Endocrine Abstracts

Introduction: Grave´s disease (GD) is the most prevalent cause of hyperthyroidism, leading to inflammation of the thyroid gland and sometimes to an enlargement of the nearest lymph nodes caused by that same inflammatory process. Peripheral lymphadenopathy of doubtful cause presents a diagnostic dilemma. There are many potential causes: biopsy is sometimes the best way to reach a definitive diagnosis. Tuberculous adenitis is usually regional and mainly affects nodes of the head and neck.

Clinical case: A 21 year-old male patient, with no significant past medical history besides rhinitis and active smoking, is sent to Endocrinology clinic (2016) in the setting of laboratory workup alterations: thyroid-stimulating hormone (TSH) < 0.008 uUI/ml (0.27–4.2); Free thyroxine (FT4) 3.26 ng/dl (0.7–1.58). He presented to the hospital complainning about sudden weight loss (15 kgs in 2 months), anxiety, palpitations, insomnia and trembling hands for over a year. He denied any prior history of similar symptoms.

Physical examination showed signs of goiter, cervical bilateral lymphadenopathies (III/IV region) and otherwise unremarkable and tiamazol 5 mg bid wasprescribed. Six weeks later, thyroid function tests showed a TSH of 0.12 µIU/ml, FT4 of 0.41 ng/, free triiodothyronine (FT3) 2.3 pg/ml (2.57–4.43), TSH receptor antibodies (TRabs) 15.9 IU/l («1) and thyroid peroxidase antibodies 2902.0 UI/ml (0–34). Thyroid ultrasound was significant for an enlarged, heterogeneous, and-hypervascular gland, consistent with an autoimmune or inflammatory thyroiditis. Multiple cervical lymphadenopaties consistent with reactive nature, probably secundary to the inflammatory thyroiditis. At this point, our patient showed a remarkable clinical improvement but a new onset of excessive tiredness, nocturnal fever and further enlargment of painless cervical lymphadenopathies, led to further testing: cervical-thoracic Computer Tomography (CT-scan) showed cervical, supraclavicular and mediastinum lymphadenopathies; serologies were all negative; peripheral blood immnunophenotyping was negative for proliferative disease; aspiration biopsy cytology of one of the lymphadenopathies was performed (Immunophenotyping was negative for proliferative disease; bacteriological and mycobacteriological were also negative). One of the cervical lymph nodes along with adenoid tissue were surgically removed and the cultural test came out positive por Mycobacterium Tuberculosis. Sputum examination was negative for this agent. The patient initiates TB still under treatment for his now assymptomatic Graves disease (tiamazol 5 mg bid). The latest blood tests revealed: Trabs 9 IU/l, TSH 0.13 uUI/ml, FT4 1.72 ng/dl and FT3 4.01 pg/ml.

Conclusions: This cases teaches us how to never overlook all the possible differential diagnosis associated with lymphadenopathies. Tuberculous adenopathies can ecographycally simulate many other conditions.