KCP 723 삼성서울병원 전공의 하상윤

49세 여자 환자 피곤한 증상과 목의 혹 다수의 결절이 만져짐 초음파 검사: 검사실 소견 Rt: 2.0x1.0cm sized ill defined low echoic lesion, 0.4cm sized isoechoic nodule Lt: diffuse heterogeneous echogenicity, 1.3x1.3cm sized low echoic lesion multiple lymph node at bilateral level VI No suspicious lymph node on bilateral lateral neck 검사실 소견 CRP; 30.4mg/L (0.1~6.0) TSH receptor Ab; 1.24 IU/L (0~1.75) T3; 160.5 ng/dL (71~161) Free T4; 2.0 ng/dL (0.8~1.7) TSH;<0.01 mIU/mL (0.86~4.69) Anti-TPO Ab; 19.5 IU/mL (5~13.6) Anti-thyroglobulin Ab; 18.4 IU/mL (10~124.2)

Cellular smear

염증세포가 background에 흩뿌려져 있고 핵이 주변 염증세포보다 큰 세포들이 모여 있는 것이 콜로이드와 함께 관찰되었습니다.크

콜로이드와 follicular cell과 epitheliod histiocyte가 loose granuloma를 형성하고 있습니다.

follicular cell과 epitheliod histiocyte가 loose granuloma를 형성

Multinuleated giant cell 핵은 uniform하고 small round to oval sharp nuclear membrane finely granular chromain 하나정도의 micronucleoli Cytoplasm을 abundant granular. 올라와 있는 사진 끝

보내 주신 슬라이드 중 convenitonal smear 입니다. 저배율에서 역시 cellular smear를 볼 수 있으며 염증세포가 background에 관찰됩니다. 찍은 사진 Conventional 시작

Colloid를 먹고 있는 듯한, multinucleated giant cell Colloid를 먹고 있는 듯한, multinucleated giant cell. dense한 cytoplasm을 가진 multinucleated giant cell 핵은 40개 정도3

Multinucleated giant cellconventional

Sheet of follicular cell

Scan conventional

neutrophil

Thin prep 에서는 background의 염증세포는 많이 관찰되지 않았습니다. Follicular cell들이 약간 핵이 커져 있고 nucleoli가 보이는 activated Follcular cell들이 sheet 형태로 관찰되었습니다.

여러 개의 multinucleated giant cell이 관찰되었습니다.

Histologic findings Cellular smear Multinucleated giant cell around colloid Aggregation of epithelioid histiocytes Sheets of mildly atypical follicular cells No oncocytic cells A few colloid Some lymphocytes and histiocytes Few neutrophils and no plasma cells A few spindle stromal cells

Multinuclear giant cells in thyroid FNA Nodular goiter or Thyroid neoplasm with cystic change (Foreign body histiocytic type) Variable in size Nuclei uniform and usually small in numbers Cytoplasm dirt, granular, ± hemosiderin Subacute thyroiditis (Multinucleated foreign body type) May be present in large numbers Enourmous in size with multiple, uniform nuclei in tens and hundreds Often seen in the vicinity of blobs of colloid, forming granulomas ± epithelioid cells Spindle shaped stromal cells Hashimoto’s thyroiditis (Multinuleated giant cell) Infrequent occurrence Nondescript morphology Fewer nuclei Associated Hashimoto’s features Palpation thyroiditis Acellular smear, rare chronic inflammatory cells Colloid follicular cells are usually absent

Multinuclear giant cells in thyroid FNA Papillary carcinoma (Multinucleated giant cell) Variable in size Anaplastic carcinoma P/D metastatic carcinoma Bizarre nuclei with malignant criteria Infectious granulomatous lesions/ Sarcoidosis (Multinucleated foreign-body giant cells) Langhans-type giant cells and necrotic acellular debris characteristic in tuberculosis granulomas (AFB stain +) Associated with epitheliod cells and granulomas Inadvertent aspiration of thyroid or thyroid cartilage (Megakaryocytes) Multilobulated nuclei Smudgy chromatin Abundant dense cytoplasm Other hematopoietc cells in background Hodgkin’s lymphoma (RS cell) Varying sized, large to giant forms, mirror-image nuclei or multinucleated with prominent nucleoli

conventional

Hashimoto’s VS Subacute Abundant mixed lymphocyte and plasma cells Germinal center cells Lymphohistiocytic aggregates Hurthle cells and variable nuclear atypia Infrequent multinucleated giant cell / absent granulomas Little colloid Many multinucleated giant cell (numerous nuclei), often in the vicinity of blobs of colloid Mixed inflmmatory cells including epitheliod histiocytes and lymphocytes Hypocellular smear: scant follicular cell Degenerative changes in follicular cells, cell debris and colloid

Hashimoto’s VS Subacute Pain over the thyroidal bed was recorded in 100% of subacute thyroiditis. Typical cases of Hashimoto’s disease do not present pain over the thyroidal bed. Cytologic findings of the final stages of the two condition may overlap: very small numbers of lymphocytes and oncocytic cells Fine-needle aspiration of subacute granulomatous thyroiditis (De Quervain's thyroiditis) : a clinico-cytologic review of 36 cases. Diagn Cytopathol. 1997 Mar;16(3):214-20.

Hashimoto’s disease Subacute thyroiditis 49세 여자 환자 o 피곤한 증상 Thyroid nodules Neck LN enlargement ? CRP; 30.4mg/L (0.1~6.0) T3; 160.5 ng/dL (71~161) Free T4; 2.0 ng/dL (0.8~1.7) TSH;<0.01 mcIU/mL (0.86~4.69) Anti-TPO Ab; 19.5 IU/mL (5~13.6) Anti-thyroglobulin Ab; 18.4 IU/mL (10~124.2)

검사실 소견의 해석 The prevalence of elevated serum C-reactive protein levels in inflammatory and noninflammatory thyroid disease. Thyroid. 2003 Jul;13(7):643-8.

검사실 소견의 해석 Salivary C-Reactive Protein in Hashimoto’s Thyroiditis and Subacute Thyroiditis International Journal of Inflammation Volume 2010, Article ID 514659, 5 pages

검사실 소견의 해석 Acute-phase reactants in Hashimoto thyroiditis Int Immunopharmacol. 2008 Dec 20;8(13-14):1863-5

검사실 소견의 해석 Anti-TPO Ab were detected TSH TT3 FT4 TPO-Ab CRP Subacute <0.005 mU/L (1.1±0.7) 2.2±0.36 ng/ml (1.09±0.25) 21.6±6.8 pg/mL (10.0±1.5) 0% 33.4±26.4 mg/L (2.6±4.0) Hashimoto 1.9±1.6 0.48±0.25 9.9±2.7 100% 2.8±4.1 KCP 723 0.01 mIU/mL (0.86-4.69) 160.5 ng/dL (71-161) 2.0 (0.8-1.7) 19.5 IU/mL (5-13.6) 30.4 (0.1-6.0) Anti-TPO Ab were detected in 10 of 119 (8.4%: range, 11-210U/mL) in normal controls. Antithyroid peroxidase autoantibodies in thyroid diseases. J Clin Endocrinol Metab. 1990 Sep;71(3):661-9.

DIAGNOSIS Some multinucleated giant cells, epthelioid histiocytes aggregation, and mildly aypical follicular cells in the background of lymphocytes and a few colloid (s.n) Note) 임상적으로 pain이 있다면 subacute thyroiditis의 가능성이 높습니다.

경청해 주셔서 감사합니다.