Graves' disease thyroid dermopathy: a case report

BACKGROUND

Graves' disease is the autoimmune activation of the thyroid gland causing diffuse enlargement and hyperfunction of the gland. Manifestations of Graves' disease are multisystemic and include thyroid orbitopathy; pretibial myxedema, also referred to as thyroid dermopathy; and thyroid acropachy, described as a severe form of thyroid dermopathy. Our paper focuses on an atypical case of thyroid dermopathy.

CASE PRESENTATION

An 11-year-old Saudi male presented with a prominent diffuse goiter and exophthalmos. Investigations were consistent with a diagnosis of Graves' disease. The physical exam showed diffuse, non-pitting swelling of the ankle and penis, mimicking a lymphatic malformation. Further, multiple nodules were found on the hands and feet. Treatment of the nodules with cautery resulted in more severe nodules.

CONCLUSION

This report describes rare presentations of thyroid dermopathy mimicking lymphatic malformation. The Koebner phenomenon can explain this patient's atypical presentations. Intralesional injections of triamcinolone and total thyroidectomy showed clear improvement.

Echocardiography in Simple Congenital Heart Diseases: Guiding Adult Patient Management

This article provides comprehensive insights into the evaluation of simple congenital heart diseases (CHDs) in adults, emphasizing the pivotal role of echocardiography. By focusing on conditions such as congenital aortic stenosis, aortic coarctation, patent ductus arteriosus, atrial septal defects (ASDs), and ventricular septal defects (VSDs), the review underscores echocardiography's intricate contributions to precise clinical decision-making. Echocardiography serves as the primary imaging modality, offering high-resolution visualization of anatomical anomalies and quantification of hemodynamic parameters. It enables tailored therapeutic strategies through its capacity to discern the dimensions, spatial orientation, and dynamic shunt dynamics of defects such as ASDs and VSDs. Moreover, echocardiography's advanced techniques, such as tissue Doppler imaging and speckle tracking, provide detailed insights into atrial mechanics, diastolic function, and ventricular filling kinetics. Integration of echocardiographic findings into clinical practice empowers clinicians to create personalized interventions based on quantified ventricular function, which spans systolic and diastolic aspects. This approach facilitates risk stratification and therapeutic planning, particularly pertinent in heart failure management within the CHD patient population. In summary, echocardiography transcends its role as an imaging tool, emerging as a precision-guided instrument adept at navigating the complexities of simple CHD in adults. Its ability to expedite diagnosis, quantify hemodynamic impacts, and unravel multifaceted functional dynamics culminates in a comprehensive depiction of these conditions. The fusion of these insights with clinical expertise empowers clinicians to navigate the intricate pathways of CHD, crafting tailored therapeutic strategies characterized by precision and efficacy.

A native mitral valve mass beyond imagination

The authors report a case of a patient with a history of IgA nephropathy that, during the admission for pneumonia, was found to have an incidental finding of a huge mitral valve (MV) mass on transthoracic echocardiography. The differential diagnosis was challenging because the clinical scenario raised the suspicion of possible infective endocarditis and the imaging features were suggestive of a myxoma or vegetation. The patient underwent urgent excision of the mass with MV replacement due to the high risk of embolism. Intraoperative findings were consistent with clot or vegetation. Pathology result of thrombus was beyond our imagination and at the best of our knowledge one case only has been reported. Awareness about native MV thrombosis and its etiologic factors, workup, and management is key for better medical and surgical management planning because this condition is extremely rare and challenging in the clinical and imaging arena.

503 Role of three dimensional echocardiography and magnetic resonance imaging findings in the decision making and surgical planning of myxomas: correlation with clinical, surgical, and pathological features

Aims

Transthoracic (TTE), transesophageal echocardiography (TEE), and cardiac Magnetic Resonance Imaging (MRI) are usually the mainstay for diagnosis of cardiac myxomas (MYX). It has been reported that three dimensional (3D) TEE has an additional value in describing the anatomical features. MYX are classified in two types: solid (with a round shape and a non-mobile surface) and papillary (asymmetrical shape with an irregular surface). Even though embolic events are linked to thrombus formation in both types, the latter are more frequently source of embolism. The detection of the attachment of the peduncle and a detailed assessment of the echotexture and of the surface characteristics of the tumour is not always possible by 2D TTE and TEE, therefore MRI is considered the gold standard for diagnosing cardiac tumours and myxomas. Our study aim to determine the accuracy of 3D echocardiographic techniques in the detection of the following anatomical features of the MYX: site of attachment (mid atrial septum, other locations), modality of attachment (pedunculated or sessile), echotexture, surface characteristics in comparison with MRI, and histological findings.

Methods and results

We retrospectively reviewed 11 cases of the confirmed myxomas by histology that underwent 2D, 3D TEE, and MRI (6 cases) in the past 6 years in order to assess the ability of the imaging techniques in identifying the anatomical features. Pathology samples were analysed in all patients. Differences in parameters were collected. Our study group is comprised by 10 patients (one recurrence), 8 female, mean age 45.6 ± 14.6 years with 15 myxomas; 11 located in the left atrium [one in left atrial appendage (LAA), one on the mitral valve annulus, 9 near the fossa ovalis], 3 in the right atrium, and 1 on the left ventricular outflow tract (LVOT). Seven were pedunculated, 8 sessile. 2D TEE was not able to diagnose two myxomas. There was an agreement between 2D TEE and 3D TEE in detecting the peduncle except in three patients (only seen by 3D TEE): in the first patient the peduncle was in the atrial septum close to the opening of the left upper pulmonary vein; in the second it was close to the LAA and in the last it was in the LVOT. 3D TEE echotexture analysis matched the pathology in all cases, also in one case of solid tumour with fimbriated edges on a one side which was found to have a clot formation at surgery. There was an excellent matching between the 3D TEE and the MRI in all cases. In our cohort 3DE was able to detect all the morphologic features of the MYX including the site and the type of attachment, the echotexture, and the surface characteristics. The above results led to predict the histologic type, solid, or papillary and there was a correlation with embolism (three patients) and papillary tumours (two patients).

Conclusions

3D TEE and MRI are reliable in assessing the anatomical features of myxomas. The described additional features (peduncle, echotexture, and surface characteristics) seen by these two methods could predict the histological type and have an additional value in the work up of the myxomas leading to correct diagnosis and evaluation of possible complications such as embolic risk. This is helpful to suggest in the management (antiplatelet vs. anticoagulation) and has a pivotal role in programming surgery.