We report a case of an uncommonly aggressive presentation of the rare entity of synchronous papillary (PTC) and follicular thyroid carcinomas (FTC) in a 67-year-old woman initially presenting with thyrotoxicosis from Graves’ disease. She was found to have two thyroid nodules with extensive intra-cardiac tumour thrombus, symptomatic left pelvis bony metastasis with pathological fracture, pulmonary metastases and mediastinal lymph node metastases. Further investigations suggested a diagnosis of synchronous papillary and metastatic follicular thyroid cancer. Treatment with radical surgery followed by adjuvant therapeutic radioiodine ablation was proposed, but the patient declined all forms of cancer-specific therapy and was elected solely for a palliative approach to treatment. We discuss the diagnostic considerations in arriving at the diagnosis of synchronous thyroid malignancy – in this case the clear features of PTC and the strong probability of FTC due to invasiveness and metastatic follicular lesions. This case underscores potential limitations of the ACR TI-RADS system, notably with certain ultrasonographic features suggesting malignancy that might not be adequately captured. Notably, the aggressive presentation of DTC in this case may be contributed by the concurrent presence of Graves’ Disease, suggesting heightened vigilance when assessing potential thyroid malignancies in such patients.
Papillary Thyroid Carcinoma ; Thyroid Cancer, Papillary ; Follicular Thyroid Carcinoma ; Adenocarcinoma, Follicular ; Graves Disease

OBJECTIVE: To report the clinical and genetic characteristics of a rare case of Gitelman syndrome with comorbid Graves disease and ACTH-independent adrenocortical adenoma. METHODS: A patient who had presented at the Nanchong Central Hospital on December 21, 2020 was selected as the study subject. Clinical data of the patient was collected. Whole-exome sequencing was carried out on DNA extracted from peripheral venous blood samples from the patient and her family members. RESULTS: The patient, a 45-year-old woman, was found to have Graves disease, ACTH-independent Cushing syndrome, hypokalemia and hypomagnesemia following the discovery of an adrenal incidentaloma. MRI scan had revealed a 3.8 cm × 3.2 cm mass in the left adrenal gland. The mass was removed by surgery and confirmed as adrenocortical adenoma. DNA sequencing revealed that the patient and her sister have both harbored compound heterozygous variants of the SLC12A3 gene, namely c.1444-10(IVS11)G>A and c.179(exon1)C>T (p.T60M), which were respectively inherited from their father and mother. Based on the guidelines from the American College of Medical Genetics and Genomics (ACMG), the c.1444-10(IVS11)G>A and c.179(exon1)C>T (p.T60M) were respectively classified as a variant of uncertain significance (PM2_Supporting+PP3) and a likely pathogenic variant (PM3_Strong+PM1+PP3). CONCLUSION The conjunction of Gitelman syndrome with Graves disease and adrenal cortex adenoma is rather rare. The newly discovered c.1444-10(IVS11)G>A variant of the SLC12A3 gene, together with the heterozygous variant of c.179(exon1)C>T (p.T60M), probably underlay the pathogenesis in this patient.
Humans ; Female ; Middle Aged ; Gitelman Syndrome/genetics* ; Adrenocortical Adenoma ; Hypokalemia ; Graves Disease/genetics* ; Mothers ; Mutation ; Solute Carrier Family 12, Member 3

Humans ; Child ; Methimazole/adverse effects* ; Graves Disease/drug therapy*

Catheter Ablation ; Graves Disease/surgery* ; Humans ; Microwaves/therapeutic use* ; Radiofrequency Ablation ; Treatment Outcome ; Ultrasonography ; Ultrasonography, Interventional

COVID-19/prevention & control* ; COVID-19 Vaccines/adverse effects* ; Graves Disease ; Humans ; SARS-CoV-2 ; Vaccination/adverse effects*

OBJECTIVES: A variety of causes can lead to cholestasis, however, cholestasis caused by Graves' disease is usually overlooked clinically. Here we analyze the clinical characteristics of Graves' disease associated cholestasis so as to have a better understanding for the disease. METHODS: We retrospectively collected 13 inpatients' data who suffered from the Graves' disease associated cholestasis in the Department of Infectious Disease of Xiangya Hospital from January 2000 to December 2018. The characteristics of the patients' age, gender, liver function, thyroid function, coagulation function, the special cardiac examination, treatment, and follow-up data were analyzed. RESULTS: Thirteen patients, including 10 males and 3 females with the age range from 33 to 55 (median 43) years old presented cholestasis, pruritus, and hypermetabolic symptoms. The levels of total bilirubin (TBIL), direct bilirubin (DBIL), glutamic-pyruvic transferase, glutamic-oxaloacetic transferase, alkaline phosphosphatase, and gamma glutamyl transpeptidase were 170.4-976.7 (median 388.8) µmol/L, 93.2-418.1 (median 199.2) µmol/L, 25.1-182.1 (median 106.4) U/L, 38.2-265.7 (median 59.7) U/L, 105.3-332.0 (median 184.5) U/L, and 20.7-345.1 (median 47.6) U/L, respectively. The levels of free triiodothyronine (FT CONCLUSIONS Graves' disease can cause cholestasis, with the low incidence. The symptoms of cholestasis can be improved or even eradicated with the cure of the Graves' disease. The cholestasis may be idiopathic. For patients with cholestasis and hyperthyroidism, Graves' disease should be considered for differential diagnosis.
Adult ; Cholestasis/etiology* ; Female ; Graves Disease/complications* ; Humans ; Male ; Middle Aged ; Retrospective Studies ; Thyroid Function Tests ; Thyroxine ; Triiodothyronine

We present a 61-year-old Chinese female who had a history of angioinvasive follicular thyroid cancer (FTC) treated with total thyroidectomy 16 years ago, without radioactive iodine (RAI) treatment who now presents with de novo pretibial myxedema (PTM) followed by active severe Graves’ ophthalmopathy (GO) requiring pulse steroids and radiotherapy.
Thyroid Neoplasms ; Graves&rsquo ; disease ; Thyroidectomy

We characterize the clinical and laboratory characteristics of 5 patients with Graves’ thyrotoxicosis whose serum free thyroxine (fT4) concentration decreased unexpectedly to low levels on conventional doses of carbimazole (CMZ) therapy. The initial fT4 mean was 40.0 pM, range 25-69 pM. Thyroid volume by ultrasound measured as mean 11 ml, range 9.0-15.6 ml. Initial TSI levels measured 1487% to >4444%. Serum fT4 fell to low-normal or hypothyroid levels within 3.6 to 9.3 weeks of initiating CMZ 5 to 15 mg daily, and subsequently modulated by fine dosage adjustments. In one patient, serum fT4 fluctuated in a “yo-yo” pattern. There also emerged a pattern of low normal/low serum fT4 levels associated with discordant low/mid normal serum TSH levels respectively, at normal serum fT3 levels. The long-term daily-averaged CMZ maintenance dose ranged from 0.7 mg to 3.2 mg. Patients with newly diagnosed Graves' hyperthyroidism who have small thyroid glands and markedly elevated TSI titres appear to be “ATD dose sensitive.” Their TFT on ATD therapy may display a “central hypothyroid” pattern. We suggest finer CMZ dose titration at closer follow-up intervals to achieve biochemical euthyroidism.
carbimazole ; Thyroid Stimulating Immunoglobulin ; Immunoglobulins, Thyroid-Stimulating ; Immunologic Tests ; Graves disease

High-intensity focused ultrasound (HIFU) is a promising ablation technique for benign thyroid nodules. Current evidence has found good short- to medium-term outcomes, similar to those of better-established ablation techniques such as radiofrequency and laser ablation. The fact that it does not require insertion of a needle into the target makes HIFU a truly non-invasive treatment. Although it is not without risks, its low risk profile makes it an attractive alternative to surgery. There is much room for future development, starting from expanding the current indications to enhancing energy delivery. Relapsed Graves disease and papillary microcarcinoma are diseases that can benefit from HIFU treatment. Its role in the mediation of immune responses and synergistic effects with immunotherapy are promising in the fight against metastatic cancers.
Ablation Techniques ; Goiter, Nodular ; Graves Disease ; High-Intensity Focused Ultrasound Ablation ; Hyperthermia, Induced ; Immunotherapy ; Laser Therapy ; Needles ; Negotiating ; Thyroid Diseases ; Thyroid Gland ; Thyroid Nodule ; Ultrasonography ; Ultrasonography, Interventional

The aim of this study was to identify the three-dimensional topography of the sphenoid door jamb (SDJ) in the lateral orbital wall and to propose navigational guidelines for safe deep lateral decompression using surgical landmarks. The 120 orbits and SDJs of 60 subjects were three-dimensionally reconstructed using Mimics software. The mean volumes of the orbit and SDJ were 24.3 mm³ and 2.0 mm³, respectively. The mean distances from the lateral orbital margin (LOM) to the anterior and posterior margins of the SDJ were 13.2 and 36.3 mm, respectively. The mean distances from the superior orbital fissure to the LOM and to the posterior margin of the SDJ were 40.2 mm and 4.6 mm, respectively. The mean distances from the inferior orbital fissure (IOF) to the anterior and posterior margins of the SDJ were 3.8 mm and 20.5 mm, respectively. In the superior approach of the orbit, it can be predicted that the area up to 3 cm posterior from the LOM is safe, while 1 cm posterior from the safe zone could be a dangerous zone. In the inferior approach of the orbit, the safe area will be about 1 cm posterior from the anterior tip of the IOF, and the area up to 1 cm posterior from the safe zone should be approached with extreme care.
Decompression ; Graves Disease ; Orbit