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Aldosterone is a mineralocorticoid hormone originating from the glomerulosa zone of the adrenal cortex. Its main mechanism of action involves the reabsorption of sodium along with the secretion of potassium and hydrogen ions. It is the final hormonal signal in the renin-angiotensin-aldosterone system, which participates in the regulation of circulating volume and systemic vascular resistance. Hypokalemia and hypertension are key indicators for diagnosing hyperaldosteronism. We present the case of a patient who was diagnosed with hypertension at the age of 30. Hypokalemia was first recorded in his 59th year (2023) with a level of 3.1 mmol/L. The analyzed RAAS markers showed an elevated ALDO/ PRA ratio. Computed tomography revealed a change in the right adrenal gland, measuring 9 mm. Given that the baseline aldosterone values were within the normal range for the healthy population, with a suppressed renin activity peak in one sample, primary aldosteronism was suspected. Consequently, confirmatory suppression tests were required to establish the diagnosis.

Graves' disease (GD) is an autoimmune disease that can affect other tissues in addition to the thyroid gland. The clinical manifestations are a result of the impact of TSH receptor antibodies. Depending on the intensity of the immune response, in addition to hyperthyroidism, orbitopathy, dermatopathy and acropachy can also occur. Extrathyroidal manifestations of GD are most often the result of a more pronounced immune response. Dermatopathy is a rare extrathyroidal manifestation, with a prevalence of 0.5-4.3%, and when it occurs, it almost always accompanies orbitopathy (96%) and hyperthyroidism, while it is associated with a severe form of orbitopathy in 13-15% of cases. It is characteristic of long-standing disease and an intense autoimmune response. We present a case series of five patients with dysthyroid dermopathy. Our patients had different thyroid function disorders (hypo/hyperthyroidism), different forms of dermopathy, and varying times of onset during the disease. Association with orbitopathy and high TRAb concentrations were also present in all our patients. The effects of therapy applied for orbitopathy were monitored, which showed a favorable response on dermopathy, especially with the use of tocilizumab in some of our patients.

Adrenocortical carcinoma is a rare malignant disease, occurring in 0.5-2 per 1,000,000 cases annually. Clinical signs may arise due to autonomous hormonal hypersecretion by the tumor, but also due to local compressive symptoms in the abdomen. The success of treatment depends on early diagnosis, with the recommended treatment being definitive adrenalectomy. An essential strategy in the further treatment of such complex malignancies is chemotherapy with mitotane. Thanks to advancements in medical sciences and comprehensive research, there will be an improved approach in the detection and treatment of adrenocortical carcinomas. We presented a female patient who, during follow-up for operated colon adenocarcinoma, was incidentally found on CT to have a lesion in the right adrenal gland. Due to its size and results consistent with subclinical Cushing's syndrome, the lesion was operated on, and histopathological findings indicated adrenocortical carcinoma. Given the confirmed adrenocortical carcinoma, therapy with mitotane was initiated.

Graves' disease is an autoimmune disorder in which TSH receptor antibodies play the main pathogenic role. Besides the usual clinical presentation as hyperthyroidism, extrathyroidal manifestations can develop. Thyroid dermopathy is one of them and it is present in about 0.5-4.3% of cases, mostly in patients with thyroid orbitopathy as main extrathyroidal manifestation. Dermopathy can manifest in different forms: non-pitting edema, plaques, nodules and elephantiasis. We are reporting a case of a patient with thyrotoxicosis caused by Graves' disease with ocular extrathyroidal manifestation and dermopathy in elephantiasis form, confirmed by punch biopsy. Corticosteroid therapy significantly improved ocular manifestations, as well as skin lesions. Elephantiasis represents the most severe form of this disease and can be resistant to any treatment thus why it is a major therapeutic challenge.

Bilateral adrenal tumors are a rare pathology, increasingly detected due to the widespread use of diagnostic imaging procedures such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). These changes can be either malignant or benign, with the potential for autonomous hormone production. Historically, tuberculosis was a leading cause of bilateral adrenal changes due to lower socio-economic status and poor hygiene. In this case, the patient was diagnosed with hypertension at 38 years old, and initial considerations included secondary endocrine causes of hypertension, specifically primary aldosteronism. CT imaging revealed bilaterally enlarged adrenal glands with multiple nodular changes showing absolute and relative washout indices characteristic of adenomas, with the largest measuring 17 x 23 mm on the right and 21 x 23 mm on the left. The patient had a history of hypokalemia, with the lowest recorded potassium level being 3.3 mmol/L. She reported spontaneous bruising on her arms and legs and weight gain in the abdominal area. Testing indicated the presence of ACTH-independent hypercortisolism. To precisely localize cortisol hypersecretion, adrenal vein sampling (AVS) was performed.

Mediastinal masses originate from the structures of the mediastinum or neck organs and can represent primary benign or malignant tumors, as well as metastases. In most cases, they are detected through radiological imaging, such as an X-ray of the enlarged mediastinum. In the differential diagnostic approach, the acronym "the terrible T" (thymoma, teratoma, terrible lymphoma, and thyroid) is useful. A retrosternal goiter with its compressive effect can lead to changes in the voice, difficult speaking, tracheal compression, and potentially superior vena cava syndrome. Additionally, visualization techniques, thyroid hormones, and tumor markers can be helpful in the diagnostic process. We presented a patient who, during a meal, stopped eating, lost consciousness, and experienced asystole. Due to a chest injury sustained during resuscitation, a computerized tomography (CT) scan was performed. The CT scan revealed a nodular formation in the right lobe of the thyroid gland that extends through the upper thoracic aperture behind the sternum, exerting a pronounced compressive effect on the trachea. Based on the examination, it was concluded that the patient has a goiter with retrosternal and mediastinal extension, accompanied by thyrotoxicosis, which was most likely induced by the iodine contrast agent. Thyrostatic therapy was initiated, followed by surgical treatment of the retrosternal goiter. Computed tomography is the most accessible form of imaging for preoperative assessment of goiter position and its extent, while surgery remains the gold standard for treating symptomatic retrosternal goiters.

Graves orbitopathy is the most common extrathyroidal manifestation of autoimmune hyperthyroidism, although it can rarely occur in euthyroid and hypothyroid patients. TSH-receptor antibodies and insulin-like growth factor-1 play a significant role in the pathogenesis of orbitopathy, and orbital fibroblasts are the central site of their action. In addition to the mentioned autoantibodies, T and B lymphocytes, as well as various cytokines, participate in this complex immune process. As the final product of this immune cascade, there is proliferation of fibroblasts, secretion of glycosaminoglycans, differentiation of fibroblasts into myofibroblasts and adipocytes, which is responsible for the appearance of the clinical presentation of orbitopathy. Before starting the therapy, it is necessary to perform a clinical assessment of orbitopathy, which is based on an assessment of the activity and severity of the disease, as well as an assessment of the patient's quality of life. The activity of orbitopathy is assessed based on the clinical activity score. For the severity of the disease the NOSPECS classification, and for the quality of life assessment the specific questionnaire of the European Group for Graves' Orbitopathy can be used. Based on the obtained data, orbitopathy is classified as active/inactive, mild/moderate-to-severe/severe. Treatment of Graves orbitopathy can be specific or supportive. The specific treatment will depend on the degree of clinical activity and severity of the disease, and the degree of impaired quality of life is taken as an additional factor when choosing individual therapy. Intravenous glucocorticoids are the most frequently used first-line therapy for active, moderate-to-severe Graves' orbitopathy, however, a certain number of patients respond poorly to the applied therapy. In such patients, the use of a second line of treatment is indicated. The most commonly used second line of therapy in our country for active, moderate-to-severe glucocorticoid-resistant GO is tocilizumab. We presented a patient with autoimmune thyroid disease who presented with primary hypothyroidism, in whom, despite the use of intravenous glucocorticoids on two occasions, maintained active, moderateto-severe orbitopathy, and therefore the treatment was continued with biological therapy (tocilizumab). A significant beneficial therapeutic effect was achieved with the applied therapy.

Pseudohypoparathyroidism type 1A is a rare endocrine disorder caused by GNAS mutation and the resulting hormone resistance at the receptor level, i.e. the activation of the intracellular pathway of the Gs alpha subunit is not possible. This disorder is most often characterized by resistance to the parathyroid hormone. However, it can also be characterized by resistance to other hormones, such as thyroid-stimulating hormone, gonadotropins (luteinizing and follicle-stimulating hormones), growth hormone-releasing hormone, and calcitonin. In this article, we describe the case of a patient diagnosed with pseudohypoparathyroidism based on phenotypic features of hereditary Albright osteodystrophy. Due to the progressive decline in intellectual functions and changing behavior, neurological examination confirmed calcifications of the CNS as part of Fahr's syndrome. During hospitalization, higher levels of thyroid-stimulating hormone and calcitonin were observed, probably as a result of resistance at the level of the receptor and its intracellular pathway. Hypercalcitoninemia occurs sporadically in cases involving pseudohypoparathyroidism type 1-a and type 1-b. Elevated levels of calcitonin should be evaluated by means of anamnesis and clinical examination involving morphological and functional tests, considering that a highly specific tumor is a marker of medullary carcinoma of the thyroid gland, as well as some neuroendocrine tumors. Some authors recommend fine needle aspiration biopsy in order to minimize the risk of medullary thyroid cancer.

Immunoassays are commonly used to measure thyroid-stimulating hormone (TSH) and thyroid hormone levels (TH). However, interference in these immunoassays may lead to the misinterpretation of patient results and incorrect therapeutic decisions. Analytical interference can occur following exposure to animals, infections, vaccination, in autoimmune diseases, or without an identified cause. Analytical interference associated with COVID-19 exposure has been observed in D-dimer measurements. A dilution test was used to confirm interference in the measurement of TSH and TH levels. In three patients, interference in TSH and TH levels was detected after COVID-19 infection or vaccination. Conclusions: Owing to the high number of infected and vaccinated individuals, we can expect an increase in the prevalence of interference in immunometric methods.

Medullary thyroid carcinoma is a form of neuroendocrine tumor that arises from parafollicular C cells which produce calcitonin. In addition to calcitonin, these cells produce smaller amounts of other peptides, including carcinoembryonic antigen (CEA), which is used as a nonspecific tumor marker in the follow-up of patients with this tumor. MTC is a rare thyroid tumor and occurs three times more often in women than in men. It can occur in two forms, sporadic (80%) and familial form (20%). The familial form can occur alone or in association with other endocrine tumors within MEN 2A and MEN 2B syndromes. The sporadic form most often occurs in the fifth and sixth decades of life. The familial form is inherited autosomally dominantly, most often based on a mutation in the RET protooncogene located on chromosome 10. C-cell hyperplasia is considered to be a premalignant lesion, which precedes medullary carcinoma. Medullary carcinoma metastasizes very early. We presented a patient with a sporadic form of MTC which appeared at a typical age. Initial values of both baseline and stimulated calcitonin were not in the range for suspected MCT, but due to persistent increases in calcitonin, with elevated baseline (63 pg / mL) and higher stimulated calcitonin (96 pg / mL), the patient was referred for surgical treatment. Due to the strong correlation of calcitonin values with tumor size, the initial calcitonin values were expected to be low because the tumor was 3 mm in size. The histopathological diagnosis was C-cell hyperplasia. However, due to the fact that nodular C-cell hyperplasia is histopathologically difficult to distinguish from medullary microcarcinoma, based on the persistent increase in calcitonin levels, the patient was likely to already have metastatic disease at the time of thyroidectomy. Definitive diagnosis was made by liver biopsy. Therapy with tyrosine kinase inhibitors was introduced, and calcitonin levels strarted to decrea, but there is an increase in carcinoembryonic antigen, which is a poor prognostic parameter.

Background: Thyrotropin receptor autoantibodies (TSH-RAb) are indispensable biomarkers in the laboratory assessment of thyroid-associated orbitopathy (TAO). Clinical sensitivity of three different assays for TSH-R-Ab determination was evaluated in patients with TAO. Methods: 87 consecutive TAO patients were enrolled and their serum samples analyzed in parallel with three assays. An ECLIA competitive binding and a chemiluminescent bridge immunoassay were used to measure total and binding TSH-R-Ab concentration, while their functional activity was determined using a stimulatory TSH-R-Ab (TSAb) cellbased bioassay. Results: Compared to the two binding assays (ECLIA p

Thyroid nodules (TN) are present in about half of the population. About 5% of all nodules are malignant. Image-guided methods for the treatment of TN are becoming a significant alternative to surgery. Percutaneous ethanol ablation (PEA) is effective in the treatment of thyroid cysts, and neck lymph node metastases. Percutaneous laser ablation (PLA) significantly reduces the size of the nodules and improves subjective symptoms. The adverse effects of PEA are rare, transitory, and mild. Radiofrequency ablation (RFA) is effective for nodules of all sizes and compositions. The major complications of RFA are rare and transient. Microwave ablation is also effective in the treatment of thyroid nodules with rare major complications. High-intensity focused ultrasound (HIFU) is a transcutaneous method. It is effective in the treatment of thyroid nodules, and complications are rare. Graves' hyperthyroidism was also treated with HIFU. As thermal ablation (TA ) methods are becoming more popular in 2020, the European Thyroid Association published clinical practice guidelines for the use of image-guided ablation in benign thyroid nodules. A meta-analysis showed that low-risk papillary thyroid microcarcinoma recurrences after TA treatment are rare, as are complications. As the TA methods are acceptable for the treatment of the low-risk papillary thyroid carcinoma European Thyroid Association and Cardiovascular and Interventional Radiological Society of Europe issued clinical practice guidelines for the use of minimally invasive treatments in malignant thyroid lesions. Image-guided treatments for thyroid nodules and cancer are here to stay. Their use will expand and become part of routine clinical practice.

Background: Although thyroid hormones have significant effect on cardiovascular system, the impact of subtle thyroid dysfunction such as subclinical hypothyroidism (SCH) remains to be determined. We investigated coronary flow reserve (CFR) in patients with subclinical hypothyroidism. Methods: Thirty two subjects with SCH and eighteen control subjects with normal serum thyroid hormones and thyroid-stimulating hormone (TSH) levels were included in the study. TSH, free thyroxine, free triiodothyronine, glucose, insulin, HbA1c, cholesterol, triglyceride and plasma levels of C-reactive protein were measured. Coronary diastolic peak flow velocities in left anterior descending coronary artery were measured at baseline and after adenosine infusion. CFR was calculated as the ratio of hyperemic to baseline diastolic peak velocity. Results: CFR values were not significantly different between the two groups (SCH 2.76±0.35 vs controls 2.76±0.42). There was a significant correlation of CFR with waist to hip ratio, hypertension, smoking habits, markers of glucose status (glucose level, HbA1c, insulin level, HOMA IR), cholesterol, LDL-cholesterol and triglyceride levels in SCH group, whereas only cholesterol level showed significant correlation with CFR in controls. There was no correlation between CFR and thyroid hormones. Conclusions: We concluded that there is a different impact of cardiovascular risk factors on CFR in SCH patients compared to healthy control and that these two groups behave differently in the same circumstances under the same risk factors. The basis for this difference could be that the altered thyroid axis "set point" changes the sensitivity of the microvasculature in patients with SCH to known risk factors.

Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a necrotizing vasculitis of small and medium-sized blood vessels characterized by diffuse inflammation of vascular structures and perivascular and extravascular granulomatosis. In its systemic form, GPA predominantly affects the ear, nose and throat, with lung and kidney involvement with typically rapidly progressive necrotizing glomerulonephritis with extracapillary crescents, while the absence of kidney damage at the time of diagnosis is defined as a limited form of GPA with a more favorable prognosis (1, 2). Antineutrophil cytoplasmic antibodies (c-ANCA) with specificity for proteinase 3 (PR3) represent a biochemical diagnostic criterion. They are detected in 90% of generalized forms and in about 50% of limited forms of granulomatosis with polyangiitis (1, 2). In the absence of treatment, GPA is a disease of progressive evolution. Systemic corticosteroid therapy and immunosuppressive therapy significantly changed the prognostic aspect of the disease. Only a few sporadic observations have been published on endocrine disorders associated with GPA. We present a case of a man, 39 years old, with Wegener's granulomatosis who developed autoimmune thyroiditis 8 years after the initial diagnosis.

Introduction/Objective. Hypothyroidism is a common disease and treatment with levothyroxine (LT4) is effective. However, variations in management are frequent. The aim of this study was to identify practices and attitudes of Serbian physicians relating to the treatment of hypothyroidism. Methods. An anonymized questionnaire was distributed electronically to members of the Serbian Thyroid Society, Serbian Association of Endocrine Surgeons, and Section for Endocrinology of the Serbian Medical Society. Results. Out of 170 invitations, 99 responses were received. LT4 was the first choice for the treatment of hypothyroidism in 90% of patients. After starting LT4 replacement therapy most respondents would recheck thyroid-stimulating hormone (TSH) in 4–6 weeks (n = 51, 62%) and in eight weeks (n = 29, 35%). In total, 61% of respondents (n = 60) indicated that they would consider treating euthyroid patients with LT4, the commonest indication being female infertility with high levels of thyroid antibodies (54%, n = 50). More than half respondents (58%, n = 45) would recommend combined LT4 + LT3 therapy for patients on LT4 with normal serum TSH who still complain of symptoms of hypothyroidism. 53% (n = 41/77), reported that the frequency of patients with normal serum TSH who still complain of hypothyroid symptoms is less than 5%. Conclusion. LT4 was the first choice of therapy for the treatment of hypothyroid patients, whereas LT3 + LT4 combination treatment is considered in patients with persistent symptoms of hypothyroidism despite normalization of TSH. The most common indication for thyroid hormone treatment in euthyroid patients was female infertility with high levels of thyroid antibodies. Alternative LT4 formulations like liquid solution or soft-gel capsules –formulations presently not available in Serbia, were largely reserved for specific conditions (interfering drugs, malabsorption, inability to take LT4 in the fasting state, unexplained poor biochemical control of hypothyroidism).

There are three basic modalities for the treatment of thyrotoxicosis: thyrosuppresive drug therapy, ablation with radioactive iodine and surgical treatment. Patients who do not achieve adequate thyrotoxicosis control, as was the case of described patient, have a high mortality rate due to the possibility of developing a thyroid storm. The use of drug therapy for hyperthyroidism, as the first line of treatment, is associated with the appearance of various side effects, as was the case in our patient. Side effects of Methimazole are dose-dependent, while in the case of Propylthiouracil, the occurrence of side effects is not clearly dose-dependent. In the case of the described patient, all alternative, lesser known modalities for the treatment of hyperthyroidism were applied, after the occurrence of adverse reactions to thyrosuppressive therapy. Sodium perchlorate, ie. Sodium with perchloric acid is rarely used in the treatment of hyperthyroidism, as in cases of severe idiosyncratic reactions to thionamides, agranulocytosis or hepatitis, if the eumetabolic state is not achieved and the application of a therapeutic dose of radioiodine is not possible. It is applied in the form of a solution, usually 8%; In more severe forms of the disease, when hyperthyroidism is very pronounced, 10 to 15 drops a day are given 4 to 6 times and the dose is sometimes reduced to the minimum maintenance dose. After the adverse reaction even to sodium perchlorate therapy we were left with one more, last option-Plasma Therapy exchange. Plasma Therapy Exchange (TPE) is an out-of-body blood purification technique designed to remove high-molecular-weight substances bound to plasma proteins (autoantibody pathogens, immunocomplexes, cryoglobulins, myeloma light chains, endotoxins, lipoprotein-containing cholesterol, and thyroid). The effectiveness of treatment depends on the volume of blood being processed, the volume of plasma exchanged in each process, the number of procedures performed, the frequency of exchange and the rate of mobilization, stabilization and re-synthesis of cells or plasma components. TPE is an effective alternative treatment that provides an opportunity to prepare patients for definitive treatment: ablative therapy such as RAI ablation or thyroidectomy. Therapeutic plasmapheresis, if performed in specialist centers, is a safe, fast and effective method.

Background/Aim. Although subclinical hypothyroidism (SCH) is frequently a biochemical diagnosis, some symptoms and signs of overt disease may be present, influencing our decision to start the treatment with levothyroxine (LT4). The aim of this study was to examine the effect a 3- month LT4 treatment on clinical presentation and quality of life in symptomatic SCH with thyroid-stimulating hormone (TSH) < 10 mIU/L. We also considered whether treatment discontinuation additionally improves reliability of these findings. Methods. Clinical parameters (disease-specific score) and quality of life (Short Form-36 questionnaire) were measured in 35 patients with persistent symptomatic SCH (TSH 7.0 ± 2.1 mIU/L) before the intervention (LT4 substitution), 3 months after the euthyroid state had been achieved and 3 months after cessation of LT4 substitution. Results. The median of the Zulewski index significantly decreased after the treatment with LT4: 5.0 (4.0–7.0) vs. 3.0 (2.0–5.0) (p < 0.001) representing a reduction of symptoms. The most common ailments before the treatment were dry skin (71.4%), hoarseness (65.7%) and rough skin (54.3 %). After the treatment, there was a significant reduction in the frequency of constipation (p = 0.004), dry skin (p = 0.022), hoarseness (p = 0.002), decreased sweating (p = 0.006), and delayed Achilles reflex (p = 0.002). Quality of life was not changed significantly after LT4 treatment. In the group of 18 patients who discontinued the treatment, many symptoms and signs reappeared with the TSH increasing (6.8 ± 1.1 mIU/L): periorbital edema, constipation, weight gain, decreased sweating, slow motion and delayed Achilles reflex. The median of the Żulewski index after discontinuation of LT4 was 6.0 (4.0–9.0) (p = 0.010). Also, there was a statistically significant reduction in the general health score, and vitality, role emotional and mental health scores. Conclusions. Clinical score, based on symptoms and signs, is a sensitive and reproducible test for objective estimation of LT4 treatment effects in symptomatic SCH patients with TSH

Syndrome Fahr is described as calcification of the basal ganglia and is a rare inherited or sporadic neurological disease with a prevalence of 1:1000000 (1). For the first time described in 1930 in the works of Dr. Karl Theodor Fahr, it is characterized by calcium deposition in areas of the brain to control movement: basal gamma, thalamus, cerebral cortex, cerebellum, dentate nucleus, subcortical white matter and hippocampus (2). The diagnostic criteria were revised and modified by Moskowitz et al. in 1971., Ellie et al. in 1989. and Manyam in 2005. and include: bilateral calcifications of the basal ganglia confirmed by neuroradiological visualization, progressive neurological dysfunction and neuropsychiatric manifestations, absence of biochemical and somatic entities of mitochondrial disease, absence of infectious, traumatic, or toxic etiology, and autosomal dominant inheritance (2,3,4). Etiologically, endocrine diseases, and especially parathyroid gland dysfunction, are closely related to Farr's syndrome, including idiopathic hypoparathyroidism, secondary hypoparathyroidism, pseudohypoparathyroidism, pseudo-pseudohypoparathyroidism, and hyperparathyroidism. Pseudo and pseudo-pseudohypoparathyroidism are defined by a phenotypic spectrum induced by a mutation in RNA. They manifest on average at the age of 8 to 10, with clinical manifestations very similar to hypoparathyroidism, except for a slightly more pronounced intellectual declension. The term pseudohypoparathyroidism (PHP) for subtypes PHP type IA and PHP type 1C includes diseases that share the biochemical characteristics of hypoparathyroidism (hypocalcemia and hyperphosphatemia), and which are the consequences of resistance of target tissues to the action of parathyroid hormone. In some cases, resistance to TSH, gonadotropins, GHRH and calcitonin, which have receptors bound to the Gs Alpha subunit, is detected. Patients with type 1A and type 1C PHP show diverse phenotypic expression combined by the term Albright hereditary osteodystrophy (AHO), which includes premature closure of bone and short bone growth zones, low growth, ectopic calcifications. More specifically, based on the dissemination of ectopic calcifications, patients were classified into three categories: pseudohypoparathyroidism, progressive bone heteroplasia, and osteoma cutis. Our patient was diagnosed as pseudohypoparathyroidism at an early age based on the phenotype characteristics of AHO and the biochemical findings of hypocalcemia. Substitution therapy with vitamin D and calcium was introduced, and after pronounced changes in behavior, feelings of being followed and extreme anxiety, he was hospitalized in the Clinic for Neurology and in the Clinic for Endocrinology, Clinical Center of Serbia. Neurofunctional studies have shown progressive decline in intellectual function, neuroradiologically were detected zones of calcification of the basal ganglia and frontal subcortical white matter, as well as hypothyroidism as a consequence of TSH resistance. High concentrations of calcitonin were detected, also as a consequence of resistance of target tissues to calcitonin.

Introduction: Amiodarone as an antiarrhythmic medication is necessary in the prevention and treatment of malignant ventricular arrhythmias, however, it can induce thyroid dysfunction. Thyroid dysfunction may be either hypothyroidism or thyrotoxicosis, however, 50% of patients who have used amiodarone are euthyroid. Case report: A 27-year-old female patient, hospitalized at the Clinic for Endocrinology due to type 2 amiodarone-induced thyrotoxicosis. The patient had previously received amiodarone for two years. At age 25, the patient was diagnosed with dilated cardiomyopathy (EF 25%, EDD/ESD 56-57/47 mm) with mild Ebstein’s anomaly, WPW Sy and recorded episodes of non-sustained VT. In order to reduce the risk of sudden death and prevent malignant ventricular arrhythmias, ICD-VR was implanted and amiodarone was prescribed. Treatment with propylthiouracil (PTU) and dexamethasone was initiated after thyrotoxicosis was diagnosed. Three weeks after the introduction of PTU, hepatotoxicity was registered, thus the medication was discontinued. Thyrozol, which regulates the hepatotoxicity parameters, was introduced. Sodium perchlorate and glucocorticoid (per os, IV and intrathyroidal) therapy was introduced. The treatment had lasted for fifty days and laboratory signs of thyrotoxicosis were still present, which is why a total of eight plasmapheresis sessions were performed. Each plasmapheresis resulted in a significant decrease in FT4 and a slight decrease in FT3. After seventy two days of treatment, an optimal hormonal status of the thyroid gland was established and total thyroidectomy was performed. Conclusion: Patient was treated for amiodarone-induced thyrotoxicosis (AIT) type 2, which was resistant to conventional therapy for a long period of time. Successful treatment was achieved by applying plasmapheresis although the effect of perchlorate and glucocorticoids application cannot be disregarded.

OBJECTIVE: The aim of the study was to assess whether sudden change in blood glucose concentration in healthy subject would produce insulin secretory pattern similar to one in type 2 diabetic subjects (T2D). DESIGN: The concept of the study was to 'reset' the pancreas and empty the stored insulin pool, so that subtle derangements of the pulsatile insulin secretion could be studied. METHODS: The study group included 6 control and 7 T2D subjects. For insulin and glucose determination, blood was sampled for 60 minutes with 2 minutes inter-sample interval. To increase blood glucose an intravenous glucose bolus was given (0.3 g/kg body weight). RESULTS: The average glucose level in the T2D group was significantly higher, but the average insulin concentration was not different between the groups. Insulin half-life, pulse amplitude, number of pulses and interpulse interval did not differ between the groups. CONCLUSIONS: Therefore, the sudden increase in blood glucose causes insulin secretory pattern to become similar in the healthy and in the T2D subjects. However, the defect in the insulin secretion or glucose sensing inherent to β-cell exists, as the insufficient quantity of insulin is secreted in response to the increased glucose level.

Female pseudohermaphroditism represents discrepancy between karyotype and gonadal features on one side and a psychogenic phenotype on the other. Congenital adrenal hyperplasia is the part of the spectrum of female pseudohaermaofroditism and is due to an enzyme deficiency in steroidogenesis. More than 95% of patients have 21 hydroxylase deficiency which leads to a lack of cortisol and ACTH hypersecretion of pituitary, overproduction of 17 hydroxy progesterone (17OHP) and androgens and adrenal cortex hyperplasia. The clinical phenotype is classified as classical and nonclassical (aka. 'Late onset' form). The classic form is represented as salt-waisting and simply virilizing, depending on the degree of lack of aldosterone. Pathophysiology of CAH due to the lack of 21α hydroxylase is closely associated with the degree of enzyme deficiency. Overproduction of androgens is leading to accelerated virilisation. Classical form is manifested in childhood and is characterized by the overproduction of cortisol precursors and adrenal androgens. In the most severe form, co-aldosterone deficiency leads to loss of salt with all the complications. Girls with the classical form of CAH typically have am ambiguous genitals at birth due to high concentrations of androgens in utero. CAH due to 21OH deficiency is the most common cause of ambiguous genitals in 46XX newborns. Characteristically, the clitoris is enlarged, partially fused labia maiora and a common urogenital sinus at the site of the urethra and vagina. The uterus, Fallopian tubes and ovaries are present and normal, a structures of Wolfian duct are absent. When diagnosed in childhood 46XX CAH patients has been assigned female gender so far, even in fully expressed in virilised external genitalia. This dogmatic approach is based on preserving fertility, and if there was at least uterus, opting for female sex was considered justified. Only about 5% of 46 patients with XX KAH has a psychogenic male gender, as described patient. In addition to mutations of CYP21A2 and effects of high concentration of androgen in the CAH, in the phenotypic expression of CAH different length of sequence of CAG androgen receptor could have an impact, which modulates the effect of androgens on the periphery. Also, while the cases of adaptation of sexual identity and the external genitalia from female to male were documented, not a single case of questionable male sexual identity is noted. In the presented patient testosterone levels are at the upper limit for men, which may be due to enzymatic block and synthesis of cortisol precursor, which is further metabolized to the active androgen: testosterone and dihydrotestosterone. High concentrations of T prenatally and in infancy has led to premature fusion epiphysis and low growth, and high concentrations of DHT to clitoromegaly. The LHRH test showed no stimulatory response of LH, which is probably suppressed by high concentrations of testosterone , but there still needs to be done endocraniaol MNR to rule out other possible etiologies of gonadotroph suppression. Dexamethasone suppression test with measurement of testosterone could give an answer. The treatment of adult patients is based on hydrocortisone in dosages that provide permanent substitution of cortisol and suppress ACTH hypersecretion. In 46 XX patients who are phenotypically male, and whose full identity is male, reconstructive surgical procedures are needed to enable adequate quality of life.

Clinical examination is the basis of a good assessment of a patient with Graves' orbitopathy. This study gives recommendations of the European orbitopathy group related to the activity and severity of the disease. The activity of the disease is estimated on the basis of inflammation of the soft tissues and the sum of clinical activity is used here. Severity of the disease is estimated by measuring exophthalmos, palpebral aperture, infection of soft tissues, extraocular muscles, corneal infection and optical nerve. The decision on the type of treatment is made on the basis of the assessment of severity and activity.

More than a half century of experience with aspiration punch of nodal changes in the thyroid gland has confirmed this procedure as a golden standard in the examination of thyroid nodal disease. Although sensitivity, specificity, reliability and reproducibility are incontestably high, this procedure cannot give a simple answer on whether the change examined is benign or malignant. Numerous attempts to improve the procedure resulted in considerably advanced findings. Besides refining the cytopathologic examination techniques, confirmation or determination of hormones, proteins and other substances in the material obtained by fine-needle aspiration are actually the greatest contribution to improvement the of procedure's diagnostic value. These markers are actually followed, in most medical centers, in aspirates of thyroid nodal changes but also surrounding lymph nodes in order to evaluate with greater certainty the type, volume and spread; this is important to establish treatment procedures and to evaluate the residual disease after accomplishing the treatment.

Copyright of Medical Gazette / Medicinski Glasnik is the property of Specijalna bolnica za bolesti stitaste zlezde i bolesti metabolizma Zlatibor and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Medical Gazette / Medicinski Glasnik is the property of Specijalna bolnica za bolesti stitaste zlezde i bolesti metabolizma Zlatibor and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Medical Gazette / Medicinski Glasnik is the property of Specijalna bolnica za bolesti stitaste zlezde i bolesti metabolizma Zlatibor and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Klinički pregled predstavlja osnovu dobre procene pacijenata sa Graves-ovom orbitopatijom. U tekstu su date preporuke Evropske grupe za orbitopatije vezane za pregled aktivnosti i težine bolesti. Aktivnost bolesti se procenjuje na osnovu inflamacije mekih tkiva i u tu svrhu se koristi zbir kliničke aktivnosti. Težina bolesti se procenjuje merenjem egzoftalmusa, palpebralne aperture, zahvaćenosti mekih tkiva, ekstraokularnih mišića, zahvaćenosti kornee i optičnog nerva. Na osnovu procene težine i aktivnosti donosi se odluka o načinu lečenja. [ABSTRACT FROM AUTHOR]

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