ACTA ENDOCRINOLOGICA (BUC)

Objective. Hyperkalemia is one of the most common acute life-threatening metabolic emergencies. Alterations in serum potassium (K+) levels can have dramatic effects on\r\ncardiac cell conduction and may lead to electrocardiographic (ECG) changes. But in some\r\npatients ECG changes do not accompany serum K+ abnormalities. Severe hyperkalemia secondary to Addison Disease (AD) is rare.\r\nCase. A 40-year-old woman with AD was admitted to emergency service with generalized pain. The patient?s serum K+ level was found to be at the highest level that can be detected in our laboratory (>10.0 mmol/L, normal 3.5-4.5 mmol/L) and repeated serum K+ confirmed the previous result. Results of repeated ECGs have revealed a normal sinus rhythm. Our case is particularly interesting because it demonstrates an Addison patient that has an extremely high level of K+ (>10 mmol/L) without any accompanying ECG changes.\r\nConclusion. Our case confirms that diagnostic ECG changes do not always accompany severe hyperkalemia. Therefore, clinicians should be careful that ECG may look\r\nnormal in the presence of severe hyperkalemia.

Metabolic syndrome may have direct myocardial effects in addition to their atherogenic effects, and this has been related to left ventricular systolic and diastolic dysfunction, as well as left ventricular remodelling. The aim of the study was to analyze the correlation between the metabolic syndrome clustering components (individual and additive) and heart failure severity in patients with prior myocardial infarction. We performed a cross-sectional study including 65 patients with heart failure post-myocardial infarction (31 men and 34 women) with a mean age at 64.1 (9.1). We evaluated the metabolic syndrome parameters (individual and additive) and analyzed their impact on heart failure severity by comparing NYHA I+II and NYHA III+IV groups. The elements of metabolic syndrome independently correlated with heart failure severity were identified by means of logistic regression method. The frequency of metabolic syndrome in our study group was high (49.23%). High blood pressure, fasting glucose, central obesity and low HDL-Cholesterol levels were significantly associated with severe heart failure (NYHA III and IV classification) in univariate logistic regression analyses. The only two independent variables: hyperglycaemia and reduced HDL-Cholesterol returned high enough levels of OR and 95%CI (1.79; 1.45-2.89 and 0.83; 0.67-0.91 respectively) to reach statistical significance beyond adjustment risk factors. In our study it was identified a significant correlation between presence of complete metabolic syndrome criteria and heart failure severity, measured in either NYHA IV categories (p=0.002), or by means of echocardiographical parameters such as: left ventricular ejection fraction (p=0.026), left ventricular masse index (p=0.006), peak E velocity (p=0.011), peak A velocity (p=0.037), Mitral E/A ratio (p=0.001) and E-deceleration time (0.021). Conclusions: Among the criteria for metabolic syndrome, hyperglycaemia and reduced HDLCholesterol levels had a strong association with heart failure severity. Our findings are relevant for\r\nclinical practice and intervention, and the aggressive treatment for conventional risk factors has also been effective in the prevention of heart failure.

Metastatic tumors account for 5-10% of all ovarian malignancies. They are usually bilateral tumors with a multinodular surface and extensive extra ovarian spread. Lung cancer is a rare source (0.3% of metastatic ovarian tumors). Among synchronous primary cancers, ovarian cancer is most frequently associated with endometrial cancer. The differential diagnosis between a primary ovarian carcinoma, synchronous primary cancers, and metastatic ovarian carcinoma is very important, as the treatment and prognosis are markedly different. We report the case of a 25-year-old woman who had been diagnosed and treated for stage IIIB small cell lung carcinoma (SCLC). Imaging undertaken for abdominal pain revealed a unilateral 8.5 cm ovarian tumor for which adnexectomy was performed. Histology and immunohistochemistry led to the diagnosis of ovarian metastasis from SCLC, a high-grade neuroendocrine lung tumor. This patient’s particular features, all infrequent in a metastatic tumor, are the lesion’s unilaterality (atypical for ovarian metastases in other cancers, but often observed in SCLC), the smooth ovarian surface with intact capsule, and the absence of intra-abdominal dissemination. The patient developed liver and vertebral metastases. This report focuses on the differential diagnosis between primary and metastatic ovarian neoplasms. We performed an extensive search of the literature on SCLC and ovarian metastases. Immunohistochemistry is essential for diagnosis when imaging and the pathological evaluation of the ovarian tumor cannot make the differential diagnosis.

Context. Open varicocelectomy is generally performed without microscopic equipment in Iran. We report our experience with loupe-assisted inguinal varicocelectomy, and its impact on semen parameters and pregnancy rate. Subjects and Methods. We conducted a retrospective interventional study on secondary data obtained from the medical records of 303 men with varicoceles, who underwent an inguinal varicocelectomy between March 2003 and April 2012. The surgical technique involved the use of a 3.0 × loupe during spermatic cord dissection at the level of the internal inguinal ring under spinal anesthesia. Semen samples were analyzed for sperm concentration, motility, and sperm morphology before the varicocelectomy and after 3 months. All the infertile patients were followedup postoperatively for more than 1 year. Results. There were 9 (3.0%) varicocele recurrences and 3 (1.0%) hydroceles. After varicocelectomy, sperm concentration and motile spermatozoa increased. In addition, spermatozoa with normal morphology improved significantly postoperatively. Of the 303 subjects treated, 153 (83.2) had a 1-year preoperative history of infertility; the spontaneous pregnancy rate of the spouses during the follow-up period was reported to be 61.4%. Conclusions. The results of this research indicated that varicocelectomy using loupe-assisted inguinal technique could improve semen parameters and pregnancy rate with a low postoperative complication rate.

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hormone (ACTH) mediated multisystemic state of adrenal hypercortisolism. An ACTH secreting benign pituitary tumor (adenoma) is the most common cause in the majority of patients with CD. Case report. This article describes a case of a 56-year-old woman presenting with clinical manifestations of hypercortisolism, with high plasma cortisol and ACTH levels that was suppressed with high-dose dexamethasone administration, suggestive of CD. Pituitary magnetic resonance imaging (MRI) of the sellar region was inconclusive. During the single photon emission computed tomography (SPECT) examination, an increased accumulation of technetium - 99m - hexakis - 2 - methoxy - isobutyl-isonitrile (99mTc-MIBI) in the pituitary gland area was noticed. Finally, response to corticotropinreleasing hormone (CRH) and ghrelin stimulatory testing, differentiated CD from ectopic ACTH and primary adrenocortical hypersecretion. Conclusion. We highlight the potential of 99mTc- MIBI SPECT as sensitive and specific method of pituitary gland adenoma detection in patients with Cushing’s disease, when MRI fails to directly detect an adenoma and stimulatory tests with CRH and ghrelin are not in routine diagnostics.

Purpose. The purpose of this study is to determine the clinical significance of incidental thyroid 18F-FDG PET/ CT uptake in oncology patients with the focus achieving the most appropriate management of this challenging situation. Materials and method. Two thousand five hundred and eighty 18F-FDG PET/CT studies performed at our institute in the past 4 years were retrospectively reviewed. Patients with incidental FDG uptake in the thyroid gland were further analysed. Results. The prevalence of incidental FDG uptake in thyroid gland was 7.6% (129 patients). 26 patients (20.1%) had diffuse 18F-FDG PET/CT uptake, 103 patients (79.1%) had nodular uptake in thyroid gland. All diffuse uptake patients who were further examined diagnosed to be a benign condition. 53 patients in the nodular uptake group were further examined and the final histopathology examinations revealed an 18.8% malignancy rate. SUV max values ranged from 2 to 21.8 with a significant highness in malignant lesions. Conclusion. 18F-FDG PET/CT uptake in the thyroid gland may be diffuse or nodular. Diffuse uptake needs no further examination as it usually accompanied by benign thyroid disorders. Patients with nodular uptake whose general condition is good should be further examined due to high rates of malignancy.

Context. Germline mutations in Succinate Dehydrogenase Complex Subunit D gene (SDHD) predispose to predominantly benign head and neck and/or thoracic-abdominal pelvic paragangliomas (PGLs). Objective. We present the case of a patient carrying a germline SDHD mutation responsible for multiple PGLs, who was followed for 40 years. He was initially diagnosed with a left cervical PGL at the age of 23 years, treated by surgery. Then, he recurred and developed a multifocal disease. The second-line therapeutic option was a threedimensional conformal radiotherapy performed in 2008. In 2013 the patient had clinical, hormonal, PET- and SPECTCT data revealing a disease progression. The treatment with the long-acting somatostatin analogue Octreotide Lar was carried out till the patient’s death caused by pulmonary embolism in December 2014. Results. Complex treatment led to a long clinical and biochemical remission and control of tumor growth. Conclusions. Despite their usually benign behavior, multicentric SDHD-related PGLs can require a multimodal approach involving surgery, radiotherapy and medical treatment for providing a long-term control of the disease and maintaining a good quality of life.

Context. Noninvasive encapsulated anaplastic thyroid carcinomas (NE-ATCs) have been described in few case reports, and consistently associated with favorable outcome compared to the classical ATCs. Objective. Our aim is to remark a rare histological finding in ATCs, encapsulation, which has been associated with a favorable outcome. Design. We have documented a rare case of an NE-ATC with its clinical, pathological, and molecular features. We also provided a thorough discussion of all the encapsulated ATCs reported in the literature. Subjects and Methods. A 50-year-old woman with an unremarkable medical history, who presented with a thyroid nodule, and diagnosed as “follicular lesion of undetermined significance” by fine needle aspiration biopsy. The patient was lost to follow-up for six years and revisited upon her neck disturbances and underwent total thyroidectomy. Results. Sections of the right lobe revealed a grossly encapsulated nodular lesion, measuring 75x55x55 mm. Histologically, the tumor consisted of both carcinomatous and sarcomatous components supported by immunohistochemical stains. Necrosis and atypical mitotic figures were evident. Capsular and/or vascular invasion was not identified. There were no BRAF codon 600, KRAS, NRAS mutations and RET/PTC rearrangement. During three-month follow-up, the patient was free of disease without adjuvant therapy. Conclusion. Encapsulated ATCs tend to follow a favorable clinical course and may deserve conservative treatment approaches.

Introduction. Clinical or subclinical hypothyroidism dictates the severity of depressive episodes and more frequently overlaps psychotic phenomenology. There are also major depressive episodes resistant to treatment in patients with euthyroidism, in which supplementation of antidepressant medication with thyroid hormones is beneficial. Material. Systematization of meta-analyses from perspectives: hypothyroidism and depression, autoimmune and depression pathology, gestational and puerperal pathology in association with hormonal and dispositional changes, presentation of therapeutic schemes. Results. Hypothyroidism is more commonly comorbid with major depression in women. It associates the need for hospitalizations, psychotic phenomenology, resistance to treatment, somatic comorbidities. Autoimmune pathology is associated with depression and requires thorough investigation. A possible genetic candidate for thyroid dysfunction is the DIO1 gene. FT4 may be a predictor, but the combination of FT4 + TBG measured during the prenatal period has a higher prognostic power for a future depressive episode. Conclusion. The article presents psychiatric medication schemes that combine antidepressants and antipsychotics of various classes with other enhancers, an important role going back to step three, which includes thyroid hormones, mainly T3. The doses used are smaller than the amount of endogenous production of T3 daily, with a small risk of inducing clinical hyperthyroidism.