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* * * * * * * * * * * * * * * * * * * * * * * * * * * * Case 2 A 23-year-old woman presents to her primary care physician complaining of diarrhea. The diarrhea is described as profuse and watery and has been getting progressively worse over the last 2 months. She has had no bloody or black bowel movements. The condition is not made worse by food and is not associated with fever, chills, sweats, nausea, or vomiting. On review of systems, she does note a 5-pound weight loss in the last 3 months. She also notes occasional flushing. She denies any significant family history. On physical examination, she is a thin white woman in no acute distress. She is afebrile, with a blood pressure of 100/60 mm Hg, heart rate of 100 beats/min, and respiratory rate of 14/min. Head examination is unremarkable. Neck examination reveals bilateral hard nodules of the thyroid, a 2-cm nodule on the right upper pole, and a 1.5-cm nodule on the left upper pole. She has a firm 1-cm lymph node in the right anterior cervical chain. Lungs are clear. Cardiac examination is mildly tachycardiac, with regular rhythm and no extra sounds. The abdomen has hyperactive bowel sounds and is soft, nontender, nondistended, and without masses. Skin examination discloses no rashes. Medullary carcinoma of the thyroid is suspected. Questions A. What is the cause of this patients diarrhea? Flushing? B. How would you make a diagnosis of medullary carcinoma of the thyroid? C. What other tests would you like to order? Why? ? Answer Medullary carcinoma of the thyroid is a C-cell neoplasm. Because C cells are neuroendocrine cells, they have the capacity to release several hormones. The secretion of serotonin, prostaglandins, or calcitonin probably causes the watery (secretory) diarrhea this patient has. Flushing is generally caused by tumor production either of substance P or of calcitonin gene-related peptide, both of which are vasodilators. The diagnosis would be made most efficiently by fine-needle aspiration of th
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