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Open access

Simone Pederzoli, Giorgia Spaggiari, Giuditta Bernardelli, Francesco Mattioli, Cinzia Baldessari, Antonino Maiorana, Vincenzo Rochira, and Daniele Santi

repeated from February to June 2013. Meanwhile, two further lymph node dissections involving retroperitoneal, lumbar and pelvic regions were performed in September 2011 and in January 2012 for the persistence of multiple node metastases. Finally, the

Open access

Ray Wang, Benjamin Solomon, Stephen J Luen, Owen W.J. Prall, Christine Khoo, Anthony J Gill, Jeremy Lewin, and Nirupa Sachithanandan

multidisciplinary meeting, a lung primary with adrenal metastasis was favoured over metastatic adrenocortical carcinoma. Carboplatin and etoposide (CE) regimen was recommended as first-line therapy and commenced in January 2020. Figure 1 Initial CT chest and

Open access

Michele Fosci, Francesca Pigliaru, Antonio Stefano Salcuni, Massimo Ghiani, Maria Valeria Cherchi, Maria Antonietta Calia, Andrea Loviselli, and Fernanda Velluzzi

January 2019 of reduction of lung and lymph node lesions. The CT of May 2019 showed a progression of pathology upon which the oncologist decided to start therapy with vivolumab (240 mg biweekly). After about 5 weeks of treatment (before the fourth cycle of

Open access

Jin-Ying Lu, Po-Ju Hung, Pei-Lung Chen, Ruoh-Fang Yen, Kuan-Ting Kuo, Tsung-Lin Yang, Chih-Yuan Wang, Tien-Chun Chang, Tien-Shang Huang, and Ching-Chung Chang

.6 cm at the longest dimension ( Fig. 1 B). Treatment A wide excision of the left thyroid tumor and intrathoracic goiter, and dissection of the left supraomohyoid neck lymph node was performed on January 4, 2012. However, after extubation

Open access

Pia T Dinesen, Jakob Dal, Plamena Gabrovska, Mette Gaustadnes, Claus H Gravholt, Karen Stals, Judit Denes, Sylvia L Asa, Márta Korbonits, and Jens O L Jørgensen

the Department of Endocrinology in Aarhus, Denmark, in January 2007 with a large pituitary tumor diagnosed by magnetic resonance imaging (MRI) performed due to a 1-year history of headaches. Twelve months before this, the patient underwent unilateral

Open access

Said Darawshi, Mahmoud Darawshi, and Deeb Daoud Naccache

Severe hypocalcaemia in breast cancer with bone metastasis is a rare finding usually associated with an advanced stage of the disease. We report a case of a 45-year-old woman with a history of local ductal carcinoma in situ (DCIS) of the breast, who presented with muscle tremors and general weakness. Hypocalcaemia was evident, with a positive Chvostek sign and a serum calcium level of 5.9 mg/dL (1.47 mmol/L), phosphorus 5.9 mg/dL (normal range: 2.3–4.7 mg/dL) with normal levels of albumin, magnesium and parathyroid hormone. High oral doses of alpha calcitriol and calcium with i.v. infusion of high calcium doses were instituted, altogether sufficient to maintain only mild hypocalcaemia. A whole-body CT revealed bone lesions along the axial skeleton. A biopsy from a bone lesion revealed a metastasis of breast carcinoma. With this pathological finding, leuprolide (GNRH analogue) and chlorambucil (alkylating agent) were initiated, followed by prompt tapering of infused calcium down to full discontinuation. Serum calcium was kept stable close to the low normal range by high doses of oral alpha calcitriol and calcium. This course raises suspicion that breast metastases to the skeleton caused tumour-induced hypocalcaemia by a unique mechanism. We assume that hypocalcaemia in this case was promoted by a combination of hypoparathyroidism and bone metastasis.

Learning points

  • Severe hypocalcaemia can a presenting symptom for breast cancer relapse.

Open access

Edmond Puca, Entela Puca, Pellumb Pipero, Holta Kraja, and Najada Como


Comorbidities are a risk factor for patients with COVID-19 and the mechanisms of disease remain unclear. The aim of this paper is to present a case report of an COVID-19 patient with severe hypocalcaemia. This is a report of an 81-year-old female, suffered from myalgia and fatigue for more than 3–4 weeks. Fever and cough appear 2 days before she presented to the emergency room. On physical examination, she was febrile with a temperature of 38.8°C, accompanied by cough, sore throat, headache, fatigue, and muscle ache. Her past medical history was remarkable with no chronic disease. She had lymphopenia. Laboratory test revealed moderate liver dysfunction, hypoalbuminemia, and severe hypocalcaemia (serum corrected calcium level: 5.7  mg/dL). Parathyroid hormone (PTH) was 107.9 pg/mL (range: 15–65) and 25(OH)2D levels was 4.5 ng/mL (range: 25–80). Chest CT scan detected peripheral ground-glass opacity. Throat swab for coronavirus by RT-PCRassay tested positive for the virus. She was treated with lopinavir/ritonavir, third generation cephalosporin, anticoagulant, daily high-dose calcium acetate, vitamin D3, fresh frozen plasma and oxygen therapy. She was discharged after two negative throat swab tests for coronavirus by conventional RT-PCR.

Learning points:

  • Comorbidities are a risk factor for patients with COVID-19.

  • Laboratory findings are unspecific in COVID-19 patients; laboratory abnormalities include lymphopenia, elevated of LDH, CPK and the inflammatory markers, such as C reactive protein, ferritinemia and the erythrocyte sedimentation rate.

  • In addition to inflammatory markers, in COVID-19 patients it is crucial to check the level of vitamin D and calcium.

  • There may be a correlation between vitamin D deficiency and the severity of COVID-19 disease.

Open access

Aye Chan Maung, May Anne Cheong, Ying Ying Chua, and Daphne Su-Lyn Gardner


Thyroid storm is a rare but potentially life-threatening complication of excessive thyroid hormone action. It is associated with a hypercoagulable state and reported to increase the risk of thromboembolism. However, the role of anticoagulation in thyroid storm still remains controversial and inconclusive. A 22-year-old male with no significant past medical history presented with acute severe generalised abdominal pain. He was found to be profoundly thyrotoxic on arrival at our institution and subsequently diagnosed with thyroid storm secondary to newly diagnosed Graves’ disease. Extensive thromboses of the splanchnic, iliac, femoral veins and pulmonary arteries were subsequently demonstrated on CT scan. He had prolonged bowel ileus as a sequela of mesenteric ischaemia requiring total parenteral nutrition and non-oral forms of anti-thyroid drugs for management of hyperthyroidism. He was in sinus rhythm throughout his inpatient stay, and there was no personal history of prothrombotic conditions. His thrombophilia screen was normal. He eventually required jejunectomy due to jejunal ischaemia from extensive involvement of portal and mesenteric veins. He underwent radioiodine ablation for definitive treatment. He is currently hypothyroid and receiving thyroxine replacement. Thyroid storms are hypercoagulable states and can be associated with extensive thromboembolism even in the absence of atrial fibrillation. To our knowledge, this is the first report of severe extensive thromboembolism complicated by severe mesenteric ischaemia and bowel ileus in the setting of a thyroid storm. Routine prophylactic anticoagulation should be considered in those presenting with thyroid storms.

Learning points:

  • Prolonged use of rectal propylthiouracil (PTU) for managing hyperthyroidism was effective in a patient who cannot take oral anti-thyroid drugs.

  • Hyperthyroidism is a hypercoagulable state due to an imbalance between coagulation and fibrinolytic factors.

  • Thyroid storm can be associated with extensive thromboembolism even in the absence of atrial fibrillation; routine prophylactic anticoagulation should be considered in the setting of thyroid storms.

Open access

Ana M Lopes and Sofia Teixeira


Molecular alterations of the transcription factor hepatocyte nuclear factor 1B (HNF1B) are associated with systemic disease, with kidney disease and maturity-onset diabetes of the young (MODY) as the most characteristic manifestations. Other features comprise pancreatic exocrine insufficiency, liver and biliary anomalies, and genital tract malformations. HNF1B-associated disease is clinically heterogeneous, and therefore the diagnosis is challenging. The authors describe the case of a 19-year-old man with new-onset diabetes after kidney transplantation (NODAT). The kidney disease presented during fetal life as bilateral hyperechogenic kidneys. Renal function progressively deteriorated during childhood, and at the age of 19, the patient was submitted to a living-kidney transplant. Two weeks after transplant, NODAT developed. Given the young age and normal body weight, NODAT was unexpected, and the possibility of HNF1B-associated disease was considered. Screening for mutations in HNF1B was undertaken, and a known mutation was found. As this case highlights, HNF1B-associated disease should be considered when NODAT unexpectedly develops in young kidney transplant recipients with a suggestive renal disease.

Learning points:

  • HNF1B anomalies are associated with systemic disease, including kidney disease, diabetes mellitus, pancreatic exocrine insufficiency, liver test abnormalities and genital tract malformations.

  • Phenotype is variable and there are no pathognomonic manifestations, but kidney disease appears to be the most common feature and diabetes the most frequent extra-renal phenotype.

  • Spontaneous gene alterations are common, and the lack of family history should not exclude the diagnosis.

  • HNF1B defects should be considered when NODAT develops in a young adult kidney transplant recipient with a suggestive kidney disease and without extensive risk factors for diabetes.

  • The most appropriate treatment for HNF1B-associated diabetes is not established, but immunosuppressive therapy superimposed on a beta-cell dysfunction seems to determine the need for insulin therapy after a variable period.

  • Immunosupressive regimens free of calcineurin inhibitors should be considered in patients with HNF1B-associated disease to minimize the risk of developing NODAT.