case_images: PMC11790437_01
case_images: Thyroid ultrasonography (US) examination showing a non-uniform hypoechoic glandular parenchyma (A), with a 17-mm well-defined hyperechoic nodule in the left lobe (B) and a diffused markedly accentuated vascularization as described in thyroid storm (C).
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case_images: Thyroid ultrasound further described an increase in thyroid volume, diffusely non-uniform structure and markedly accentuated vascularization, and a 17-mm round solid iso-hyperechoic nodule with well defined margins and predominantly peripheral vascularization in the left lobe ( Figure 1 ). The day after admission, total serum calcium was 11.1 mg/dL, or 2.77 mmol/L (8.5-10.5 mg/dl, or 2.12-2.62 mmol/L), ionized calcium 6.0 mg/dL (4.7-5.2 mg/dL), serum phosphate 3.0 mg/dL, or 0.97 mmol/L (2.5-4.5 mg/dL, or 0.8-1.5 mmol/L), magnesium 1.5 mg/dL (1.4-2.4 mg/dL), 25-hydroxy vitamin D3 (25-OH-D3) 50 ng/mL (20-100 ng/mL), 1,25-dihydroxy vitamin D3 [1,25-(OH)2-D3] 56 ng/L (20-80 ng/L), alkaline phosphatase (ALP) 101 U/L (43-115 U/L), C-terminal telopeptides of type I collagen (CTX) 1900 ng/L (120-630 ng/L), serum creatinine 0.53 mg/dL (0.7-1.2 mg/dL), 24-hour urinary calcium 20.2 mg/dL (8.3-26.6 mg/dL), and PTH was significantly low (< 5.5 ng/L; normal range 14.9-56.9 ng/L).
case_images: Serum adjusted total calcium (blue line) and free T4 (fT4; orange line) levels before and during hyperthyroidism treatment. A parallel reduction in fT4 and calcium values is shown.
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case_images: In the meantime, calcium levels were decreasing with hydration, diuretics combined with thyrostatic treatment ( Figure 2 ;  Supplementary Table 1 ), with patient's subjective improvement in anxiety, asthenia and dysphagia. After a week of thyrostatic treatment, intravenous hydration and diuretics, calcium levels stabilized at a level of <12 mg/dL, or <3.0 mmol/L ( Figure 2 ), and thyroid function significantly improved with TSH <0.01 mIU/mL, FT4 14.8 pmol/L (9-19 pmol/L) and FT3 6.8 pmol/L (2.4-6 pmol/L).
case_images: Contrast-enhanced CT scan sections: at mammary (A) and gluteal (B) level, images are compatible with patient history of silicone injections, in the form of soft-tissue densities with surrounding fat stranding (arrows) and peripheral calcifications.
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case_images: f3
case_images: The patient revealed that in the past he had silicone injections performed in those sites as part of gender transition: as a matter of fact, upon revision of previously performed CT scan sections, compatible images were visible at mammary and gluteal level ( Figure 3 ).