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Madhok J, Kloosterboer A, Venkatasubramanian C, Mihm FG. Catecholamine-induced cerebral vasospasm and multifocal infarctions in pheochromocytoma. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200078. [PMID: 32820130 PMCID: PMC7487175 DOI: 10.1530/edm-20-0078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/29/2020] [Indexed: 11/22/2022] Open
Abstract
SUMMARY We report the case of a 76-year-old male with a remote history of papillary thyroid cancer who developed severe paroxysmal headaches in the setting of episodic hypertension. Brain imaging revealed multiple lesions, initially of inconclusive etiology, but suspicious for metastatic foci. A search for the primary malignancy revealed an adrenal tumor, and biochemical testing confirmed the diagnosis of a norepinephrine-secreting pheochromocytoma. Serial imaging demonstrated multiple cerebral infarctions of varying ages, evidence of vessel narrowing and irregularities in the anterior and posterior circulations, and hypoperfusion in watershed areas. An exhaustive work-up for other etiologies of stroke including thromboembolic causes or vasculitis was unremarkable. There was resolution of symptoms, absence of new infarctions, and improvement in vessel caliber after adequate alpha-adrenergic receptor blockade for the management of pheochromocytoma. This clinicoradiologic constellation of findings suggested that the etiology of the multiple infarctions was reversible cerebral vasoconstriction syndrome (RCVS). Pheochromocytoma remains a poorly recognized cause of RCVS. Unexplained multifocal cerebral infarctions in the setting of severe hypertension should prompt the consideration of a vasoactive tumor as the driver of cerebrovascular dysfunction. A missed or delayed diagnosis has the potential for serious neurologic morbidity for an otherwise treatable condition. LEARNING POINTS The constellation of multifocal watershed cerebral infarctions of uncertain etiology in a patient with malignant hypertension should trigger the consideration of undiagnosed catecholamine secreting tumors, such as pheochromocytomas and paragangliomas. Reversible cerebral vasoconstriction syndrome is a serious but reversible cerebrovascular manifestation of pheochromocytomas that may lead to strokes (ischemic and hemorrhagic), seizures, and cerebral edema. Alpha-adrenergic receptor blockade can reverse cerebral vasoconstriction and prevent further cerebral ischemia and infarctions. Early diagnosis of catecholamine secreting tumors has the potential for reducing neurologic morbidity and mortality in patients presenting with cerebrovascular complications.
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Affiliation(s)
- Jai Madhok
- Department of Anesthesiology, Perioperative and Pain Medicine
| | | | - Chitra Venkatasubramanian
- Department of Neurology & Neurological Sciences, Stanford University Medical Center, Stanford, California, USA
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Shekhar S, Haykal R, Kamilaris C, Stratakis CA, Hannah-Shmouni F. Curative resection of an aldosteronoma causing primary aldosteronism in the second trimester of pregnancy. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200043. [PMID: 32755966 PMCID: PMC7424322 DOI: 10.1530/edm-20-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 07/13/2020] [Indexed: 11/21/2022] Open
Abstract
SUMMARY A 29-year-old primigravida woman with a known history of primary aldosteronism due to a right aldosteronoma presented with uncontrolled hypertension at 5 weeks of estimated gestation of a spontaneous pregnancy. Her hypertension was inadequately controlled with pharmacotherapy which lead to the consideration of surgical management for her primary aldosteronism. She underwent curative right unilateral adrenalectomy at 19 weeks of estimated gestational age. The procedure was uncomplicated, and her blood pressure normalized post-operatively. She did, however, have a preterm delivery by cesarean section due to intrauterine growth retardation with good neonatal outcome. She is normotensive to date. LEARNING POINTS Primary aldosteronism is the most common etiology of secondary hypertension with an estimated prevalence of 5-10% in the hypertensive population. It is important to recognize the subtypes of primary aldosteronism given that certain forms can be treated surgically. Hypertension in pregnancy is associated with significantly higher maternal and fetal complications. Data regarding the treatment of primary aldosteronism in pregnancy are limited. Adrenalectomy can be considered during the second trimester of pregnancy if medical therapy fails to adequately control hypertension from primary aldosteronism.
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Affiliation(s)
- Skand Shekhar
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Rasha Haykal
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Crystal Kamilaris
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Fady Hannah-Shmouni
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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Wang M, Jonker B, Killen L, Bogum Y, McCormack A, Bishay RH. Fatal high-grade skull osteosarcoma 30 years following radiotherapy for Cushing's disease. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200062. [PMID: 32698127 PMCID: PMC7354738 DOI: 10.1530/edm-20-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/15/2020] [Indexed: 11/09/2022] Open
Abstract
SUMMARY Cushing's disease is a rare disorder characterised by excessive cortisol production as a consequence of a corticotroph pituitary tumour. While the primary treatment is surgical resection, post-operative radiation therapy may be used in cases of ongoing inadequate hormonal control or residual or progressive structural disease. Despite improved outcomes, radiotherapy for pituitary tumours is associated with hypopituitarism, visual deficits and, rarely, secondary malignancies. We describe an unusual case of a 67-year-old female with presumed Cushing's disease diagnosed at the age of 37, treated with transsphenoidal resection of a pituitary tumour with post-operative external beam radiotherapy (EBRT), ketoconazole for steroidogenesis inhibition, and finally bilateral adrenalectomy for refractory disease. She presented 30 years after her treatment with a witnessed generalised tonic-clonic seizure. Radiological investigations confirmed an extracranial mass infiltrating through the temporal bone and into brain parenchyma. Due to recurrent generalised seizures, the patient was intubated and commenced on dexamethasone and anti-epileptic therapy. Resection of the tumour revealed a high-grade osteoblastic osteosarcoma. Unfortunately, the patient deteriorated in intensive care and suffered a fatal cardiac arrest following a likely aspiration event. We describe the risk factors, prevalence and treatment of radiation-induced osteosarcoma, an exceedingly rare and late complication of pituitary irradiation. To our knowledge, this is the longest reported latency period between pituitary irradiation and the development of an osteosarcoma of the skull. LEARNING POINTS Cushing's disease is treated with transsphenoidal resection as first-line therapy, with radiotherapy used in cases of incomplete resection, disease recurrence or persistent hypercortisolism. The most common long-term adverse outcome of pituitary tumour irradiation is hypopituitarism occurring in 30-60% of patients at 10 years, and less commonly, vision loss and oculomotor nerve palsies, radiation-induced brain tumours and sarcomas. Currently proposed characteristics of radiation-induced osteosarcomas include: the finding of a different histological type to the primary tumour, has developed within or adjacent to the path of the radiation beam, and a latency period of at least 3 years. Treatment of osteosarcoma of the skull include complete surgical excision, followed by systemic chemotherapy and/or radiotherapy. Overall prognosis in radiation-induced sarcoma of bone is poor. Newer techniques such as stereotactic radiosurgery may reduce the incidence of radiation-induced malignancies.
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Affiliation(s)
- Mawson Wang
- Department of Endocrinology and Diabetes, Blacktown Hospital, Sydney, Australia
- Blacktown Clinical School, School of Medicine, Western Sydney University, Sydney, Australia
| | - Benjamin Jonker
- Department of Neurosurgery, St. Vincent’s Hospital, Sydney, Australia
| | - Louise Killen
- Department of Pathology, St. Vincent’s Hospital, Sydney, Australia
| | - Yvonne Bogum
- NSW Health Pathology East, Prince of Wales Hospital, Sydney, Australia
| | - Ann McCormack
- Department of Endocrinology, St. Vincent’s Hospital, Sydney, Australia
- Garvan Institute of Medical Research, Sydney, Australia
- St. Vincent’s Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Ramy H Bishay
- Department of Endocrinology and Diabetes, Blacktown Hospital, Sydney, Australia
- Blacktown Clinical School, School of Medicine, Western Sydney University, Sydney, Australia
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Pedro J, Cunha FM, Neto V, Hespanhol V, Martins DF, Guimarães S, Varela A, Carvalho D. Coexistence of DIPNECH and carotid body paraganglioma: is it just a coincidence? Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM190141. [PMID: 32408270 PMCID: PMC7274547 DOI: 10.1530/edm-19-0141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/21/2020] [Indexed: 01/10/2023] Open
Abstract
SUMMARY We describe the case of a 56 year-old woman with the almost simultaneous appearance of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) and a carotid body paraganglioma. Of interest, 6 years earlier, the patient underwent total thyroidectomy due to papillary thyroid carcinoma and, in the meantime, she was submitted to mastectomy to treat an invasive ductal carcinoma of the breast. In order to explain these lesions, an extensive genetic study was performed. Results showed positivity for the presence of the tumor suppressor gene PALB2, whose presence had already been detected in a niece with breast cancer. The patient underwent different procedures to treat the lesions and currently she is symptom-free over 2 years of follow-up. LEARNING POINTS The presence of two rare neoplasms in a single person should raise the suspicion of a common etiology. To the best of our knowledge, this is the first case that shows the coexistence of DIPNECH and paraganglioma. The contribution of the PALB2 gene in the etiology of these rare neoplasms is a possibility.
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Affiliation(s)
- J Pedro
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
- Faculty of Medicine of Universidade do Porto, Porto, Portugal
| | - F M Cunha
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal
| | - V Neto
- Department of Pneumology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - V Hespanhol
- Faculty of Medicine of Universidade do Porto, Porto, Portugal
- Department of Pneumology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - D F Martins
- Faculty of Medicine of Universidade do Porto, Porto, Portugal
- Department of Pathology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - S Guimarães
- Department of Pathology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - A Varela
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
- Faculty of Medicine of Universidade do Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - D Carvalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
- Faculty of Medicine of Universidade do Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
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Catarino D, Ribeiro C, Gomes L, Paiva I. Corticotroph adenoma and pituitary fungal infection: a rare association. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200010. [PMID: 32213650 PMCID: PMC7159253 DOI: 10.1530/edm-20-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/04/2020] [Indexed: 01/16/2023] Open
Abstract
SUMMARY Pituitary infections, particularly with fungus, are rare disorders that usually occur in immunocompromised patients. Cushing's syndrome predisposes patients to infectious diseases due to their immunosuppression status. We report the case of a 55-year-old woman, working as a poultry farmer, who developed intense headache, palpebral ptosis, anisocoria, prostration and psychomotor agitation 9 months after initial diabetes mellitus diagnosis. Cranioencephalic CT scan showed a pituitary lesion with bleeding, suggesting pituitary apoplexy. Patient underwent transsphenoidal surgery and the neuropathologic study indicated a corticotroph adenoma with apoplexy and fungal infection. Patient had no preoperative Cushing's syndrome diagnosis. She was evaluated by a multidisciplinary team who decided not to administer anti-fungal treatment. The reported case shows a rare association between a corticotroph adenoma and a pituitary fungal infection. The possible contributing factors were hypercortisolism, uncontrolled diabetes and professional activity. Transsphenoidal surgery is advocated in these infections; however, anti-fungal therapy is still controversial. LEARNING POINTS Pituitary infections are rare disorders caused by bacterial, viral, fungal and parasitic infections. Pituitary fungal infections usually occur in immunocompromised patients. Cushing's syndrome, as immunosuppression factor, predisposes patients to infectious diseases, including fungal infections. Diagnosis of pituitary fungal infection is often achieved during histopathological investigation. Treatment with systemic anti-fungal drugs is controversial. Endocrine evaluation is recommended at the time of initial presentation of pituitary manifestations.
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Affiliation(s)
- Diana Catarino
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Cristina Ribeiro
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Leonor Gomes
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Isabel Paiva
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
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Popławska-Kita A, Wielogórska M, Poplawski Ł, Siewko K, Adamska A, Szumowski P, Myśliwiec P, Myśliwiec J, Reszeć J, Kamiński G, Dzięcioł J, Tobiaszewska D, Szelachowska M, Krętowski AJ. Thyroid carcinoma with atypical metastasis to the pituitary gland and unexpected postmortal diagnosis. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM190148. [PMID: 32168468 PMCID: PMC7077587 DOI: 10.1530/edm-19-0148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/21/2020] [Indexed: 12/19/2022] Open
Abstract
SUMMARY Papillary thyroid gland carcinoma is the most common type of malignancy of the endocrine system. Metastases to the pituitary gland have been described as a complication of papillary thyroid cancer in few reported cases since 1965. We report the case of a 68-year-old female patient with a well-differentiated form of thyroid gland cancer. Despite it being the most common malignant cancer of the endocrine system, with its papillary form being one of the two most frequently diagnosed thyroid cancers, the case we present is extremely rare. Sudden cardiac arrest during ventricular fibrillation occurred during hospitalization. Autopsy of the patient revealed papillary carcinoma of the thyroid, follicular variant, with metastasis to the sella turcica, and concomitant sarcoidosis of heart, lung, and mediastinal and hilar lymph nodes. Not only does atypical metastasis make our patient's case most remarkable, but also the postmortem diagnosis of sarcoidosis makes her case particularly unusual. LEARNING POINTS The goal of presenting this case is to raise awareness of the clinical heterogeneity of papillary cancer and promote early diagnosis of unexpected metastasis and coexisting diseases to improve clinical outcomes. Clinicians must be skeptical. They should not fall into the trap of diagnostic momentum or accept diagnostic labels at face value. Regardless of the potential mechanisms, clinicians should be aware of the possibility of the coexistence of thyroid cancer and sarcoidosis as a differential diagnosis of lymphadenopathy. This case highlights the importance of the diagnostic and therapeutic planning process and raises awareness of the fact that one uncommon disease could be masked by another extremely rare disorder.
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Affiliation(s)
| | | | | | | | | | - Piotr Szumowski
- Departments of Nuclear Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Myśliwiec
- 1st Clinic Department of General and Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Janusz Myśliwiec
- Departments of Nuclear Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Joanna Reszeć
- Departments of Medical Pathomorphology, Medical University of Bialystok, Bialystok, Poland
| | - Grzegorz Kamiński
- Department of Endocrinology and Radioisotopy Therapy, Military Institute of Medicine, Warsaw, Poland
| | - Janusz Dzięcioł
- Departments of Human Anatomy, Medical University of Bialystok, Bialystok, Poland
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Zaman S, Patel B, Glynne P, Vanderpump M, Alsafi A, Khan S, Flora R, Palazzo F, Wernig F. A rare cause of severe Cushing's syndrome. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200011. [PMID: 32168466 PMCID: PMC7077516 DOI: 10.1530/edm-20-0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 02/26/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Ectopic adrenocorticotropic hormone (ACTH) production is an uncommon cause of Cushing's syndrome and, rarely, the source can be a phaeochromocytoma. A 55-year-old man presented following an episode of presumed gastroenteritis with vomiting and general malaise. Further episodes of diarrhoea, joint pains and palpitations followed. On examination, he was hypertensive with no clinical features to suggest hypercortisolaemia. He was subsequently found to have raised plasma normetanephrines of 3.98 nmol/L (NR <0.71) and metanephrines of 0.69 nmol/L (NR <0.36). An adrenal CT showed a 3.8 cm right adrenal nodule, which was not MIBG-avid but was clinically and biochemically consistent with a phaeochromocytoma. He was started on alpha blockade and referred for right adrenalectomy. Four weeks later, on the day of admission for adrenalectomy, profound hypokalaemia was noted (serum potassium 2.0 mmol/L) with non-specific ST-segment ECG changes. He was also diagnosed with new-onset diabetes mellitus (capillary blood glucose of 28 mmol/L). He reported to have gained weight and his skin had become darker over the course of the last 4 weeks. Given these findings, he underwent overnight dexamethasone suppression testing, which showed a non-suppressed serum cortisol of 1099 nmol/L. Baseline serum ACTH was 273 ng/L. A preliminary diagnosis of ectopic ACTH secretion from the known right-sided phaeochromocytoma was made and he was started on metyrapone and insulin. Surgery was postponed for 4 weeks. Following uncomplicated laparoscopic adrenalectomy, the patient recovered with full resolution of symptoms. LEARNING POINTS Phaeochromocytomas are a rare source of ectopic ACTH secretion. A high clinical index of suspicion is therefore required to make the diagnosis. Ectopic ACTH secretion from a phaeochromocytoma can rapidly progress to severe Cushing's syndrome, thus complicating tumour removal. Removal of the primary tumour often leads to full recovery. The limited literature suggests that the presence of ectopic Cushing's syndrome does not appear to have any long-term prognostic implications.
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Affiliation(s)
- Shamaila Zaman
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Bijal Patel
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Ali Alsafi
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sairah Khan
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Rashpal Flora
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Fausto Palazzo
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Florian Wernig
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Gild ML, Heath L, Paik JY, Clifton-Bligh RJ, Robinson BG. Malignant struma ovarii with a robust response to radioactive iodine. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM190130. [PMID: 32061155 PMCID: PMC7040530 DOI: 10.1530/edm-19-0130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/21/2020] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Struma ovarii is a rare, usually benign ovarian tumour with malignancy occurring in <5% of cases. Metastases, particularly seeding to bone, are extremely rare. Presentation is variable but often features local pain and/or ascites and hyperthyroidism may occur. It is not established how to best treat and follow patients with extensive disease. Case reports of radioiodine (I131) ablative therapy following thyroidectomy have shown reduced recurrence. We describe the case of a 33-year-old woman who presented with bone pain and was diagnosed with skeletal metastases with features of follicular thyroid carcinoma. However, thyroid pathology was benign. She recalled that 5 years prior, an ovarian teratoma was excised, classified at that time as a dermoid cyst. Retrospective review of this pathology confirmed struma ovarii without obvious malignant features. The patient was found to have widespread metastases to bone and viscera and her thyroglobulin was >3000 µg/L following recombinant TSH administration prior to her first dose of I131. At 25 months following radioiodine treatment, she is in remission with an undetectable thyroglobulin and clear I131 surveillance scans. This case demonstrates an unusual presentation of malignant struma ovarii together with challenges of predicting metastatic disease, and demonstrates a successful radioiodine regimen inducing remission. LEARNING POINTS Malignant transformation of struma ovarii (MSO) is extremely rare and even rarer are metastatic deposits in bone and viscera. MSO can be difficult to predict by initial ovarian pathology, analogous to the difficulty in some cases of differentiating between follicular thyroid adenoma and carcinoma. No consensus exists on the management for post operative treatment of MSO; however, in this case, three doses of 6Gbq radioiodine therapy over a short time period eliminated metastases to viscera and bone. Patients should continue to have TSH suppression for ~5 years. Monitoring thyroglobulin levels can predict recurrence.
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Affiliation(s)
- M L Gild
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - L Heath
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - J Y Paik
- Department of Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - R J Clifton-Bligh
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - B G Robinson
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Shetty I, Fuller S, Raygada M, Merino MJ, Thomas BJ, Widemann BC, Reilly KM, Pacak K, Del Rivero J. Adrenocortical carcinoma masquerading as pheochromocytoma: a histopathologic dilemma. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM190147. [PMID: 31917677 PMCID: PMC6993251 DOI: 10.1530/edm-19-0147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/05/2019] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Adrenocortical carcinoma (ACC) is an aggressive cancer that originates in the cortex of the adrenal gland and generally has a poor prognosis. ACC is rare but can be more commonly seen in those with cancer predisposition syndromes (e.g. Li-Fraumeni and Lynch Syndrome). The diagnosis of ACC is sometimes uncertain and it requires the use of precise molecular pathology; the differential diagnosis includes pheochromocytoma, adrenal adenoma, renal carcinoma, or hepatocellular carcinoma. We describe a case of a 57-year-old woman with Lynch Syndrome and metastatic ACC who was initially diagnosed as having pheochromocytoma. The tumor was first identified at 51 years of age by ultrasound followed by a CT scan. She underwent a left adrenalectomy, and the histopathology identified pheochromocytoma. Two years later, she had tumor recurrence with imaging studies showing multiple lung nodules. Following a wedge resection by video-assisted thoracoscopic surgery (VATS), histopathology was read as metastatic pheochromocytoma at one institution and metastatic ACC at another institution. She later presented to the National Institutes of Health (NIH) where the diagnosis of ACC was confirmed. Following her ACC diagnosis, she was treated with mitotane and pembrolizumab which were stopped due to side effects and progression of disease. She is currently receiving etoposide, doxorubicin, and cisplatin (EDP). This case highlights the importance of using a multi-disciplinary approach in patient care. Thorough evaluation of the tumor's pathology and analysis of the patient's genetic profile are necessary to obtain the correct diagnosis for the patient and can significantly influence the course of treatment. LEARNING POINTS Making the diagnosis of ACC can be difficult as the differential diagnosis includes pheochromocytoma, adrenal adenoma, renal carcinoma, or hepatocellular carcinoma. Patients with Lynch Syndrome should undergo surveillance for ACC as there is evidence of an association between Lynch Syndrome and ACC. Conducting a complete tumor immunoprofile and obtaining a second opinion is very important in cases of suspected ACC in order to confirm the proper diagnosis. A multi-disciplinary approach including genetic testing and a thorough evaluation of the tumor's pathology is imperative to ensuring that the patient receives an accurate diagnosis and the appropriate treatment.
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Affiliation(s)
- Impana Shetty
- Pediatric Oncology Branch, Rare Tumor Initiative, Center for Cancer Research, National Cancer Institute, Clinical Center
| | - Sarah Fuller
- Pediatric Oncology Branch, Rare Tumor Initiative, Center for Cancer Research, National Cancer Institute, Clinical Center
| | - Margarita Raygada
- Pediatric Oncology Branch, Rare Tumor Initiative, Center for Cancer Research, National Cancer Institute, Clinical Center
| | - Maria J Merino
- Laboratory of Pathology, National Cancer Institute, Clinical Center
| | - B J Thomas
- Pediatric Oncology Branch, Rare Tumor Initiative, Center for Cancer Research, National Cancer Institute, Clinical Center
| | - Brigitte C Widemann
- Pediatric Oncology Branch, Rare Tumor Initiative, Center for Cancer Research, National Cancer Institute, Clinical Center
| | - Karlyne M Reilly
- Pediatric Oncology Branch, Rare Tumor Initiative, Center for Cancer Research, National Cancer Institute, Clinical Center
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Jaydira Del Rivero
- Pediatric Oncology Branch, Rare Tumor Initiative, Center for Cancer Research, National Cancer Institute, Clinical Center
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Decaestecker K, Wijtvliet V, Coremans P, Van Doninck N. Olfactory neuroblastoma (esthesioneuroblastoma) presenting as ectopic ACTH syndrome: always follow your nose. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190093. [PMID: 31627184 DOI: 10.1530/edm-19-0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/25/2019] [Indexed: 11/08/2022] Open
Abstract
SUMMARY ACTH-dependent hypercortisolism is caused by an ectopic ACTH syndrome (EAS) in 20% of cases. We report a rare cause of EAS in a 41-year-old woman, presenting with clinical features of Cushing's syndrome which developed over several months. Biochemical tests revealed hypokalemic metabolic alkalosis and high morning cortisol and ACTH levels. Further testing, including 24-hour urine analysis, late-night saliva and low-dose dexamethasone suppression test, confirmed hypercortisolism. An MRI of the pituitary gland was normal. Inferior petrosal sinus sampling (IPSS) revealed inconsistent results, with a raised basal gradient but no rise after CRH stimulation. Additional PET-CT showed intense metabolic activity in the left nasal vault. Biopsy of this lesion revealed an unsuspected cause of Cushing's syndrome: an olfactory neuroblastoma (ONB) with positive immunostaining for ACTH. Our patient underwent transnasal resection of the tumour mass, followed by adjuvant radiotherapy. Normalisation of cortisol and ACTH levels was seen immediately after surgery. Hydrocortisone substitution was started to prevent withdrawal symptoms. As the hypothalamic-pituitary-axis slowly recovered, daily hydrocortisone doses were tapered and stopped 4 months after surgery. Clinical Cushing's stigmata improved gradually. LEARNING POINTS Ectopic ACTH syndrome can originate from tumours outside the thoracoabdominal region, like the sinonasal cavity. The diagnostic accuracy of IPSS is not 100%: both false positives and false negatives may occur and might be due to a sinonasal tumour with ectopic ACTH secretion. Olfactory neuroblastoma (syn. esthesioneuroblastoma), named because of its sensory (olfactory) and neuroectodermal origin in the upper nasal cavity, is a rare malignant neoplasm. It should not be confused with neuroblastoma, a tumour of the sympathetic nervous system typically occurring in children. If one criticises MRI of the pituitary gland because of ACTH-dependent hypercortisolism, one should take a close look at the sinonasal field as well.
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Affiliation(s)
- Karen Decaestecker
- Department of Diabetology-Endocrinology, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Veerle Wijtvliet
- Department of Diabetology-Endocrinology, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Peter Coremans
- Department of Diabetology-Endocrinology, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Nike Van Doninck
- Department of Diabetology-Endocrinology, AZ Nikolaas, Sint-Niklaas, Belgium
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Ohsugi H, Takizawa N, Kinoshita H, Matsuda T. Pheochromocytoma arising from an ectopic adrenal tissue in multiple endocrine neoplasia type 2A. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190073. [PMID: 31610522 PMCID: PMC6790906 DOI: 10.1530/edm-19-0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 09/20/2019] [Indexed: 11/08/2022] Open
Abstract
SUMMARY A 21-year-old woman was referred to our hospital to treat bilateral pheochromocytomas (PCCs) after a diagnosis of multiple endocrine neoplasia type 2A (MEN2A). We performed bilateral laparoscopic adrenalectomy. One year after the operation, urinary fractionated metanephrines in 24-h urine increased. MRI showed a 30 mm tumor on the interaortocaval region and 123I-MIBG concentrated in this area. We excised the tumor and performed para-aortic lymphadenectomy. Histopathologic examination confirmed a PCC arising from ectopic adrenal tissue. Urinary fractionated metanephrines in 24-h urine declined to basal levels immediately after the operation. We detected no recurrence of paraganglioma or PCC for 5 years after the treatment. LEARNING POINTS Most ectopic adrenal tissue is associated with no symptoms and contains only the adrenal cortex. Adrenocortical tumors sometimes arise from ectopic adrenal tissues similarly to in the normal adrenal gland. PCC arising from ectopic adrenal tissue occurs infrequently. MEN2-related PCC is accompanied by adrenal medullary hyperplasia, which might be part of tumorigenesis.
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Affiliation(s)
- Haruyuki Ohsugi
- Department of Urology and Andrology, Kansai Medical University, Hirakata, Japan
| | - Nae Takizawa
- Department of Urology and Andrology, Kansai Medical University, Hirakata, Japan
| | - Hidefumi Kinoshita
- Department of Urology and Andrology, Kansai Medical University, Hirakata, Japan
| | - Tadashi Matsuda
- Department of Urology and Andrology, Kansai Medical University, Hirakata, Japan
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12
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Teramoto S, Tange Y, Ishii H, Goto H, Ogino I, Arai H. Mixed gangliocytoma-pituitary adenoma containing GH and GHRH co-secreting adenoma cells. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190099. [PMID: 31581122 PMCID: PMC6790896 DOI: 10.1530/edm-19-0099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 11/23/2022] Open
Abstract
SUMMARY A 67-year-old woman with a past history of type 2 diabetes mellitus presented with worsening glycemic control. She had some acromegaly symptoms and magnetic resonance imaging demonstrated a pituitary tumor. Endocrinological examination found the resting growth hormone (GH) level within the normal range, but elevated insulin-like growth factor 1 level. A 75 g oral glucose tolerance test showed inadequate suppression of nadir GH levels. Acromegaly due to GH-secreting pituitary tumor was diagnosed. The patient underwent endoscopic transsphenoidal surgery resulting in gross total removal of the tumor and recovered well postoperatively. Histological examination of the tumor showed coexistence of relatively large gangliocytoma cells and pituitary adenoma cells, suggesting mixed gangliocytoma-pituitary adenoma. In addition, colocalization of GH and GH-releasing hormone (GHRH) in pituitary adenoma cells was revealed, so the adenomatous components were more likely to produce GHRH in our mixed gangliocytoma-pituitary adenoma case. Mixed gangliocytoma-pituitary adenoma is very rare, and the present unique case demonstrated only the adenomatous components associated with GHRH production. LEARNING POINTS Sellar gangliocytoma coexisting with pituitary adenoma is recognized as a mixed gangliocytoma-pituitary adenoma and is very rare. A proposed developmental mechanism of growth hormone (GH)-secreting mixed gangliocytoma-pituitary adenoma involves GH-releasing hormone (GHRH) produced by the gangliocytic components promoting the growth of tumor including GH-secreting adenomatous components. Since our present case indicated that the adenomatous components of mixed gangliocytoma-pituitary adenoma could secrete both GH and GHRH simultaneously, progression of GH-secreting mixed gangliocytoma and pituitary adenoma may involve exposure to spontaneously produced GHRH due to the adenomatous components.
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Affiliation(s)
- Shinichiro Teramoto
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuichi Tange
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hisato Ishii
- Department of Neurosurgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Hiromasa Goto
- Department of Metabolism and Endocrinology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ikuko Ogino
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
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Jahan S, Hasanat MA, Mahmood T, Morshed S, Haq R, Fariduddin M. Postoperative expression of Cushing disease in a young male: metamorphosis of silent corticotroph adenoma? Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190046. [PMID: 31671410 PMCID: PMC6790907 DOI: 10.1530/edm-19-0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Silent corticotroph adenoma (SCA) is an unusual type of nonfunctioning pituitary adenoma (NFA) that is silent both clinically and biochemically and can only be recognized by positive immunostaining for ACTH. Under rare circumstances, it can transform into hormonally active disease presenting with severe Cushing syndrome. It might often produce diagnostic dilemma with difficult management issue if not thoroughly investigated and subtyped accordingly following surgery. Here, we present a 21-year-old male who initially underwent pituitary adenomectomy for presumed NFA with compressive symptoms. However, he developed recurrent and invasive macroadenoma with severe clinical as well as biochemical hypercortisolism during post-surgical follow-up. Repeat pituitary surgery was carried out urgently as there was significant optic chiasmal compression. Immunohistochemical analysis of the tumor tissue obtained on repeat surgery proved it to be an aggressive corticotroph adenoma. Though not cured, he showed marked clinical and biochemical improvement in the immediate postoperative period. Anticipating recurrence from the residual tumor, we referred him for cyber knife radio surgery. LEARNING POINTS Pituitary NFA commonly present with compressive symptoms such as headache and blurred vision. Post-surgical development of Cushing syndrome in such a case could be either drug induced or endogenous. In the presence of recurrent pituitary tumor, ACTH-dependent Cushing syndrome indicates CD. Rarely a SCA presenting initially as NFA can transform into an active corticotroph adenoma. Immunohistochemical marker for ACTH in the resected tumor confirms the diagnosis.
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Affiliation(s)
- Sharmin Jahan
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - M A Hasanat
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Tahseen Mahmood
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Shahed Morshed
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Raziul Haq
- Department of Neurosurgery, Dhaka Medical College and Hospital (DMCH), Dhaka, Bangladesh
| | - Md Fariduddin
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
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Prokop J, Estorninho J, Marote S, Sabino T, Botelho de Sousa A, Silva E, Agapito A. POEMS syndrome: a rare cause of adrenal insufficiency in a young male. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190010. [PMID: 31967972 DOI: 10.1530/edm-19-0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/16/2019] [Indexed: 11/08/2022] Open
Abstract
SUMMARY POEMS syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein and Skin changes) is a rare multisystemic disease. Clinical presentation is variable, the only mandatory criteria being polyneuropathy and monoclonal gammapathy in association with one major and one minor criterion. Primary adrenal insufficiency is rarely reported. We describe a case of a 33-year-old patient, in whom the presenting symptoms were mandibular mass, chronic sensory-motor peripheral polyneuropathy and adrenal insufficiency. The laboratory evaluation revealed thrombocytosis, severe hyperkalemia with normal renal function, normal protein electrophoresis and negative serum immunofixation for monoclonal protein. Endocrinologic laboratory work-up confirmed Addison's disease and revealed subclinical primary hypothyroidism. Thoracic abdominal CT showed hepatosplenomegaly, multiple sclerotic lesions in thoracic vertebra and ribs. The histopathologic examination of the mandibular mass was nondiagnostic. Bone marrow biopsy revealed plasma cell dyscrasia and confirmed POEMS syndrome. Axillary lymphadenopathy biopsy: Castleman's disease. Gluco-mineralocorticoid substitution and levothyroxine therapy were started with clinical improvement. Autologous hematopoietic cell transplantation (HCT) was planned, cyclophosphamide induction was started. Meanwhile the patient suffered two ischemic strokes which resulted in aphasia and hemiparesis. Cerebral angiography revealed vascular lesions compatible with vasculitis and stenosis of two cerebral arteries. The patient deceased 14 months after the diagnosis. The young age at presentation, multiplicity of manifestations and difficulties in investigation along with the absence of serum monoclonal protein made the diagnosis challenging. We report this case to highlight the need to consider POEMS syndrome in differential diagnosis of peripheral neuropathy in association with endocrine abnormalities even in young patients. LEARNING POINTS POEMS syndrome is considered a 'low tumor burden disease' and the monoclonal protein in 15% of cases is not found by immunofixation. Neuropathy is the dominant characteristic of POEMS syndrome and it is peripheral, ascending, symmetric and affecting both sensation and motor function. Endocrinopathies are a frequent feature of POEMS syndrome, but the cause is unknown. The most common endocrinopathies are hypogonadism, primary hypothyroidism and abnormalities in glucose metabolism. There is no standard therapy; however, patients with disseminated bone marrow involvement are treated with chemotherapy with or without HCT.
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Affiliation(s)
- Joanna Prokop
- Departments of Endocrinology, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - João Estorninho
- Departments of Endocrinology, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Sara Marote
- Departments of Internal Medicine, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Teresa Sabino
- Departments of Endocrinology, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Aida Botelho de Sousa
- Departments of Hemato-Oncology, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Eduardo Silva
- Departments of Internal Medicine, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Ana Agapito
- Departments of Endocrinology, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
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15
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Ng HY, Namboodiri D, Learoyd D, Davidson A, Champion B, Preda V. Clinical challenges of a co-secreting TSH/GH pituitary adenoma. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190068. [PMID: 31967973 DOI: 10.1530/edm-19-0068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/16/2019] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Co-secreting thyrotropin/growth hormone (GH) pituitary adenomas are rare; their clinical presentation and long-term management are challenging. There is also a paucity of long-term data. Due to the cell of origin, these can behave as aggressive tumours. We report a case of a pituitary plurihormonal pit-1-derived macroadenoma, with overt clinical hyperthyroidism and minimal GH excess symptoms. The diagnosis was confirmed by pathology showing elevated thyroid and GH axes with failure of physiological GH suppression, elevated pituitary glycoprotein hormone alpha subunit (αGSU) and macroadenoma on imaging. Pre-operatively the patient was rendered euthyroid with carbimazole and underwent successful transphenoidal adenomectomy (TSA) with surgical cure. Histopathology displayed an elevated Ki-67 of 5.2%, necessitating long-term follow-up. LEARNING POINTS Thyrotropinomas are rare and likely under-diagnosed due to under-recognition of secondary hyperthyroidism. Thyrotropinomas and other plurihormonal pit-1-derived adenomas are more aggressive adenomas according to WHO guidelines. Co-secretion occurs in 30% of thyrotropinomas, requiring diligent investigation and long-term follow-up of complications.
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Affiliation(s)
- Hui Yi Ng
- Department of Clinical Medicine, Level 4, Macquarie University, 2 Technology Place, Macquarie University, New South Wales, Australia
| | - Divya Namboodiri
- Department of Clinical Medicine, Level 4, Macquarie University, 2 Technology Place, Macquarie University, New South Wales, Australia
| | - Diana Learoyd
- University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Reserve Road St Leonards, New South Wales, Australia
| | - Andrew Davidson
- Department of Neurosurgery, Level 2, Macquarie University, 2 Technology Place Macquarie University, New South Wales, Australia
| | - Bernard Champion
- Department of Clinical Medicine, Level 4, Macquarie University, 2 Technology Place, Macquarie University, New South Wales, Australia
| | - Veronica Preda
- Department of Clinical Medicine, Level 4, Macquarie University, 2 Technology Place, Macquarie University, New South Wales, Australia
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16
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Wong SWP, Yap YW, Narayanan RP, Al-Jubouri M, Grossman A, Daousi C, Mahgoub Y. Etomidate in the management of severe Cushing's disease and MRSA bacteraemia in a district general hospital in the United Kingdom. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190044. [PMID: 31967974 DOI: 10.1530/edm-19-0044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 08/20/2019] [Indexed: 11/08/2022] Open
Abstract
SUMMARY We report our experience on managing a case of florid Cushing's disease with Methicillin-resistant Staphylococcus aureus (MRSA) sepsis using intravenous etomidate in the intensive care unit of a UK district general hospital. LEARNING POINTS Severe Cushing's syndrome is associated with high morbidity and mortality. Etomidate is a safe and effective medical therapy to rapidly lower cortisol levels even in the context of severe sepsis and immunosuppression. Etomidate should ideally be administered in an intensive care unit but is still feasible in a district general hospital. During treatment with etomidate, accumulation of serum 11β-deoxycortisol (11DOC) levels can cross-react with laboratory cortisol measurement leading to falsely elevated serum cortisol levels. For this reason, serum cortisol measurement using a mass spectrometry assay should ideally be used to guide etomidate prescription.
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Affiliation(s)
- Stephanie Wei Ping Wong
- Department of Diabetes and EndocrinologySt Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Yew Wen Yap
- Department of Diabetes and EndocrinologySt Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Ram Prakash Narayanan
- Department of Diabetes and EndocrinologySt Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Mohammad Al-Jubouri
- Department of BiochemistrySt Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Ashley Grossman
- Centre for EndocrinologyWilliam Harvey Research Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Christina Daousi
- Department of Diabetes and EndocrinologyAintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Yahya Mahgoub
- Department of Diabetes and EndocrinologySt Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
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17
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Jhawar S, Lakhotia R, Suzuki M, Welch J, Agarwal SK, Sharretts J, Merino M, Ahlman M, Blau JE, Simonds WF, Del Rivero J. Clinical presentation and management of primary ovarian neuroendocrine tumor in multiple endocrine neoplasia type 1. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190040. [PMID: 31480016 PMCID: PMC6709536 DOI: 10.1530/edm-19-0040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/30/2019] [Indexed: 12/13/2022] Open
Abstract
SUMMARY Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant condition characterized by parathyroid, anterior pituitary and enteropancreatic endocrine cell tumors. Neuroendocrine tumors occur in approximately in 5-15% of MEN1 patients. Very few cases of ovarian NETs have been reported in association with clinical MEN1 and without genetic testing confirmation. Thirty-three-year-old woman with MEN1 was found to have right adnexal mass on computed tomography (CT). Attempt at laparoscopic removal was unsuccessful, and mass was removed via a minilaparotomy in piecemeal fashion. Pathology showed ovarian NET arising from a teratoma. Four years later, patient presented with recurrence involving the pelvis and anterior abdominal wall. She was treated with debulking surgery and somatostatin analogs (SSAs). Targeted DNA sequencing analysis on the primary adnexal mass as well as the recurrent abdominal wall tumor confirmed loss of heterozygosity (LOH) at the MEN1 gene locus. This case represents to our knowledge, the first genetically confirmed case of ovarian NET arising by a MEN1 mechanism in a patient with MEN1. Extreme caution should be exercised during surgery as failure to remove an ovarian NET en masse can result in peritoneal seeding and recurrence. For patients with advanced ovarian NETs, systemic therapy options include SSAs, peptide receptor radioligand therapy (PRRT) and novel agents targeting mammalian target of rapamycin (mTOR) and vascular endothelial growth factor (VEGF). LEARNING POINTS Ovarian NET can arise from a MEN1 mechanism, and any adnexal mass in a MEN1 patient can be considered as a possible malignant NET. Given the rarity of this disease, limited data are available on prognostication and treatment. Management strategies are extrapolated from evidence available in NETs from primaries of other origins. Care should be exercised to remove ovarian NETs en bloc as failure to do so may result in peritoneal seeding and recurrence. Treatment options for advanced disease include debulking surgery, SSAs, TKIs, mTOR inhibitors, PRRT and chemotherapy.
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Affiliation(s)
- Sakshi Jhawar
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Rahul Lakhotia
- Medical Oncology Service, Center for Cancer Research, National Cancer Institute, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Mari Suzuki
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - James Welch
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Sunita K Agarwal
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - John Sharretts
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Maria Merino
- Laboratory of Pathology, National Cancer Institute, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Mark Ahlman
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Jenny E Blau
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - William F Simonds
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Jaydira Del Rivero
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
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de Miguel V, Paissan A, García Marchiñena P, Jurado A, Isola M, Alfie J, Fainstein-Day P. Bilateral pheochromocytoma after kidney transplantation in neurofibromatosis type 1. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180162. [PMID: 31125973 PMCID: PMC6548217 DOI: 10.1530/edm-18-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/08/2019] [Indexed: 12/30/2022] Open
Abstract
We present the case of a 25-year-old male with a history of neurofibromatosis type 1 and bilateral pheochromocytoma 4 years after kidney transplantation that was successfully treated with simultaneous bilateral posterior retroperitoneoscopic adrenalectomy. Learning points: Hypertensive patients with NF1 should always be screened for pheochromocytoma. Pheochromocytoma is rarely associated with transplantation, but it must be ruled out in patients with genetic susceptibility. Posterior retroperitoneoscopic adrenalectomy (PRA) allows more direct access to the adrenal glands, especially in patients with previous abdominal surgeries.
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Affiliation(s)
| | - Andrea Paissan
- Departments of Endocrinology, Metabolism and Nuclear Medicine
| | | | | | | | - José Alfie
- Hypertension Unit of Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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19
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Adnan Z, Nikomarov D, Weiler-Sagie M, Roguin Maor N. Phosphaturic mesenchymal tumors among elderly patients: a case report and review of literature. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM1801396. [PMID: 31051470 PMCID: PMC6499915 DOI: 10.1530/edm-18-01396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/11/2019] [Indexed: 11/08/2022] Open
Abstract
Phosphaturic mesenchymal tumor (PMT) represents a rare cause of osteomalacia. The clinical signs and symptoms are vague and these lead to diagnosis delay. In the presence of hypophosphatemia and relatively high urine phosphate excretion, this entity should be taken into consideration in the deferential diagnosis of osteomalacia. In the present article, we report 81-year-old man presented to our clinic for evaluation due to osteopenia. His laboratory results disclosed hypophosphatemia, relatively increased urine phosphate excretion and increased level of intact fibroblast growth factor 23 (FGF23). A 68Gallium DOTATATE PET/CT revealed pathological uptake in the upper aspect of the left shoulder adjacent to the coracoid process. For suspected PMT a wide resection of the tumor was performed and pathological findings were consistent for PMT. Laboratory tests were normalized postoperatively. Reviewing the literature, we had identified 33 reported cases of PMTs among elderly patients age ≥70 years. Unlike previously reported data, where tumors predominantly localized in the lower extremities and pelvis, our search disclosed a high rate of tumor localization (10 cases - 33.3%) in the head with equal number of tumors (14 cases - 42.4%) localized in the head and upper extremity as well as in pelvis and lower extremity. The present case describes unique tumor localization in an elderly patient and our literature search demonstrated for the first time a high rate of tumor localization in the head among this group of patients. Learning points: PMTs represent a rare entity that should be considered in the differential diagnosis of elderly patients presented with persistent hypophosphatemia. Unlike previously reported data, head and neck tumor localization is frequent among elderly patients. 68Gallium-conjugated somatostatin peptide analogs, such as 68Ga-DOTATATE PET/CT demonstrated the greatest sensitivity and specificity for tumor localization in patients with phosphaturic mesenchymal tumors (PMTs). Wide tumor resection using intraoperative ultrasound is of major importance in order to ensure long-term cure.
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Affiliation(s)
- Zaina Adnan
- Endocrinology and Metabolism Department, Zvulon Medical Center, Clalit Medical Health Care Services, Haifa, Israel
| | - David Nikomarov
- Orthopedic Surgery Department, Nuclear Medicine Department, Rambam Health Care Campus, Haifa, Israel
| | - Michal Weiler-Sagie
- Michal Weiler-Sagie, Nuclear Medicine Department, Rambam Health Care Campus, Haifa, Israel
| | - Noga Roguin Maor
- Clalit Medical Health Care and the Clinical Research Unit, Haifa and Western Galilee, Haifa, Israel
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Marques P, Tufton N, Bhattacharya S, Caulfield M, Akker SA. Hypertension due to a deoxycorticosterone-secreting adrenal tumour diagnosed during pregnancy. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180164. [PMID: 31051469 PMCID: PMC6499913 DOI: 10.1530/edm-18-0164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/11/2019] [Indexed: 11/25/2022] Open
Abstract
Mineralocorticoid hypertension is most often caused by autonomous overproduction of aldosterone, but excess of other mineralocorticoid precursors can lead to a similar presentation. 11-Deoxycorticosterone (DOC) excess, which can occur in 11-β hydroxylase or 17-α hydroxylase deficiencies, in DOC-producing adrenocortical tumours or in patients taking 11-β hydroxylase inhibitors, may cause mineralocorticoid hypertension. We report a 35-year-old woman who in the third trimester of pregnancy was found to have a large adrenal mass on routine obstetric ultrasound. On referral to our unit, persistent hypertension and long-standing hypokalaemia was noted, despite good compliance with multiple antihypertensives. Ten years earlier, she had hypertension noted in pregnancy which had persisted after delivery. A MRI scan confirmed the presence of a 12 cm adrenal mass and biochemistry revealed high levels of DOC and low/normal renin, aldosterone and dehydroepiandrosterone, with normal catecholamine levels. The patient was treated with antihypertensives until obstetric delivery, following which she underwent an adrenalectomy. Histology confirmed a large adrenal cortical neoplasm of uncertain malignant potential. Postoperatively, blood pressure and serum potassium normalised, and the antihypertensive medication was stopped. Over 10 years of follow-up, she remains asymptomatic with normal DOC measurements. This case should alert clinicians to the possibility of a diagnosis of a DOC-producing adrenal tumours in patients with adrenal nodules and apparent mineralocorticoid hypertension in the presence of low or normal levels of aldosterone. The associated diagnostic and management challenges are discussed. Learning points: Hypermineralocorticoidism is characterised by hypertension, volume expansion and hypokalaemic alkalosis and is most commonly due to overproduction of aldosterone. However, excess of other mineralocorticoid products, such as DOC, lead to the same syndrome but with normal or low aldosterone levels. The differential diagnosis of resistant hypertension with low renin and low/normal aldosterone includes congenital adrenal hyperplasia, syndrome of apparent mineralocorticoid excess, Cushing's syndrome, Liddle's syndrome and 11-deoxycorticosterone-producing tumours. DOC is one intermediate product in the mineralocorticoid synthesis with weaker activity than aldosterone. However, marked DOC excess seen in 11-β hydroxylase or 17-α hydroxylase deficiencies in DOC-producing adrenocortical tumours or in patients taking 11-β hydroxylase inhibitors, may cause mineralocorticoid hypertension. Excessive production of DOC in adrenocortical tumours has been attributed to reduced activity of the enzymes 11-β hydroxylase and 17-α hydroxylase and increased activity of 21-α hydroxylase. The diagnosis of DOC-producing adrenal tumours is challenging because of its rarity and poor availability of DOC laboratory assays.
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Affiliation(s)
- Pedro Marques
- Department of Endocrinology, St. Bartholomew’s Hospital, West Smithfield, London, UK
| | - Nicola Tufton
- Department of Endocrinology, St. Bartholomew’s Hospital, West Smithfield, London, UK
| | - Satya Bhattacharya
- Hepatobiliary and Pancreatic Surgery Unit, The Royal London Hospital, London, UK
| | - Mark Caulfield
- Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Scott A Akker
- Department of Endocrinology, St. Bartholomew’s Hospital, West Smithfield, London, UK
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Ferreira AG, Nunes da Silva T, Alegria S, Cordeiro MC, Portugal J. Paraganglioma presenting as stress cardiomyopathy: case report and literature review. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190017. [PMID: 30991354 PMCID: PMC6477651 DOI: 10.1530/edm-19-0017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/28/2019] [Indexed: 11/25/2022] Open
Abstract
Pheochromocytoma/paraganglioma (PPGL) are neuroendocrine tumors that can secrete catecholamines. The authors describe a challenging case who presented as stress cardiomyopathy and myocardial infarction (MI). A 76-year-old man, with a medical history of Parkinson's disease, type 2 diabetes mellitus, hypertension, dyslipidaemia and a previous inferior MI in 2001, presented to the emergency department due to chest pain, headaches and vomiting. He also reported worsening blood glucose levels and increasing constipation over the preceding weeks. BP was 185/89 mmHg (no other relevant findings). EKG had ST segment depression in leads V2-V6, T troponin was 600 ng/L (<14) and the echocardiogram showed left ventricular hypokinesia with mildly compromised systolic function. Nevertheless, he rapidly progressed to severe biventricular dysfunction. Coronary angiogram showed a 90% anterior descendent coronary artery occlusion (already present in 2001), which was treated with angioplasty/stenting. In the following days, a very labile BP profile and unexplained sinus tachycardia episodes were observed. Because of sustained severe constipation, the patient underwent an abdominal CT that revealed a retroperitoneal, heterogeneous, hypervascular mass on the right (62 × 35 mm), most likely a paraganglioma. Urinary metanephrines were increased several fold. 68Ga-DOTANOC PET-CT scan showed increased uptake in the abdominal mass (no evidence of disease elsewhere). He was started on a calcium-channel blocker and alpha blockade and underwent surgery with no major complications. Eight months after surgery, the patient has no evidence of disease. Genetic testing was negative for known germline mutations. This was a challenging diagnosis, but it was essential for adequate cardiovascular stabilization and to reduce further morbidity. Learning points: PPGL frequently produces catecholamines and can manifest with several cardiovascular syndromes, including stress cardiomyopathy and myocardial infarction. Even in the presence of coronary artery disease (CAD), PPGL should be suspected if signs or symptoms attributed to catecholamine excess are present (in this case, high blood pressure, worsening hyperglycaemia and constipation). Establishing the correct diagnosis is important for adequate treatment choice. Inodilators and mechanical support might be preferable options (if available) for cardiovascular stabilization prior to alpha blockade and surgery. Laboratory interference should be suspected irrespective of metanephrine levels, especially in the context of treated Parkinson's disease.
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Affiliation(s)
| | - Tiago Nunes da Silva
- Endocrinology Department, Portuguese Institute of Oncology Francisco Gentil, Lisbon, Portugal
| | - Sofia Alegria
- Cardiology Department, Garcia de Orta Hospital, Almada, Portugal
| | | | - Jorge Portugal
- Endocrinology and Diabetes Department, Garcia de Orta Hospital, Almada, Portugal
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22
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Olmedilla Y, Khan S, Young V, Joseph R, Cudlip S, Ansgorge O, Grossman A, Pal A. Plurihormonal Pit-1 lineage adenoma presenting as meningitis with recurrence after somatostatin analogue. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180130. [PMID: 30897548 PMCID: PMC6432976 DOI: 10.1530/edm-18-0130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 03/04/2019] [Indexed: 11/17/2022] Open
Abstract
A 21 year-old woman was found to have a pituitary macroadenoma following an episode of haemophilus meningitis. Biochemical TSH and GH excess was noted, although with no clear clinical correlates. She was treated with a somatostatin analogue (SSA), which restored the euthyroid state and controlled GH hypersecretion, but she re-presented with a further episode of cerebrospinal fluid (CSF) leak and recurrent meningitis. Histology following transsphenoidal adenomectomy revealed a Pit-1 lineage plurihormonal adenoma expressing GH, TSH and PRL. Such plurihormonal pituitary tumours are uncommon and even more unusual to present with spontaneous bacterial meningitis. The second episode of CSF leak and meningitis appears to have been due to SSA therapy-induced tumour shrinkage, which is not a well-described phenomenon in the literature for this type of tumour. Learning points: Pit-1 lineage GH/TSH/PRL-expressing plurihormonal pituitary adenomas are uncommon. Moreover, this case is unique as the patient first presented with bacterial meningitis. Inmunohistochemical plurihormonality of pituitary adenomas does not necessarily correlate with biochemical and clinical features of hormonal hypersecretion. Given that plurihormonal Pit-1 lineage adenomas may behave more aggressively than classical pituitary adenomas, accurate pathological characterization of these tumours has an increasing prognostic relevance. Although unusual, a CSF leak and meningitis may be precipitated by SSA therapy of a pituitary macroadenoma via tumour shrinkage.
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Affiliation(s)
- Yoko Olmedilla
- Endocrinology and Nutrition Service, Gregorio Marañón General Universitary Hospital, Madrid, Spain
| | - Shoaib Khan
- Oxford Centre for Endocrinology, Diabetes and Metabolism, Churchill Hospital, Oxford, UK
| | - Victoria Young
- Departments of Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - Robin Joseph
- Departments of Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - Simon Cudlip
- Departments of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Olaf Ansgorge
- Departments of Neuropathology, John Radcliffe Hospital, Oxford, UK
| | - Ashley Grossman
- Oxford Centre for Endocrinology, Diabetes and Metabolism, Churchill Hospital, Oxford, UK
| | - Aparna Pal
- Oxford Centre for Endocrinology, Diabetes and Metabolism, Churchill Hospital, Oxford, UK
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Uppal S, Blackburn J, Didi M, Shukla R, Hayden J, Senniappan S. Hepatoblastoma and Wilms' tumour in an infant with Beckwith-Wiedemann syndrome and diazoxide resistant congenital hyperinsulinism. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180146. [PMID: 30817313 DOI: 10.1530/edm-18-0146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/11/2019] [Indexed: 11/08/2022] Open
Abstract
Beckwith-Wiedemann syndrome (BWS) can be associated with embryonal tumours and congenital hyperinsulinism (CHI). We present an infant with BWS who developed congenital hepatoblastoma and Wilms' tumour during infancy. The infant presented with recurrent hypoglycaemia requiring high intravenous glucose infusion and was biochemically confirmed to have CHI. He was resistant to diazoxide but responded well to octreotide and was switched to Lanreotide at 1 year of age. Genetic analysis for mutations of ABCC8 and KCNJ11 were negative. He had clinical features suggestive of BWS. Methylation-sensitive multiplex ligation-dependent probe amplification revealed hypomethylation at KCNQ1OT1:TSS-DMR and hypermethylation at H19 /IGF2:IG-DMR consistent with mosaic UPD(11p15). Hepatoblastoma was detected on day 4 of life, which was resistant to chemotherapy, requiring surgical resection. He developed Wilms' tumour at 3 months of age, which also showed poor response to induction chemotherapy with vincristine and actinomycin D. Surgical resection of Wilms' tumour was followed by post-operative chemotherapy intensified with cycles containing cyclophosphamide, doxorubicin, carboplatin and etoposide, in addition to receiving flank radiotherapy. We report, for the first time, an uncommon association of hepatoblastoma and Wilms' tumour in BWS in early infancy. Early onset tumours may show resistance to chemotherapy. UPD(11p15) is likely associated with persistent CHI in BWS. Learning points: Long-acting somatostatin analogues are effective in managing persistent CHI in BWS. UPD(11)pat genotype may be a pointer to persistent and severe CHI. Hepatoblastoma and Wilms' tumour may have an onset within early infancy and early tumour surveillance is essential. Tumours associated with earlier onset may be resistant to recognised first-line chemotherapy.
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Affiliation(s)
- Saurabh Uppal
- Departments of Paediatric Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - James Blackburn
- Departments of Paediatric Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Mohammed Didi
- Departments of Paediatric Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Rajeev Shukla
- Departments of Pathology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - James Hayden
- Departments of Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Senthil Senniappan
- Departments of Paediatric Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Institute of Child Health, University of Liverpool, Liverpool, UK
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24
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Lawrence L, Zhang P, Choi H, Ahmad U, Arrossi V, Purysko A, Makin V. A unique case of ectopic Cushing's syndrome from a thymic neuroendocrine carcinoma. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190002. [PMID: 30802210 PMCID: PMC6391898 DOI: 10.1530/edm-19-0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/05/2019] [Indexed: 11/26/2022] Open
Abstract
Ectopic adrenocorticotropic hormone (ACTH) production leading to ectopic ACTH syndrome accounts for a small proportion of all Cushing's syndrome (CS) cases. Thymic neuroendocrine tumors are rare neoplasms that may secrete ACTH leading to rapid development of hypercortisolism causing electrolyte and metabolic abnormalities, uncontrolled hypertension and an increased risk for opportunistic infections. We present a unique case of a patient who presented with a mediastinal mass, revealed to be an ACTH-secreting thymic neuroendocrine tumor (NET) causing ectopic CS. As the diagnosis of CS from ectopic ACTH syndrome (EAS) remains challenging, we emphasize the necessity for high clinical suspicion in the appropriate setting, concordance between biochemical, imaging and pathology findings, along with continued vigilant monitoring for recurrence after definitive treatment. Learning points: Functional thymic neuroendocrine tumors are exceedingly rare. Ectopic Cushing's syndrome secondary to thymic neuroendocrine tumors secreting ACTH present with features of hypercortisolism including electrolyte and metabolic abnormalities, uncontrolled hypertension and hyperglycemia, and opportunistic infections. The ability to undergo surgery and completeness of resection are the strongest prognostic factors for improved overall survival; however, the recurrence rate remains high. A high degree of initial clinical suspicion followed by vigilant monitoring is required for patients with this challenging disease.
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Affiliation(s)
- Lima Lawrence
- Departments of Endocrinology, Diabetes & Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peng Zhang
- Departments of Pulmonary Medicine & Critical Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Humberto Choi
- Departments of Pulmonary Medicine & Critical Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Usman Ahmad
- Departments of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Valeria Arrossi
- Departments of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrei Purysko
- Departments of Diagnostic Radiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vinni Makin
- Departments of Endocrinology, Diabetes & Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
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Garrahy A, Mijares Zamuner MB, Byrne MM. An evolving spectrum of diabetes in a woman with GCK-MODY. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180145. [PMID: 30608898 DOI: 10.1530/edm-18-0145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 12/11/2018] [Indexed: 02/28/2024] Open
Abstract
Coexistence of autoimmune diabetes and maturity-onset diabetes of the young (MODY) is rare. We report the first case of coexisting latent autoimmune diabetes of adulthood (LADA) and glucokinase (GCK) MODY. A 32-year-old woman was treated with insulin for gestational diabetes at age 32 years; post-partum, her fasting blood glucose was 6.0 mmol/L and 2-h glucose was 11.8 mmol/L following an oral glucose tolerance test, and she was maintained on diet alone. Five years later, a diagnosis of LADA was made when she presented with fasting blood glucose of 20.3 mmol/L and HbA1C 125 mmol/mol (13.6%). GCK-MODY was identified 14 years later when genetic testing was prompted by identification of a mutation in her cousin. Despite multiple daily insulin injections her glycaemic control remained above target and her clinical course has been complicated by multiple episodes of hypoglycaemia with unawareness. Although rare, coexistence of latent autoimmune diabetes of adulthood and monogenic diabetes should be considered if there is a strong clinical suspicion, for example, family history. Hypoglycaemic unawareness developed secondary to frequent episodes of hypoglycaemia using standard glycaemic targets for LADA. This case highlights the importance of setting fasting glucose targets within the expected range for GCK-MODY in subjects with coexisting LADA. Learning points: We report the first case of coexisting latent autoimmune diabetes of adulthood (LADA) and GCK-MODY. It has been suggested that mutations in GCK may lead to altered counter-regulation and recognition of hypoglycaemia at higher blood glucose levels than patients without such mutation. However, in our case, hypoglycaemic unawareness developed secondary to frequent episodes of hypoglycaemia using standard glycaemic targets for LADA. This case highlights the importance of setting fasting glucose targets within the expected range for GCK-MODY in subjects with coexisting LADA to avoid hypoglycaemia.
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Affiliation(s)
- Aoife Garrahy
- Department of Diabetes and Endocrinology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | | | - Maria M Byrne
- Department of Diabetes and Endocrinology, Mater Misericordiae University Hospital, Dublin 7, Ireland
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26
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Broughton C, Mears J, Williams A, Lonnen K. A clinically functioning gonadotroph adenoma presenting with abdominal pain, ovarian hyperstimulation and fibromatosis. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180123. [PMID: 30532999 PMCID: PMC6300858 DOI: 10.1530/edm-18-0123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/22/2018] [Indexed: 12/11/2022] Open
Abstract
Pituitary adenomas can be classified as functioning or non-functioning adenomas. Approximately 64% of clinically non-functioning pituitary adenomas are found to be gonadotroph adenomas on immunohistochemistry. There are reported cases of gonadotroph adenomas causing clinical symptoms, but this is unusual. We present the case of a 36-year-old female with abdominal pain. Multiple large ovarian cysts were identified on ultrasound requiring bilateral cystectomy. Despite this, the cysts recurred resulting in further abdominal pain, ovarian torsion and right oophorectomy and salpingectomy. On her 3rd admission with abdominal pain, she was found to have a rectus sheath mass which was resected and histologically confirmed to be fibromatosis. Endocrine investigations revealed elevated oestradiol, follicle-stimulating hormone (FSH) at the upper limit of the normal range and a suppressed luteinising hormone (LH). Prolactin was mildly elevated. A diagnosis of an FSH-secreting pituitary adenoma was considered and a pituitary MRI revealed a 1.5 cm macroadenoma. She underwent transphenoidal surgery which led to resolution of her symptoms and normalisation of her biochemistry. Subsequent pelvic ultrasound showed normal ovarian follicular development. Clinically functioning gonadotroph adenomas are rare, but should be considered in women presenting with menstrual irregularities, large or recurrent ovarian cysts, ovarian hyperstimulation syndrome and fibromatosis. Transphenoidal surgery is the first-line treatment with the aim of achieving complete remission.
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Affiliation(s)
- Chloe Broughton
- Southmead Hospital, North Bristol NHS Trust, Westbury-on-Trym, Bristol, UK
| | - Jane Mears
- Southmead Hospital, North Bristol NHS Trust, Westbury-on-Trym, Bristol, UK
| | - Adam Williams
- Southmead Hospital, North Bristol NHS Trust, Westbury-on-Trym, Bristol, UK
| | - Kathryn Lonnen
- Southmead Hospital, North Bristol NHS Trust, Westbury-on-Trym, Bristol, UK
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27
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Fountas A, Chai ST, Ayuk J, Gittoes N, Chavda S, Karavitaki N. A rare challenging case of co-existent craniopharyngioma, acromegaly and squamous cell lung cancer. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180018. [PMID: 29623208 PMCID: PMC5881427 DOI: 10.1530/edm-18-0018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/12/2018] [Indexed: 12/28/2022] Open
Abstract
Co-existence of craniopharyngioma and acromegaly has been very rarely reported. A 65-year-old man presented with visual deterioration, fatigue and frontal headaches. Magnetic resonance imaging revealed a suprasellar heterogeneous, mainly cystic, 1.9 × 2 × 1.9 cm mass compressing the optic chiasm and expanding to the third ventricle; the findings were consistent with a craniopharyngioma. Pituitary hormone profile showed hypogonadotropic hypogonadism, mildly elevated prolactin, increased insulin-like growth factor 1 (IGF-1) and normal thyroid function and cortisol reserve. The patient had transsphenoidal surgery and pathology of the specimen was diagnostic of adamantinomatous craniopharyngioma. Post-operatively, he had diabetes insipidus, hypogonadotropic hypogonadism and adrenocorticotropic hormone and thyroid-stimulating hormone deficiency. Despite the hypopituitarism, his IGF-1 levels remained elevated and subsequent oral glucose tolerance test did not show complete growth hormone (GH) suppression. Further review of the pre-operative imaging revealed a 12 × 4 mm pituitary adenoma close to the right carotid artery and no signs of pituitary hyperplasia. At that time, he was also diagnosed with squamous cell carcinoma of the left upper lung lobe finally managed with radical radiotherapy. Treatment with long-acting somatostatin analogue was initiated leading to biochemical control of the acromegaly. Latest imaging has shown no evidence of craniopharyngioma regrowth and stable adenoma. This is a unique case report of co-existence of craniopharyngioma, acromegaly and squamous lung cell carcinoma that highlights diagnostic and management challenges. Potential effects of the GH hypersecretion on the co-existent tumours of this patient are also briefly discussed.
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Affiliation(s)
- Athanasios Fountas
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Departments of Endocrinology and Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Shu Teng Chai
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Departments of Endocrinology and Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Departments of Endocrinology and Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Neil Gittoes
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Departments of Endocrinology and Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Swarupsinh Chavda
- Departments of Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Departments of Endocrinology and Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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28
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Wong CL, Fok CK, Tam VHK. Concurrent primary hyperparathyroidism and pheochromocytoma in a Chinese lady with neurofibromatosis type 1. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180006. [PMID: 29623209 PMCID: PMC5881428 DOI: 10.1530/edm-18-0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 03/06/2018] [Indexed: 12/13/2022] Open
Abstract
We report a case of elderly Chinese lady with neurofibromatosis type-1 presenting with longstanding palpitation, paroxysmal hypertension and osteoporosis. Biochemical testing showed mild hypercalcaemia with non-suppressed parathyroid hormone level suggestive of primary hyperparathyroidism, and mildly elevated urinary fractionated normetanephrine and plasma-free normetanephrine pointing to a catecholamine-secreting pheochromocytoma/paraganglioma. Further scintigraphic investigation revealed evidence of a solitary parathyroid adenoma causing primary hyperparathyroidism and a left pheochromocytoma. Resection of the parathyroid adenoma and pheochromocytoma resulted in normalization of biochemical abnormalities and hypertension. The rare concurrence of primary hyperparathyroidism and pheochromocytoma in neurofibromatosis type-1 is discussed. Learning points All NF-1 patients who have symptoms suggestive of a pheochromocytoma/paraganglioma (PPGL), even remotely, should undergo biochemical testing.The initial biochemical tests of choice for PPGL in NF-1 are either plasma-free metanephrines or urinary fractionated metanephrines. Any elevations of metanephrines should be carefully evaluated for the presence of PPGLs in NF-1 patients.Primary hyperparathyroidism (PHPT) is described in subjects with NF-1. Due to the lack of epidemiological and functional studies, their association is yet to be substantiated. Meanwhile, PHPT may further exacerbate the metabolic bone defect in these patients and should be treated when present according to published guidelines.Coexistence of PPGL and PHPT can occur in subjects with NF-1, mimicking multiple endocrine neoplasia type 2 (MEN2).
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Affiliation(s)
- Cheuk-Lik Wong
- Department of Medicine and Geriatrics, Caritas Medical Centre, Shamshuipo, Kowloon, Hong Kong SAR
| | - Chun-Kit Fok
- Department of Medicine and Geriatrics, Caritas Medical Centre, Shamshuipo, Kowloon, Hong Kong SAR
| | - Vicki Ho-Kee Tam
- Department of Medicine and Geriatrics, Caritas Medical Centre, Shamshuipo, Kowloon, Hong Kong SAR
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Tay WL, Loh WJ, Lee LAL, Chng CL. Persistent hyperthyroidism and de novo Graves' ophthalmopathy after total thyroidectomy. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170109. [PMID: 29062485 PMCID: PMC5640566 DOI: 10.1530/edm-17-0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/25/2017] [Indexed: 11/08/2022] Open
Abstract
We report a patient with Graves' disease who remained persistently hyperthyroid after a total thyroidectomy and also developed de novo Graves' ophthalmopathy 5 months after surgery. She was subsequently found to have a mature cystic teratoma containing struma ovarii after undergoing a total hysterectomy and salpingo-oophorectomy for an incidental ovarian lesion. LEARNING POINTS It is important to investigate for other causes of primary hyperthyroidism when thyrotoxicosis persists after total thyroidectomy.TSH receptor antibody may persist after total thyroidectomy and may potentially contribute to the development of de novo Graves' ophthalmopathy.
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Affiliation(s)
- Wei Lin Tay
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | | | - Chiaw Ling Chng
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
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30
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Schober HC, Kneitz C, Fieber F, Hesse K, Schroeder H. Selective blood sampling for FGF-23 in tumor-induced osteomalacia. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170006. [PMID: 29026610 PMCID: PMC5633052 DOI: 10.1530/edm-17-0006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 09/08/2017] [Indexed: 01/26/2023] Open
Abstract
Tumor-induced osteomalacia (TIO) is caused by the hormone fibroblast growth factor 23 (FGF-23). It is mainly produced in the tissue of mesenchymal tumors. Patients with TIO frequently suffer from a chronic decompensated pain syndrome and/or muscle weakness with postural deformity. Despite the severity of the disease, the diagnosis is frequently established late. In some cases, it takes several years to establish the condition. This case report concerning a 68-year old woman demonstrates the selective blood sampling for FGF-23 as path-breaking diagnostics to confirm the diagnosis of a neuroendocrine tumor. LEARNING POINTS Tumor-induced osteomalacia is a rare condition compared to other paraneoplastic syndromes.It causes complex symptoms such as progressive reduction of physical capacity, exhaustion, fatigue, a decompensated pain syndrome of the musculoskeletal system and fractures of several bones.Elevated serum levels of FGF-23 implicate massive phosphate elimination and resulting hypophosphatemia.The diagnosis is often established over a period of several years because the localization of small FGF-23-producing tumors is complicated.It is the combination of MRI and selective blood sampling for FGF-23 which permits reliable identification of tumors causing TIO and leads to accurate localization.In a patient with generalized pain and reduced physical capacity, osteological parameters such as phosphate, 25-OH vitamin D3 and 1,25-(OH)2D3, as well as bone-specific alkaline phosphatase levels in serum should be determined. Hypophosphatemia should always lead to further diagnostic investigations aiming at the detection of an FGF-23-producing tumor.
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Affiliation(s)
- Hans-Christof Schober
- Departments of Internal Medicine.,Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Christian Kneitz
- Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Franziska Fieber
- Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Kathrin Hesse
- Departments of Internal Medicine.,Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Henry Schroeder
- Department of Neurosurgery, Universitätsmedizin Greifswald, Greifswald, Germany
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