전경부 종대를 주소로 내원한 환자 내분비대사 내과 R1 권성진

Case 1

이 O 심 (F/41) OPD : Chief complaint - Rt. lower neck mass Chief complaint - Rt. lower neck mass Present illness Present illness - F/41, 평소 특이병력 없이 지내오던 환자로 2005 년 7 월 - F/41, 평소 특이병력 없이 지내오던 환자로 2005 년 7 월 15 일 건강 검진에서 실시한 thyroid function test 에서 15 일 건강 검진에서 실시한 thyroid function test 에서 subclinical hypothyroidism 소견 확인하고 내분비 내과 subclinical hypothyroidism 소견 확인하고 내분비 내과 진료 후 ( ) Rt. lower neck 에 촉지되는 1X1 cm 의 진료 후 ( ) Rt. lower neck 에 촉지되는 1X1 cm 의 mass 에 대한 further evaluation 위해 내원함 mass 에 대한 further evaluation 위해 내원함

 Past medical history DM / HTN / Hepatitis / TB (-/-/-/-) Op Hx : augmented rhinoplasty : '92 Op Hx : augmented rhinoplasty : '92 Personal history alcohol (-) Personal history alcohol (-) smoking(-) smoking(-) Family history Family historynone

Review of systems fatigue (+) dry skin(-) pigmentation(-) edema(-) temperature tolerance(-) constipation(-) Physical examination Vital sign: 100/60 mmHg – 76/min – 20/min – 36.4 °C Vital sign: 100/60 mmHg – 76/min – 20/min – 36.4 °C Head & Neck Head & Neck - No neck vein engorgement (-/-) - No cervical lymph node enlargement - Rt. Lower neck ill defined mass (1x1cm) - No cervical lymph node enlargement - Rt. Lower neck ill defined mass (1x1cm)

Lab results ( ) CBC/DC 5.300/mm3 – 13.0 g/dl – 38.1 % - 242k ( seg % ) 5.300/mm3 – 13.0 g/dl – 38.1 % - 242k ( seg % ) MCV : 89.5 fl (80~96) MCH : 30.5 pg ( 27~33) MCV : 89.5 fl (80~96) MCH : 30.5 pg ( 27~33)Chemistry T/D–bilirubin 0.82/ 0.25 mg/dL T/D–bilirubin 0.82/ 0.25 mg/dL AST / ALT 18 / 11 U/L AST / ALT 18 / 11 U/L T-protein / albumin 7.3 / 4.2 g/dL T-protein / albumin 7.3 / 4.2 g/dL BUN / Cr11 / 0.8 mg/dL BUN / Cr11 / 0.8 mg/dL Na/ K /Cl142 / 4.1 / 102 mmol/L Na/ K /Cl142 / 4.1 / 102 mmol/L Ca/P/Mg 9.0 / 3.7 / 2.3 mg/dL Ca/P/Mg 9.0 / 3.7 / 2.3 mg/dL Glucose 97 mg/dl Glucose 97 mg/dl T-cholesterol /TG 167 / 116 mg/dl T-cholesterol /TG 167 / 116 mg/dl HDL/LDL 54/90 mg/dl HDL/LDL 54/90 mg/dl

내분비 검사 결과 건강검진 (7/15) 1st OPD (7/22) T3 ( 80~200 ng/dl ) FT4 ( 0.77~1.94 ng/d l) TG –Ab (<100 IU/ml) 530 TMS (<8ng) 2385 TBII (<10 %) 5.8 TSH (0.3~4.0 u/ml)

Thyroid Sono ( )

FNA ( ) 1. Specimen adequacy : satisfactory 2. Rt. : follicular epithelia with many macrophage Dx. : Benign follicular lesion with cystic change Dx. : Benign follicular lesion with cystic change Lt. : follicular epithelia with nuclear grooving and Lt. : follicular epithelia with nuclear grooving and slightly enlarged nuclei slightly enlarged nuclei Dx. : Benign follicular proliferation Dx. : Benign follicular proliferation Rec : Follow-up & repeat examination of thyroid Rec : Follow-up & repeat examination of thyroid mass(B) mass(B)

F/U thyroid Sono ( )

FNA ( ) Rt. Thyroid : insufficient specimen Rt. Thyroid : insufficient specimen Lt. Thyroid : some papillary clusters of atypical cells with nuclear grooving and few Lt. Thyroid : some papillary clusters of atypical cells with nuclear grooving and few pseudoinclusions pseudoinclusions Dx. : Papillary carcinoma Dx. : Papillary carcinoma

Neck CT ( )

Thyroid papillary cancer Op 1. Date : Name of Op. : - Total thyroidectomy with paratracheal and supraclavicular LN dissection (2/5)

Diagnosis Diagnosis  Thyroid, right, total thyroidectomy: - Papillary carcinoma (x2) - Nodular hyperplasia - Nodular hyperplasia - Lymphocytic thyroiditis - Lymphocytic thyroiditis - A parathyroid gland present - A parathyroid gland present  Thyroid, left, total thyroidectomy: - Papillary carcinoma (x4) - Nodular hyperplasia - Lymphocytic thyroiditis - A parathyroid gland present  Lymph node, paratracheal, supraclavicular, right, excision: Papillary carcinoma, metastatic (2/5)

Follow up of Ca level P (2.5~5.5mg/dl) Ca (8.4~10.2mg/dl) Mg (1.9~2.5mg/dl) Ionized Ca (1.12~1.30mmol/L) Op Ca & Vit D Supplement

Follow up of TFT T3 (80~200ng/dl) FT4 (0.77~1.94ng/dl) TG-Ab (<100IU/ml) ? TMS (<8 UG/ml) TBII (<10%) TSH (0.3~4.0 u/nl) >80.0 6/5 Op 1 st OPD 7/5 1 st RAI

Whole Body Scan ( )

Final Diagnosis and plan #1. Thyroid papillary cancer with LN meta - Radioactive iodine (I-131) therapy - Radioactive iodine (I-131) therapy - T4 suppression therapy - T4 suppression therapy #2. Iatrogenic hypoparathyroidism #2. Iatrogenic hypoparathyroidism - Ca. and Vit.D supply - Ca. and Vit.D supply

Case 2

안 O 애 (F/40) OPD : Chief complaint Chief complaint - Lt. neck pain and swelling onset: 1 days ago Present illness - F/40, 평소 특이병력 없이 지내오던 환자로 내원 1 일전 Present illness - F/40, 평소 특이병력 없이 지내오던 환자로 내원 1 일전 갑자기 발생한 Lt. neck pain, swelling 으로 내분비내과 갑자기 발생한 Lt. neck pain, swelling 으로 내분비내과 외래 방문 외래 방문

 Past medical history DM / HTN / Hepatitis / TB (-/-/-/-) Op. HX (-) Op. HX (-) Personal history alcohol (-) Personal history alcohol (-) smoking(-) smoking(-)

Review of systems Lt. neck - swelling(+) pain (+) : refer to Lt. ear limitation of neck movement (+) limitation of neck movement (+) fever (-) chills (-) URI Sx(-) fatigue(-) weakness(-) Physical examination Vital sign 100/60 mmHg – 71/min Vital sign 100/60 mmHg – 71/min Head & Neck Head & Neck - Lt. neck - Lt. neck : diffuse swelling(+) tenderness(+) : diffuse swelling(+) tenderness(+) - No cervical lymph node enlargement - No cervical lymph node enlargement - No neck vein engorgement - No neck vein engorgement

Neck and thyroid Sono ( )

Post FNA #1 Lt. neck swelling, pain aggravation Lt. neck swelling, pain aggravation dyspnea, chest tightness, ecchymosis on neck 발생 ENT OPD 에서 laryngoscory 시행 ENT OPD 에서 laryngoscory 시행 - Diffuse laryngeal edematous swelling 확인 - Diffuse laryngeal edematous swelling 확인 Neck CT 시행 Neck CT 시행

Neck CT ( )

Lab results ( ) CBC/DC /mm3 – 13.3 g/dl – 40.5 % - 381k ( seg % ) /mm3 – 13.3 g/dl – 40.5 % - 381k ( seg % ) MCV : 97.9 fl (80~96) MCH : 32.1 pg ( 27~33) MCV : 97.9 fl (80~96) MCH : 32.1 pg ( 27~33) ESR : 7 mm/hr ESR : 7 mm/hrChemistry T/D–bilirubin 1.24 / 0.33 mg/dL T/D–bilirubin 1.24 / 0.33 mg/dL AST / ALT15 / 15 U/L AST / ALT15 / 15 U/L T-protein / albumin 7.2 / 4.0 g/dL T-protein / albumin 7.2 / 4.0 g/dL BUN / Cr 5 / 0.5 mg/dL BUN / Cr 5 / 0.5 mg/dL Na/ K /Cl 141 / 5.0 / 107 mmol/L Na/ K /Cl 141 / 5.0 / 107 mmol/L Ca/P/Mg 12.2 / 4.1 / 1.9 mmol/L Ca/P/Mg 12.2 / 4.1 / 1.9 mmol/L Glucose 95 mg/dl Glucose 95 mg/dl CRP 0.1 mg/dl CRP 0.1 mg/dl 13100/mm3 – 10.9 g/dl – 31.9 % - 329k 13100/mm3 – 10.9 g/dl – 31.9 % - 329k MCV : 96.7 fl (80~96) MCH : 32.1 pg ( 27~33) MCV : 96.7 fl (80~96) MCH : 32.1 pg ( 27~33)

Emergency Operation 1. Date : Date : Pre Op. Dx. : Thyroid hemorrhagic cyst or mass 2. Pre Op. Dx. : Thyroid hemorrhagic cyst or mass Diffuse hematoma, soft tissue of neck Diffuse hematoma, soft tissue of neck 3. Post Op. Dx. 3. Post Op. Dx. - Parathyroid adenoma rupture and hematoma - Parathyroid adenoma rupture and hematoma 4. Name of Op. 4. Name of Op. - Lt. thyroid lobectomy & mass excision - Lt. thyroid lobectomy & mass excision (suspicious parathyroid adenoma) (suspicious parathyroid adenoma) - Hematoma evacuation - Hematoma evacuation - parathyroid auto-transplantation (SCM) - parathyroid auto-transplantation (SCM)

Post Op. lab Post Op. Ca/P/Mg level Post Op. Ca/P/Mg level : Ca/P/ Mg – 8.5/3.1/ : Ca/P/ Mg – 8.5/3.1/ : Ca/P/ Mg – 8.2/2.9/ : Ca/P/ Mg – 8.2/2.9/ : Ca/P – 9.3/ : Ca/P – 9.3/4.0 - Ca (8.4~10.2mg/dl) / P (2.5~5.5mg/dl) / Mg (1.9~2.5mg/dl ) - Ca (8.4~10.2mg/dl) / P (2.5~5.5mg/dl) / Mg (1.9~2.5mg/dl )내분비검사 T3 (80~200 ng/dl ) FT4 (0.77~1.95 ng/dl) TSH (0.3~4.0 u/ml) PTH (13~54 pg/ml)

Final Diagnosis #1. Spontaneous rupture of parathyroid adenoma, Lt. adenoma, Lt.

Case 3

정 O 의 (F/37) OPD : Chief complaint Chief complaint - midline neck mass onset : Present illness - F/37, 평소 특이병력 없이 지내오던 환자로 2004 년 Present illness - F/37, 평소 특이병력 없이 지내오던 환자로 2004 년 6 월경부터 우연히 만져지는 midline neck mass 있었으며 6 월경부터 우연히 만져지는 midline neck mass 있었으며 local 내과에서 TFT 결과 특이 소견 없음 확인함 local 내과에서 TFT 결과 특이 소견 없음 확인함 - Mass 에 대한 further evaluation 위해 내분비내과 - Mass 에 대한 further evaluation 위해 내분비내과 외래 방문 외래 방문

 Past medical history DM / HTN / Hepatitis / TB (-/-/-/+) : 7 년전, 완치 Op. HX (-) Op. HX (-) Personal history alcohol (-) Personal history alcohol (-) smoking(-) smoking(-)

Review of systems fatigue (-) fever (-) chills (-) pain(-) tenderness(-) weight change(-) temperature tolerance(-) A/N/V/D/C (-/-/-/-/-) diarrhea (-) constipation(-) Physical examination Vital sign 100/60 mmHg – 104/min – 20/min – 36.4 °C Vital sign 100/60 mmHg – 104/min – 20/min – 36.4 °C Head & Neck Head & Neck - Egg-sized midline neck mass (+) pain(-) swelling (-) fluctuation(-) tenderness(-) bruit(-) pain(-) swelling (-) fluctuation(-) tenderness(-) bruit(-) - No cervical lymphnode enlargement - No cervical lymphnode enlargement - No neck vein engorgement - No neck vein engorgement

Lab results CBC/DC 5630/mm3 – 12.9 g/dl – 38.8 % - 283k 5630/mm3 – 12.9 g/dl – 38.8 % - 283k Chemistry T/D–bilirubin 0.43 / 0.13 mg/dL T/D–bilirubin 0.43 / 0.13 mg/dL AST / ALT 14 / 20 U/L AST / ALT 14 / 20 U/L T-protein / albumin 7.1 / 4.3 g/dL T-protein / albumin 7.1 / 4.3 g/dL Glucose 99 mg/dL Glucose 99 mg/dL BUN / Cr 10 / 0.8 mg/dL BUN / Cr 10 / 0.8 mg/dL Na/ K /Cl 140 / 4.6 / 107 mmol/L Na/ K /Cl 140 / 4.6 / 107 mmol/L Ca/P 9.5 / 3.3 mmol/L Ca/P 9.5 / 3.3 mmol/L

내분비검사 내분비검사 - T3 ( 80~200 ng/dl ) : T3 ( 80~200 ng/dl ) : FT4 ( 0.77~1.94 ng/d l) : FT4 ( 0.77~1.94 ng/d l) : TG –Ab (<100 IU/ml) : <50 - TG –Ab (<100 IU/ml) : <50 - TMS (<8ng) : TMS (<8ng) : TG (<50ng) : TG (<50ng) : TBII (<10ng) : TBII (<10ng) : TSH (0.3~4.0 u/ml) : TSH (0.3~4.0 u/ml) : 0.10

Thyroid scan ( )

Neck and thyroid Sono ( )

Fluid Aspiration 1) ) ) ) ) : aspiration 후 mass growing 3) : aspiration 후 mass growing 4) ) ) : 25 ml, almost black ~ dark brown color 5) : 25 ml, almost black ~ dark brown color 6) : 30 ml 6) : 30 ml 7) : 47 ml, almost black ~ dark brown color 7) : 47 ml, almost black ~ dark brown color 8) : 37 ml 8) : 37 ml 9) : 35 ml, black color 9) : 35 ml, black color 10) : 42 ml, percutaneous ethanol injection 10) : 42 ml, percutaneous ethanol injection

Alcohol Injection ( ) - Supine position and neck extension - Supine position and neck extension - Cystic fluid 40 ml evacuation - Cystic fluid 40 ml evacuation - 99% ethanol 2ml X 2 회 injection - 99% ethanol 2ml X 2 회 injection - Transient mild pain and no acute complication - Transient mild pain and no acute complication - 1 개월 후 OPD F/U : recurrent mass - 1 개월 후 OPD F/U : recurrent mass - Refer to GS - Refer to GS

Neck and thyroid Sono pre-PEI ( )

Neck and thyroid Sono post-PEI ( )

Final Diagnosis #1. Recurrent thyroid cystic mass

Case 4

강 O 옥 (F/72) ER : Chief complaint - Rt. painful neck mass with fever onset : 1 week ago Chief complaint - Rt. painful neck mass with fever onset : 1 week ago Present illness Present illness - F/72, 15 년전 HTN 으로 본원 신장 내과 F/U 받던 환자로 - F/72, 15 년전 HTN 으로 본원 신장 내과 F/U 받던 환자로 내원 2 주전부터 Headache 와 general weakness 발생 후 내원 2 주전부터 Headache 와 general weakness 발생 후 local 및 본원 한방에서 내원 전까지 전신에 3-4 회 local 및 본원 한방에서 내원 전까지 전신에 3-4 회 acupuncture Tx 받음. 내원 1 주일 전부터 Rt neck 에 soft acupuncture Tx 받음. 내원 1 주일 전부터 Rt neck 에 soft mass enlargement, fever 발생하였고 내원 2 일전부터 mass enlargement, fever 발생하였고 내원 2 일전부터 tenderness, pain aggravation 되면서 size 증가되어 내원함 tenderness, pain aggravation 되면서 size 증가되어 내원함

 Past medical history DM / HTN / Hepatitis / TB (-/+/-/-); 15 년전 Personal history alcohol (-) Personal history alcohol (-) smoking(-) smoking(-)

Review of systems fever (+) chills (+) headache (+) neck pain(+) dyspnea(-) sore thraot (-) Physical examination Vital sign 120/80 mmHg – 72/min – 20/min – 38.5 °C Vital sign 120/80 mmHg – 72/min – 20/min – 38.5 °C Head & Neck Head & Neck - No neck vein engorgement (-/-) - Rt thyroidal enlargement & tenderness(+) (3x3cm) Chest - Clear breath sounds without crackle or wheezing - Regular heart beat without murmur Chest - Clear breath sounds without crackle or wheezing - Regular heart beat without murmur

Lab results CBC/DC 17350/mm3 – 13.5 g/dl –39.7 % - 347k ( seg % ) 17350/mm3 – 13.5 g/dl –39.7 % - 347k ( seg % ) MCV : 85.0 fl (80~96) MCH : 29.0 pg ( 27~33) MCV : 85.0 fl (80~96) MCH : 29.0 pg ( 27~33)Chemistry T/D–bilirubin 0.9/ 0.15 mg/dL T/D–bilirubin 0.9/ 0.15 mg/dL AST / ALT24 / 21 U/L AST / ALT24 / 21 U/L T-protein / albumin 6.4 / 3.1 g/dL T-protein / albumin 6.4 / 3.1 g/dL BUN / Cr10 / 0.8 mg/dL BUN / Cr10 / 0.8 mg/dL Na/ K /Cl133 / 3.9 / 98 mmol/L Na/ K /Cl133 / 3.9 / 98 mmol/L Ca/P/Mg 8.8 / 3.8 / 2.1 mg/dL Ca/P/Mg 8.8 / 3.8 / 2.1 mg/dL Glucose 112 mg/dl Glucose 112 mg/dl T-cholesterol /TG 166 / 75 mg/dl T-cholesterol /TG 166 / 75 mg/dl HDL/LDL 40/112 mg/dl HDL/LDL 40/112 mg/dl ESR/CRP67/13.3 mg/dl ESR/CRP67/13.3 mg/dl

내분비 검사 결과 - T3 ( 80~200 ng/dl ) : T3 ( 80~200 ng/dl ) : FT4 ( 0.77~1.94 ng/d l) : FT4 ( 0.77~1.94 ng/d l) : TG – Ab (<100 IU/ml) : <50 - TG – Ab (<100 IU/ml) : <50 - TBII (<10 %) : TBII (<10 %) : TSH (0.3~4.0 u/ml) : TSH (0.3~4.0 u/ml) : 0.24

Chest PA

Neck and thyroid Sono ( )

FNA ( ) 1. Right thyroid: benign looking follicular cells and many neutrophils in colloid background Diagnosis: Insufficient specimen with a few follicles Diagnosis: Insufficient specimen with a few follicles 2. Left thyroid nodule: benign looking follicular cells in colloid background Diagnosis: Benign follicular lesion Diagnosis: Benign follicular lesion

1. Blood culture x 3: no growth (06-5-9) 2. Urinalysis:RBC 0~1, WBC 5~9 Urine culture:no growth ( ) 3.1st pus culture: no grwoth ( ) 2nd pus culture: no grwoth ( ) AFB (-), TB-PCR (-), culture (-) AFB (-), TB-PCR (-), culture (-)

Clinical Course Ceftriaxone 2g iv qd Cefazolin 500mg bid Thyroid Sono

Final Diagnosis #1. Pyogenic thyroiditis