Endocrine and Metabolic Aspects of Tuberculosis

Epidemiology of Endocrine Dysfunctions in Pediatric Patients with Previous Central Nervous System Infection: A Scoping Review of the Literature

Purpose The incidence of endocrine sequelae following central nervous system (CNS) infections in pediatric age is not known. We conducted this scoping review to assess the incidence of endocrinological alterations in patients with prior CNS infections in pediatric age. Methods Our screening process included both randomized and non-randomized controlled trials. All types of observational studies, prospective and retrospective, have been included. Results Ten studies were included in our review. The cumulative number of patients in all of the studies was 211, the mean age of the population study was 4.9 (±5 years). The included papers described the following acute CNS infections: meningitis (nine studies reported eighty-five cases) and encephalitis (three studies described sixty-five cases). Two case reports and one retrospective study reported hypopituitarism as a consequence of Mycobacterium tuberculosis CNS infection. In five studies the patients developed endocrine comorbidities at the time of infection. Another study analyzed 49 young adults who previously had tuberculous meningitis at a mean age of 5.9 ± 5.0 years: seven patients had growth hormone deficiency, four of whom also had gonadotropin deficiency; the other three had gonadotropin deficiency, corticotropin deficiency, and mild hyperprolactinemia. Conclusion Standardized multidisciplinary follow-up and research of patients with prior CNS infection is crucial. Although pituitary reserve screening is not commonly performed in these patients, clinical and research centers should set up an endocrinological evaluation with monitoring of auxological parameters to detect the signs and symptoms of hypopituitarism early and to initiate the appropriate care in children with previous CNS infections.

Prevalence, Clinical Features, and Predictors of Adrenal Insufficiency in Adults With Tuberculosis or HIV: A Systematic Review and Meta-analysis

Background

Despite the high frequency of adrenal insufficiency (AI) in patients with tuberculosis or HIV, its diagnosis is often missed or delayed resulting in increased mortality. This systematic review and meta-analysis aimed to document the prevalence, significant clinical features, and predictors of AI in adult patients with tuberculosis or HIV.

Methods

We systematically searched databases (Medline, Embase, CINAHL, Cochrane Library, and Africa Journal Online) for published studies on AI in adult patients with tuberculosis or HIV. The pooled prevalence of AI was determined by a random-effect model meta-analysis. A narrative review was used to describe the significant clinical features and predictors of AI in adult patients with tuberculosis or HIV.

Results

A total of 46 studies involving 4044 adults were included: 1599 with tuberculosis and 2445 with HIV. The pooled prevalence of AI was 33% (95% CI, 22%-45%; I2 = 97.7%, P < .001) in participants with tuberculosis and 28% (95% CI, 18%-38%; I2 = 98.9%, P < .001) in those with HIV. Presentation with multidrug-resistant tuberculosis, abdominal pain, salt craving, myalgia, increased severity and duration of tuberculosis disease, and the absence of nausea predicted AI in participants with tuberculosis in 4 studies. Cytomegalovirus antigenemia positivity, rifampicin therapy, and eosinophilia >3% predicted AI in participants with HIV in 2 studies.

Conclusions

AI is relatively common in adults with tuberculosis or HIV. Its timely screening, diagnosis, and management in patients with these 2 conditions should be encouraged to avert mortality.

Explainable machine learning for early predicting treatment failure risk among patients with TB-diabetes comorbidity

The present study aims to assess the treatment outcome of patients with diabetes and tuberculosis (TB-DM) at an early stage using machine learning (ML) based on electronic medical records (EMRs). A total of 429 patients were included at Chongqing Public Health Medical Center. The random-forest-based Boruta algorithm was employed to select the essential variables, and four models with a fivefold cross-validation scheme were used for modeling and model evaluation. Furthermore, we adopted SHapley additive explanations to interpret results from the tree-based model. 9 features out of 69 candidate features were chosen as predictors. Among these predictors, the type of resistance was the most important feature, followed by activated partial throm-boplastic time (APTT), thrombin time (TT), platelet distribution width (PDW), and prothrombin time (PT). All the models we established performed above an AUC 0.7 with good predictive performance. XGBoost, the optimal performing model, predicts the risk of treatment failure in the test set with an AUC 0.9281. This study suggests that machine learning approach (XGBoost) presented in this study identifies patients with TB-DM at higher risk of treatment failure at an early stage based on EMRs. The application of a convenient and economy EMRs based on machine learning provides new insight into TB-DM treatment strategies in low and middle-income countries.

[A thyroid pathology: The great simulator]

INTRODUCTION

Tuberculosis remains a major public health problem in developing countries. Thyroid localization is very rare, and often the cause of misdiagnosis. Pathological anatomy plays an important role in the diagnosis of certainty. The authors report a case of primary thyroid tuberculosis in a 22-year-old patient. We highlight the epidemiological particularities of this case, and discuss diagnostic methods and the contribution of pathological anatomy.

OBSERVATION

A 22 year-old male patient, with no reported pathological history, was seen in the clinic for the management of an isolated anterior cervical swelling that had been evolving for two months. Clinical examination revealed only a small thyroid nodule, with no inflammatory or vascular features. Biological tests were unremarkable. Ultrasound revealed a 2.4cm hypoechoic, homogeneous, poorly vascularized tissue mass in the left lobe, classified as EU-TIRADS 3. Fine needle aspiration with cytopathological study revealed a necrotizing granulomatous lesion suggestive of tuberculosis. A lobo-isthmectomy was performed, and histopathology revealed thyroid parenchyma destroyed by tubercular granulomas. The postoperative course was straightforward, with an exeat on postoperative day 6. Anti-tuberculosis treatment was instituted for 6 months. Three- and six-month follow-up examinations were unremarkable. The evolution was favorable, with recovery after treatment.

CONCLUSION

Primary thyroid tuberculosis is rare. Cytology is important for orientation, and often helps to avoid misdiagnosis. The diagnosis should be considered in the presence of any thyroid mass in a patient from a tuberculosis-endemic region.

Adrenal Abscesses: A Systematic Review of the Literature

Objective: To summarize the existing knowledge about adrenal gland abscesses, including etiology, clinical presentation, common laboratory and imaging findings, management and overall morbidity and mortality. Design: Systematic literature review. Methods: We performed a search in the PubMed database using search terms: 'abscess and adrenal glands', 'adrenalitis', 'infection and adrenal gland', 'adrenal abscess', 'adrenal infection' and 'infectious adrenalitis'. Articles from 2017 to 2022 were included. We found total of 116 articles, and after applying exclusion criteria, data from 73 articles was included in the final statistical analysis. Results: Of 84 patients included in this review, 68 were male (81%), with a mean age of 55 years (range: 29 to 85 years). Weight loss was the most frequent symptom reported in 58.3% patients, followed by fever in 49%. Mean duration of symptoms was 4.5 months. The most common laboratory findings were low cortisol (51.9%), elevated ACTH (43.2%), hyponatremia (88.2%) and anemia (83.3%). Adrenal cultures were positive in 86.4% cases, with Histoplasma capsulatum (37.3%) being the leading causative agent. Blood cultures were positive in 30% of patients. The majority of the adrenal infections occurred through secondary dissemination from other infectious foci and abscesses were more commonly bilateral (70%). A total of 46.4% of patients developed long-term adrenal insufficiency requiring treatment. Abscess drainage was performed in 7 patients (8.3%) and adrenalectomy was performed in 18 (21.4%) patients. The survival rate was 92.9%. Multivariate analysis showed that the only independent risk factor for mortality was thrombocytopenia (p = 0.048). Conclusion: Our review shows that adrenal abscesses are usually caused by fungal pathogens, and among these, Histoplasma capsulatum is the most common. The adrenal glands are usually involved in a bilateral fashion and become infected through dissemination from other primary sources of infection. Long-term adrenal insufficiency develops in 46% of patients, which is more common than what is observed in non-infectious etiology of adrenal gland disorders. Mortality is about 7%, and the presence of thrombocytopenia is associated with worse prognosis. Further prospective studies are needed to better characterize optimal testing and treatment duration in patients with this relatively rare but challenging disorder.

Hypercalcemia during initiation of antiretroviral therapy in human immunodeficiency virus and Leishmania coinfection: A case report

RATIONALE

Hypercalcemia is a common complication of many granulomatous diseases but is not typically associated with leishmaniasis. Here we report an unusual case of hypercalcemia during the initiation of antiviral therapy in a patient with acquired immunodeficiency syndrome coinfected with visceral leishmaniasis.

PATIENT CONCERNS

Our patient presented with malaise and altered mental status following antiretroviral therapy initiation. He was found to have de novo hypercalcemia complicated by acute kidney injury.

DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

An extensive workup for other etiologies of hypercalcemia was negative. The patient was ultimately thought to have hypercalcemia secondary to visceral leishmaniasis in the setting of immune reconstitution inflammatory syndrome. He was treated with intravenous volume expansion, bisphosphonates, and oral corticosteroid therapy with complete resolution.

LESSONS

This case highlights an unusual presentation of immune reconstitution inflammatory syndrome, in which proinflammatory cytokine signaling during the restoration of cellular immunity may have led to increased ectopic calcitriol production by granuloma macrophages, thereby altering bone-mineral metabolism and driving hypercalcemia.

Tuberculosis of Adrenal Glands-A Population-based Case-control Study

Purpose

Adrenal tuberculosis (ATB) can cause primary adrenal insufficiency (PAI) or may be misdiagnosed as nonfunctional adrenal tumors (NFATs) in patients with tuberculosis. Very little is known about its epidemiology in a modern, high-income setting. The aim was to investigate adrenal involvement and associated mortality in patients with tuberculosis.

Methods

By using national registers, patients with tuberculosis and adrenal lesions were compared with controls without adrenal tumors. To analyze mortality in individuals with ATB or possible adrenal affection (ie, tuberculosis and NFAT), a subgroup of controls with tuberculosis was selected. The study population was included from 2005 to 2019 and followed until death or 2020. In mortality adjustments were made for age and sex.

Results

Eight patients with ATB, 23 232 patients with NFAT, and 144 124 controls were included. Among those with NFAT, we found 34 with tuberculosis and NFAT. Among controls, 129 individuals diagnosed with tuberculosis were identified. The risk of having an adrenal tumor was increased in tuberculosis (odds ratio, 1.64; 95% CI, 1.12-2.39). Of those with ATB, 7 (88%) had PAI. One patient (3%) with tuberculosis and NFAT and 1 (0.8%) control with tuberculosis had PAI. Compared with controls with tuberculosis, mortality was increased in patients with ATB (hazard ratio, 5.4; 95% CI, 2.2-13.2; adjusted hazard ratio, 6.2; 95% CI, 2.5-15.6), and in patients with tuberculosis and NFAT (1.3; 0.6-2.7; 2.3; 1.1-5.1). PAI was a contributing factor in 4/6 (67%) deaths in patients with ATB.

Conclusions

Tuberculosis with adrenal lesions was extremely rare. Most patients with ATB had PAI and mortality was increased.

Evidence of Cushing's syndrome in a pre-Columbian Mexican statue?

INTRODUCTION

In the absence of skeletons or written narrations, information about diseases in past societies may be acquired from icono-diagnosis. From the observation of a masterpiece presenting pathological features, we tried to make retrospective diagnosis.

MATERIAL AND METHOD

A pre-Columbian Mexican statuette originating from the Chupicuaro culture and dated 600 BC to 200 AD - conserved in the Louvre Museum in Paris (Section of the quai Branly - Jacques Chirac museum) was examined; it was found to display a huge spinal curvature with excessive dorsal kyphosis and obesity.

RESULTS

The appearance of the figurine with large head, shortened stature and limbs, may suggest a form of dwarfism; however, many statuettes in the Chupicuaro culture were found displaying large head and relatively short limbs, suggesting that these pictorial features are more of an artistic style. On the contrary, uncommon kyphosis and obesity led us to diagnose a case of either Pott disease associated with neuro-endocrine complications, or of Cushing's disease.

CONCLUSION

Although icono-diagnosis could have allowed us to contribute to the health mapping of ancient Americas and propose the presence of complicated tuberculosis in central Mexico between 600 BC and 200 AD, we believe "Choupi" portrays here an individual having suffered from hypercortisolism (Cushing's disease). Even though considerations related to cultural and artistic context may constitute limitations to interpretation, iconotopsy/iconodiagnosis are important for a better description of the natural history of diseases, as a complement to morphological analyses of human remains (paleopathology) and laboratory exams (DNA or immunology testing).

Associations of hyponatremia and SIADH with increased mortality, young age and infection parameters in patients with tuberculosis

BACKGROUND AND OBJECTIVE

Hyponatremia and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) are associated with and can be caused by tuberculosis (TB) through meningitis by locally invading the hypothalamus, adrenal, or pituitary glands or possibly through ectopic ADH production. This study assessed the association of TB mortality with hyponatremia and SIADH in a large cohort of a university hospital in Austria.

METHODS

This retrospective study enrolled patients with hyponatremia and patients diagnosed with TB from 01/2001-11/2019 to assess the prevalence of TB in hyponatremia and TB morbidity and mortality in patients with and without hyponatremia. Sex, age, microbiological results, laboratory tests and comorbidities were analysed and used to calculate survival rates.

RESULTS

Of 107.532 patients with hyponatremia (0.07%) and 186 patients with TB (43%), 80 patients were diagnosed with both-hyponatremia and TB. Only three TB patients had SIADH, precluding further SIADH analysis. In hyponatremia, young age and high CRP levels showed significant associations with TB diagnosis (p<0.0001). Survival rates of patients diagnosed with TB with moderate to profound hyponatremia were significantly lower than those without hyponatremia (p = 0.002).

CONCLUSION

In this study of a large cohort from a tertiary care hospital in a non-endemic area of TB, 0.07% of patients presenting with hyponatremia, but especially younger patients and patients with high CRP values, were diagnosed with TB. Crucially, patients with moderate to profound hyponatremia had a significantly higher mortality rate and thus required increased medical care.

Adrenal crisis during pregnancy: Case report and obstetric perspective

Adrenal dysfunction (AD) and, in particular, adrenal crisis are uncommon events in pregnant women, but associated with significant maternal and fetal morbidity and mortality if untreated or undiagnosed. Adrenal crisis may be confused with the common symptoms of pregnancy: the obstetricians should be able to promptly diagnose and treat it in order to avoid the adverse outcomes regarding the mother and the fetus. For this reason, AD must be treated by an expert multidisciplinary team. We presented a case report of a young pregnant woman with adrenal crisis due to tuberculosis, cocaine abuse, and massive bilateral hemorrhage with symptoms of emesis, hypotension, sudden abdominal pain, and leukocytosis. The most common issues of diagnosis and treatment are discussed and analyzed. Finally, we performed a review of the literature regarding adrenal crisis and adrenal insufficiency (AI) in pregnancy in order to clarify the management of these diseases in obstetrics setting.

Disseminated tuberculosis associated with autoimmune haemolytic anaemia and adrenal deficiency: a rare association

Tuberculosis (TB) is one of the greatest masqueraders in medical practice and can have manifestations involving any organ or organ systems of the body. The presentation of disseminated TB can range from typical features like fever, weight loss and fatigue to protean manifestations. We share the case of an elderly man who presented to us with weight loss, anaemia, weakness and lymphadenopathy involving thoracic and intraabdominal locations. Work up of anaemia revealed features of Coombs-positive autoimmune haemolytic anaemia (AIHA) and evaluation of weakness showed laboratory results consistent with adrenal insufficiency. Biopsy of the abdominal lymphnode yielded caseating granulomas with CB-NAAT positivity for Mycobacterium tuberculosis Anti-TB chemotherapy with short-term replacement dose of systemic steroids corrected the haemolysis, anaemia and addisonian crisis. The case alerts clinicians regarding the uncommon association of TB with Coombs positive AIHA and adds one more aetiology to the pathogenesis of anaemia in TB. Furthermore, the occurrence of AIHA and hypoadrenalism in the same patient with TB is exceedingly rare and has not been reported.

Macrophages Control the Bioavailability of Vitamin D and Vitamin D-Regulated T Cell Responses

The active form of vitamin D₃ (1,25(OH)₂D₃) has a great impact on T cell effector function. Thus, 1,25(OH)₂D₃ promotes T helper 2 (Th2) and regulatory T (Treg) cell function and concomitantly inhibits Th1 and Th17 cell function. Thus, it is believed that vitamin D exerts anti-inflammatory effects. However, vitamin D binding protein (DBP) strongly binds both 1,25(OH)₂D₃ and the precursor 25(OH)D₃, leaving only a minor fraction of vitamin D in the free, bioavailable form. Accordingly, DBP in physiological concentrations would be expected to block the effect of vitamin D on T cells and dendritic cells. In the present study, we show that pro-inflammatory, monocyte-derived M1 macrophages express very high levels of the 25(OH)D-1α-hydroxylase CYP27B1 that enables them to convert 25(OH)D₃ into 1,25(OH)₂D₃ even in the presence of physiological concentrations of DBP. Co-cultivation of M1 macrophages with T cells allows them to overcome the sequestering of 25(OH)D₃ by DBP and to produce sufficient levels of 1,25(OH)₂D₃ to affect T cell effector function. This study suggests that in highly inflammatory conditions, M1 macrophages can produce sufficient levels of 1,25(OH)₂D₃ to modify T cell responses and thereby reduce T cell-mediated inflammation via a vitamin D-mediated negative feed-back loop.

Serologic and urinary characteristics of laboratory-confirmed genitourinary tuberculosis at a tertiary hospital in the Philippines

BACKGROUND

Genitourinary tuberculosis (GUTB) is known to cause high rates of structural organ damage, however, literature on its biochemical manifestations is limited. Additionally, local studies in the Philippine setting, where cases are rampant, are few and dated. This study aimed to determine the serologic and urinary profile of patients with GUTB admitted at a tertiary hospital within January 2009 to March 2020 and their association with short-term outcomes.

METHODS

This retrospective study included 112 patients with laboratory-confirmed GUTB (i.e., positivity in acid-fast smear, polymerase chain reaction, culture, or histology). Demographic data, clinical characteristics, laboratory and radiologic findings, histopathology reports, treatment, and short-term outcomes were recorded.

RESULTS

Bladder (54.5%) and kidney (36.4%) were the most affected organs. The male:female ratio was 1:1.15, and the mean age was 35.79 ± 18.29 years. Weakness (14.29%) was the most common chief complaint. A majority presented with anemia (83.04%), while several had leukocytosis (41.96%) and thrombocytosis (26.79%). Hypoalbuminemia (58.10%), impairment of renal function (36.94%), and electrolyte abnormalities such as hyponatremia (50.93%), hypercalcemia (20.19%), and hypokalemia (21.82%) were common. Proteinuria (67.96%) and pyuria (67.96%) were the most frequent abnormal findings, followed by hematuria (51.46%), acidic urine (45.63%) and low specific gravity (31.07%). Age, leukocytosis, and the need for pressors were all significantly associated with mortality (p values of <0.001, 0.010, and <0.001, respectively).

CONCLUSIONS

The young age at presentation with severe clinical and laboratory manifestations may reflect local epidemiology as TB continues to be widespread in the country. Apart from the more commonly cited abnormalities in literature, multiple electrolyte imbalances and urinary concentration defects were also observed in many cases, possibly indicating tubulointerstitial involvement-a complication increasingly mentioned in case reports. As several patient characteristics were found to be associated with the high mortality rates observed in the study, further research is recommended to explore predictive modeling.

Overt and Subclinical Adrenal Insufficiency in Pulmonary Tuberculosis

BACKGROUND

Tuberculosis of the adrenal glands may cause overt or subclinical adrenal insufficiency. An algorithm-based approach including assessment of paired basal cortisol and plasma adrenocorticotropic hormone (ACTH), short Synacthen, and plasma renin activity assays could be useful to diagnose all forms of adrenal insufficiency.

METHODS

This cross-sectional study included consecutive, treatment-naive subjects diagnosed with pulmonary tuberculosis. Tuberculosis severity was classified by radiological criteria. Baseline parameters plus morning (8 am) serum cortisol and paired plasma ACTH were measured in all patients. Synacthen stimulation tests and plasma renin activity assays were performed as required.

RESULTS

Eighty-four treatment-naive consecutive cases of pulmonary tuberculosis were evaluated for adrenal insufficiency. Twenty-seven (32.14%) subjects had normal adrenocortical function and 8 (9.5%), 7 (8.3%), 40 (47.6%), and 2 (2.4%) subjects had stage 1, stage 2, stage 3, and stage 4 adrenal insufficiency, respectively. Serum cortisol was negatively correlated with radiological severity (P = .01) and duration of illness (P = .001). Adrenal dysfunction was present in 27.3%, 82.5%, and 80% of those with radiologically minimal, moderately advanced, and far-advanced disease, respectively. Mean cortisol was 19.74 ± 5.52, 17.42 ± 8.53, and 15.71 ± 7.14 (μg/dL) in the 3 groups, respectively (P = .042). Hyponatremia was present in 83.3% of the patients. Serum sodium was negatively correlated with severity but not with the duration of disease.

CONCLUSION

The prevalence of overt and subclinical adrenal dysfunction in pulmonary tuberculosis was high and was correlated with disease severity and duration. An algorithmic approach may be useful to detect the same and may have important clinical implications.

Challenges of Diagnosing Hyponatremic Syndromes in Pulmonary and Extra Pulmonary Tuberculosis

Introduction Pulmonary tuberculosis (PTB) is one of the rare pulmonary infections causing hyponatremia (serum sodium ˂135 mmol/L) and severe hyponatremia (serum sodium ˂125 mmol/L). Although the major cause of hyponatremia in TB patients is syndrome of inappropriate antidiuretic hormone (SIADH) secretion, cerebral salt wasting syndrome (CSWS) can occur and requires evidence of inappropriate urinary salt losses and reduced arterial blood volume. Adrenal insufficiency (AI) is rare in TB with scanty literature describing it. The two reported cases highlight three possible causes of severe symptomatic hyponatremia in TB pleural effusion and disseminated TB, their treatment modalities, and the need to increase the index of suspicion to diagnose TB hyponatremia in children.

Case Report Case 1: a 10-year-old girl with TB pleural effusion who developed recurrent hyponatremia in the first few weeks of anti-TB treatment which was responsive to sodium correction. Case 2: an 8-year-old girl presenting to our facility with presumptive TB. She deteriorated over several months and progressed to disseminated TB with AI.

Discussion Early diagnosis and prompt and correct treatment of TB hyponatremia cannot be overemphasized, as AI, SIADH secretion, and CSWS, each require different therapeutic regimens, most especially AI on its own poses a huge clinical challenge.

Conclusion A high index of suspicion, with intensified case finding at all levels of care, is necessary to identify and manage children with TB hyponatremia because early diagnosis and prompt treatment is lifesaving.

UNDERSTANDING PROLACTIN REGULATION AND DETERMINING THE EFFICACY OF CABERGOLINE AND DOMPERIDONE TO MITIGATE PROLACTIN-ASSOCIATED OVARIAN CYCLE PROBLEMS IN ZOO AFRICAN ELEPHANTS (LOXODONTA AFRICANA )

Perturbations in serum prolactin secretion, both over- and underproduction, are observed in zoo African elephants (Loxodonta africana) that exhibit abnormal ovarian cycles. Similar prolactin problems are associated with infertility in other species. Pituitary prolactin is held under constant inhibition by a hypothalamic-derived neurotransmitter, dopamine; thus, regulation by exogenous treatment with agonists or antagonists may be capable of reinitiating normal ovarian cycles. This study tested the efficacy of oral administration of cabergoline (agonist) and domperidone (antagonist) as possible treatments for hyperprolactinemia or chronic low prolactin, respectively. Hyperprolactinemic (overall mean prolactin, >30 ng/ml), acyclic elephants were administered oral cabergoline (2 mg, n = 4) or placebo (dextrose capsule, n = 4) twice weekly. Overall mean prolactin concentration decreased in treated females compared with controls (32.22 ± 14.75 vs 77.53 ± 0.96 ng/ml; P = 0.01). Interestingly, overall mean progestagen concentrations also increased slightly (P < 0.05) in treated females (0.15 ± 0.01 ng/ml) compared with controls (0.07 ± 0.01 ng/ml), but no reinitation of normal cyclic patterns was observed. Chronic low prolactin (overall mean prolactin, <10 ng/ml), acyclic females were orally administered domperidone (2 g/day, n = 4) or placebo (dextrose capsule, n = 4) for 4 wk, followed by 8 wk of no treatment (four cycles) to simulate the prolactin pattern observed in normal cycling elephants. Overall mean prolactin concentrations increased (P = 0.005) during domperidone treatment (21.77 ± 3.69 ng/ml) compared with controls (5.77 ± 0.46 ng/ml), but progestagen concentrations were unaltered. Prolactin regulation by dopamine was confirmed by expected responses to dopamine agonist and antagonist treatment. Although prolactin concentrations were successfully reduced by cabergoline, and domperidone initiated the expected cyclic prolactin pattern, neither treatment induced normal ovarian activity.

Hyponatremia presenting with hourly fluctuating urine osmolality

SUMMARY

The etiology of hyponatremia is assessed based on urine osmolality and sodium. We herein describe a 35-year-old Asian man with pulmonary tuberculosis and perforated duodenal ulcer who presented with hyponatremia with hourly fluctuating urine osmolality ranging from 100 to 600 mosmol/kg, which resembled urine osmolality observed in typical polydipsia and SIADH simultaneously. Further review revealed correlation of body temperature and urine osmolality. Since fever is a known non-osmotic stimulus of ADH secretion, we theorized that hyponatremia in this patient was due to transient ADH secretion due to fever. In our case, empiric exogenous glucocorticoid suppressed transient non-osmotic ADH secretion and urine osmolality showed highly variable concentrations. Transient ADH secretion-related hyponatremia may be underrecognized due to occasional empiric glucocorticoid administration in patients with critical illnesses. Repeatedly monitoring of urine chemistries and interpretation of urine chemistries with careful review of non-osmotic stimuli of ADH including fever is crucial in recognition of this etiology.

LEARNING POINTS

Hourly fluctuations in urine osmolality can be observed in patients with fever, which is a non-osmotic stimulant of ADH secretion. Repeated monitoring of urine chemistries aids in the diagnosis of the etiology underlying hyponatremia, including fever, in patients with transient ADH secretion. Glucocorticoid administration suppresses ADH secretion and improves hyponatremia even in the absence of adrenal insufficiency; the etiology of hyponatremia should be determined carefully in these patients.

Tuberculous Meningitis in Children and Adults: New Insights for an Ancient Foe

PURPOSE OF REVIEW

Tuberculous meningitis is the most devastating manifestation of infection with Mycobacterium tuberculosis and represents a medical emergency. Approximately one half of tuberculous meningitis patients die or suffer severe neurologic disability. The goal of this review will be to review the pathogenic, clinical, and radiologic features of tuberculous meningitis and to highlight recent advancements in translational and clinical science.

RECENT FINDINGS

Pharmacologic therapy includes combination anti-tuberculosis drug regimens and adjunctive corticosteroids. It is becoming clear that a successful treatment outcome depends on an immune response that is neither too weak nor overly robust, and genetic determinants of this immune response may identify which patients will benefit from adjunctive corticosteroids. Recent clinical trials of intensified anti-tuberculosis treatment regimens conducted in Indonesia and Vietnam, motivated by the pharmacologic challenges of treating M. tuberculosis infections of the central nervous system, have yielded conflicting results regarding the survival benefit of intensified treatment regimens. More consistent findings have been observed regarding the relationship between initial anti-tuberculosis drug resistance and mortality among tuberculous meningitis patients. Prompt initiation of anti-tuberculosis treatment for all suspected cases remains a key aspect of management. Priorities for research include the improvement of diagnostic testing strategies and the optimization of host-directed and anti-tuberculosis therapies.