasing density with increasing distance from the central lesion. Furthermore, all malignant tumors and lymph nodes harbored the activating BRAF V600E mutation. The present case highlights various pathological features that support a mechanism of intraglandular spread, namely a strategic isthmic location of the primary tumor, radial pattern of distribution and extensive number of small malignant foci and BRAF mutational homogeneity.

Learning points:

  • Multifocal papillary thyroid carcinoma (PTC) is commonly seen in clinical practice, but the number of malignant foci is usually limited to ten or less.

  • There is no clear consensus in the literature as to whether multifocal PTC arises from a single or multiple distinct tumor progenitor cells.

  • Strategic location of the dominant tumor in the thyroid isthmus may favor intraglandular dissemination of malignant cells by means of the extensive lymphatic network.

  • An important pathological finding that may be suggestive of intrathyroidal metastatic spread is a central pattern of distribution with a reduction in the density of satellite lesions with increasing distance from the dominant focus.

  • PTCs originating from the isthmus with intraglandular metastatic dissemination behave more aggressively. As such, a more aggressive treatment course may be warranted, particularly with regard to the extent of surgery.

Open access

Lisa Burback

Summary

A previously healthy 32-year-old woman developed cyclical mood swings after being prescribed cabergoline for a pituitary microprolactinoma. These mood swings persisted for over 2 years, at which point she developed an acute manic episode with psychotic features and was admitted to a psychiatry unit. Cabergoline was discontinued and replaced with aripiprazole 10 mg/day. Her manic episode quickly resolved, and she was discharged within 6 days of admission. The aripiprazole suppressed her prolactin levels for over 18 months of follow-up, even after the dose was lowered to 2 mg/day. There was no significant change in tumor size over 15 months, treatment was well tolerated. However, after 9 months of taking 2 mg aripiprazole, she developed brief manic symptoms, and the dose was returned to 10 mg daily, with good effect.

Learning points

  • Dopamine agonists such as cabergoline, which are a standard treatment for microprolactinomas, can have serious adverse effects such as psychosis or valvular heart disease.

  • Aripiprazole is a well-tolerated atypical antipsychotic that, unlike other antipsychotics, is a partial dopamine agonist capable of suppressing prolactin levels.

  • Adjunctive, low-dose aripiprazole has been utilized to reverse risperidone-induced hyperprolactinemia.

  • This case report demonstrates how aripiprazole monotherapy, in doses ranging from 2 to 10 mg/day, was effective in suppressing prolactin in a woman with a microprolactinoma who developed psychiatric side effects from cabergoline.

Open access

V Larouche and M Tamilia

Summary

Enteroviruses, including coxsackieviruses and Echovirus, are well known pathogens responsible for the development of thyroiditis. We describe the case of a 49-year-old woman with no personal or family history of thyroid disease who presented to the emergency room with a two-week history of daily fevers up to 39°C, a sore throat, occasional palpitations and diaphoresis, decreased appetite and an unintentional 10 kg weight loss over the same time course Physical examination revealed mild tachycardia, an intention tremor and a normal-sized, nontender thyroid gland without palpable nodules. The remainder of the physical examination was unremarkable and without stigmata of Graves’ disease. Her initial blood tests revealed overt thyrotoxicosis, elevated liver enzymes, an elevated C-reactive protein, a negative monospot and a positive CMV IgM antibody. Thyroid sonography revealed areas of hypoechogenicity and relatively low vascularity. Fine-needle biopsy showed a lymphocytic infiltrate. The patient was treated symptomatically with propranolol. On follow-up, the patient became euthyroid, and her liver enzymes normalised. Previous cases of CMV-induced thyroiditis occurred in immunosuppressed patients. This is the first reported case of a CMV-mononucleosis-induced thyroiditis in an immunocompetent adult patient and serves as a reminder that viral illnesses are a common cause of thyroiditis with abnormal liver enzymes.

Learning points:

  • The differential diagnosis of thyrotoxicosis with abnormal liver enzymes includes severe hyperthyroidism and thyroid storm caused by Graves’ disease as well as the thyrotoxic phase of a thyroiditis, usually caused by a virus such as coxsackievirus or, in this case, cytomegalovirus.

  • Cytomegalovirus appears to be a recently recognized causal agent for thyroiditis, both in immunosuppressed and immunocompetent patients.

  • Careful follow-up of thyroid function tests in patients with thyroiditis allows clinicians to determine if patients’ thyroid hormone secretion normalizes or if they remain hypothyroid.