---

Background and purpose: Thyroid nodules are quite common witch are found in clinical or ultrasound examinations. They are detected in 4-8% of clinical examinations and 7-15% are malignant. TSH is one of the growth factors for nodule growth. Controversial reports are published on the effect of TSH on thyroid nodule malignancy. This study aimed at investigating the effect of TSH in predicting malignancy in thyroid nodules.
Materials and methods: In this cross sectional research, 500 patients were studied. Serum TSH level was measured prior to fine needle aspiration (FNA). Data analysis was done applying inferential statistics. 
Results: The patients were 457 (91.4%) females and 43 (8.6%) males and the mean age was 43.43±13.9 years.  Among the patients 240 had single nodule and 260 had multiple thyroid nodules (P=0.08). The mean size of nodules in benign and malignant nodules were 26.1±12.2 and 27.3±9.8 mm, respectively (P=0.6). Malignant and benign nodules were observed in 31 (6.2%) and 469 (93.8%) patients. Mean TSH level was 3.3±6.9 and 2.4±2 in patients with benign and malignant nodules, respectively (P= 0.47). To investigate the association between TSH and FNA cytology, TSH levels were divided into <0.5, 4.9-0.5, and ≥5 using person correlation. This study showed no significant difference between the three groups (P= 0.3).
Conclusion: TSH alone is not a suitable marker for predicting thyroid malignancy.
 

---

Background and purpose: Novel coronavirus (COVID-19) can cause acute kidney injury (AKI), and underlying kidney diseases worsen the prognosis of COVID-19 patients.
Materials and methods: This observational study examined the clinical and laboratory outcomes of patients with COVID-19 and assessed the major risk factors for death and intensive care unit (ICU) hospitalization in COVID-19 patients. The sample consisted of 296 COVID-19 patients with or without underlying kidney diseases. In total, 37 patients died (mean age: 66.6 ± 17.6).
Results: Most patients who passed away initially suffered from shortness of breath (37.8%), cough (21.6%), old age, insulin use, central nervous system (CNS) disease, septic shock, hypoalbuminemia (P<0.0001), and high international normalized ratio (P<0.0001). Median time to death was higher in patients hospitalized in the ICU than in those without chronic kidney disease (OR=3.08; P=0.006). The use of azithromycin and ceftriaxone was lower than the use of Recigen and meropenem in deceased people (P<0.0001).
Conclusion: The risk of mortality and ICU hospitalization was higher in patients with CKD than in those without CKD. The results revealed the therapeutic effects of azithromycin and ceftriaxone and the side effects of Recigen and meropenem in deceased COVID-19 patients. In addition, low albumin level, high INR, neutrophil count, white blood cell (WBC) significantly increased the risk of death in these patients.
 

---

Schmidt syndrome is a polyendocrinopathy characterized by multiple organ failures. Patients with two or more of the following characteristics are diagnosed with this syndrome: Graves' disease, adrenal insufficiency, autoimmune thyroiditis, and type I diabetes. The present case report concerns a Schmidt syndrome patient (polyglandular autoimmune syndrome type II). The patient is a 42-year-old woman with type I diabetes and complaints of imbalance, weakness and lethargy, weight loss, darkened skin, blood pressure drop, hypoglycemia, and hyperkalemia who visited the Hospital frequently and was discharged every time after intravenous potassium chloride and dextrose injections and orders to reduce insulin consumption at home. Her blood cortisol level was measured in her last visit with suspicion of adrenal insufficiency, which was revealed to be low (less than 0.5 μg/dL). A high ACTH, low aldosterone, and normal renin were also reported, indicating secondary adrenal insufficiency. Furthermore, T4 and TSH tests were performed, reporting a TSH lower than 0.2 in the initial TSH test, which was revealed to be normal after the test was repeated. Subclinical hyperthyroidism was indicated, given the high TRAb figure. The patient underwent treatment with fludrocortisone and prednisolone, which improved her condition. This report accentuates that diabetic patients with reduced insulin requirements must be checked for adrenal insufficiency immediately to prevent potential complications.

 

---

Urinothorax is a rare cause of pleural effusion and often occurs unilaterally. In a urinothorax, the pleural fluid has the color and odor of urine, and the ratio of pleural fluid creatinine to serum creatinine is greater than one. In this report, a case of urinothorax after prostate cancer is presented. The patient is a 79-year-old man with a history of BPH who presented with urinary retention, nausea, and dyspnea. Laboratory tests revealed high serum creatinine, hypercalcemia and hyperkalemia. Ultrasound revealed moderate left-sided hydronephrosis, moderate ascites and massive left-sided pleural effusion on chest X-ray. Thoracentesis and aspiration of ascitic fluid were performed, and the ratio of creatinine in pleural fluid and ascitic fluid to serum creatinine was greater than one. The patient underwent bilateral nephrostomy, after which the pleural effusion and ascites resolved without further aspiration. A prostate examination revealed an enlarged and firmer prostate than normal. The patient's PSA level was checked and found to be over 100, and a prostate biopsy diagnosed adenocarcinoma of the prostate. The patient received the first cycle of chemotherapy and was discharged from hospital in good general health.
 

---

Papillary carcinoma is considered the most common thyroid malignancy. This cancer often presents with a good prognosis. This report introduces a patient with papillary thyroid carcinoma with multiple metastases and elevated CA19-9 levels. The 65-year-old male patient presented with weight loss. Gastrointestinal investigations were normal. CA19-9 levels were requested and reported as high. Additionally, blurred vision was present, and metastasis to the choroid was mentioned. Imaging revealed a mass in the left lobe of the thyroid. Fine-needle aspiration was performed, and the histopathology report confirmed papillary thyroid carcinoma. The patient underwent a thyroidectomy and was subsequently treated with iodine-131. Initial tests showed low thyroglobulin levels and high anti-thyroglobulin antibody levels. CA19-9 levels also showed an increasing trend in serial tests. Three months later, the patient experienced abdominal pain, generalized bone pain, neck pain, and right shoulder swelling. Further investigations confirmed metastases from papillary thyroid carcinoma. The patient also developed speech problems and memory loss, with brain metastasis evident in magnetic resonance imaging. The patient underwent ten sessions of brain radiotherapy and was subsequently prescribed sorafenib. During the course of treatment, the patient contracted COVID-19 and passed away due to the resulting pneumonia. In papillary thyroid carcinoma, it is important to take diagnostic measures to rapidly detect metastatic forms in case of any new symptoms. Additionally, if anti-thyroglobulin antibodies are present, CA19-9 can be used as a tumor marker.

---

Background and purpose: Adverse drug reaction (ADR) is one of the main causes of mortality and morbidity and can contribute to high costs in healthcare system of a country. This study was conducted to evaluate ADRs in the Food and Drug deputy at Mazandaran University of Medical Sciences.
Materials and methods: This retrospective descriptive study was carried out after collecting the reports of yellow cards sent to the Center for Registration and Investigation of Adverse Drug Reaction in the Food and Drug Deputy of Mazandaran and the reports registered in the online system for registering medical complications and errors in 2019-2021. We analyzed data, including the frequency of the drugs with side effects, the frequency of routs of administration, number of reports per year, patient characteristics (gender and age), as well as the frequency of the organs damaged, and the reporters.
Results: A total of 2122 reports of adverse drug reactions were submitted to the Adverse Drug Reactions Center at Mazandaran Food and Drug Department. Nurses reported 52.78% of the side effects and 44.82% of the ADRs were seen in women. Injectable drugs were found with high rate of ADRs (87.40%) and the most prevalent side effects were associated with skin and hair disorders (28.07%). Anti-infective agents were the most common drugs that caused ADR (47.10%) and Vancomycin was found to be more prevalent than other drugs.
Conclusion: Adverse drug reactions were reported at a good level in Mazandaran province. It is believed that training the medical staff about pharmacovigilance and appropriate reporting, will bring us closer to world standards.
 

---

Vaccination is a highly effective medical intervention in the COVID-19 pandemic. Systemic Capillary Leakage Syndrome (SCLS) is a severe and rare condition that can occur following COVID-19 vaccination, leading to recurrent shock episodes in patients. This report highlights a case where a patient experienced leakage syndrome after receiving the AstraZeneca vaccine. The 31-year-old female patient experienced shortness of breath, blood pressure drops, edema, and limb coldness 48 hours after receiving the COVID-19 vaccine. The clinical assessments identified low blood pressure, rapid heart rate, and reduced breath sounds at the bases of the lungs. Bilateral pleural effusion was observed in a chest CT scan, and pericardial effusion of moderate severity was seen in echocardiography. Laboratory tests showed leukocytosis, hyponatremia, hypoalbuminemia, hypocalcemia, and transudative pleural fluid. The remaining observations fell within standard parameters. Measures such as fluid restriction, correction of electrolyte imbalances, prescription of corticosteroids, and antibiotic therapy were applied. These interventions resulted in an improvement in the patient's overall condition, leading to the resolution of her symptoms. Since the symptoms of leakage syndrome are non-specific, and its diagnosis is based on excluding other causes, and considering that no paraneoplastic evidence was found in the studied patient, the diagnosis of leakage syndrome was attributed to the individual.
For individuals exhibiting hypovolemic shock and edema linked to pleural effusion or ascites, and upon excluding conditions such as nephrotic syndrome, hypercoagulability syndromes, sepsis, and connective tissue vascular diseases, attention should be directed towards the possibility of leakage syndrome. Supportive care is the mainstay of treatment in these patients, and fluid restriction is a key component of management. Awareness of the symptoms and signs of this syndrome, as well as factors that may trigger its recurrence, is essential for physicians to make appropriate decisions for timely diagnosis and treatment in similar cases