Volkanovska ilijevska, Cvetanka
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Volkanovska ilijevska, Cvetanka
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Volkanovska ilijevska, Cvetanka
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Item type:Publication, Cystic pheochromocytoma, a diagnostic challenge: A case report(Bioscientifica, 2020-08); ; We describe a case of cystic pheochromocytoma (PCC) with negative biochemical evaluation, diagnosed on the basis of hypertensive crises during operative management and histopathologic findings. A 57-year-old woman complained of several episodes of stabbing right upper abdominal pain accompanied by tachycardia, headache, lack of breath, elevated blood pressure and vomiting in the preceding three years. At presentation, blood investigations were significant only for mildly elevated transaminases and serum amylase. An abdominal ultrasound was performed and revealed large right adrenal incapsulated and heterogenous mass, 7 × 7 cm in size, with mass effect. Computed tomography imaging confirmed incapsulated adrenal mass with internal septations and unenhanced attenuation of >30 Hounsfield units. Based on imaging appearance and patient’s history, a suspicion of PCC was established, and the patient was referred to endocrinologist. Laboratory exams for Cushing’s syndrome were unremarkable and urinary vanilmandelic acid, metanephrines and serum chromorgranin A were within normal range on several occasions. Further evaluation with iodine-123 (123I)-labeled metaiodobenzylguanidine (MIBG) scintigraphy would have been useful to differentiate the mass, but it was not available at the moment of investigations. Despite negative biochemical diagnosis,strong clinical suspicion for PCC was established and the patient was preoperatively prepared with α-adrenoreceptor and beta blockers. Initial attempt for laparoscopic adrenelectomy was unsuccessful due to early intraoperative occurrence ofhypertensive crises with blood pressure 300/150 mmHg. Three months later a successful open adrenelectomy was performed with nonsignificant intraoperative hemodynamic instability. Histopathologic evaluationconfirmed cystic benign PCC with dominance of multnuclear giant, foamy macrophages, presence of hemosiderin deposition and hemolyzed erythrocytes. Although cystic adrenal lesions comprise several types of non-functionating benign lesions, the differential diagnosis should include cystic form of PCC, an entity that is rarely reported. In cystic PCC the number of cateholamin-producing cells are low, especially when an extensive necrotic cystic regions are present. Furthermore, catecholamines stored in the capsular mass may not be released into the blood circulation until surgical attempt for isolation of PCC is made. Therefore, high clinical suspicion for PCC is necessary since negative biochemical diagnosis is possible. As demonstrated by our case, clinical presentation was crucial in the diagnosis and preoperative management. Preoperative optimization with antihypertensive drugs and blood volume expansion fluids is obligatory in PCC surgery in order to prevent detrimental intraoperative hemodynamic instability. Albeit laparoscopic adrenelectomy is becoming a first line surgical option for PCC, still it’s not always feasible as shown in our case. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Association of the APOEgene polymorphism with diabetic nephropathy(Bioscientifica, 2020-08) - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Hypercalcaemia in patient with primary hyperparathyroidism and acromegaly(Bioscientifica, 2015-05); ; Introduction: Hypercalcaemia in acromegaly can be a result of several pathophysiological mechanisms. Multiple endocrine neoplasia type 1 (MEN1) syndrome, mitogenic effect of hyperactivated GH–parathyroid gland axis, i.e. primary hyperparathyroidism and hypercalcaemia mediated by elevated 1,25-dihydroxyvitamin D should be considered. Case report: We describe a case of acromegaly associated with primary hyperparathyroidism. A 52-year-old female was diagnosed with acromegaly due to GH secreting pituitary microadenoma. Evaluation at diagnosis showed normal levels of hormones other than GH and IGF1, and presence of hypertension and multinodular goiter (volume 80 mm3). Because the patient denied surgery, treatment with cabergoline was administrated and a biochemical control was accomplished. Within 1 year of the diagnosis laboratory data showed hypercalcaemia (serum calcium 1.51 mmol/l (1.10–1.40)) in the setting of elevated parathormone (PTH) levels (158 pg/ml (15–65)) and low levels of vitamin D (5.6 nmol/l (>25)). Bone densitometry detected osteoporosis limited to the right radius (T score value −4.0 S.D.). Analysis of 24-h urine showed normal calcium and phosphate excretion. This findings were consistent with diagnosis of primary hyperparathyroidism. Imaging and radioisotope studies identified enlarged thyroid gland, predominantly the left lobe with consequent tracheal compression, and higher radioisotope uptake in the lower pole of the left thyroid lobe. Surgical excision of left lower parathyroid gland and subtotal thyroidectomy was done. Histopathological examination confirmed hyperplasia of parathyroid and thyroid gland. After surgery, serum calcium normalised, PTH levels significantly reduced to 73.2 pg/ml. Vitamin D remained low (17.8 nmol/l) and TSH levels elevated to 27 mU/l (0.4–4) for which vitamin D and levothyroxine substitution was started. Conclusion: The approach to hypercalcaemia in the course of acromegaly implies evaluation for several potential pathophysiological mechanisms, which in turn dictates the treatment strategy – parathyroidectomy vs biochemical control of acromegaly. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Right heart failure in patient with resistant thyrotoxicosis due to Graves' disease(Bioscientifica, 2018-05); Tonovska, IrinaIntroduction: Resistant thyrotoxicosis is condition in which patients fail to respond to maximal doses of antithyroid drugs. Definitive treatment is radioactive ablation and operative treatment. However, achievement of euthyroid status before definitive treatment is important in patients with underlying cardiovascular disorder in whom thyroid crises can be detrimental. Case report: We describe a case of resistant thyrotoxicosis and right heart failure. A 55-year-old lady presented to our emergency center with complaints of chest pain, shortness of breath and distended stomach. On examination, she had blood pressure 140/80 mmHg, heart rate 40 bpm, jugular venous distension, pretibial edema, pansystolic murmur in the left paratsternal region and diffuse goitre. The abdomen was distended and the liver was palpable 2 cm below the right costal margin. The patient was diagnosed with Graves’ disease 15 days previously in another institution and had already started taking high doses of methimazole (60 mg) and propranolol (60 mg). Blood analysis confirmed a severe hyperthyroidism with a thyroid-stimulating hormone (TSH) <0.004 uIU/ml and elevated fT4–4.03 ngl/dl (N 0.90–1.80), fT3–9.94 pg/ml (N1.80–4.20) and normocytic anemia. Electrocardiogram showed bradicardic (40/min) sinus rhythm. Transthoracic echocardiography revealed a dilated right ventricle (52 mm) with a normal function and dimensions of left chambers. A severe tricuspid valve insufficiency was detected and estimated pulmonary artery systolic pressure was 60 mm Hg. The vena cava inferior was dilated and non-collapsing (24 mm). There was a mild mitral regurgitation grade III-IV. The methimazole was discontinued and treatment with maximum doses propylthiouracil (PTU) (300 mg three times a day), spironolacton and furosemid were initiated. The dose of propranolol was reduced (10 mg two times a day). After 2 weeks, fT4 and Ft3 were still significantly elevated and prednisolone (40 mg) was given in addition to the antithyroid drug. Four months later the patient clinically improved, but biochemical hyperthyroidism was still present. Definitive operative treatment was scheduled and in order to reduce the risk of precipitating thyroid crises the patient was given potassium iodide (150 mcg) in the next two weeks. Biochemical euthyroid state ensued and patient underwent total thyroidectomy. Thereafter tyroxine replacement therapy was started and pulmonary hypertension, atrial fibrillation and anemia resolved. Conclusion: Adjunctive drugs like prednisolone and potassium iodide play an important role in preparing patients with resistant thyreotoxisocis for more definitive treatment. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Frequency of Left Atrial Enlargement According to Different Modes of Indexing in Overweight and Obese Individuals(Macedonian Academy of Sciences and Arts, 2023-03); ; Background: Current guidelines recommend indexing left atrial volume (LAV) by body surface area (BSA). However, in overweight and obese individuals this may result in the underestimation of left atrial enlargement (LAE). The aim of our study was to assess whether alternative LAV indexing to height and/or height-squared better identifies individuals with LAE among those who are overweight and/or obese. Methods: LAV was indexed to BSA (LAVI), height (LAVh), and height-squared (LAVh2) in 127 individuals with a mean age of 45.7 years and a mean body mass index (BMI) of 34.9 kg/m2 who underwent outpatient echocardiography at the University clinic of cardiology in Skopje. Results: LAVI, LAVh, and LAVh2 showed a progressive increase of respective values with the extent of BMI showing the most enlarged LA size in individuals with Class III obesity. There was a progressive significant increase in the prevalence of LAEh and LAEh2 in obese groups with the highest prevalence among those with class III obesity (p=0.002, p=0.002, respectively), on the contrary of LAEBSA where we could not find any significance in its distribution among obese classes. The greatest degree of reclassification occurred when indexing for height-squared, having relatively less reclassification when indexing for height (p=0.0001). The degree of reclassification varied depending on BMI with the greatest impact among the Class III obese patients, where as many as 76.5% and 88.2% of individuals were reclassified according to height or height-squared, respectively. Conclusions: The use of height, and especially height-squared, in comparison to BSA-based indexing methods are more successful in identifying the LAE prevalence in each class of obesity. Using allometric indexation leads to the significant reclassification of LA size from normal to dilated, especially in women and those with severe obesity, thereby providing an opportunity to identify more individuals at increased risk of adverse events. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Case report: therapeuthic approach in risperidone induced hyperprolactinemia(University Clinic of Endocrinology, Diabetes and Metabolic Disorders, Medical Faculty, University “Ss. Cyril and Methodius” - Skopje, 2022-10-13); ; - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Adrenal Cyst-Diagnostic Dilemma: Case report(2022); ; - Some of the metrics are blocked by yourconsent settings
Item type:Publication, ПРИКАЗ НА СЛУЧAJ: ПАЦИЕНТ СО АКРОМЕГАЛИЈА И ПОЛИОСТОТИЧНА ФИБРОЗНА ДИСПЛАЗИЈА - McCUNE ALBRIGHT СИНДРОМ(Македонско лекарско друштво = Macedonian medical association/De Gruyter, 2014); McCune-Albright syndrome (MAS) is classically defined by the clinical triad of café-au-lait skin spots, poly/monostotic fibrous dysplasia (FD) of bone and precocious puberty. However, MAS is an extremely heterogeneous disease and numbers of atypical and partial forms exist beyond the classic MAS. Growth hormone (GH) excess has been reported as a common manifestation in MAS. Polyostotic fibrous dysplasia is reported to be more common in MAS, with involvement of the craniofacial (CF) region in over 90% of the cases. Involvement of the CF bones with FD often results in overgrowth and asymmetry of bone and hence recognition of GH excess might be unrecognized. Moreover, morbidity related to FD is more common in patients with GH excess. Medical treatment using a somatostatin analog or dopamine agonist is often the only option in patients with MAS and acromegaly, because surgery is not possible due to the massive thickening of the CF with FD. We report an atypical case of MAS in a 35-year-old male patient showing PFD with severe involvement of the base of the skull, along with acromegaly. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, A case report of Wegener granulomatosis (WG) presenting epistaxis, hemoptysis and polyarthralgia(Slovenian Respiratory Society, 2020-12); ; Kuzmanovska Dimitrovska, MelinaBackground: Wegener granulomatosis (WG) is a rare multisystem autoimmune disease characterized by necrotizing granulomatous inflammation, tissue necrosis, and vasculitis in small and medium-sized blood vessels. The classic clinical pattern is a triad involving the upper airways, lungs and kidneys. Case presentation: A 33-year-old woman was admitted to our hospital with a history of progressively worsening dry cough, shortness of breath, polyarthralgia, fever, epistaxis and hemoptysis. Two months before admission, she had episodes of nasal bleeding, dry cough, fever not more than 38.2°C. Her primary physician did not detect any abnormal findings in the chest radiographs at that time. Two months later, she consulted the doctor again due to the symptoms and because of the chest X-ray with multiple small infiltrates in both lungs, high sedimentation rate she was admitted to our hospital. Lungs were clear to auscultation bilaterally. Laboratory results revealed anemia with Hgb 90g/L, hematocrit 30%, erythrocytes 3600/L, leucocytes 13800/L, CRP 110mg/L, sedimentation rate 70mm/h. Urine sediment – erythrocytes 16-18, proteins +, epithelial cells ++. 24hour proteinuria 0,5g/L (upper limit 0,2). Rheumatoid antibodies: positive c-ANCA 95U/ml, RF 158IU/ml, ASO 88U/ml. ECG with sinus tachycardia of 120 beats/min. Gas analyses in partial respiratory failure with hypoxemia 7,5kPa and hypocapnia 3,6kPa, oxygen saturation 91%. Chest radiography and lung CT showed multiple infiltrates in the bilateral upper lobes. Bronchoscopy finding of intranasal coagulum without changes of nasal mucosa, transoral intubation revealed diffuse erythema and edema of the vulnerable tracheobronchial mucosa without any ulcerous lesions or infiltrative changes. Chest ultrasound with many apical bilateral, subpleural, hypoechogenic changes with zones of central necrosis with maximal diameter 20mm. Ophthalmology examination - punctiform conjunctival bleeding. Transbronchial biopsy was performed and revealed necrotic granulomas with multinucleated giant cells in the bronchial/bronchiolar and parenchymal lesions. Bronchial alveolar lavage (BAL) was performed and showed the small increase of neutrophils (total cell counts: 320/μL, neutrophils: 19.2%, macrophages: 85.0%, lymphocytes: 7.4%, eosinophils: 0.0%) and no growth of bacterial culture. According to the results the diagnosis granulomatosis with polyangiitis, Wegener’s granulomatosis. She was successfully treated by rheumatologist with high-dose steroids and cyclophosphamide. Conclusion: The recognition of multisystem disease involving joints, kidney, eye and lung is critical for diagnosing Wegener's vasculitis. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Diagnostic performance of prostate health index(PHI) in predicting prostate cancer on prostate biopsy; a single center study.(Macedonian Association of Anatomists and Morphologists, 2023-12)