Unusual manifestations of craniofacial fibrous dysplasia: clinical, endocrinological and computed tomographic features

Clinical, endocrinological and computed tomographic features of three patients with unusual manifestations or complications of craniofacial involvement of fibrous dysplasia are presented. One patient with polyostotic fibrous dysplasia presented in late pregnancy with acute onset of bilateral optic nerve compression and blindness secondary to a rapidly expanding mass of fibrous dysplasia tissue involving the sphenoid, pituitary and optic chiasm regions. A second patient with polyostotic fibrous dysplasia developed thyrotoxicosis and probable gigantism/acromegaly in keeping with a rare form of McCune-Albright syndrome. Extensive bony distortion of the skull and facial bones by fibrous dysplasia made clinical recognition of these complications more difficult. A third patient had monostotic fibrous dysplasia with marked sclerosis of the sphenoid bone on plain radiographs which mimicked appearances of a meningioma and resulted in a negative craniotomy as computed tomography was not yet available at the time of presentation. Each case demonstrated rare complications of craniofacial fibrous dysplasia and highlighted the wide spectrum of appearances in which it may manifest, often resulting in overlap and diagnostic confusion with other disease processes. The value of computed tomography in assessment is emphasized.

Adrenocortical function and involvement in high risk cases of pulmonary tuberculosis

SETTING

A regional hospital in Hong Kong.

OBJECTIVE

To evaluate adrenocortical function in older patients admitted to hospital with active pulmonary tuberculosis (TB) and to determine whether adrenal insufficiency contributes to mortality in this high risk group.

DESIGN

Adrenocortical function was assessed in 39 consecutive patients aged over 50 admitted to hospital with active pulmonary TB. Short Synacthen stimulation tests were performed before treatment and repeated at 2 months. In patients who died during treatment, a post-mortem examination was performed. Particular attention was paid to TB involvement of the adrenal glands.

RESULTS

None of the patients had a subnormal basal cortisol concentration before treatment. 7 (18%) had raised basal cortisol concentrations and 16 (41%) had suboptimal cortisol responses to Synacthen stimulation. 14 patients (36%) died during treatment. The basal cortisol concentrations were significantly higher in the non-survivors compared to the survivors (743.7 +/- 288.5 vs 460.5 +/- 123.2 nmol/L, P < 0.0001). Autopsies were performed in 9 patients who died during treatment. Tuberculous involvement of the adrenal glands was found in only 1 patient who had a high basal cortisol concentration. After 2 months of treatment, all patients had normal cortisol concentrations and only 4 had borderline suboptimal Synacthen responses. The basal cortisol concentrations were significantly higher at presentation compared to those at 2 months after treatment (570.4 +/- 243.8 vs 386.3 +/- 108.3 nmol/L, P = 0.0014).

CONCLUSION

Adrenal insufficiency is uncommon in patients with pulmonary TB. Suboptimal cortisol responses to Synacthen usually reflect a hyperstimulated basal state secondary to stress. Treatment with anti-TB drugs causes reduction in basal cortisol with associated improvement in the Synacthen response.

Lithium-associated transient thyrotoxicosis in 4 Chinese women with autoimmune thyroiditis

Four Chinese female patients who suffered from manic-depressive disorder and underlying autoimmune thyroiditis developed transient episodes of thyrotoxicosis during maintenance lithium therapy. Endocrinologically speaking, three of them had "Hashitoxicosis", while the other had silent lymphocytic thyroiditis. Albeit rare among Western patients, such lithium-associated thyroid dysfunctions appeared to be more likely to occur in Hong Kong Chinese. They seemed to involve multiple aetiological factors, such as autoimmune thyroid disease, the toxic and immunomodulatory roles of lithium and perhaps genetic and dietary factors. Because of their self-limiting nature, the importance of avoiding unnecessary and potentially deleterious antithyroid treatment is emphasised.

Thyroid abnormalities during chronic lithium treatment in Hong Kong Chinese: a controlled study

Fifty Chinese psychiatric patients on chronic lithium treatment and the same number of sex- and age-matched control outpatients were assessed by a thyroidologist and underwent laboratory investigations. Lithium patients had a higher rate of goitres (50% vs 10%, P < 0.0001) and a higher mean TSH level (P < 0.005) than controls. Thyroid antibodies were detected in 7 older manic-depressive patients as opposed to 1 control, but not in patients with recurrent unipolar mania. Five patients, but no controls, had single or multiple episodes of hyperthyroidism, which was followed in 2 of them by biochemical hypothyroidism. It is suggested that variations in iodine status, dietary goitrogens, immunogenetic makeup and their complex interactions with chronic lithium treatment may contribute to ethnically different patterns of thyroid abnormalities.

Folate concentration in Chinese psychiatric outpatients on long-term lithium treatment

Among 46 Chinese and mostly manic-depressive (85%) outpatients attending a lithium clinic in Hong Kong, virtually no patients had low serum (0%) or erythrocyte (2%) folate. Their mean folate levels did not differ from lithium-free outpatients. Although serum folate correlated negatively with lithium dose (P less than 0.002) and serum level (P less than 0.01), lithium treatment probably did not by itself cause low folate. Folate level was not related to diagnosis, duration of mental illness, other drug usage or spot affective morbidity. Patients with a good response to lithium in the previous one year had a higher mean serum folate level than those with unsatisfactory response (P less than 0.05). These data suggest that folate deficiency is uncommon among Chinese psychiatric outpatients, but support recent evidence that folate at high concentrations enhances lithium prophylaxis.

Ga-67 citrate in diagnosing tracheoesophageal fistula in a patient with AIDS. Case report

Increased radiopharmaceutical uptake in the mediastinum and/or hilum on Ga-67 citrate scan in patients with AIDS has been attributed, to date, mostly to infectious etiologies. Because other complications are being reported in these patients, awareness of their presentation in diagnostic imaging is important. Tracheoesophageal fistula can also be accompanied by a focal area of increased uptake in the mediastinum. In this patient, a Ga-67 citrate scan was the first modality of diagnostic imaging to raise suspicion of such a diagnosis.

In vivo and in vitro sodium pump activity in subjects with thyrotoxic periodic paralysis

OBJECTIVE

To examine whether sodium pump activity plays a part in the pathogenesis of thyrotoxic periodic paralysis.

DESIGN

Measurement of platelet sodium-potassium ATPase and in vivo sodium pump activities in healthy subjects and thyrotoxic subjects with and without paralysis.

SETTING

University hospital in Hong Kong.

SUBJECTS

21 healthy subjects, 23 untreated thyrotoxic subjects, 13 untreated men with periodic paralysis, seven treated thyrotoxic subjects, and six treated men with periodic paralysis.

MAIN OUTCOME MEASURES

Platelet Na+, K(+)-ATPase activity and plasma rubidium concentration after oral loading.

RESULTS

Median (range) platelet Na+, K(+)-ATPase activity in thyrotoxic subjects was 253 (169-821) mumol inorganic phosphate/h/g protein--significantly higher than that in healthy subjects (134 (81-180) mumol/h/g protein; p less than 0.001). Na+, K(+)-ATPase activity in those with periodic paralysis was 374 (195-1196) mumol/h/g protein, again significantly higher than that in healthy subjects (p less than 0.001) and that in other thyrotoxic subjects (p less than 0.01) despite similar degrees of hyperthyroidism. Activities in treated thyrotoxic subjects with and without periodic paralysis were 148 (110-234) and 131 (86-173) mumol/h/g protein respectively. Mean (95% confidence interval) plasma rubidium concentration five hours after oral administration in thyrotoxic subjects (7.0 (6.6 to 7.5) mumol/l) was significantly lower than in healthy subjects (10.2 (9.5 to 10.9) mumol/l; p less than 0.001) and higher than in those with periodic paralysis (6.0 (5.7 to 6.3) mumol/l; p less than 0.01).

CONCLUSIONS

Sodium pump activity in untreated subjects with periodic paralysis is higher than in other thyrotoxic subjects, and this may be responsible for the hypokalaemia.

Mania secondary to thyrotoxicosis

A case of severe mania due to thyrotoxicosis responded to propranolol and propylthiouracil.

Effect of low dose iodide supplementation on thyroid function in potentially susceptible subjects: are dietary iodide levels in Britain acceptable?

OBJECTIVE The aim of the study was to evaluate the risk of exposure to an increase in dietary iodide intake amongst potentially susceptible population groups in Britain. DESIGN A randomized controlled trial was performed in healthy women and in women with underlying thyroid abnormalities due to subclinical Hashimoto's thyroiditis (diagnosed on the basis of antithyroid antibodies) or previous iodide deficiency of supplementation with 500 micrograms/day iodide (giving a total intake of approximately 750 micrograms/day) for 28 days versus placebo. PATIENTS Two hundred and twenty-five women aged 25-54, randomly selected from a general practice in Cardiff, were screened for thyroid microsomal antibody. Antibody positive women (n = 20), and antibody negative controls (n = 30) were recruited into the trial comparing iodide and placebo. In addition, groups of patients aged 60-75 randomly selected from the Cardiff practice (n = 29), an iodide sufficient area, and a practice in Dowlais (n = 35), a previously iodide deficient area, were also enrolled into the trial. MEASUREMENTS Changes in free thyroxine and thyrotrophin levels were measured after 14 and 28 days of iodide supplementation. RESULTS All the iodide supplemented groups responded in the same way with a small fall in free thyroxine and rise in thyrotrophin levels (combined fall in free thyroxine 14 days after the start of supplementation -1.22 (95% confidence interval -0.59 to -1.84) pmol/l and at 28 days -0.86 (-0.30 to -1.43) pmol/l and rise in thyrotrophin at 14 days 0.55 (0.19 to 0.92) mU/l and at 28 days 0.59 (0.12 to 1.07) mU/l). In two of the iodide supplemented subjects thyrotrophin levels rose above the laboratory reference range and in a further three subjects initially elevated thyrotrophin values increased further. In contrast, no changes in thyroid function were observed in the placebo treated controls and none developed biochemical hypothyroidism. CONCLUSIONS Dietary iodide intakes of 750 micrograms/day or more may adversely affect thyroid function, especially in individuals with borderline hypothyroidism.

Abdominal wall cyst: a complication of ventriculoperitoneal shunting

An abdominal wall cyst developed as a complication of ventriculoperitoneal shunting. Sonography showed the cystic nature of the lesion and computerized tomography localized it to the abdominal wall.

Response to control of hyperthyroidism in patients with myasthenia gravis and thyrotoxicosis

Three patients presenting with both myasthenia gravis and thyrotoxicosis were treated initially with pyridostigmine and carbimazole respectively. Control of the hyperthyroidism was achieved in all cases but was accompanied by deterioration of the myasthenic symptoms in two and persistence in one. Thymectomy was performed with subsequent improvement in all three patients. Histology showed thymic hyperplasia in each case. The relationship of myasthenia gravis, thyrotoxicosis and the thymus is discussed.

Serum soluble interleukin 2 receptor in hyperthyroid Graves' disease and effect of carbimazole therapy

To study the activation of T lymphocytes in hyperthyroid Graves' disease, the serum concentrations of soluble interleukin 2 receptors (sIL2R) were determined during active thyrotoxicosis and following the return to a euthyroid state with carbimazole therapy. Serum sIL2R was measured by an enzyme linked immunoassay. The mean +/- SD serum sIL2R concentration during untreated hyperthyroidism was elevated as compared with controls (919.1 +/- 523.4 vs 374.2 +/- 189.4 U/ml, P less than 0.005). However, after carbimazole therapy the serum sIL2R in euthyroid patients fell to 377.9 +/- 90.3 U/ml, which did not differ from healthy controls. Serum sIL2R correlated significantly with the serum free T3 only during hyperthyroidism (r = 0.678, P less than 0.01). Our study suggests that in vivo measurement of serum sIL2R released from activated T lymphocytes is a useful immunological indicator of disease activity.

Sleep apnoea presenting as severe hypertension and silent occipital haemorrhage

A 39-year old Chinese man presented with an acute onset of severe headache, accelerated hypertension and subsequently an unexpected extensive right occipital haemorrhage. These were found to be related to a sleep apnoea syndrome which had been unrecognized for many years despite its typical symptoms of loud snoring and excessive daytime sleepiness. Weight reduction led to significant clinical but not polysomnographic improvement of the sleep apnoea syndrome.

Inhibition of muscarinic-coupled phosphoinositide hydrolysis by N-methyl-D-aspartate is dependent on depolarization via channel activation

The intent of this work was to elucidate the mechanism by which N-methyl-D-aspartate (NMDA) receptor agonists inhibit a second messenger system, namely, the stimulation of phosphoinositide (PI) hydrolysis activated by muscarinic cholinergic receptor agonists. NMDA inhibited cholinergic stimulation of PI hydrolysis in a dose- and time-dependent manner. NMDA exerts this effect indirectly through channel activation, because both MK-801 and N-[1-(2-thienyl)cyclohexyl]piperidine (TCP) prevented this action. Prevention of the NMDA effect by removal of sodium, but not calcium, from the incubation buffer suggested that depolarization may be the responsible mechanism. Depolarization alone proved sufficient to inhibit cholinergic activation of PI hydrolysis, because both veratridine and an elevated extracellular potassium level inhibited cholinergic stimulation of PI hydrolysis. The effect of NMDA appeared to require sodium flux through NMDA channels rather than through voltage-dependent sodium channels, because tetrodotoxin failed to inhibit the effect of NMDA. In correlative electrophysiologic experiments, NMDA profoundly inhibited evoked excitatory postsynaptic potentials and population action potentials of CA1 neurons, an effect almost certainly due to depolarization. The dose and time course of the electrophysiologic effects correlated well with the biochemical effects. Taken together, the data support the assertion that NMDA receptor activation inhibits PI hydrolysis by depolarization mediated by sodium flux through NMDA channels.

Erythrocyte zinc concentrations in subacute (de Quervain's) thyroiditis

Images

Allergic granulomatosis and angiitis (Churg-Strauss syndrome): response to 'pulse' intravenous cyclophosphamide

A 51 year old Chinese woman suffering from classical Churg-Strauss syndrome is presented. She deteriorated with acute pulmonary infiltrates resulting in hypoxaemic respiratory failure but responded dramatically with 'pulse' intravenous cyclophosphamide.

Gastric outlet obstruction masquerading as anorexia nervosa

A 30-year-old Chinese housewife presenting with what appeared to be late-onset anorexia nervosa was subsequently found to have peptic ulcer disease complicated by gastric outlet obstruction. Surgical treatment led to rapid improvement of body weight but not immature personality. Extra caution should be exercised in the diagnosis of anorexia nervosa presenting with atypical features in a community in which that condition is rare.

T lymphocyte activation in euthyroid Graves' ophthalmopathy: soluble interleukin 2 receptor release, cellular interleukin 2 receptor expression and interleukin 2 production

The present study was undertaken to examine the cellular control arm of the immune response with regard to T lymphocyte proliferation in euthyroid Graves' ophthalmopathy. Twenty patients with euthyroid Graves' ophthalmopathy (7 on antithyroid drugs and 13 on no treatment) and 18 healthy controls were studied in an infection-free period. Mitogen-stimulated cellular interleukin 2 (IL2) receptor expression, soluble interleukin 2 receptor release, and interleukin 2 production, were studied in peripheral blood mononuclear cells cultured for 24 h. The cellular IL2 receptor expression and soluble IL2 receptor release did not differ between the patients and healthy controls. In contrast, IL2 production in response to pokeweed mitogen stimulation was increased in lymphocytes from patients with Graves' ophthalmopathy. The IL2 release did not correlate with the quantities of cellular and soluble IL2 receptor. The mitogen-stimulated cellular IL2 receptor expression, IL2 receptor release, and IL2 production did not differ between patients with or without carbimazole therapy. Despite a suggested role of autoreactive T cells in mediating the development and propagation of autoimmune thyroid disease, this study fails to demonstrate a defective T lymphocyte activation state in patients with Graves' ophthalmopathy during an euthyroid state.

Altered state of consciousness in a compulsive water drinker

A relatively normal 16-year-old Chinese woman with a six-month history of compulsive water drinking resulting in a comatose state is reported. The drinking was perpetuated by an enjoyable altered state of consciousness after ingestion of an average of 20 litres of water per day. Treatment by fluid restriction and, later, simple education was successful. The subjective dimension of an altered state of consciousness may provide an important explanation for the obscure aetiology.

Malfunction of Tenckhoff catheter due to a rare kink

A case of sudden malfunction of Tenckhoff Catheter in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD) treatment is reported. Upon laparotomy, the catheter was found to form a knob inside the peritoneal cavity. The report emphasized on the simple but effective diagnostic value of abdominal X-ray and the importance of care of the bowel motion in a patient on CAPD.

Massive hydrothorax in continuous ambulatory peritoneal dialysis: diagnosis, management and review of the literature

Recurrent massive hydrothorax is an uncommon but serious complication in patients on continuous ambulatory peritoneal dialysis (CAPD). Accurate confirmative diagnostic procedures of the pleuroperitoneal communication is lacking and the management remains difficult. We reported three patients who developed massive hydrothorax at different periods after commencement of CAPD treatment (1.5-9 months). These patients underwent different investigatory procedures for demonstrating the pleuroperitoneal communication. We conclude that both technetium 99m-tagged macroaggregated albumin intraperitoneal radionuclide scan and stereoisomeric analysis of lactate in the peritoneal and pleural fluid are safe and reliable procedures to demonstrate the pleuroperitoneal communication. The massive hydrothorax was successfully treated in two patients by pleurodesis induced by intrapleural administration of oxytetracycline combined with 10-days small volume intermittent peritoneal dialysis. The clinical findings of 18 other cases previously reported in the literature are also reviewed.

Fatal hepatitis associated with ketoconazole therapy

A 67-year-old woman receiving ketoconazole, 200 mg daily for two months, had progressive jaundice, anorexia, and malaise develop. She had greatly elevated liver enzyme levels on hospital admission, and she died as a result of rapidly progressive liver failure. Histologic findings at autopsy disclosed acute hepatic necrosis. There was no clinical or serologic evidence of viral hepatitis. It is suggested that ketoconazole therapy was a causal factor in this case of fatal hepatic failure.