This report concerns a 71-year-old female with long standing untreated toxic multinodular goiter (TMG) coexisting with anaplastic thyroid carcinoma who presented with progressive shortness of breath and easy fatigability. Thyroid function tests showed suppressed TSH and elevated FT4 and FT3. Anti-thyroid hormone drugs were started. Thyrotropin receptor antibody was negative. A thyroid scan revealed both hot and cold nodules and fine needle aspiration biopsy (FNAB) of the thyroid gland showed colloid nodule. Chest CT scan imaging revealed an enlarged thyroid gland with the right lobe compressing the trachea. Patient underwent total thyroidectomy, final histopathology showed Anaplastic thyroid carcinoma. Our case is interesting from a pathophysiologic perspective,since it suggests that TMG can potentially transform into an aggressive form of thyroid carcinoma. High index of suspicion in patients with TMG with other risk factors for malignancy requires careful evaluation to detect cancer.

Human ; Female ; Aged ; Goiter ; Immunoglobulins, Thyroid-stimulating ; Receptors, Thyrotropin ; Thyroid Carcinoma, Anaplastic ; Thyroid Hormones ; Thyroid Neoplasms ; Thyroid Nodule ; Thyroidectomy ; Hyperthyroidism

BACKGROUND: Philippine studies on primary hyperparathyroidism (PHPT) and preoperative localization are scarce, making improvements on detection and recognition particularly difficult.OBJECTIVE: Describe the clinical profile of post-parathyroidectomy PHPT patients at The Medical City (TMC) and  assess localization rates and concordance of neck ultrasound (UTZ) and 99mTc-sestamibi scan (MIBI) with surgical histopathologic findings.METHODOLOGY: Retrospective chart review of PHPT Filipino patients who underwent parathyroidectomy at The Medical City from January 2004 to August 2018. Clinical profile and presentations were described and compared with international data. Imaging results were compared with surgical histopathology findings and the level of agreement was determined.RESULTS: Thirty-five patients were analyzed with female predominance (63%) and an average age of 53 years. Our population had more overt manifestations including skeletal abnormalities (51%), renal calculi (49%) and musculoskeletal symptoms (43%) prior to surgery compared to western countries, where symptoms were noted in less than 20%. MIBI had higher rates of detection than UTZ (80% versus 58%) but had similar localization rates (96.4% versus94%). Whe n performed together, given a positive result from either test, a much higher yield (93.8%) was observed. The level of agreement between MIBI and surgery was 72.5% (?=0.54) while UTZ and surgery was 54.1% (?=0.38).CONCLUSION: Our Filipino subjects had predominantly overt symptomatic hyperparathyroidism upon diagnosis prior to surgery as opposed to more asymptomatic surgical patients in western countries. Combining UTZ and MIBI is a more successful preoperative localization approach in our setting than performing either imaging alone, especially in patients with nodular goiter.
Human ; Parathyroidectomy ; Hyperparathyroidism, Primary

Aldosterone-producing adrenocortical carcinoma comprises less than 7% of all functioning adrenocortical carcinomas. We report a rare case of adrenocortical carcinoma with a clinical picture of primary aldosteronism and subclinical Cushing’s syndrome and feminization. Complete surgical resection normalized blood pressures and aldosterone, cortisol and estradiol levels. Long-term monitoring is recommended with imaging and hormonal evaluation used as tumor markers for recurrence.
Adrenal Gland Neoplasms ; Adrenocortical Carcinoma ; Hyperaldosteronism ; Hypertension

Objectives: The general objective was to compare the efficacy and safety of the Markovitz insulin protocol (MIP) with physician directed insulin infusion (PDI). Specific objectives were to compare the rate of change to normal glucose levels between MIP and PDP, time to achieve normal glucose levels and to determine the number of hypoglycemic episodes between MIP and PDI. Methodology: This is a retrospective study examining the medical records of critically ill patients admitted from 2001-2009. Efficacy outcome was measured as the time to achieve normal glucose level and the mean difference of percentage change towards normal blood glucose level. Safety outcome was measured in terms of frequency of hypoglycemic episodes. Results: One hundred and one patients met the inclusion criteria. The mean time required to achieve target blood glucose levels was 24 hrs (SD=19.5) for MIP compared to PDI. The mean drop in blood glucose levels was -235.49 (SD=113.4), with mean percent difference of -57.5% (SD=20.72) (p-value = 0.919) for MIP compared to physician directed. The MIP resulted in a higher percentage of blood glucose within target (19.57% vs 9.86 %) compared to PID (p= 0.005). Patients in MIP had shorter ICU stay (p=0.049). In addition, MIP was associated with a significantly lower rate of hypoglycemia at 4.2%, compared to PID at 30% (p<0.001). Conclusions Markovitz insulin protocol appeared to be significant to physician directed insulin infusion in terms of its greater percentage of glucose measurements maintained within target range, without an increased risk of severe hypoglycemia.
Critical Illness