Consilium Medicum

Hypothyroidism is one of the most common thyroid gland disorders. The article addresses the epidemiology and classification of hypothyroidism. Hypothyroidism can have different etiologies. Deficiency of thyroid hormones leads to dysfunction of many organs and systems, manifested by numerous symptoms that can be nonspecific and mimic other diseases. Undiagnosed hypothyroidism is a risk factor for the progression of pre-existing cardiovascular diseases. The prevalence of hypothyroidism is related to the sex and age of patients. The article discusses the main causes of primary and secondary hypothyroidism. The most common cause of primary hypothyroidism is autoimmune thyroiditis, which can develop both independently or associated with other autoimmune conditions as part of the polyglandular syndrome. The causes of hypothyroidism include thyroid surgery and ablation. Transient hypothyroidism may develop in patients with destructive thyroiditis (postpartum, etc.). Thyroid insufficiency as an adverse reaction related to some drugs is discussed. The article describes the clinical symptoms of hypothyroidism. The severity of thyroid hormone deficiency determines the severity of clinical manifestations. Primary hypothyroidism is classified by severity into subclinical and manifest hypothyroidism. There are no significant clinical differences between severe primary and secondary hypothyroidism. Secondary hypothyroidism may be associated with other manifestations of hypothalamic-pituitary disorders. The challenges of diagnosing hypothyroidism, which can simulate another disease, are discussed. The final diagnosis is confirmed by several laboratory and instrumental tests. Subclinical hypothyroidism is characterized by an increase in thyroid-stimulating hormone (TSH) concentration with a normal level of free thyroxine (fT4). Manifest hypothyroidism presents with an increase in the TSH and a decrease in fT4. In secondary hypothyroidism, TSH and fT4 levels decrease. Levothyroxine sodium (L-T4) replacement therapy is used to treat hypothyroidism of any etiology.

Background. Currently, the most common method of preoperative imaging of affected parathyroid glands (PTG) is a combination of scintigraphy with technetium [99mTc] sestamibi and neck ultrasound (with a sensitivity of 81–95%). In some cases, such as multiple PTG lesions, their ectopic location, multiple nodular thyroid lesions, and their hyperfunction or inflammation, standard imaging methods may show negative or contradictory results, which requires the use of 2nd-line diagnostic studies. One is positron emission tomography combined with computed tomography (PET/CT) with 11C-choline.

Aim. To determine the role of PET/CT with 11C-choline in the topical diagnosis of primary hyperparathyroidism.

Materials and methods. Retrospective analysis of data from 33 patients with primary hyperparathyroidism who underwent parathyroidectomy at the Department of Surgical Endocrinology of Pavlov First Saint Petersburg State Medical University from 2022 to 2024. Due to the ineffectiveness of standard imaging and/or the persistence of primary hyperparathyroidism after the first surgery, all patients included in the study underwent PET/CT with 11C-choline (Almazov National Medical Research Centre). The accuracy, sensitivity, specificity, and positive and negative predictive values were calculated considering the pathological postoperative verification of adenoma/hyperplasia and/or achievement of the reference range of parathyroid hormone and calcium plasma levels.

Results. A total of 41 masses were removed in 33 patients (8 patients had 2 masses removed each). Thirty-seven areas were positive according to PET/CT with 11C-choline. Its diagnostic accuracy was 95.5%, sensitivity 90.2%, specificity 97.8%, positive predictive value 94.9%, and negative predictive value 95.7%.

Conclusion. PET/CT with 11C-choline demonstrated high efficacy in preoperative localization assessment of PTG adenomas, even in cases where the results of first-line imaging methods were ambiguous. We use this method in complex cases, although it can be considered an alternative to first-line imaging. This question remains open and requires further studies comparing economic feasibility.

Background. Diabetic foot syndrome (DFS) complicated by osteomyelitis is a severe consequence of diabetes mellitus, often leading to amputations. Chronic inflammation and cytokine imbalance (interleukin – IL-1β, 6, tumor necrosis factor – TNF-α) play a key role in pathogenesis, making the search for immunomodulatory therapies, such as ozone therapy (OT), highly relevant.

Aim. To study the role of proinflammatory cytokines in the complex treatment of patients with DFS complicated by osteomyelitis.

Materials and methods. The study included 62 patients with DFS complicated by osteomyelitis, divided into two groups: the main group (n = 31) received standard treatment supplemented with OT (intravenous infusions of ozonated saline) and ultrasonic cavitation (USC) of osteomyelitic lesions, while the control group (n = 31) received only standard treatment. Levels of IL-1β, TNF-α, and IL-6 were measured using Enzyme-Linked Immunosorbent Assay before treatment and on days 14–15.

Results. In the main group, levels of IL-1β, TNF-α and IL-6 decreased by 4.4, 10.24 and 3.2 times respectively (p < 0.001). The frequency of postoperative complications (phlegmons) was lower in the main group (9.7% vs 22.6%; p = 0.04). The average hospitalization duration decreased from 20.3 ± 4.84 to 14.9 ± 2.08 days.

Conclusion. OT and USC demonstrated significant immunomodulatory effects, reducing pro-inflammatory cytokine levels and improving clinical outcomes. The inclusion of OT and USC in the comprehensive treatment of diabetic foot syndrome complicated by osteomyelitis is advisable to reduce healing time and complications.

Background. Determination of skeletal muscle mass (SMM) for the diagnosis of sarcopenia using bioimpedance analysis of body composition (BIAST) is a well-recognised method. However, as data are accumulating, alternative possibilities for its diagnosis are occurring, particularly the determination of phase angle (PA) and other BIAST parameters.

Aim. Тo determine BIAST parameters, which can be used to predict presarcopenia in elderly and senile individuals with type 2 diabetes mellitus (2 DM).

Materials and methods. A one-stage single-centre cross-sectional study of patients over 60 years old hospitalized in the endocrinological department of Buyanov City Clinical Hospital due to decompensation of 2 DM was carried out. During hospitalisation, the Sarcopenia Fast questionnaire was used to detect sarcopenia syndrome, patients with more than 4 points were included in the main stage of the study to detect sarcopenia according to the European Working Group on Sarcopenia in Older People 2 Consensus. Statistical processing was performed using the SPSS Statistics 23 software package.

Results. Patients with presarcopenia had higher mean values of fat mass (FM) (p = 0.037), whereas levels of specific basal metabolic rate (SBM) (p = 0.0001), active cell mass (ACM) (p = 0.002), PA (p = 0.0001), SMM (p = 0.003) and SMM fraction (fSMM) (p = 0.002) were significantly lower in patients with presarcopenia than in patients without presarcopenia. The diagnostic significance of the derived risk factors by binary logistic regression was assessed by ROC analysis. The area under the ROC curve corresponding to the relationship between the combined BIAST parameters: PA, SMM, fSMM, ACM, and probability of outcome p was 0.772 ± 0.04. The threshold probability p-value at the cut-off point was 0.54. P-values equal to or greater than these values were consistent with predicting the presence of presarcopenia. Sensitivity and specificity were 78.2 and 66.7 respectively with 95% confidence interval 0.694–0.85.

Conclusion. The study has identified universal boundaries for both men and women, FU, SMM, dSMM, ACM, which are included in the prognostic model for the diagnosis of presarcopenia in patients with 2 DM. The availability of information on the threshold values of the main bioimpedance indicators of body composition in patients with presarcopenia and 2 DM significantly expands research and diagnostic opportunities in aging medicine. Interpretation of these data is promising for further studies.

Itsenko-Cushing’s disease (ICD) is a rare neuroendocrine disease caused by hyperproduction of adrenocorticotropic hormone (ACTH) by pituitary adenoma, leading to a persistent increase in cortisol levels and the development of endogenous hypercorticism. Without treatment, ICD leads to severe complications and significantly reduces life expectancy. Transsphenoidal adenomectomy remains the “gold standard” of treatment, but a significant proportion of patients experience persistence or recurrence of the disease, requiring the use of alternative treatments. This paper presents a clinical case of a patient H., 62 years old, with confirmed ACTH-dependent hypercorticism. The diagnosis was made in 2023 based on the following tests: cortisol level in a nocturnal suppression test with 1 mg of dexamethasone – 458 nmol/L, salivary cortisol at 23:00 – 10.37 nmol/L, daily urinary cortisol excretion – > 200 μg/day, ACTH – 14.7 pmol/L. Magnetic resonance imaging showed a pituitary microadenoma. A transsphenoidal adenomectomy was performed; however, remission was not achieved. Ketoconazole therapy was administered, with clinical improvement, but the patient subsequently discontinued the drug on her own. Upon follow-up examination a year later, the persistence of ICD was confirmed (salivary cortisol at 23:00 – 10.5 nmol/L, daily urinary cortisol excretion – 475.2 μg/day, ACTH – 49.8 pg/mL), magnetic resonance imaging showed signs of a residual pituitary tumor. Repeated transsphenoidal adenomectomy was performed, but remission was not achieved again. At follow-up, clinical and laboratory signs of hypercorticism and the patient’s severe condition persisted. Due to the ineffectiveness of surgical treatment, the patient was referred for stereotactic radiosurgery. The management of patients with a persistent or recurrent ICD remains clinically challenging due to the lack of a universal, highly effective, and safe therapeutic approach. The treatment strategy is determined individually, considering the severity of hypercorticism, the presence of complications, the disease prognosis, and the availability of therapies.