Hyperthyroidism Secondary to Disseminated Mucormyc

Authors: Ninela Irga Wojciech Kosiak Radoslaw Jaworski Jolanta Komarnicka Dorota Birkholz

Publish Date: 2012/09/25

Volume: 175, Issue: 1-2, Pages: 123-127

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Abstract

Thyroiditis due to fungal infection is an extremely rare cause of hyperthyroidism The most common etiological factor of thyroiditis is Aspergillus Infections due to members of the Mucorales have been an increasing clinical problem in recent years and the prognosis in generalized infections due to those fungi is usually very poor No hyperthyroidism in a child with thyroiditis due to mucormycosis has been reported in the literature so far We describe a clinical course of generalized mucormycosis with thyroid involvement in a 12yearold girl treated for acute lymphoblastic leukemia The child underwent a hyperthyroidism connected with thyroid involvement due to a fungal process The diagnosis was based on the clinical signs laboratory findings and typical ultrasound scan however later attempt to amplify the fungi DNA from the tissue block has failed The child died because of multiorgan failure due to general fungal infection 49 days after the invasive fungal infection was diagnosed The generalized mucormycosis is always connected with poor prognosis and the mortality is highHyperthyroidism HT due to thyroiditis is rarely observed in children treated for neoplastic diseases One of the causes of HT may be an infectious process in the thyroid gland Fungi most commonly Candida and Aspergillus species belong to infectious factors of HT 1 2 3 Literature gives only few reports on thyroid involvement in the history of mucormycosis even though a constant increase in invasive fungal infections IFIs due to members of Mucorales has been observed in recent years especially in children treated because of proliferative diseases of the hematopoietic system 4 5 Mucormycosis may be a reason of hyperthyroidism in the history of thyroiditis No hyperthyroidism in a child with thyroiditis due to mucormycosis has been so far reported in the literatureAfter 2 years we tried to amplify the fungi DNA from tissue in reference mycology center Formalinfixed paraffinembedded FFPE tissue was sent to the Mycology Laboratory at the New York state Department of Health Albany New York for molecular identification of etiologic agent identified by histopathology The tissue was processed for DNA extraction using QIAamp DNA FFPE tissue Qiagen Valencia CA kit as per the manufacturers’ instructions with minor modifications After tissue lysis step glass beads were added and the mixture was disrupted in a cell disrupter for 30 min followed by DNA extraction using reagents provided in the kit The conventional PCR was carried out to amplify internal transcribed spacer 1 ITS1 and ITS2 regions and the 58S ribosomal DNA rDNA region by using universal primers ITS1 and ITS4 The ITS2 region was simultaneously amplified by using universal primers ITS3 and ITS4 No PCR amplicon was detected with either set of primers These results indicated that either there was complete lack of fungal DNA in the extracted tissue DNA or the amount of fungal DNA was not sufficient to be amplified by conventional ITSPCR It is also important to note that paraffinembedded tissue has historically been viewed as an insensitive source for PCR assay 6In the available literature there is no case report of a child with HT due to mucormycosis The diagnosis of HT is based on the presence of clinical signs such as fever tachycardia and heart palpitations nausea diarrhea muscle weakness fatigue and insomnia However in children who undergo antineoplastic therapy such symptoms most commonly suggest the onset of general bacterial or fungal infection Therefore the diagnosis of HT in the described patient was not easy for oncohematologists It is also important that the child presented no previous signs of hyperthyroidism which would make the diagnosis easier The ultrasound scan of the thyroid gland performed during the initial diagnosis of leukemia showed no abnormalities It should also be stressed that psychotic symptoms came long before the other symptoms of HT That is why it is extremely important for pediatric hematologists to include HT in the differential diagnosis of those symptoms

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