Introduction: The relationship between the administration of recombinant TSH (rhTSH) and the progression of thyroid cancer has been described in some case reports (1). There are scant data suggesting that rhTSH acts as a growth factor that stimulates metastatic tumor expansion. Case Report: A 55 year old male patient who 3 years ago reported an evident mass at cervical level. The ultrasound documented a large thyroid mass with an endothoracic component. The FNA reported BETHESDA IV, suspicious for follicular neoplasia. Extension studies showed lytic left parietal bone lesion and liver metastatic compromise. The pathology of the total thyroidectomy showed a follicular carcinoma with a micronodular pattern and capsular invasion, of 19x9x7 cm, vascular and esophageal involvement T4BN0M1. He was sent to radioiodine therapy with 100 MCI with previous suspension of LT4 (Preablative TGL> 300 ng / ml (<50 ng / ml) Abs-TGL 2 IU / ml (<2 IU / ml) TSH 31.3 mIU / L (0.37-4.7 mIU / L) and body scan documenting uptake of the radiotracer at the left parietal, the anterior costal grating, and liver. A second dose of iodine was applied, with 150 MCI after stimulation with thyrotropin (Preablative TGL> 300 ng / ml, Abs-TGL 1.76 IU / ml, TSH 83 mIU / L) Immediately after the administration of rhTSH, the patient described the appearance of alopecic plaques on the scalp, sensation of mass at the right upper quadrant of the abdomen and bone pain in the right rib cage and at the right hip, which progressively worsened the following days until they were incapacitating. The scan report showed a new uptake in dorsal vertebrae, the MRI showed new bone injury at the innominate bone, as well as increase in the sum of its maximum dimensions by 22%, indicative of progression. The cerebral angio-MRI showed hypervascularized metastasis at the left parietal level. Bone scintigraphy documented foci of hyper uptake in both parietals, manubrium and sternal body, 5-8 right anterior costal arches, right scapula, both humeral heads, vertebral bodies T3-T5-T7L4, right acetabulum, left proximal femur and the entire length of the right femur. The clinical and imaging worsening of the bone lesions after the application of rhTSH was striking, for this reason radiotherapy and embolization of the liver lesion was performed. The patient was not a candidate for neurosurgical management due to the vascular component of the cranial lesions. Conclusion: rhTSH is a very well-tolerated method that avoids symptoms associated with severe hypothyroidism. However, it has been associated with neoplastic progression. This is one of the few cases documented in the literature where there is a direct association between the administration of rhTSH and the progression of bone metastases. References: (1)Braga M. Ringel M. Cooper DS. Sudden Enlargement of Local Recurrent Thyroid Tumor after Recombinant Human TSH Administration. J Clin Endocrinol Metab. 2001; 86(11):5148–51.

Introducción: la enfermedad de Graves se conoce como una de las patologías tiroideas de origen autoinmunitario más frecuentes a nivel mundial, la cual se caracteriza por un aumento en la producción de hormonas tiroideas y de factores de coagulación, lo que produce un síndrome clínico con componente autoinmune y metabólico que es propio de la respuesta fisiológica al estímulo de la tiroxina y que constituye un factor de riesgo para eventos trombóticos. En la relación entre la función tiroidea y la hemostasis a nivel corporal, las altas concentraciones de hormona tiroidea se relacionan con un mayor riesgo de trombosis venosa, produciendo alteraciones sobre la cantidad de factores de la coagulación como el VIII, el IX, y el X, así como el gen inhibidor activador del plasminógeno (PAI-1) y el factor de von Willebrand, los cuales predisponen la presentación de eventos tromboembólicos. Entre otras causas se encuentran las mecánicas, como la estasis vascular en casos relacionados con el bocio, además de las complicaciones cardiovasculares relacionadas (fibrilación auricular) que empeoran el pronóstico del paciente. Objetivo: Presentación del caso: en esta oportunidad se presenta el caso de una mujer con clínica y diagnóstico de un proceso consolidativo pulmonar de etiología infecciosa, por lo que se inicia terapia empírica antibiótica; sin embargo, durante su estancia hospitalaria la paciente cursa con evolución clínica estacionaria con requerimiento de aumento de oxígeno suplementario, taquicardia persistente y dolor torácico de características pleuríticas. Debido a esto se considera como posible diagnóstico una embolia pulmonar aguda, gracias a un hallazgo de angioTAC de tórax que corrobora el compromiso trombótico. Se inicia entonces un manejo anticoagulante a dosis plena, aunque durante los estudios realizados, con el fin de evaluar una etiología maligna o autoinmune, se realiza el perfil metabólico. Discusión y conclusión: en dicho estudio se realiza el diagnóstico de hipertiroidismo, por lo que se solicita gammagrafía de tiroides, evidenciando una importante captación de radio-isotopo y siendo concordante con la etiología autoinmune. Se documenta y se realiza el diagnóstico de embolia pulmonar como hallazgo inicial de enfermedad de Graves.

El hipertiroidismo primario es una condición que requiere manejo idealmente definitivo, los medicamentos antitiroideos son una opción viable y no invasiva, pero con la desventaja de ser curativa solo en el 30% de los casos y en casos de intolerancia, ausencia de respuesta o efectos secundarios se requiere manejo definitivo con yodo radioactivo o cirugía. Con frecuencia los pacientes son llevados a estas terapias definitivas, sin embargo, hay evidencia divergente sobre las pautas de seguimiento posterior al manejo quirúrgico o post-yodo, sin protocolos establecidos en muchas instituciones. Por lo anterior, se realizó una revisión del tema y un protocolo con el fin de homogenizar el conocimiento y ser una guía para el manejo post terapia de los pacientes hipertiroideos llevados a tratamiento definitivo.

In the context of the COVID19 pandemic, diabetes mellitus constitutes a main risk factor that increases overall mortality (1). The continuous glucose monitoring system (CGM) is an alternative that allows strict glucose monitoring and reduces the contact of the healthcare providers with the patients in the pandemic era. We conducted a study using CGM in COVID vs non-COVID patients hospitalized at the San José Hospital in Bogotá Colombia. Methods: Single center, prospective study of glucose monitoring in patients with and without COVID19 using the Freestyle system. We included patients of 18 years and older, hospitalized at Hospital San José de Bogotá, with diagnosis of diabetes and treated with insulin. We used the T student distribution to analize the data. Primary outcomes were the usefulness of the device in inpatients, and the clinical outcomes according to glucometric measures in patients with and without COVID19 infection. Results: CGM devices were placed on 30 patients: 10 with, and 20 without COVID. The system was feasible with good nurse acceptance. The age of the patients was between 18 and 90 years. Of the COVID positive patients, 30% required ICU and 10% died, the mean HBA1C was 9.5% (CI 95% 7.5–10.09%) with a general variability of 35.6%, only 3 patients archieved goals of time in range. The general glycemic index was 7.04% (CI 0.66-0.100)Of the non COVID patients, 10% required ICU and 10% died, the average variability was 30.9% and hypoglycemic episodes predominated in 3 patients. The general glycemic index was 6.6% (CI 0.61–0.71)The patients who required ICU had an average HBA1C of 10.4%, 80% received corticosteroid management during the hospital stay. No patient had skin or soft tissue infection at the sensor insertion site. Conclusions: During the COVID-19 pandemic, CGM is a useful method for glucometric control that reduces the contact of healthcare providers and allows early interventions to improve metabolic control. Worse outcomes are seen in patients with higher variability and with COVID infection. References: 1. Apicella M. Campopiano MC. Mantuano M. Mazoni L. Coppelli A. Del Prato S. COVID-19 in people with diabetes: understanding the reasons for worse outcomes. Lancet Diabetes Endocrinol.2020: 8; 782–92.