Hashimoto’s encephalopathy – an up-to-date overview

Introduction: Hashimoto’s encephalopathy (HE) is a rare, potentially life-threatening disease with a wide spectrum of clinical manifestations from slight symptoms to mainly neurological and psychiatric syndromes, which significantly debilitate the quality of life and make the diagnostic process complicated, especially in patients with no previous history of thyroid disorders. According to the recent data, it occurs in about 2.1 cases per 100 000 population with still increasing prevalence. Despite, over than fifty years have passed since the first case of HE was reported, its etiopathogenesis is not completely clarify and there is no universal diagnostic criteria. Aim of the study: This article summarizes the current knowledge about pathophysiology, clinical manifestations, difficulties in differential diagnosis and therapeutic dilemmas in patients with HE. Description of knowledge: HE is an autoimmune-mediated encephalopathy associated with Hashimoto’s disease and elevated titers of anti-thyroid antibodies, mainly anti-thyroid peroxidase antibody. The diagnostic process is usually multi-step due to various diseases mimicking HE, such as Creutzfeldt-Jacob disease, brain tumors, epilepsy, Alzheimer's disease, stroke, other forms of autoimmune encephalitis, schizophrenia, spontaneous cerebrospinal fluid leak or infectious encephalitis. The range of diagnostic procedures includes physical and mental examination, laboratory tests, brain imaging, EEG as well as cerebrospinal fluid analysis. However, the first line strategy based on steroids is effective, there are some cases in the literature that reveal this management as not fully sufficient, because only partial improvement was achieved or the steroid-dependence was observed. Among other therapeutic methods, plasmapheresis may be used additionally. Conclusions: HE requires interdisciplinary approach and it constitutes a great challenge for clinicians of various specialties, such as endocrinologists, neurologists, and psychiatrists. The prompt implementation of adequate therapy usually provides the full recovery of the patients without any early or late complications

The diagnostic and therapeutic difficulties in management with pheochromocytoma in pregnancy – a review

Introduction: Pheochromocytoma (PCC) is a very rare and life-threatening condition in pregnancy. According to different data, it occurs in about 0,00002%-0,007% of pregnant women. The early diagnosis and the proper clinical management play a crucial role in decreasing maternal and fetal mortality. Aim of the study: This article summarizes the current knowledge about the management with PCC in pregnancy and presents the possible maternal and fetal outcomes. Description of knowledge: The review revealed, that manifestations of catecholamine-secreting tumors are similar to the most common hypertension-associated problems occurring in pregnancy, such as pre-eclampsia. That is why, timely diagnosis is essential for the mothers and fetuses’ survivals. Despite the fact, that the fetus is protected from influence of maternal overproduction of catecholamines due to the presence of placental enzymes activity, there is an enormous risk of spontaneous abortion, fetal growth restriction, premature delivery, when the optimal therapy will not be applied on time. The diagnosis is based on laboratory tests – determination of plasma and urine concentration of catecholamines and imaging tests to localize the tumor, from which only MRI, in 1st and 3rd trimester, and ultrasound examination can be safely used in pregnancy. The guidelines suggest surgical tumor removal as the treatment of choice for women with PCC in pregnancy. The 2nd trimester seems to be the best period for the surgery, however it can be performed only after 10-14 days of effective therapy with alfa- and beta-blockers. The review of literature revealed that, surgical tumor removal carried out before the end of 24. hbd, is safe both for mother and her fetus life. Conclusions: PCC is a great challenge, because of the extremely rare occurrence in pregnant women and serious complications due to the secretion of catecholamines, which may result in catecholamin crisis, increasing the risk of mortality. Nevertheless, there is still no clear consensus on PCC treatment and further researches are needed to develop the optimal management in this clinical condition

Matrix metalloproteinases and their tissue inhibitors as novel markers in invasive pituitary adenomas – a review

Introduction: Pituitary adenomas are generally benign central nervous system neoplasms with still increasing prevalence, especially in younger people. According to the recent data, approximately 30-45% of them invade the local structures, which make their total resection impossible and result in high recurrence rate. Despite the huge advances in management with pituitary tumors, there are no universal biomarkers predicting their course. That is why, the two-way relationship between matrix metalloproteinases (MMPs) activities and the microenvironment of pituitary adenomas is an important object of extensive studies. Aim of the study: This article summarizes the current knowledge about selected MMPs and their tissue inhibitors (TIMPs) in tumorigenesis of pituitary adenomas as well as their role in local invasion in different hormonally active and inactive pituitary tumors. Description of knowledge: MMPs are a family of zinc-dependent proteolytic enzymes, which are engaged in various physiological and pathological conditions. So far, their role in different malignancies have been known for many years. Nevertheless, the possible effects of MMPs and TIMPs in pituitary adenomas are not fully understood. Recent studies suggested that MMPs’ expression is significantly higher in invasive pituitary tumors as compared to non-invasive pituitary adenomas, while the expression of TIMPs is decreased, which may prove their involving in tumorigenesis. Conclusions: MMPs may be predictive factors of the invasiveness and the higher recurrence rate in the group of patients with pituitary adenomas. Understanding the changes in the MMPs-TIMPs system and discovering of its exact mechanisms may result in applying novel screening options as well as modifying diagnostic process and treatment scheme. Therefore, further researches are required to determine the effects of MMPs and TIMPs and their role in the pathogenesis of invasive pituitary tumors

The role of gut microbiota in patients with autoimmune thyroid diseases – current status and future perspectives

Introduction: Autoimmune diseases constitute a significant clinical problem, due to the increasing incidence, that is why the potential causes that determine their occurrence are sought. Intestinal microbiota greatly outnumber the all of human body’s cells. Its metabolic activity and disorders in the structure, resulting from, for example, antibiotic therapy, lead to homeostasis dysregulation, and in this way gain a new meaning in the etiology of autoimmune diseases. Aim of the study: This article summarizes the current knowledge about gut microbiota in patients with autoimmune thyroid diseases as well as discussed the alterations in the gut microbiota and their potential relationship with thyroid cancer. Description of knowledge: The analyzed scientific literature revealed a relationship between the occurrence of autoimmune diseases and intestinal flora disorders. It is believed that the microbiota that colonized the entire human body, due to diversity, co-formation of the intestinal barrier, its own metabolic activity and participation in many metabolic processes, plays an important role in regulating the immune system functioning. Many data indicate, that the changes in the composition of the intestinal flora in many autoimmune diseases can also be influenced by individual factors, environmental conditions, genetic predisposition, and diet. Conclusions: Gut microbiota is an important element of the immune system and due to the demonstrated changes in its composition in various disease processes and its significant effects on metabolism, the researchers are still underway to clarify all pathogenetic mechanisms of microbiota influencing human homeostasis. Therefore, further studies are required to determine the effect of microbiota and its role in the pathogenesis of autoimmune diseases

Multiple myeloma during pregnancy as a challenge in clinical practice – a review

Introduction: Multiple myeloma (MM) is a hematological malignancy characterized by an abnormal proliferation and accumulation of monoclonal plasma cells. MM typically affects the elderly people with the median age at the diagnosis between 65 to 74 years. Only in < 2% of cases it is observe

Assessment of white blood cell distribution as a prognostic factor in type 2 diabetes mellitus and its complications - literature overview

Introduction: Type 2 diabetes (T2DM) mellitus is the chronic, low-grade inflammatory disorder, which is considered to be the leading cause of morbidity and mortality worldwide. Wherefore, it is indispensable to look for new, non-invasive and widely available markers that will allow for early detection of predisposition to the development of diabetes as well as its macro- and microvascular complications. Aim of the study: The aim of our study was to present the role of white blood cells (WBC) count as a prognostic factor in type 2 diabetes mellitus. Moreover, we discussed the perspectives for the usefulness of WBC subtypes and neutrophil to lymphocyte ratio (NLR) as a marker of glycemic control as well as an indicator of the risk of developing diabetes complications. Description of knowledge: The abundant number of previous studies revealed that the elevated level of total WBC count strongly correlates with the predisposition to prediabetes and T2DM development. There is also association between the insulin resistance as well as the function and mass of beta-cells. The numerous research confirm that the increase in NLR may be the useful laboratory tool to evaluate the glycemic control and the effectiveness of antidiabetic treatment. NLR ratio as a marker, which directly reflects the level of inflammation is considered to indicate the risk of development of cardiovascular complications, diabetic peripheral neuropathy or nephropathy, even in the early stage of T2DM duration. Conclusions: Measurements of WBC count and changes in the number of subpopulations of them seem to be a useful, widely accessible marker of development of T2DM as well as its complications and may be helpful in management of T2DM patients

Adiponectin as novel biomarker of endothelial dysfunction in insulin resistance and obesity – a narrative review

Introduction: Obesity is a chronic fatal disease with still growing incidence among children, adolescents, and adults worldwide. The subclinical inflammatory process together with hipoadiponectinemia may lead to the development of various comorbidities, including cardiovascular complications. That is why, the relationship between adipose tissue activity, obesity, insulin resistance, and endothelial function is in high interest and an object of extensively studies.Aim of the study: This article summarizes the current knowledge on the anti-atherogenic effects of adiponectin and its properties to improve endothelial function in obesity-related insulin resistance.Description of knowledge: Adiponectin, an adipose tissue-derived pleiotropic hormone with anti-inflammatory, anti-atherogenic, anti-diabetic, and insulin-sensitizing actions, is not only engaged in modulation of type 2 diabetes mellitus, hypertension or coronary artery disease, but the latest researches highlight its role in improving vascular wall integrity. It affects complex signaling pathways in endothelial cells and influence inflammatory responses in the subendothelial space. Pre-clinical and clinical studies suggest that agents leading to increase in adiponectin levels, simultaneously contribute to decrease insulin resistance, and improve endothelial dysfunction.Conclusions: Adiponectin may be a predictive factor of endothelial dysfunctionality and vascular remodeling development in the group of patients with overweight, obesity, and insulin resistance. Discovering pharmacological agents and non-pharmacological interventions that increase the level of circulating adiponectin will become novel and innovative therapeutic strategy to ameliorate obesity-related comorbidities. Therefore, further studies are required to determine the exact role of adiponectin in the pathogenesis of metabolic diseases

Adiponectin as novel key player in tumors of adrenal glands – what do we know? A review

Introduction: Adrenal incidentalomas without clinically apparent hormonal activities have becoming a huge socio-economic problem due to recent advances in radiological techniques. Patients with incidentalomas are considered to be at high risk of developing metabolic disorders and cardiovascular diseases. That is why, the two-way relationship between adipose tissue activity and adrenal glands is in high interest and an object of extensively studies. Aim of the study: This article summarizes the current knowledge about adiponectin and its receptors in the tumorigenesis of adrenal neoplasia as well as their role in the developing obesity-related diseases. Description of knowledge: Adiponectin, an adipose tissue-derived pleiotropic hormone, with anti-inflammatory, anti-atherogenic, anti-diabetic, and insulin-sensitizing properties is engaged in developing diabetes mellitus type 2, hypertension or ischemic heart disease, but the latest researches also revealed its role in tumor cells proliferation and angiogenesis. The possible effects of adiponectin and its two receptors in both physiological processes and pathophysiology of adrenal glands is not fully understood. Recent studies suggested that adiponectin receptors expression is significantly higher in hormonally active adrenal tumors as compared to normal tissues of adrenal glands, which may prove the involving of adipose tissue and periadrenal fat depot in regulating the function of adrenal cortex or medulla. Conclusions: Adiponectin may be predictive factor of developing metabolic disorders in the group of patients with accidentally detected adrenal lesions. The discovering of its exact mechanism may result in modifying novel screening options as well as diagnostic process and treatment scheme. Therefore, further research is required to determine the effect of adiponectin and its role in the pathogenesis of obesity-related diseases in the course of adrenal tumors

Long-term observation of the patient after CABG with asymptomatic high-grade aortic regurgitation – a clinical case study

Introduction: The aortic valve regurgitation (AR) is a heart defect consisting of the retrograde flow of blood from the aorta to the left ventricle due to the improper closure of the aortic valve leaflets. It occurs approximately in 13% of men and 8.5% of women, and the incidence increases with age. A crucial issue in regards to a patient with asymptomatic AR, especially of a high degree, is determination of the time of qualification for invasive treatment. Aim: To draw attention to the necessity of holistic approach to a patient with asymptomatic high-grade aortic regurgitation. Moreover, the complications of delayed implementation of invasive treatment were discussed. Case report: A clinical case of a 62-year-old patient with a history of coronary artery bypass grafting and with AR – stage II, accidentally detected two years later in a control echocardiogram, was presented. Despite gradual progress of regurgitation, none of the disturbing symptoms were noted, whereas cardiac parameters were systematically monitored using ECG, ECHO and CT imaging. Beta blockers, ACE inhibitors, loop diuretics and aspirin were used as conservative treatment. After 10-year transthoracic echocardiographic follow-up due to progression of AR and development of heart failure, the patient was qualified to surgical replacement of the aortic valve. This procedure significantly improved the patient's quality of life. Summary: The key element in the treatment of chronic asymptomatic AR is the individualization of the therapy. An essential role is played by appropriate pharmacotherapy, precise monitoring using transthoracic echocardiography, which is recommended as the first-line imaging strategy. Delaying in the implementation of surgical treatment may result in failure of the therapy and the onset of serious complications

Thrombotic thrombocytopenic purpura - a disease with multiple organ manifestations. Diagnostic and therapeutic difficulties in clinical practice

Introduction: Thrombotic thrombocytopenic purpura (TTP) is a rare, heterogeneous and life-threating disease requiring prompt differential diagnosis. The most common form of that disease is idiopathic form affects usually young adults. The etiopathogenesis is most likely based on the excessive formation of platelet aggregates and microthrombosis in small vessels, capillaries due to the deficiency of a specific enzyme, ADAMTS13 (disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13). Aim of the study: The aim of this review was to present the diagnostic difficulties of the TTP, which are mainly related to the range of multi-organ deficiency and symptoms that resemble lots of other diseases. Moreover, we discussed the current, as well as future perspectives of the treatment of thrombotic thrombocytopenic purpura. Description of knowledge: The principal symptoms, which occur in TTP patient are caused by microangiopathic hemolytic anemia and thrombocytopenia. Moreover, that disease may also manifest by neurological, renal, cardiac abnormalities as well as abdominal disturbances, fever and flu-like symptoms. The other thrombotic microangiopathies, especially hemolytic-uremic syndrome, immune-mediated diseases, infections, stroke, myocardial infarction should be taken initially in the differential diagnosis. The current management is based on plasma exchange therapy, steroids, rituximab, but the novel methods are investigated. Conclusions: The differential diagnosis of hematological patients presenting clinical symptoms of thrombocytopenia, anemia associated with multi-organ dysfunction, especially when we suspect an autoimmune background of a given disease is crucial to implement the appropriate therapy and save the patient's life