1/18. Leukocytoclastic vasculitis: a rare manifestation of propylthiouracil allergy.OBJECTIVE: To report a case of leukocytoclastic vasculitis as a manifestation of propylthiouracil allergy. methods: We present the history, findings on physical examination, and results of laboratory evaluation in a 25-year-old woman. Associated reports from the literature are reviewed. RESULTS: The patient, with a history of Graves' disease, was referred for evaluation of a purpuric rash on the pinnas and buttocks bilaterally. Findings included exophthalmos and bilateral goiter with neck bruits. She was biochemically hyperthyroid. biopsy of the skin lesions revealed leukocytoclastic vasculitis. propylthiouracil therapy was discontinued, and prednisone was prescribed. Treatment with radioactive iodine resulted in appreciably diminished skin lesions and reduction in the size of the thyroid gland, but thyroxine and triiodothyronine levels increased. Administration of a second, higher dose of radioactive iodine with concomitant lithium carbonate resulted in clinical and biochemical improvement. Six months after initial assessment, the rash had resolved, and the patient's free thyroxine value had normalized, although the thyrotropin level was still suppressed. CONCLUSION: Leukocytoclastic vasculitis, although rarely seen as a manifestation of propylthiouracil allergy, has been reported in the medical literature and should be considered in the differential diagnosis of patients with a vasculitic rash. Treatment consists of discontinuation of the offending medication and administration of a corticosteroid and, occasionally, cyclophosphamide or plasmapheresis.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/18. Graves' disease presented as painful goiter.Pain in the thyroid gland is rarely present in Graves' disease. We describe a 32-year-old female hyperthyroid Graves' disease patient with an initial manifestation of painful goiter. On physical examination, the thyroid gland was diffusely enlarged and tender. The laboratory examinations showed high serum thyroid hormone and low thyrotropin values. serum inflammatory markers, including c-reactive protein and erythrocyte sedimentation rate, were elevated. Thyroid ultrasound revealed multiple focal hypoechoic areas. All these findings gave an initial impression of an acute inflammatory and destructive process in the thyroid gland. However, subsequent thyroid scintigraphy demonstrated a diffuse radioactive iodide uptake pattern with positive serum thyrotropin receptor antibodies. Fine-needle aspiration cytology showed only the presence of lymphocytes. She was diagnosed as having Graves' disease and was treated with propylthiouracil, and prednisolone was given for neck pain. Within a few days, the thyroid tenderness dramatically improved, and the erythrocyte sedimentation rate progressively normalized. However, follow-up thyroid function tests still showed high serum thyroid hormone levels. The possible etiologies of a painful thyroid gland in Graves' disease will be discussed.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
3/18. Pretibial myxedema as the initial manifestation of Graves' disease.Pretibial myxedema (PM) is a localized thickening of the pretibial skin due to accumulation of acid mucopolysacharides (glycosaminoglycans). Its pathogenesis is still under investigation. Pretibial myxedema, exophthalmus and thyroid acropachy are the dassic extrathyroidal manifestations of Graves' disease. Almost invariably, PM follows the onset of ophthalmopathy, developing after the diagnosis and treatment of hyperthyroidism. Pretibial myxedema preceding Graves' ophthalmopathy is rare. We report the case of a 28-year-old Greek woman, who presented with multiple, asymptomatic nodules and plaques of the lower legs in the absence of other physical findings. Histopathologic examination revealed deposition of mucopolysacharides in the lower dermis. Laboratory investigation showed elevated serum T3 and T4 and depressed TSH levels. In our patient, pretibial myxedema was the earliest manifestation, leading to the diagnosis of Graves' disease.- - - - - - - - - - ranking = 0.07537851467695keywords = physical (Clic here for more details about this article) |
4/18. Coexistence of malignant struma ovarii and Graves' disease.OBJECTIVE: To report an unusual case of hyperthyroidism from Graves' disease that was coexistent with malignant struma ovarii. methods: We summarize the clinical history, physical findings, laboratory data, imaging studies, pathologic features, and treatment in a patient with recurrent hyperthyroidism and discuss the incidence of ovarian tumors of various histologic origins, including thyroid tissue (that is, struma ovarii). RESULTS: Five years after diagnosis of Graves' disease and resolution of symptoms with 1 year of antithyroid drug therapy, a 53-year-old woman had recurrence of palpitations, tremors, and weight loss. Results of thyroid function tests showed high total and free thyroxine levels and a low thyrotropin level. Thyroid radioiodine uptake was high (69% at 24 hours). Abdominal ultrasound studies disclosed a cystic mass in the right adnexal area. Total abdominal hysterectomy and bilateral oophorectomy revealed a 7.5-cm cystic right ovary that contained a 1.0-cm struma ovarii with a 0.4-cm nodule of follicular variant papillary thyroid carcinoma within it. The patient was treated with methimazole and radioiodine ablation of the thyroid. Three months later, a massive myocardial infarction resulted in her death. CONCLUSION: The concomitant presence of Graves' disease complicates the management of struma ovarii and raises interesting questions about treatment and prognosis.- - - - - - - - - - ranking = 0.07537851467695keywords = physical (Clic here for more details about this article) |
5/18. A 20-year-old active duty male soldier with tachycardia and palpitations during Operation Iraqi freedom.A 20-year-old active duty male presented with palpitations, tachycardia, and a nontender, diffusely enlarged thyroid. The differential diagnosis and appropriate management of this patient's symptoms and physical examination findings are reviewed. Various diagnostic modalities are highlighted and effective treatment strategies as well as their risks and benefits are discussed.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
6/18. Graves' disease in the cervical thyroid and thyroglossal duct remnant: case report and review of literature.OBJECTIVE: To describe a patient with a rare presentation of Graves' disease in the cervical thyroid and thyroglossal duct remnant. methods: We present a detailed case report, including initial manifestations, laboratory findings, and radiologic evaluation of a patient with Graves' disease. A review of the relevant medical literature is included. A search for articles in the medline database from 1966 to November 2003 was performed with use of the following key words: thyroglossal duct remnant, thyroglossal duct cyst, thyrotoxicosis, Graves' disease, hyperthyroidism, and ectopic thyroid tissue. The reference lists from the articles obtained from the medline database were then reviewed for other pertinent articles. English abstracts of non-English articles were also reviewed. RESULTS: A 63-year-old woman presented with thyrotoxicosis. Examination of her neck was notable for a 3.5-cm soft, mobile midline mass overlying the thyroid cartilage. She had no extrathyroidal manifestations of Graves' disease. The rest of the physical examination was unremarkable. Laboratory studies revealed a thyrotropin (thyroid-stimulating hormone) level of 0.01 microIU/mL (normal range, 0.3 to 6.6) and free thyroxine level of 4.7 ng/dL (normal range, 0.6 to 1.5). An ultrasound study showed a normal-appearing thyroid and an infrahyoidal neck mass (3.0 by 1.7 cm). A radioiodine (123I) thyroid scan demonstrated diffuse homogeneous uptake throughout the gland in conjunction with 66.6% uptake at 24 hours. In addition, a large rounded area of increased activity slightly left of the midline was noted. The left anterior oblique image showed that this area was not continuous with the left upper pole. We thought that this finding represented a hyperfunctioning thyroglossal duct cyst or remnant tissue. Our patient subsequently underwent radioiodine therapy with 15.56 mCi of 131I. A review of the English-language literature revealed only rare case reports of thyrotoxicosis in ectopic thyroid tissue. CONCLUSION: Although the occurrence of thyrotoxicosis is common, to the best of our knowledge this is only the second case of Graves' disease involving the thyroglossal duct remnant reported in the English literature.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
7/18. Thyrotoxic periodic paralysis in a Hispanic man after the administration of prednisone.OBJECTIVE: To present a case of thyrotoxic periodic paralysis (TPP) in a Hispanic man and to discuss the potential precipitating mechanisms. methods: We review the clinical and laboratory findings relative to the occurrence of TPP in a 34-year-old Hispanic man, who had been diagnosed as having Graves' disease. RESULTS: TPP is a rare complication of thyrotoxicosis. The two known triggers of TPP are high carbohydrate intake and rest after strenuous physical activity. Other precipitating factors include ingestion of alcohol, infection, trauma, emotional stress, and exposure to cold. Nonselective beta-adrenergic blocking agents are used as prophylaxis for the paralytic attacks. glucocorticoids have been used to treat nonresponsive and recurrent episodes. Nevertheless, our patient, a 34-year-old Hispanic man, had received propranolol for 7 days and one single dose of prednisone 2 hours before the onset of the paralysis. In patients with TPP, the Na /K -adenosinetriphosphatase (ATPase) pump activity is considerably increased by excess thyroid hormones, resulting in an increased intracellular potassium shift. insulin activates the Na /K -ATPase pump as well; thus, the precipitating effect of a high carbohydrate diet is explained. glucocorticoids have been shown to increase the number of Na /K -ATPase molecules in skeletal muscle. They also increase insulin secretion in the basal state and the first-phase insulin release after a glucose load. CONCLUSION: In our patient with TPP, the onset of the attack was not prevented by the use of propranolol and was likely triggered by the administration of prednisone.- - - - - - - - - - ranking = 0.07537851467695keywords = physical (Clic here for more details about this article) |
8/18. rhabdomyolysis associated with hyperthyroidism.BACKGROUND: Nontraumatic rhabdomyolysis has been associated with alcohol and drug abuse, seizures, strenuous exercise, muscle hypoperfusion, hyperthermia, electrolyte disturbances, diabetic coma, and hypothyroidism. hyperthyroidism can be associated with several neuromuscular manifestations, such as thyrotoxic myopathy and thyrotoxic periodic paralysis, both associated with weakness and normal creatine phosphokinase levels. There have been only three reported cases of rhabdomyolysis as a result of thyrotoxicosis. We are reporting the fourth case of such association. CASE REPORT: The patient is a 26-year-old black woman with history of hypertension. She presented to the clinic with blurred vision, headaches, palpitations, weight loss, weakness, and persistent high blood pressure. She was found to have exophthalmus, lid lag, and a symmetric, smooth, and diffuse goiter. Ptosis and diplopia were absent; neurologic examination findings was normal. The patient had positive TPO antibodies, elevated free T4 level, and low thyroid-stimulating hormone (TSH) level. graves disease was diagnosed and propylthiouracil was prescribed. The patient then returned to the clinic 2 weeks later with weakness and myalgias. Her physical examination findings were unchanged except for mild muscle weakness. Laboratory evaluation showed normal electrolytes, normal renal function, and negative urine drug screening. creatine phosphokinase was 1276 U/L. Her free T4 and T3 levels were elevated and TSH level was low. The patient was treated with aggressive oral fluid resuscitation. propylthiouracil was continued and free T4 and T3 normalized along with creatine phosphokinase with resolution of symptoms. CONCLUSIONS: hyperthyroidism may, theoretically, cause rhabdomyolysis by means of increasing energy consumption associated with depletion of muscle energy stores and substrates. Our patient constitutes the fourth reported case of rhabdomyolysis associated with hyperthyroidism.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
9/18. Euthyroid thyrotoxic periodic paralysis.Thyrotoxic periodic paralysis (TPP) is a dramatic complication of thyrotoxicosis usually seen in young men with untreated Graves' disease. We report the case of a 29-year-old active duty man with TPP attacks atypical in that they occurred during and after resolution of the hyperthyroidism. Our literature review revealed only two previously reported cases of TPP concurrent with euthyroidism. risk factors for TPP include the postprandial state after carbohydrate-rich meals and the post-exertional state. At least a 2-week "window of vulnerability" for TPP appears to exist after initiation of antithyroid therapy. Hyperthyroid active duty males are especially at risk of TPP, and require physical profiling at the time of diagnosis and for a limited period after they become euthyroid, to minimize the occurrence of this complication.- - - - - - - - - - ranking = 0.07537851467695keywords = physical (Clic here for more details about this article) |
10/18. A case of Graves' disease associated with Klinefelter's syndrome.Graves' disease was found in a 41-year-old, married male patient with Klinefelter's syndrome. The patient began having finger tremor 5 years previously, and developed palpitation and weight loss 3 months prior to examination. He had a diffuse goiter, exophthalmos, and atrial fibrillation. Plasma levels of T3, T4 and free T4 were 2.8 ng/ml, 16.6 micrograms/dl and 4.5 ng/dl respectively. [123I] uptake was 53%, and TSH receptor antibody was 75%. Although he had no gynecomastia, his general physical appearance was that of typical eunuchoism. Chromosome studies showed a karyotype of 47,XXY. A diagnosis of Graves' disease associated with Klinefelter's syndrome was made.- - - - - - - - - - ranking = 0.07537851467695keywords = physical (Clic here for more details about this article) |
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