Od bola u vratu do dijagnoze histiocitoze Langerhansovih ćelija u štitastoj žlezdi
Abstract
Uvod. Histiocitoza Langerhansovih ćelija (HLĆ), hematopoetska neoplazma, predstavlja klonsku proliferaciju Langerhansovih dendritskih ćelija. Detaljan klinički pregled ponekad je presudan za otkrivanje retkih bolesti odraslog doba, kao što je HLĆ sa prisutnom autoimunskom bolešću štitaste žlezde. Prikaz bolesnika. Žena stara 43 godine prvi put se javila na pregled kod endokrinologa zbog bolova i otoka prednjeg dela vrata, praćenog umorom i malaksalošću. Inspekcijom i palpacijom utvrđen je uvećan desni režanj štitaste žlezde, izuzetno čvrste konzistencije, bolno osetljiv pri palpaciji. Ehosonografskim pregledom zapažen je uvećan desni režanj štitaste žlezde, nejasno ograničen od okolnog tkiva, sa izrazito nehomogenim parenhimom, smanjenom ehogenošću anteriornog aspekta i izraženom hipoehogenošću posteriornog aspekta parenhima štitaste žlezde, prožet fibroznim trakama i kalcifikacijama. Viđena je pseudonodularno izmenjena struktura levog režnja štitaste žlezde, sa karakteristikama hroničnog zapaljenskog procesa. Biohumoralni nalaz je ukazivao na hronični autoimunski tiroiditis i primarnu hipotireozu. Anamneza, klinički nalaz, lična i porodična sklonost ka malignitetu zahtevali su ubrzanu dopunsku dijagnostiku. Rezultat aspiracione biopsije tankom iglom odgovarao je atipiji neodređene značajnosti sa Hurthle-ovim ćelijama, nuklearnim preklapanjima, anizocitozom, anizonukleozom i prisustvom nuklearnih useka. Patohistološki nalaz nakon tireoidektomije odgovarao je fibroznoj formi hroničnog tiroiditisa, sa sumnjom na postojanje monoklonalne proliferacije histiocitnih i/ili limfoidnih ćelija. Imunohistohemijski nalaz potvrdio je Hashimoto tiroiditis i HLĆ. Postoperativni tok prošao je bez komplikacija i bolesnici je uvedena supstituciona terapija L-tiroksinom, uz nastavak kontinuiranog i sistemskog praćenja u pogledu histiocitoze. Zaključak. Na HLĆ treba češće posumnjati s obzirom na visoku učestalost autoimunske bolesti štitaste žlezde u odraslom životnom dobu. Pravovremena dijagnoza HLĆ u velikoj meri određuje ishod lečenja.
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