Introduction. Fine needle aspiration biopsy is a non-surgical invasive diagnostic method for the cytological evaluation of the thyroid gland. Complications of fine needle aspiration biopsy are rare. Case Report. A female patient, 64 years of age, underwent left-sided nodulectomy in 2006, due to a follicular adenoma of the thyroid gland. In September of 2016, ultrasonography of the thyroid gland confirmed a node in the right lobe, approximately 10 mm in the longest diameter. The thyroid-stimulating hormone level was within the reference range (1,8 mIU/L), as well as calcitonin and carcinoembryonic antigen levels, but with elevated anti-thyroid peroxidase antibodies and anti-thyroglobulin antibodies, so fine needle aspiration was indicated. The cytological finding indicated a suspected follicular lesion and total thyroidectomy with an ex tempore biopsy was proposed in November of 2016. Prior to the surgery, hormone levels were measured and high thyroid-stimulating hormone levels were recorded (79 mIU/L). Further investigation showed low levels of free thyroid hormone concentrations, and levothyroxine was initiated at a dose of 75 mcg per day and the surgical treatment was delayed. The indicated dose of levothyroxine resulted in satisfactory values of the thyroid gland free hormones, and in February 2017, right-sided lobectomy was performed, whereas the histopathological findings indicated lymphocytic thyroiditis. Levothyroxine replacement therapy showed satisfactory results in the postoperative period. Further outpatient ultrasonographic monitoring showed a residual thyroid tissue, with slightly non-homogeneous echostructure in the left thyroid bed, 12 x 11 x 32 mm in size. Regular follow-up was suggested. Conclusion. Hypothyroidism has not been reported as a fine needle aspiration complication in the available literature.

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Apstrakt: Autoimuni poliglandularni sindrom (PGA) podrazumeva disfunkciju dve ili više endokrinih žlezda, u čijoj osnovi je autoimuni mehanizam. Mnogi autori, pored dva osnovna PGA sindroma, izdvajaju treći koji podrazumeva autoimunu tireoidnu bolest (ATD) udruženu sa drugim autoimunim bolestima. PGA tip 1 se javlja ređe, sa početkom u ranom detinjstvu i ključna je mutacija autoimunog regulator-gena. Tri glavne komponente karakterišu ovaj sindrom: mukokutana kandidijaza, hipoparatireoidizam i autoimuna adrenalna insufi cijencija. PGA tip 2 je povezan sa HLA sistemom antigena i u osnovi je poremećaj CD4+ i CD25+ regulatornih T-ćelija. Glavne komponente sindroma su Addisonova bolest, ATD i tip 1 diabetes mellitus. Bitna karakteristika PGA sindroma je da se ispoljavanje komponenti javlja u različitim vremenskim intervalima sa višegodišnjim međusobnim periodima. ATD je mnogo češća od drugih autoimunih endokrinih bolesti i obuhvata Gravesovu bolest, hronični autoimuni tireoiditis i postpartalni tireoiditis. ATD asocira sa HLA klasom II gena i polimorfi zmom citotoksičnih T-limfocitnih antigena 4. U osnovi je poremećaj celularnog i humoralnog imuniteta sa stvaranjem autoantitela na tkivno specifi čni antigen i prisutnom infi ltracijom mononuklearnih ćelija, dominantno limfocita u afektiranom tkivu. Najčešće su prisutna antitela na tireoidnu peroksidazu, tireoglobulin i TSH receptor. ATD je često udružena sa drugim endokrinim (diabetes mellitus tip 1, Addisonova bolest, autoimune bolesti hipofi ze, hipoparatireoidizam, prevremena ovarijalna insufi cijencija), ali i ne-endokrinim autoimunim bolestima. S obzirom na frekventnost ATD opravdan je skrining na ATD u okviru drugih autoimunih bolesti, a ne * Prof.dr Ljiljana Todorović-Đilas, Klinika za endokrinologiju, dijabetes i bolesti metabolizma, Klinički centar Vojvodine, Klinika za endokrinologiju, dijabetes i bolesti metabolizma, Hajduk Veljkova 1-3, 21000 Novi Sad, drdjilas@eunet.rs

Introduction:We present a case of a 40-year-old woman with IVF gemellar pregnancy in the 28th week of gestation, with primary hyperparathyroidism which complicated the course of pregnancy causing acute pancreatitis and AKI, who was treated with CRRT and succesfully overcame a hypercalcemic crisis. Methods:Case report: On admission to the Obstetrics and gynecology clinic patient was somnolent, hypertensive, tachicardic, oliguric, respiratory stable with pretibial oedema. Laboratory data showed raised inflammatory markers, anemia, elevated serum amylases, urea, creatinine and hypokalemia. Abdominal ultrasound revealed an enlarged, voluminous pancreas, whereas chest radiograph showed a large left sided pleural effusion. An inital diagnosis of severe preeclampsia was determined, with suspected acute pancreatitis. Emergent cesarean delivery was performed. In the post partum period she was treated with isotonic saline infusions, antibiotic therapy (cephalosporins, carbapenems), antihypertensive drugs, anticonvulsants, antiedematous therapy with preventive doses of heparin. After two days she was transfered to the Intensive Care Unit. She was dyspnoic with compensated respiratory acidosis. Additional laboratory findings indicated high levels of serum lipases and severe hypercalcemia (total calcium: 3,99mmol/l, ionized calcium 2,47mmol/l, hyperphosphatemia 0,45mmol/l, high levels of parathyroid hormone 834pg/ml) and hypokalemia. CT of the chest and abdomen, revealed acute pancreatitis, bilateral pleural effusions and signs of AKI. Endocranial MR showed signs of brain edema. US of the thyroid and parathyroid gland identified a cystic formation with clear borders and intranodular vascularisation in the parenchyma of the lower left lobe, size 9x13x26mm, resembling an enlarged parathyreoid gland. Other causes of hypercalcemia were excluded. Results: Previous therapy was continued with the addition of hydration (rate of 200ml/h), proton -pump inhibitors, corticosteroids, bolus doses of furosemide and byphosphonates (calcitonin was unavailable). Two combined pre-dilution procedures were performed using heparin anticoagulation and normal calcium levels of 1,5mmol/l in the dialysate. Initially CVVHDF was started (Multifiltrate Kit 8 CVVHF 1000, surface 1,8m 2 ; flow dialysate 200-300ml/h; blood flow 180-100ml/h; dialytic fluid/substitute ratio was 1:1) and further changed to CVVH with continuous potassium substitution. After the first CRRT procedure, a decrease in calcium levels was noted, with tendency for further reduction, resulting in desired (total calcium 2,23mmol/l, ionized calcium levels 1.26mmol/l) and gradual normalisation of other laboratory findings. The patients state of consciousness improved, diuresis was established and complete hemodynamic stability was reached, after which, on the 12th day of treatment, she was transfered to the Clinic of endocrionology for further treatment. Conclusions: Combining CRRT modality with heparin anticoagulation and careful monitoring of electrolyte levels can contribute to adequate...

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