ACTA ENDOCRINOLOGICA (BUC)

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Background. Primary hyperparathyroidism (PHPT) is caused most commonly by a solitary adenoma and less commonly by multiglandular hyperplasia of the parathyroid glands (MGD). Minimally invasive parathyroidectomy (MIP) has become a frequently used strategy, but there are limitations to current preoperative localization techniques. Results. We report the case of a patient, 63 years old, female, with clinical and biochemical features of primary hyperparathyroidism (total serum calcium: 10.1mg/dL; PTH: 171pg/mL). Neck ultrasonography (USG) revealed a mixed hypoechoic tumor along the posterior aspect of the left thyroid lobe of 1.54x0.78 cm, being difficult to say if it was intrathyroidal or not. There was only minimal residual uptake in the left thyroid lobe at 4 h on Tc99m sestamibi imaging. She underwent USG-guided fine-needle aspiration (FNA) of the suspected tumor followed by PTH measurement from the needle washing (FNA-PTH). The cytology was non-diagnostic but the level of PTH in the aspirated fluid was 10.000 pg/ mL. The patient underwent an en bloc resection of the left thyroid lobe and the tumor, which was curative, as calcium (8.9 mg/dL) and PTH (25.52 pg/mL) decreased from the first day after surgery. Histopathology of the surgical specimen revealed a left parathyroid adenoma made of chief cells and included in the thyroid capsule together with the entire left thyroid lobe. Conclusion. This case report highlights the importance of FNA-PTH in the localization of functionally parathyroid tissue in difficult cases, where a clear target exists.

Background. HDR syndrome is an autosomal dominant disorder characterized by hypoparathyroidism, sensorineural deafness, and renal dysplasia caused by mutation of the GATA3 gene. Case report. We describe a case of HDR syndrome diagnosed in a 46-yearold male patient. He had hand numbness, intermittent dizziness, and imbalance due to hypocalcemia. Physical examination was slim in appearance, had marfanoid features, and presented the typical apathetic face. He had a narrow rib cage and pectus excavatum deformity. Laboratory findings included serum calcium of 7.4 mg/dL, phosphorus of 4.87 mg/dL, albumin of 4.5 g/dL, intact parathormone (iPTH) of 13.3 pg/mL, 25(OH) D3 vitamin of 16.3 μg/L, daily urinary calcium excretion of 23.4 mg/day. Noncontrast computerized tomography (CT) of the brain showed bilateral basal ganglia calcification. Abdominal ultrasonography and CT showed the absence of renal tissue in the left kidney site and pelvis (left renal aplasia). Audiometry revealed mild sensorineural hearing loss at high frequencies. Conclusions. The patients with HDR syndrome are often diagnosed when they are examined for symptomatic hypoparathyroidism and deafness. To the best our knowledge, the present case is the second case of Barakat Syndrome reported from Turkey. The treatment of HDR syndrome is focused on clinical symptoms. The prognosis of the disease correlates with hypoparathyroidism and the severity of renal disease. HDR syndrome has an autosomaldominant inheritance, screening of family members is recommended for early diagnosis and treatment.

The incidence of primary adrenocortical insufficiency is 4.7 to 6.2 per one million. Among primary cancers developed in the adrenal gland, malignant lymphoma is very rare. We report here on an 82-year-old male patient who had primary adrenocortical insufficiency caused by bilateral adrenal lymphoma.

Context. This is the first case of proton pump induced hypomagnesemia and hypocalcemia, accompanied with increased parathormone levels. Objective. The proton pump inhibitors are widely used medications. They are considered safe, however, they have some side effects. One of these side effects is hypomagnesemia. Here we report a case with severe hypocalcemia and hypomagnesemia due to long term proton pump inhibitor. Case. A 73 years old woman, admitted to emergency room due to generalized tonic-clonic seizures. She had a previous history of muscle cramps and paresthesia for 4 months. She had a medical history of peptic ulcer and she was taking omeprazole for 7 years. Her laboratory evaluation showed marked hypomagnesemia [0.5 mg/dL (normal: 1.7-2.55 mg/dL)] and hypocalcemia [6.2 mg/dL (8.8-10.2 mg/ dL)] with extremely low urinary calcium (Ca) and magnesium (Mg) excretion [0.01 gr/24 h (normal:0.05-0.3 gr/24 h), <1.22 mg/24 h (normal: 9.7-12.20) respectively]. Her vitamin D level was normal [35 ng/ mL (normal:30-80 ng/mL)] and PTH was increased [129 pg/mL (normal: 15-65 pg/ mL)] in accordance with the secondary hyperparathyroidism. Symptoms resolved with the intravenous supplementation of calcium gluconate and magnesium sulphate. However, despite high levels of oral replacement, Mg levels remained low. With omission of omeprazole two months after the admission, her ion levels returned to normal without any replacement. Conclusion. Especially elderly patients with long term proton pump inhibitor therapy, should be monitored for the symptoms of hypocalcemia and hypomagnesemia.

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British Thyroid Association Guidelines for the management of thyroid cancer (third edition) was published recently (July 2014). The most common presentation of thyroid cancer is a newly discovered thyroid nodule or increase in size of a preexisting nodule. The long-term outcome of patients treated effectively for differentiated thyroid carcinoma is usually favorable. Nine per cent of patients with a diagnosis of thyroid cancer die of their disease. All patients with thyroid cancer should be seen within a multidisciplinary team (MDT) framework. Supra-physiological doses of levothyroxine are used to reduce the risk of thyroid cancer recurrence. The surgeon should have training and expertise in the management of thyroid cancer and be a core member of the MDT. Tumor recurrence or progression can be diagnosed earlier by detecting a raised serum thyroglobulin (Tg) after TSH stimulation (sTg) than by measurement of Tg on suppressive levothyroxine therapy.

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