Papillary thyroid carcinoma is the most common well-differentiated thyroid malignancy accounting for more than 80 to 90% of all thyroid tumors. It has an overall excellent prognosis owing to advances in screening via imaging and ultrasound-guided fine-needle aspiration biopsy, which have facilitated early detection, diagnosis, and surgical treatment followed by adjuvant radioactive iodine therapy. Exceptionally rare cases of papillary thyroid tumors may present with enormous growth due to delayed consultation and, thus, late diagnosis, posing a challenge to definitive management, quality of life, overall survival, and prognosis. We report a case of a 35-year-old woman who presented with a 4-year history of a bleeding exophytic and fungating anterior neck mass. Computed tomography showed a fungating mass arising from the left thyroid lobe that measured 14.1 x 14.0 x 11.1 cm with areas of necrosis and hemorrhage, left internal jugular vein thrombus formation, and compression of the left internal carotid artery. The mass causes a displacement of the trachea to the right side and multiple bilateral cervical lymphadenopathies. The patient was fully aware, and she consented to undergo wide excision, total thyroidectomy, neck dissection, and pectoralis major muscle flap reconstruction. However, she went into arrest intraoperatively attributed to massive pulmonary embolism. Papillary thyroid cancer is well known for its excellent prognosis. However, outcomes may not be favorable and can even be fatal in advanced and extensive cases. Although fungating papillary cancers are rare, they remain more common in the developing countries, where early detection and access to healthcare remains limited. They also represent a big challenge to surgeons. Even if the outcome was not good, we opted to report this case as there were many learning points. If only patients with good and excellent outcomes are reported in the literature, it will overestimate the treatment success of these complex cases.
papillary thyroid cancer

Background and Objective: Epidemiological studies have shown that Filipinos have a higher prevalence of welldifferentiated thyroid cancer and a higher rate of recurrence. The BRAF V600E mutation has been proposed as a potential prognostic marker in aggressive papillary thyroid cancers. In this study, we determined whether this mutation is a risk factor for tumor recurrence in papillary thyroid cancer among Filipinos. Methods: We conducted an age and sex-matched case-control study of patients with papillary thyroid cancer; we had two groups – with and without tumor recurrence – of 14 patients each, with at least a 5-year follow-up. We extracted the DNA samples from the patients’ (paraffin-embedded) tumor biopsy tissue blocks from thyroidectomy specimens, then detected the BRAF V600E mutation using polymerase chain reaction. The McNemar’s test for difference of proportions in paired data was used to determine the association of BRAF V600E mutation with recurrence. Results: The BRAF V600E mutation was found in 57.14% of all cases. We found a prevalence of 64.29% among those with recurrence and 50.00% among those without recurrence, with no significant difference between the two groups (p = 0.688). Conclusion Our study showed the BRAF V600E mutation was not associated with recurrence. We encountered several limitations: we had limited data regarding molecular methodologies in the Philippine setting, we had a small sample size, and therefore we could not study other parameters (e.g., tumor characteristics, lymph node metastasis, stage of disease). We hope that this paves the way for future studies and collaborations to establish the role of BRAF V600E in Filipinos with papillary thyroid tumor recurrence.
papillary thyroid cancer ; molecular diagnostics ; tumor recurrence

Objective: This study aimed to determine the prevalence, analyze, and compare the risk factors of anxiety, depression, and quality of life of cancer patients in the out-patient cancer clinic of the Cancer Institute one year into the pandemic. These were compared to the prevalence of anxiety and depression before the pandemic. Methods: A cross-sectional analytic study described the prevalence of anxiety, depression, and quality of life and analysis of its related factors among patients with cancer seen in the outpatient cancer clinic of the Cancer Institute of the Philippine General Hospital from November 1 to 20, 2021, using the Hospital Anxiety and Depression Scale – Pilipino and EORTC (European Organisation for Research and Treatment of Cancer) QLQ-C30 (Quality of Life questionnaire) tools. Results: A total of 408 cancer patients were enrolled in the study. The prevalence of anxiety and depression was 58.33% and 24.51%, respectively. Before the pandemic, the prevalence of anxiety and depression was 9.45% and 4.72%, respectively. Two hundred seventy participants (66.18%) had a positive quality of life. The comparison between the prevalence of anxiety and depression between this study (one year into the pandemic) and the pre-pandemic study revealed a statistically significant difference in the majority of both, with more anxious and depressed cancer patients in this study. The participants agreed that the pandemic had affected their daily activities. Conclusion The study showed that the COVID-19 pandemic significantly increased anxiety and depression among cancer patients. The quality of life (QOL) of cancer patients in this study has not been distinctly affected by the pandemic, but for those who have, they still require the attention and support of not just the physicians but the community as a whole. Our findings highlight the need to integrate better psychosocial support and the important role of carers in the evolving pandemic response measures.
pandemic ; anxiety ; depression ; quality of life ; cancer ; COVID-19

Background and Objective: Dyslipidemia in hypothyroidism results from the effects of thyroid hormones on lipid metabolism. These, in combination with hypothyroidism-induced hemodynamic changes, are risk factors for cardiometabolic diseases. We determined the prevalence of metabolic syndrome (MS) among adult Filipinos with hypothyroidism and compared clinical and laboratory characteristics of those with versus without MS. Methods: This is a retrospective study of 105 patients with biochemically confirmed hypothyroidism. A review of records obtained anthropometric measurements, blood pressure, fasting blood glucose, lipid profile, and thyroid hormones. Clinical and laboratory characteristics were then compared between MS and those without. Significant differences were determined by two-way ANOVA, while heterogeneity of categorical variables was determined by chi-square or Fisher exact test. All data analyses were performed using Stata version 17.0 with a significance level of p<0.05. Results: The prevalence of MS is 36.19% (95%CI: 27.04%,46.15%). Body mass index (BMI) peaks at obese class I among those with MS. There is a significantly higher proportion of patients diagnosed to have diabetes (28.95% vs. 7.46%; p=0.003) and hypertension (52.63% vs. 14.93%; p<0.001) in the MS group. No significant differences were noted between groups regarding age, sex, etiology of hypothyroidism, blood pressure, fasting glucose, lipid profile, and thyroid hormone levels. Conclusion Our study showed that the prevalence of MS in adult Filipinos with hypothyroidism is increased at 36.19%. Only BMI, presence of diabetes, and hypertension were shown to be significantly higher. Emphasis must be placed on early screening among hypothyroid patients at high risk of developing MS. A prospective study using waist circumference and clinical and metabolic parameters is needed to validate these findings.
dyslipidemia ; hypothyroidism ; metabolic syndrome ; prevalence

Background: Flavonoids from Emblica officinalis effectively reduced serum and tissue lipid levels through their inhibitory effect on the hepatic β-hydroxy-β-methylglutaryl coenzyme A reductase activity. This study aimed to determine the efficacy and safety of E. officinalis extract in adults with dyslipidemia. Methods: We searched the following electronic databases: MEDLINE (PubMed), MEDLINE (Ovid), Google Scholar, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science, and ClinicalTrials.gov from inception until January 31, 2022. Two reviewers independently screened the abstracts, reviewed full-text papers, and critically appraised the quality of included studies. Meta-analysis was performed using the random-effects model. Our primary outcomes were total cholesterol, LDL-C, serum triglycerides, and HDL-C levels, while secondary outcomes included adverse events. Results: A total of four randomized trials (N = 227) were included in the final analysis. There were statistically significant decreases in total cholesterol levels (SMD = -21.23 mg/dL, 95% CI: -34.22, -8.25; P = 0.001) and LDL-C levels (SMD = -25.12 mg/dL, 95% CI: -40.24, -10.00; P = 0.001) and significant increase in HDL-C levels (SMD = 4.74 mg/dL, 95% CI: 0.40, 9.07; P = 0.03) after 12 weeks of intervention favoring the use of the Emblica extract over placebo. However, there were no statistically significant difference in the serum triglycerides levels following 12 weeks of treatment (SMD = -22.28 mg/dL, 95% CI: -53.33, 8.76; P = 0.16). There was high heterogeneity noted across all outcomes: total cholesterol (P = 0.01, I2 = 72%), LDL-C (P = 0.0004, I2 = 83%), HDL-C (P < 0.00001, I2 = 91%) and serum triglycerides (P < 0.00001, I2 = 93 %). The intervention was well tolerated and adverse events reported in the three of four studies were all mild: dyspepsia (7 events – treatment), mild diarrhea (3 events – placebo), fever (1 event – placebo), headache (1 event – placebo). Conclusion Compared to placebo, Emblica officinalis fruit extract resulted in lower total cholesterol and LDL-C levels and increased HDL-C levels but with no effect on serum triglyceride levels based on low certainty of evidence. Trials with a larger sample size that directly compare E. officinalis extract to statins, preferably local data, are needed to support its use in patients with dyslipidemia further.
dyslipidemia ; Emblica officinalis ; Phyllanthus emblica ; meta-analysis

Behçet's disease (BD) is a systemic vasculitis characterized by recurrent acute vascular inflammation. There is currently limited epidemiological data in Southeast Asia. We discuss a 26-year-old woman who came to our institution for recurrent vulvar abscesses for a year. Physical examination showed labial, tongue, and vulvar ulcers. Pathergy test was negative and biopsy done were unremarkable . We diagnosed her clinically as a case of Behçet’s disease. We started her on colchicine 0.6 mg once daily and educated her on skin, oral, and perineal hygiene. On follow-up after one month, she noted resolution of her lesions. However, symptoms recurred in the last three months after discontinuing treatment. We used telemedicine to communicate due to the COVID-19 pandemic and lockdown, advising her to continue her medication. Timely diagnosis is essential in order to provide symptomatic relief and enhance patient education.
Behcet Syndrome ; Ulcer ; Vasculitis

Sheehan’s syndrome is characterized by hypopituitarism following ischemic necrosis of the pituitary gland caused by postpartum hemorrhage and impaired blood supply to the enlarged pituitary gland during pregnancy. The worldwide prevalence has since decreased due to improvements in obstetric care. Behavioral change is a rare presentation and is often misdiagnosed and managed as psychosis. We report a 42-year-old woman presenting with behavioral changes associated with postpartum failure of lactation and amenorrhea. Hormonal work-up revealed panhypopituitarism; serum cortisol, 98.93 (NV: 138–690 nmol/L); free T4, less than 5.15 (NV: 11.5–23.00 pmol/L); free T3, less than 2.30 (NV: 2.89–4.88 pmol/L); FSH, 3.63 (NV: 30–135 mIU/mL); LH, 3.88 (NV: 13–80 mIU/mL); serum estradiol, 3.89 (NV: 10.41–35.0 pg/mL); IGF-1, 13.13 (NV: 56–194 ng/mL); and serum prolactin, 1.8 (NV: 2.6–24.8 ng/mL). Cranial MRI with contrast revealed an atrophic pituitary gland consistent with Sheehan's syndrome. The symptoms improved substantially upon replacement with steroids and thyroid hormones and she was able to resume her routine activities. The psychiatric features of hypopituitarism can be attributed to a combination of hypothyroidism, hypoglycemia, and hypocortisolism and have been shown to reverse with adequate hormone replacement.
Hypopituitarism ; Psychotic Disorders ; Hypopituitarism

Thyroid storm is a life-threatening condition with mortality rates reaching up to 20 to 30%. First-line treatment includes inhibition of thyroid hormone synthesis, prevention of release of preformed hormones, blocking of peripheral FT4 to FT3 conversion, enhancing hormone clearance, and definitive radioactive iodine ablation. However, in the presence of life-threatening adverse effects (e.g., agranulocytosis) and contraindications (e.g., fulminant hepatic failure), therapeutic plasma exchange (TPE) can be used to rapidly remove circulating thyroid hormones, antibodies, and cytokines in plasma; this is recommended by the American Society of Apheresis (ASFA) and the American Thyroid Association (ATA) as second-line treatment for thyroid storm. Here, we report a 49-year-old female with Graves' disease admitted in our emergency room for a 6-week history of fever, weight loss, jaundice, exertional dyspnea, palpitations, and diarrhea. Her initial thyroid hormone levels were: FT4 64.35 (NV 9.01-19.05 pmol/L), FT3 23.91 (NV: 2.89-4.88 pmol/L), and TSH 0.00000 (NV: 0.35-4.94 mIU/L) and we managed her as a case of thyroid storm (Burch-Wartofsky score 70) by initiating high dose propylthiouracil. However, her sensorium deteriorated and serum bilirubin continued to rise from 307.2 on admission to 561.6 umol/L on the 5th hospital day (NV: 3 - 22 umol/L). TPE was performed after consultation with the Division of Hematology. Over the treatment course, her thyroid hormones normalized: FT4 13.18 pmol/L, FT3 2.30 pmol/L. However, despite TPE, her symptoms worsened and she became comatose, had hypotension despite vasopressors and developed new-onset atrial fibrillation. She expired on her 7th hospital day from multiorgan failure. TPE is effective in decreasing circulating thyroid hormone levels. However, it had no effect on clinically important outcomes as our patient still deteriorated and eventually succumbed. We still wrote and submitted this case report since if only successful cases were reported, the true effectiveness rate of TPE could not be determined.Thyroid storm is a life-threatening condition with mortality rates reaching up to 20 to 30%. First-line treatment includes inhibition of thyroid hormone synthesis, prevention of release of preformed hormones, blocking of peripheral FT4 to FT3 conversion, enhancing hormone clearance, and definitive radioactive iodine ablation. However, in the presence of life-threatening adverse effects (e.g., agranulocytosis) and contraindications (e.g., fulminant hepatic failure), therapeutic plasma exchange (TPE) can be used to rapidly remove circulating thyroid hormones, antibodies, and cytokines in plasma; this is recommended by the American Society of Apheresis (ASFA) and the American Thyroid Association (ATA) as second-line treatment for thyroid storm. Here, we report a 49-year-old female with Graves' disease admitted in our emergency room for a 6-week history of fever, weight loss, jaundice, exertional dyspnea, palpitations, and diarrhea. Her initial thyroid hormone levels were: FT4 64.35 (NV 9.01-19.05 pmol/L), FT3 23.91 (NV: 2.89-4.88 pmol/L), and TSH 0.00000 (NV: 0.35-4.94 mIU/L) and we managed her as a case of thyroid storm (Burch-Wartofsky score 70) by initiating high dose propylthiouracil. However, her sensorium deteriorated and serum bilirubin continued to rise from 307.2 on admission to 561.6 umol/L on the 5th hospital day (NV: 3 - 22 umol/L). TPE was performed after consultation with the Division of Hematology. Over the treatment course, her thyroid hormones normalized: FT4 13.18 pmol/L, FT3 2.30 pmol/L. However, despite TPE, her symptoms worsened and she became comatose, had hypotension despite vasopressors and developed new-onset atrial fibrillation. She expired on her 7th hospital day from multiorgan failure. TPE is effective in decreasing circulating thyroid hormone levels. However, it had no effect on clinically important outcomes as our patient still deteriorated and eventually succumbed. We still wrote and submitted this case report since if only successful cases were reported, the true effectiveness rate of TPE could not be determined.

The Senior–Loken syndrome was first described in 1961 as an oculo-renal disease consisting of familial juvenile nephronophthisis and Leber congenital amaurosis. It is a rare autosomal recessive disorder with a prevalence of 1:1,000,000 caused by mutations in nine genes (NPHP 1-8 and NPHP 10). Ocular manifestations (e.g., photophobia, nystagmus, and extreme hyperopia) occur within the first few years of life while renal manifestations (e.g., formation of multiple cysts impairing kidney function and end-stage renal disease) appear in late childhood to adolescence. Here, we report a case of a Filipino male presenting with rotatory nystagmus and progressive deterioration of vision since childhood. He had congenital amaurosis and juvenile nephronophthisis that progressed to end stage renal disease by age 19. All laboratory and imaging findings were consistent with chronic kidney disease. Molecular genetic testing of ciliopathy-related genes was performed revealing a homozygous mutation in exon 11 of the IQCB1/NPHP5 gene, c.1090C>T (p.Arg364*). This sequence change created a premature translational stop signal resulting in a truncated protein product, nephrocystin-5 and its consequent loss of function. His symptoms eventually improved with initiation dialysis. The prognosis of Senior–Loken syndrome remains dismal and a high index of suspicion, early diagnosis and timely intervention of renal complications are warranted.

A 26-year-old female came in with progressive blurring of vision. She had developed memory loss and complained of headache, significant weight loss, and exertional left calf pain after prolonged walking. Pertinent physical findings included light perception on visual acuity examination, and the brachial and radial pulses of both arms were not appreciable. Thoracic and abdominal aortic imaging by computed tomography with contrast revealed narrowing along the thoracic aorta and its branches. Carotid Doppler showed bilaterally thickened walls in the common carotid arteries, with near total occlusion of the left carotid artery. These findings were consistent with bilateral ocular ischemic syndrome in Takayasu arteritis. She was given methylprednisolone 500 mg intravenously daily for 3 days with noted improvement in vision. She was discharged and showed improvement on prednisone 35 mg/day and aspirin 80 mg/day. On follow-up two weeks post-discharge, she reported being able to see silhouettes of persons and objects.