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Introduction The Thyroid hormone resistance syndrome is characterized by decreased tissue sensitivity to thyroid hormones. The incidence is about 1/50,000. We present two clinical cases of this disease. Clinical case 1A 59-year-old woman was evaluated for presenting palpitations for more than one year during exercise and rest. Also, she noticed heat even in the winter. Headache, hair loss, dry skin, capillary fragility were other complaints. She denies trembling in the hands, diarrhea and subcutaneous edemas. Cardiologist didn't find any cardiac alterations. Holter showed sinus tachycardia with average heart rate 84/min (59-135/min). No evidence of ectopic beats. Bisoprolol 5mg/day was indicated. Three years ago, in routine control "high thyroid hormones" was found. A year ago, one doctor said her "that she had altered thyroid hormones". Her daughter has hyperthyroidism recentely diagnosed. The physical exam showed uniform goiter. Not acanthosis. Slight distal tremor. Soft skin, no edemas. No exophthalmos. Her first blood profile showed: Total T3 1.15 (0.8-2), Total T4 14.34 (5.1-14.1) TSH 5.43 (0.27-4.2) Free T4 1.81 (0.93-1.7). The second one showed Free T3 3.25 (2-4.4), Free T4 1.94 (0.93-1.7), TSH 4.78 (0.27-4.2). The thyroid antibodies: TSI, AbTG and AbTPO were negative. Pituitary hormone profile was normal and according to the age. Pituitary MRI was normal. Clinical case 2 A 15-year-old male was evaluated for tachycardia, weight loss, nervousness, anxiety, and sweaty hands. Evaluated by Cardiology, the Holter monitor shows sinus tachycardia. In endocrinology department, the clinical evaluation showed only goiter and sweaty hands. Hepatic and renal profile were normal. Urinary and blood catecholamines and norepinephrine were normal. His first blood profile showed: Total T3 1.54 (0.8-2), Total T4 14.56 (5.1-14.1) Free T4 1.79 (0.93-1.7), TSH 0.54 (0.27-4.2). The second profile: Total T4 14.37 (5.1-14.1), Free T4 1.8 (0.93-1.7), TSH 0.48 (0.27-4.2). The thyroid antibodies: TSI, AbTG and AbTPO were negative. The thyroid ultrasound showed diffuse goiter. The pituitary MRI didn't show any lesions. He started treatment with Metoprolol every 24 hours. In both patients, we can´t made genetic testing because is not available in country. Discussion The thyroid profile in patients with thyroid hormone resistance syndrome is very characteristic: they present with elevated free thyroid hormones and normal or slightly elevated TSH. It is important to rule out alterations in transporter proteins, the presence in serum of a factor that interferes with hormonal determination, or a TSH-producing pituitary tumor. The diagnosis requires a high degree of suspicion. BibliographyMARBAN CALZON, Mercedes; GONZALEZ JIMENO, Alicia; GARCIA BERMEJO, Alba, BELMONTE PINTRE, Zaira. Perfil hormonal tiroideo poco frecuente. Síndrome de resistencia a hormonas tiroideas. Rev Pediatr Aten Primaria[online]. 2019, vol.21, n.81BERNAL J. Sindromes de resistencia a las hormonas tiroideas. Endocrinología y Nutrición. 2011. Vol 58, Num 4.1 Presentation: No date and time listed

BACKGROUND In the thyroglossal duct (TD) there are remains of thyroid tissue in 1-40%. Thyroid cancer diagnosed in this duct is an uncommon finding, with a prevalence of less 1% and must meet these criteria: identify the TD, locate remains of carcinoma in it; absence of cancer in the thyroid gland and presence of thyroid follicles in the TD. We present a patient with thyroid cancer in the TD. CLINICAL CASE 63-years-old-woman. 18 months ago, she noted a submandibular tumor associated to asthenia, weight loss and tremor. On physical examination: 3cm tumor, increased consistency, near to the hyoid bone and 1.5cm left cervical adenopathy. Blood analysis: TSH 0.01 (0.2-4.5) and FT4 5.53 (0.9-1.7). Hyperthyroidism was diagnosed and she started Tiamazol 10mg/bid and propanolol 20mg/tid. Thyroid US: diffuse goiter. Soft tissue US: heterogeneous mass 39x15x26mm in midline of suprathyroid region suggestive of neoformative process. Cervical CT scan: solid, heterogeneous, neoformative tissue, located in the midline, infiltrating prelaringeal muscles in contact with hyoid bone. Cervical adenopathy in group II on right side and group III and IV on the left side. Increase in thyroid gland volume. FNA US guided of suprathyroid tumor was performed: cytology compatible with papillary thyroid carcinoma, Bethesda VI. FNA left adenopathy: compatible with metastasis papillary carcinoma. Midline tumor exeresis in relation to a TD (Sistrunk surgery), total thyroidectomy plus left lymph node dissection group IIA, IIB, III, IV and V was performed. Surgical findings: Right lobe thyroid 4x3x2cm with 1cm nodule on the upper pole. Left thyroid lobe 6x4x2cm with multiple nodules, the largest one in upper pole, 2cm. Multiple adenopathies. A 3x3x1cm tumor with irregular edges, hard consistency, adhered to the hyoid bone was removed. The histology was compatible with papillary thyroid carcinoma in the TD. Thyroid gland was informed as simple goiter. 150ug of levothyroxine was initiated. Six months later, she receives 100mCi I131. The total body scan was positive for thyroid remnant in cervical region. TSH 0.8 FT4 1.71. Thyroglobulin (TG) 13.98 and AntiTG 400. One year later, new total body scan was negative. TG 10,3 and antiTG 816. New thyroid US showed group III cervical adenopathy 4x7x3mm. Biopsy was compatible with metastasis of papillary thyroid carcinoma. The patient is awaiting a new surgery for lymph node dissection. CONCLUSION Sistrunk surgery and total thyroidectomy plus lymphadenectomy should be the treatment of choice in thyroid cancer in TD, followed by ablative therapy. This attitude improves long-term follow-up and reduces the risk of recurrence. BIBLIOGRAPHY 1. Granado A, et al. Cáncer del conducto tirogloso. Acta Chir Catal, 8 (1987), 37-44 2. Echenique E. Thyroid cancer arising in a thyroglossal duct cyst. Cir Esp. 2000 67 (6) 567-71.

BACKGROUND Pheochromocytoma is a tumor arising from adrenomedullary chromaffin cells that commonly produces one or more catecholamines. Surgical removal of a pheochromocytoma does not always lead to long-term cure of pheochromocytoma, pheochromocytoma recurred in approximately 16 percent, with more frequency in patients with familial pheochromocytoma and extraadrenal tumors. CLINICAL CASE A 41 years woman with a history of hypertension diagnosed 3 years before the admission, began having puncturing holocarnaeal headache of moderate intensity 2 years before hospital admission. The pain got worse, and a chest pain and dyspnea were associated in an episodic way. These episodes were accompanied by diaphoresis, palpitations, flushing and nervousness. Patient went to a doctor being diagnosed heart failure so he receives medication, but symptomatology does not improve. The episodes became more frequent and were associated with nausea, vomiting and distal coldness. Physical examination showed: BP:160/110 HR:130 Slight diaphoresis rest without particularities Labs: 05/23/18 24 h urine: Vanilmandelic acid 25.9 (0-10 mg / 24h) Metanephrines 2.26 ((0.05-1 mg / 24h) Creatinine 0.8 (1-2 mg) Rel. Metanephrine / Creatinine 2.83 (0- 0.6) Abdominal TEM: Image of tumor appearance in right adrenal gland. 45x51mm 06/06/18 Calcitonin 5 cm, which is why follow-up and individualized management is indicated even those apparently cured after a total resection. REFERENCES Lenders JW, Duh QY, Eisenhofer G, et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2014; 99:1915. William F Young, et al. Treatment of pheochromocytoma in adults. UptoDate http://www.uptodate.com (Accessed on November 05, 2018.)

BACKGROUND Cushing's disease (CD) is mainly due to pituitary microadenomas producing ACTH. Only 10% of CD presents with macroadenomas. CD is suspected by the presence of classic signs and symptoms and is often associated with metabolic diseases. We present a case of non-classical presentation of CD due to a pituitary macroadenoma CLINICAL CASE 73-years woman with hypertension, diabetes and dyslipidemia in treatment with metformin 850mg bid, insulin NPH 50U/d, Enalapril 10mg bid and Atorvastatin 20mg was referred to endocrinology clinic for noticed in the last year cervical tumor that increases in volume. She noticed occasional headache and decreased visual acuity, denied difficulty in breastfeeding, menopause at 45 years old. Physical evaluation reveals TA 110/60 Weight 82 Kg BMI 39 Central obesity. Thin skin. Abdomen white and thin striae. Nodule in left thyroid lobe 2cm. Muscular atrophy in lower limbs. Absence of reddish striae, hump, skin or mucosa hyperpigmentation, hirsutism and facial plethora. Campimetry by confrontation: bitemporal heteronymous hemianopsia. Blood analysis: Glucose 103mg/dL HbA1C 11.3% Creatinine 1.25mg/dL Total cholesterol 94mg/dl LDLc 40mg/dl Triglyceride 112mg/dl ALT 18 AST 23 TSH 1.83uU/ml (0.27-4.2) Free T4 0.86ng/ml (0.93-1.7). Thyroid US: left nodule 26x20mm with macrocalcifications, irregular edges and central vascularization. FNA Bethesda III. To rule out secondary hypothyroidism, was requested TSH 2.77 Free T4 0.72 FSH 35.6 (48.6-143) LH 14.35 (13-45) Prolactin 9.98 (18-24) Cortisol AM 10.5 (3.7-19.4). A 75ug qd levothyroxine was started 3 months later, she reported headache more frequently, asthenia and difficulty climbing stairs, lower limbs paresthesias, higher dose of insulin was needed (NPH 58U, insulin Lispro 5U before lunch) Glucose 225 HbA1C 14.9% Triglycerides 300 Cortisol AM 9.3ug/dl Cortisol PM 9.7 ACTH1 118.1pg/ml (5-63) ACTH2 135.8. Free urinary cortisol 76.4ug/24h. Dexamethasone suppression test 2mg/6h by 48h: Cortisol before test was 11ug/dL and after 1.4 Pituitary MRI described a macroadenoma involving the left cavernous sinus and the left carotid artery. After Transsphenoidal surgery, pathology was informed as Pituitary Adenoma, Positive immunohistochemistry ACTH, proliferation index Ki67 1% 1-year post surgery, she had stopped insulin and enalapril. Her only medication is levothyroxine 100ug. Her last blood analysis: Glucose 92 HbA1C 7.2% Creatinine 1.48 Free T4 1.3 FSH 30 LH 16 Prolactin 10.4 Cortisol AM 9.2. CONCLUSION Sometimes, CD can be oligosymptomatic despite being a pituitary macroadenoma, so it can be considered a differential diagnosis in patients with metabolic syndrome REFERENCES Buliman A, et al. Cushing´s disease: a multidisciplinary overview of the clinical features, diagnosis and treatment. J Med Life 2016

Aim The pandemic has generated the need for COVID-19 patients to be treated as best as possible; however, the effect of these treatments on glycemic control has not yet been taken into account. This article aims to determine whether the daily variation of glucose is influenced by the use of corticosteroids in COVID-19 patients treated in Lima-Peru. Methodology A prospective cohort study was undertook, in which glucose was measured four times a day in 53 patients hospitalized due to COVID-19. These values were associated with the use of corticosteroids and adjusted for other socio-educational variables, all by means of PA-GEE models. Results Nested multivariate analysis of daily glucose variation found that those using corticosteroids increased the daily average glucose as well as the first and last glucose measurements, this is, at 6am and 10pm, respectively (all p-values

Background: Weight loss is important for the control of type 2 diabetes mellitus but is difficult to achieve and sustain. Programmes employing financial incentives have been successful in areas such as smoking cessation. However, the optimum design for an incentivised programme for weight loss is undetermined, and may depend on social, cultural and demographic factors. Methods: An original questionnaire was designed whose items addressed respondent personal and health characteristics, and preferences for a hypothetical incentivised weight loss programme. One hundred people with type 2 diabetes mellitus were recruited to complete the questionnaire from the endocrinology clinic of a public hospital in Lima, Peru. A descriptive analysis of responses was performed. Results: Ninety-five percent of subjects who had previously attempted to lose weight had found this either 'difficult' or 'very difficult'. Eighty-five percent of subjects would participate in an incentivised weight loss programme. Median suggested incentive for 1 kg weight loss every 2 weeks over 9 months was PEN 100 (~USD $30). Cash was preferred by 70% as payment method. Only 56% of subjects would participate in a deposit-contract scheme, and the median suggested deposit amount was PEN 20 (~USD $6). Eighty percent of subjects would share the incentive with a helper, and family members were the most common choice of helper. Conclusions: The challenge of achieving and sustaining weight loss is confirmed in this setting. Direct cash payments of PEN 100 were generally preferred, with substantial scope for involving a co-participant with whom the incentive could be shared. Employing direct financial incentives in future weight loss programmes appears to be widely acceptable among people with type 2 diabetes mellitus.

Family support is crucial for managing chronic conditions but it is often overlooked when designing behavioral interventions in type 2 diabetes mellitus (T2DM). As part of the formative phase of a feasibility randomized control trial (RCT), we conducted 20 semistructured interviews with people with T2DM from Lima, Peru. Based on such results, we describe the support people with T2DM receive from their families and the role that such support has in their efforts to implement diabetes management practices. We learned that participants receive support from family members, but mostly from their spouses and children. Their relatives encourage them and motivate them to fight for their health, they also provide instrumental support by preparing healthy meals, reminding them to take medications, and sharing physical activity. Participants also reported controlling actions which were not always “well received.” Thus, any intervention supporting self-management practices need to work with key family members. We support the literature that suggests that interventions should target family members to ensure improved T2DM self-management practices.

Chylous leak is a rare complication after breast cancer surgery. We present the case of a patient with a chylous leak and discuss the management options.