- Case report
- Open Access
- Open Peer Review
Papillary thyroid cancer associated with syndrome of inappropriate antidiuresis: a case report
© Beier et al; licensee BioMed Central Ltd. 2010
- Received: 23 October 2009
- Accepted: 21 April 2010
- Published: 21 April 2010
The syndrome of inappropriate antidiuresis is the most common cause of euvolemic hypo-osmolality. This syndrome is associated with a wide variety of diseases. However, its most frequent causes are related to malignancies, especially lung cancer. In this case report, we describe an unknown association of the syndrome of inappropriate antidiuresis with papillary thyroid cancer.
We present the case of a 71-year-old Caucasian, German woman with marked hyponatremia and neurological symptoms. After a detailed clinical investigation, the common causes of syndrome of inappropriate antidiuresis and other malignancies were ruled out. A thyroid nodule was detected by ultrasound and magnetic resonance imaging. Although fine needle aspiration cytology showed negative results, our patient underwent surgery. Papillary thyroid cancer was later diagnosed. After total thyroidectomy, a complete remission of the clinical symptoms occurred and our patient subsequently had iodine-131 radioactive therapy. Hyponatremia was no longer observed during the follow-up investigations.
This is the first reported case of paraneoplastic syndrome of inappropriate antidiuresis caused by papillary thyroid carcinoma. Since its symptoms occurred before the development of local symptoms, total thyroidectomy may provide a timely and efficient treatment for the underlying malignancy.
- Thyroid Cancer
- Papillary Thyroid Carcinoma
- Thyroid Nodule
- Total Thyroidectomy
- Optic Neuritis
The first clinical description of a patient with syndrome of inappropriate antidiuresis (SIAD) was published by Schwartz et al. in 1957 . Two patients with lung cancer presenting with hyponatremia and continual loss of urinary sodium were described. The authors concluded that the syndrome is caused by inappropriate release of the antidiuretic hormone (ADH). Their hypothesis was later confirmed in several studies .
Overview of the syndrome of inappropriate antidiuresis criteria and our patient's laboratory findings
Papillary thyroid cancer is the most common subtype of thyroid cancer. The prognosis of patients with papillary thyroid cancer is very good (10-year overall survival in more than 80% of cases) . So far, only a few cases of thyroid cancer have been described in relation to hyponatremia . However, research on the association of papillary thyroid cancer with SIAD has yet to be published.
In this report, we describe a patient with papillary thyroid cancer associated with neurological symptoms resulting from marked hyponatremia due to SIAD. The complete disappearance of her symptoms after total thyroidectomy confirmed the diagnosis of paraneoplastic SIAD related to papillary thyroid cancer.
In May 2008, a 71-year-old Caucasian, German woman was referred to our hospital presenting with weakness, somnolence, confusion and slurred speech. As reported by her family, her symptoms had slowly deteriorated within the previous three months. On physical examination, our patient had no edema and no evidence of dehydration or hyperhydration. Her initial laboratory evaluation, however, showed severe hyponatremia (107 mmol/L), low serum osmolality (227 mmol/kg), high urine sodium (86 mmol/L), and urine osmolality ranging above the normal serum osmolality (495 mmol/kg) (Table 1). Her renal function was normal (creatinine = 0.48 mg/dL). Although unnecessary for the diagnosis, her ADH level was measured in the serum and found to be inappropriately high in relation to the respective serum osmolality. Cerebral MRI revealed no abnormalities, suggesting that hyponatremia had caused her neurological symptoms. As thyroid parameters and adrenal function tests were normal, endocrine dysfunction could be excluded.
Our patient's medical history revealed intermittent atrial fibrillation and hypertension for which she had been treated with metoprolol and ramipril for more than three years. A drug-induced SIAD was considered as very unlikely due to her long history of taking metoprolol and ramipril. The medication was maintained during her diagnosis and treatment. Her SIAD did not reappear after thyroidectomy. Neither the parameters investigated nor the medication given provided an alternative explanation for the presence of hyponatremia, thus establishing a diagnosis of SIAD.
Paraneoplastic SIAD has been described in relation to a wide variety of malignant tumors. The syndrome has a prevalence of up to 15% in patients diagnosed with lung cancer, especially small-cell lung cancer . Furthermore, SIAD is present in 3% of patients with head and neck tumors. A detailed analysis of the available literature revealed no association between thyroid cancers and SIAD . In a larger prospective study investigating head and neck tumors, no evidence of the syndrome was observed before and after neck dissection in patients with thyroid cancer .
While rare, paraneoplastic syndromes, especially ectopic adrenocorticotropic hormone (ACTH) synthesis, have been described as being related to medullary thyroid cancer, and fewer associations have been reported in cases of papillary thyroid cancer . To the best of our knowledge, cases of paraneoplastic syndromes are sparse in patients suffering from papillary thyroid cancer, such as polymyalgia rheumatica, hypercalcemia, dermatopolymyositis, paraneoplastic neutrophilia, and neurological paraneoplastic syndromes such as myoclonus, optic neuritis and Isaac's Syndrome [10–17].
Symptomatic hyponatremia was reported in five patients with metastatic papillary or follicular thyroid cancer in relation to a low-iodine diet and levothyroxine withdrawal prior to I-131 treatment . All these patients presented with hyponatremia and hypothyroidism. Four of the five patients underwent total thyroidectomy and all developed hyponatremia between surgery and the initiation of I-131 radioactive therapy. Based on this, endocrine dysfunction has to be ruled out before making a diagnosis of SIAD .
Surgery (total thyroidectomy) and subsequent radioactive therapy are standard procedures for the treatment and management of patients with papillary thyroid cancer. The surgical treatment is based on thyroidectomy and the excision of locoregional lymph node metastases. I-131 radioactive therapy is usually administered four to 12 weeks after surgery and its purpose is to destroy any remnant of thyroid tissue. Differentiated thyroid cancers, such as papillary thyroid cancer, respond to the stimulation of the thyroid-stimulating hormone (TSH). Based on this, the suppression of TSH levels using supraphysiological doses of levothyroxine is recommended in order to decrease the rate of recurrence. A further part of the long-term management is the control of thyroglobulin levels as a possible marker of recurrence or residual disease . Our patient received the standard treatment according to the official guidelines for total thyroidectomy and post-operative I-131 radioactive therapies.
There are several treatment options for SIAD. Slight hyponatremia can be treated by fluid restriction and by monitoring the sodium levels of patients. In addition, low doses of loop diuretics can be administered in order to increase their serum sodium level. If a patient is suffering from acute neurological symptoms, a hypertonic saline infusion (3% sodium chloride [NaCl]) might be necessary to correct the sodium levels. It is essential to ensure a very slow rise in sodium levels in order to avoid cerebral damage, such as pontine myelinolysis, which can be caused by fast changes. In this context, a so-called "limited and controlled" therapy has been suggested (elevating sodium levels of 0.5 to 1 mmol/L/h to a maximum of 120 mmol/L and not to normal ranges).
Currently, there are no official guidelines for the treatment of SIAD. Every physician has to evaluate the best therapy for treating hyponatremia . In our case, fluid restriction was sufficient to improve our patient's sodium levels.
The complete disappearance of our patient's symptoms after total thyroidectomy confirmed the diagnosis of paraneoplastic SIAD related to papillary thyroid cancer. This is the first reported case of paraneoplastic SIAD caused by papillary thyroid carcinoma. As SIAD symptoms appeared before the development of local symptoms, papillary thyroid cancer has to be added to the list of tumors associated with SIAD. This knowledge may lead to a timely and efficient treatment for this underlying malignancy.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We would like to thank Christoph P Beier for the critical review of the manuscript. Furthermore, we thank the Institute of Radiology of the University of Regensburg for providing the magnetic resonance images of our patient.
- Schwartz WB, Bennett W, Curelop S, Bartter FC: A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. Am J Med. 1957, 23: 529-542. 10.1016/0002-9343(57)90224-3.View ArticlePubMedGoogle Scholar
- Amatruda TT, Mulrow PJ, Gallagher JC, Sawyer WH: Carcinoma of the lung with inappropriate antidiuresis: demonstration of antidiuretic hormone-like activity in tumor extract. N Engl J Med. 1963, 269: 544-549. 10.1056/NEJM196309122691102.View ArticlePubMedGoogle Scholar
- Ellison DH, Berl T: Clinical practice: the syndrome of inappropriate antidiuresis. N Engl J Med. 2007, 356: 2064-2072. 10.1056/NEJMcp066837.View ArticlePubMedGoogle Scholar
- Sorensen JB, Andersen MK, Hansen HH: Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in malignant disease. J Intern Med. 1995, 238: 97-110. 10.1111/j.1365-2796.1995.tb00907.x.View ArticlePubMedGoogle Scholar
- Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Sherman SI, Tuttle RM: Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2006, 16: 109-142. 10.1089/thy.2006.16.109.View ArticlePubMedGoogle Scholar
- Shakir MK, Krook LS, Schraml FV, Hays JH, Clyde PW: Symptomatic hyponatremia in association with a low-iodine diet and levothyroxine withdrawal prior to I131 in patients with metastatic thyroid carcinoma. Thyroid. 2008, 18: 787-792. 10.1089/thy.2008.0050.View ArticlePubMedGoogle Scholar
- Ferlito A, Rinaldo A, Devaney KO: Syndrome of inappropriate antidiuretic hormone secretion associated with head neck cancers: review of the literature. Ann Otol Rhinol Laryngol. 1997, 106: 878-883.View ArticlePubMedGoogle Scholar
- Zacay G, Bedrin L, Horowitz Z, Peleg M, Yahalom R, Kronenberg J, Taicher S, Talmi YP: Syndrome of inappropriate antidiuretic hormone or arginine vasopressin secretion in patients following neck dissection. Laryngoscope. 2002, 112: 2020-2024. 10.1097/00005537-200211000-00020.View ArticlePubMedGoogle Scholar
- Barbosa SL, Rodien P, Leboulleux S, Niccoli-Sire P, Kraimps JL, Caron P, Archambeaud-Mouveroux F, Conte-Devolx B, Rohmer V: Ectopic adrenocorticotropic hormone-syndrome in medullary carcinoma of the thyroid: a retrospective analysis and review of the literature. Thyroid. 2005, 15: 618-623. 10.1089/thy.2005.15.618.View ArticlePubMedGoogle Scholar
- Tabata M, Kobayashi T: Polymyalgia rheumatica and thyroid papillary carcinoma. Intern Med. 1994, 33: 41-44. 10.2169/internalmedicine.33.41.View ArticlePubMedGoogle Scholar
- Attarian H, Applebee G, von Lepel A: Paraneoplastic myoclonus with papillary thyroid carcinoma. Eur Neurol. 2007, 58: 182-183. 10.1159/000104721.View ArticlePubMedGoogle Scholar
- Vassilatou E, Fisfis M, Morphopoulos G, Savva S, Voucouti E, Stefanoudaki K, Tzavara I: Papillary thyroid carcinoma producing granulocyte-macrophage colony-stimulating factor is associated with neutrophilia and eosinophilia. Hormones (Athens). 2006, 5: 303-309.View ArticleGoogle Scholar
- Iguchi H, Miyagi C, Tomita K, Kawauchi S, Nozuka Y, Tsuneyoshi M, Wakasugi H: Hypercalcemia caused by ectopic production of parathyroid hormone in a patient with papillary adenocarcinoma of the thyroid gland. J Clin Endocrinol Metab. 1998, 83: 2653-2657. 10.1210/jc.83.8.2653.View ArticlePubMedGoogle Scholar
- Vernino S, Adamski J, Kryzer TJ, Fealey RD, Lennon VA: Neuronal nicotinic ACh receptor antibody in subacute autonomic neuropathy and cancer-related syndromes. Neurol. 1998, 50: 1806-1813.View ArticleGoogle Scholar
- Cross SA, Salomao DR, Parisi JE, Kryzer TJ, Bradley EA, Mines JA, Lam BL, Lennon VA: Paraneoplastic autoimmune optic neuritis with retinitis defined by CRMP-5-IgG. Ann Neurol. 2003, 54: 38-50. 10.1002/ana.10587.View ArticlePubMedGoogle Scholar
- Lee JH, Kim SI: A case of dermatomyositis associated with papillary cancer of the thyroid gland. Clin Rheumatol. 2005, 24: 437-438. 10.1007/s10067-004-0979-3.View ArticlePubMedGoogle Scholar
- Kalliabakos D, Pappas A, Lagoudianakis E, Papadima A, Chrysikos J, Basagiannis C, Tsakoumagou M, Skanelli Y, Manouras A: A case of polymyositis associated with papillary thyroid cancer: a case report. Cases J. 2008, 1: 289-10.1186/1757-1626-1-289.View ArticlePubMedPubMed CentralGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.