Objective: To present a case of Hashimoto encephalopathy as a complication of autoimmune thyroiditis. Clinical Presentation and Intervention: A previously healthy 56-year-old female presented with rapidly progressive cognitive decline and visual hallucinations. Being a diagnosis of exclusion, Hashimoto encephalopathy required an extensive laboratory and diagnostic workup, which was done over the course of a 15-day hospitalization. The patient recovered after initial treatment with intravenous methylprednisolone and was then switched to prednisone p.o. Conclusion: This case report illustrates the importance of awareness for Hashimoto encephalopathy, as it remains one of the few easily treatable and reversible causes of rapid cognitive decline.

No abstract

Introduction: Subacute thyroiditis is a self-limited inflammation of the thyroid associated with recent upper respiratory tract viral infection. Graves’ disease has also been associated with viral illness. Clinical Case:A 55-year-old female presented to the emergency department complaining of sore throat, cough, and shortness of breath. She also had fatigue, dyspnea on exertion, palpitations, and a family member who recently had bronchitis. She denied chest pain, weight changes, temperature intolerance, constipation, or diarrhea. She had never had similar symptoms before. On initial evaluation, the patient was febrile at 101.2 °F, tachycardic at 156 beats per minute (bpm), and tachypneic at 33 breaths per minute. She was thin and her thyroid gland was tender upon palpation. She had eyelid lag, her skin was warm, and she was diaphoretic. Chest x-ray showed increased interstitial lung markings bilaterally. CBC showed anemia with hemoglobin of 9.7 g/dL (n<12 g/dL). Lactic acid was elevated to 2.00 mmol/L (n<1.9 mmol/L). D-dimer was 3020 ng/mL (n<230 ng/mL) and BNP was 961 pg/mL (n<100 pg/mL). An electrocardiogram showed sinus tachycardia at 140 bpm. Blood, sputum, and urine cultures were drawn, as were studies for viral respiratory pathogens. CT angiography of the chest and bilateral lower extremity venous ultrasound were ordered to rule out thromboembolism. A point-of-care echocardiogram showed reduced ejection fraction of 20%. Thyroid function tests revealed TSH < 0.03 mIU/mL (range 0.5-5.0 mIU/L), free T4 of 4.5 ng/dL (n<2.15 ng/dL), and T3 251 ng/dL (n<200 ng/dL). Patient was started on an esmolol drip for heart rate control. CT angiogram of the chest was negative for thromboembolism but revealed a bilaterally enlarged thyroid gland with multiple small nodules. RNA for Respiratory Syncytial Virus (RSV) type A was detected by PCR. A thyroid ultrasound was done and revealed heterogenous echotexture with increased blast flow. Thyroid antibody studies revealed thyrotropin receptor antibody of 26.5 IU/L (n<1.75 IU/L), thyroid-stimulating immunoglobulin 19.40 IU/L (n<0.55 IU/L), thyroglobulin antibody 235.6 IU/mL (n<0.9 IU/mL), and thyroid peroxidase antibody 11 IU/mL (range 0-34 IU/mL). Patient was started on methimazole 30 mg daily. A formal echocardiogram showed preserved ejection fraction of 50-55%. She was transitioned to oral propranolol. Patient’s shortness of breath and cough resolved, and she was discharged on methimazole 10 mg daily. Conclusion:This case emphasizes the importance of measuring thyrotropin receptor antibodies in confirming Graves’ disease in a patient presenting with upper respiratory viral illness and supports the idea of viral-induced autoimmune thyroid disease.

No abstract

Introduction: Primary neuroendocrine carcinoma of the breast is rare and must be differentiated from metastatic neuroendocrine carcinoma from the gastrointestinal tract. Clinical Case: A 66-year-old white female presented to the outpatient clinic complaining of abdominal fullness with unintentional weight loss of over 30 pounds over 3 months. She had no nausea, vomiting, diarrhea, or constipation. During initial evaluation, she had hepatomegaly with the liver edge palpable 4 cm below the costal margin. Laboratory studies are within normal limits except for elevated alkaline phosphatase at 369 U/L (n<130 U/L). A CT scan of the abdomen and pelvis with contrast showed extensive malignant lesions involving the liver consistent with prior hepatocellular carcinoma versus metastatic disease. Patient had a colonoscopy and esophagogastroduodenoscopy in an attempt to identify a primary gastrointestinal malignancy, but both studies were unremarkable. Ultrasound guided biopsy of the liver masses revealed malignant cells with morphologic features that were suggestive of metastatic neuroendocrine carcinoma. The patient was started on monthly intramuscular octreotide 30 mg. She had a Gallium-68 dotatate scan showing increased uptake in the area of several large heterogeneous necrotic tumors throughout the liver, and in the left sixth posterolateral rib. The maximum uptake was noted in a 3.7 cm x 3.5 cm ovoid mass in the right breast. The patient admitted to noticing a mass in her right breast which decreased in size after her initial dose of octreotide. She had not had a mammogram in several years and refused a breast exam during initial evaluation. The patient was sent for mammography and ultrasound as well as for biopsy of the breast lesion. Results of the breast biopsy showed intermediate grade neuroendocrine tumor of the breast. The patient underwent right total mastectomy with lymph node staging, and intraoperative pathology identified neuroendocrine carcinoma of intermediate grade in the right breast and right axillary lymph nodes, and macrometastatic carcinoma in a right axillary tail lymph node. Immunohistochemistry showed the malignant cells were chromogranin and synaptophysin positive. They were also estrogen receptor positive. The cells were negative for progesterone receptor and human epidermal growth factor receptor 2. The patient follows up regularly with oncology and continues to receive monthly doses of octreotide. She was also started on exemestane and had Yittrium-90 radioembolization of liver metastases. Conclusion: Patients with neuroendocrine carcinoma of the breast rarely present with clinical conditions related to hormonal hypersecretion as in neuroendocrine carcinoma of the GI tract but respond to treatment with somatostatin analogs.