The flushing patient: Differential diagnosis, workup, and treatment. A false-negative test result may be seen in rare medullary thyroid cancers that do not secrete calcitonin. In patients with thyroid nodules, however, the routine assessment of serum calcitonin is controversial, and the American Thyroid Association guidelines published in Thyroid in 2016 do not recommend for or against routine measurement of serum calcitonin in patients with thyroid nodules.įalse-positive calcitonin results may be obtained in patients with hypercalcemia, hypergastrinemia, neuroendocrine tumors, renal insufficiency, papillary and follicular thyroid carcinomas, goiter, chronic autoimmune thyroiditis, and prolonged use of certain medications.
Blood concentrations of calcitonin are elevated in patients with medullary thyroid cancer. In this case, an elevated calcitonin led to further investigations, diagnosis and cure. Markers for other potential etiologies such as serum calcitonin.Serum tryptase and 24-hour urine for methylhistamine, 2,3-dinor-11beta-prostaglandin F2-alpha, and leukotriene E4 to screen for mast cell disease.24-hour urine for 5-hydroxyindoleacetic acid to screen for carcinoid syndrome.A complete blood count and liver function tests.
When an etiology is not identified by history and physical examination, initial laboratory evaluation includes: The most common etiologies for which a patient will present with flushing are fever, hyperthermia, primary gonadal failure such as menopause, emotional blushing and rosacea. Thyroid ultrasound image showing a 1.8-cm nodule in right thyroid lobe (arrow), which proved to be medullary thyroid cancer.Īs highlighted in a review published in the Journal of the American Academy of Dermatology in 2006, flushing is a sensation of warmth accompanied by transient erythema that most commonly occurs on the face, but may also involve the neck, ears, chest, epigastrium, and arms or other areas. Ultrasound of a 1.8-cm nodule in right thyroid lobe Neck ultrasound showed no evidence of adenopathy. At his six-month follow-up visit, he had an undetectable serum calcitonin concentration and a normal serum concentration of carcinoembryonic antigen. After surgery, he had complete resolution of his symptoms of flushing and the rash. He also had an incidental 0.7-cm papillary thyroid carcinoma in the midportion of the right lobe of the thyroid. He underwent a near-total thyroidectomy, and pathology showed that the MTC formed a 1.8-by-1.4-by-1.1-cm mass. Bidirectional sequence analysis was performed to test for the presence of a mutation in exons 10, 11, 13, 14, 15 and 16 of the RET proto-oncogene and was negative. Fine-needle aspiration biopsy findings were consistent with medullary thyroid carcinoma (MTC). Ultrasound of the thyroid showed a 1.8-cm suspicious nodule in the midright thyroid lobe. Based on this information, thyroid ultrasound was obtained. Tests for other potential causes of flushing disorder were obtained, which were remarkable for a serum calcitonin concentration markedly elevated at 552 pg/mL (normal < 16 pg/mL).
#Steroid facial flushing skin
Skin biopsies showed multiple telangiectasias and no sign of mast cell abnormalities. The 24-hour urine for 2,3-dinor-11beta-prostaglandin F2-alpha was mildly increased at 1,363 ng (normal, < 1,000 ng). 24-hour urine for 5-hydroxyindoleacetic acid, N-methylhistamine, fractionated metanephrines and catecholamines.Complete blood count and routine chemistries.The remainder of the physical examination was normal. The thyroid appeared normal on examination, without any nodules appreciated on palpation. With his arms raised his facial flush did not change. On physical examination, he had a moderately flushed face and a diffuse red rash over his back. Photographs taken before (A) and three months after (B) surgery to resect medullary thyroid cancer.
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