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Arai Y, Okada S, Miyagami T, Sue N, Kainaga C. Supraglottic myxoedema successfully treated orally. Endocrinol Diabetes Metab Case Rep 2024; 2024:23-0078. [PMID: 38377682 PMCID: PMC10895324 DOI: 10.1530/edm-23-0078] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 01/30/2024] [Indexed: 02/22/2024] Open
Abstract
Summary Myxoedema coma is a severe form of hypothyroidism with multiple organ dysfunction, characterised by an altered state of consciousness and hypothermia. Intravenous thyroid hormone replacement therapy is the preferred treatment for myxoedema. The mortality rate associated with this disease is high, and early detection and intervention are essential. Supraglottal myxoedema is a rare form of periglottic oedema and can be fatal. A previously healthy 66-year-old man presented with impaired consciousness, hypothermia, and nonpitting oedema. Blood tests revealed the presence of hypothyroidism and respiratory acidosis. He was intubated for type 2 respiratory failure; however, severe laryngeal oedema made the procedure difficult to perform. Oral thyroid hormone therapy was initiated under the diagnosis of myxoedema coma. Tracheostomy was performed because of prolonged type 2 respiratory failure and laryngeal oedema. Three weeks after admission, the patient was weaned off the ventilator. Approximately a week later, laryngeal oedema improved, and the tracheostomy tube was removed. The patient was discharged and remained stable for 3 months. This case report describes a patient with comatose myxoedema and supraglottic oedema who was successfully treated with oral medication alone. This case shows that supraglottic oedema should be considered even in the absence of wheezing or other signs of upper airway obstruction. Learning points Myxoedema coma is a differential diagnosis of respiratory acidosis. In myxoedematous coma, the possibility of difficult intubation due to supraglottic oedema should be considered. Tracheostomy should be considered for supraglottic myxoedema, which often results in prolonged ventilator use. Supraglottic myxoedema can be treated with oral medications.
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Affiliation(s)
- Yu Arai
- Department of Family & General Medicine, Tokyo-Kita Medical Center, Japan
| | - Satoru Okada
- Department of Family & General Medicine, Tokyo-Kita Medical Center, Japan
| | - Taiju Miyagami
- Department of General Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Narumi Sue
- Department of Family & General Medicine, Tokyo-Kita Medical Center, Japan
| | - Chisato Kainaga
- Department of Family & General Medicine, Tokyo-Kita Medical Center, Japan
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Kitamura T, Nanba K, Doi K, Kishimoto N, Abiko K, Kuwahara R, Moriyoshi K, Inoshita N, Tagami T. FSH-producing pituitary neuroendocrine tumor as a cause of ovarian hyperstimulation syndrome. Endocrinol Diabetes Metab Case Rep 2024; 2024:23-0119. [PMID: 38421932 PMCID: PMC10959052 DOI: 10.1530/edm-23-0119] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/07/2024] [Indexed: 03/02/2024] Open
Abstract
Summary Functioning gonadotroph tumors are rare neoplasms that can cause ovarian hyperstimulation syndrome (OHSS) in women of reproductive age. Here, we present a case of a follicle-stimulating hormone (FSH)-producing pituitary neuroendocrine tumor (PitNET) with irregular menstrual cycles and OHSS in a Japanese woman. A 34-year-old woman with bilateral multi-cystic ovarian mass was referred to our hospital for ovarian surgery. The imaging feature of magnetic resonance imaging (MRI) of the ovary and elevated estradiol levels with normal FSH and low luteinizing hormone (LH) levels led us to suspect the presence of a functioning gonadotroph PitNET. MRI revealed a 19-mm pituitary tumor, and increased tracer uptake was observed in the pituitary lesion on 111In-pentetreotide scintigraphy. Transsphenoidal tumor resection resulted in the resolution of the ovarian enlargement, normalization of her menstrual cycles, and spontaneous pregnancy. Immunohistochemistry (IHC) of the resected tumor for pituitary transcription factors, including steroidogenesis factor 1 (SF1) and estrogen receptor alpha, demonstrated positive immunoreactivity, whereas IHC for pituitary-specific positive transcription factor 1 was negative, suggesting that the tumor belonged to the SF1 lineage of PitNETs (gonadotroph tumor). The tumor cells showed positive expression of FSHβ, while LHβ was mostly negative. Consistent with the high pituitary tumor uptake observed on 111In-pentetreotide scintigraphy, the pituitary tumor showed positive expression of somatostatin receptor 2A. Detailed clinical and histological evaluations will provide useful information to understand these rare functioning gonadotroph tumors better. Learning points Functioning gonadotroph tumors are very rare neuroendocrine tumors of pituitary origin. Women of reproductive age presenting with bilateral multi-cystic ovarian enlargement, irregular menstrual cycles, and hyperestrogenemia under unsuppressed follicle-stimulating hormone (FSH) levels should be evaluated for FSH-producing tumor. Raising awareness of OHSS due to functioning gonadotroph tumors is crucial to prevent unnecessary ovarian surgery. Comprehensive histological analysis may provide useful information to better understand the characteristics of functioning gonadotroph tumors.
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Affiliation(s)
- Takuya Kitamura
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kazutaka Nanba
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kento Doi
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Naoya Kishimoto
- Department of Obstetrics and Gynecology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kaoru Abiko
- Department of Obstetrics and Gynecology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Ryo Kuwahara
- Department of Radiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Koki Moriyoshi
- Department of Diagnostic Pathology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Naoko Inoshita
- Department of Pathology, Moriyama Memorial Hospital, Tokyo, Japan
| | - Tetsuya Tagami
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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Kiyohara Y, Hirose R, Kawamata H, Nakai K, Hirataka A, Saito J, Tsurutani Y. Segmental low-density area on contrast-enhanced CT is a possible clue to diagnosing branch artery fibromuscular dysplasia. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0054. [PMID: 38006656 PMCID: PMC10762593 DOI: 10.1530/edm-23-0054] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/31/2023] [Indexed: 11/27/2023] Open
Abstract
Summary Fibromuscular dysplasia can cause renovascular hypertension. Since fibromuscular dysplasia may be underdiagnosed, precise diagnosis and management are crucial, especially for young women. A 20-year-old woman with hypertension and hypokalemia was referred to our hospital for further evaluation of secondary hypertension. At the previous hospital, her blood pressure was 160/110 mmHg and the serum potassium level was 2.9 mEq/L. The equilibrium phase on contrast-enhanced computed tomography revealed a low-density area in the upper median portion of the right kidney. On admission to our hospital, her blood pressure was 141/96 mmHg under 5 mg of amlodipine. Laboratory tests revealed plasma renin activity of 11.3 ng/mL/h and plasma aldosterone concentration of 117.1 pg/mL. Renal venous sampling of active renin concentration showed a right-to-left renin ratio of 3.13, confirming a significant increase in renin secretion from the right kidney. Selective reno-angiography detected focal stenosis with adjacent aneurysmal dilation and tortuosity in the proximal branch of the right renal artery. She was diagnosed with branch artery fibromuscular dysplasia and successfully treated with percutaneous transluminal angioplasty. After the treatment, she was free from hypertension and hypokalemia without any medications. Since branch artery fibromuscular dysplasia is sometimes difficult to diagnose, contrast-enhanced computed tomography can be a promising diagnostic tool as shown in this case. Concerning treatment, our patient was treated with percutaneous transluminal angioplasty, which should be considered for women of reproductive age because recommended antihypertensive medications can be teratogenic even in the first trimester of pregnancy. Learning points Although branch artery fibromuscular dysplasia (FMD) is sometimes difficult to diagnose, it should be considered in patients with high-renin, high-aldosterone hypertension. Branch artery FMD can present with a low-density area of the kidney on contrast-enhanced computed tomography, as shown in this case. Percutaneous transluminal angioplasty (PTA) can be an appropriate treatment for branch artery FMD, especially in young female patients. PTA may immediately improve hypertension and hypokalemia without the need for medications.
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Affiliation(s)
- Yuko Kiyohara
- Department of Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Rei Hirose
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Hiroshi Kawamata
- Department of Interventional Radiology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Kazuki Nakai
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Akane Hirataka
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Yuya Tsurutani
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
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Iwasaki H. Elderly-onset calcinosis of hyperphosphataemic familial tumoural calcinosis/hyperostosis-hyperphosphataemia syndrome: the role of comorbid scleroderma. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0071. [PMID: 37787752 PMCID: PMC10563600 DOI: 10.1530/edm-23-0071] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/11/2023] [Indexed: 10/04/2023] Open
Abstract
Summary A 73-year-old woman with type 2 diabetes mellitus was referred to our department for glycaemic control. Physical examination revealed two subcutaneous hard masses around the left shoulder and the right hip joint. The patient could not fully extend her fingers because of skin sclerosis in both hands. Laboratory studies showed hyperphosphataemia and a high ratio of renal tubular maximum reabsorption of phosphate to glomerular filtration rate. There were no abnormalities in serum calcium, creatinine, alkaline phosphatase, and intact parathyroid hormone levels, whereas serum fibroblast growth factor 23 was low. Hyperphosphataemic familial tumoural calcinosis/hyperostosis-hyperphosphataemia syndrome (HFTC/HHS) was diagnosed using whole genome sequencing that revealed a novel frameshift beyond the 584th threonine located in the lectin domain of UDP-N-acetyl-alpha-D-galactosamine:polypeptide N-acetylgalactosaminyltransferase 3 associated with a duplication of the 1748th thymine in the coding region of the corresponding gene. Furthermore, anti-nuclear, anti-centromere, and anti-cardiolipin antibodies were positive, implying that comorbid limited type scleroderma might play a role in tumoural calcinosis (TC) development. A low phosphate diet was prescribed with phosphate-lowering medications, including aluminium hydroxide, acetazolamide, and sevelamer hydrochloride. The patient displayed a decrease in serum phosphate levels from 6.5 to 5.5 mg/dL 10 months after the initiation of treatment, but her TC had not improved during treatment for more than 1 year. This case was interesting because the patient with HFTC/HHS exhibited TC despite being over her 60s, and subsequent scleroderma might contribute to the specific clinical course. When HFTC/HHS presents with elderly-onset TC, the involvement of comorbidities in exacerbating TC should be considered. Learning points HFTC/HHS occurs on an autosomal recessive basis, but its clinical course and manifestations differ significantly throughout the cases. HFTC/HHS may be undiagnosed until later in life because of its rarity, unfamiliarity, and phenotype diversity; therefore, HFTC/HHS should be included in the differential diagnosis of elderly patients with unexplained hyperphosphataemia or ectopic calcinosis. Comorbidities, including rheumatologic disorders, may contribute to developing HFTC/HHS-associated calcinosis.
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Affiliation(s)
- Hiroaki Iwasaki
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Toshiba Rinkan Hospital, Sagamihara, Kanagawa, Japan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Minamiyamato Hospital, Yamato, Kanagawa, Japan
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Kubori M, Fujimoto M, Okauchi Y, Matsuno K, Yamabayashi E, Sakamoto R, Inada S, Iwahashi H. A case of IgG4-related hypophysitis maintained remission of diabetes insipidus for over 3 months after completion of steroid treatment. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0007. [PMID: 38131878 PMCID: PMC10762578 DOI: 10.1530/edm-23-0007] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 11/24/2023] [Indexed: 12/23/2023] Open
Abstract
Summary IgG4-related disease is a multiorgan disorder in which nodules and hypertrophic lesions are observed simultaneously, or separately, in areas including the pancreas, liver, lungs, salivary glands, thyroid glands, and pituitary glands. IgG4-related hypophysis is one of several IgG4-related diseases and is characterized by pituitary gland and pituitary stalk thickening, various degrees of hypopituitarism, and increased serum IgG4 levels. Steroid therapy is effective for patients with IgG4-related hypophysis, but the reported effectiveness of steroid therapy for restoring pituitary function differs between studies. Following an episode of autoimmune pancreatitis 10 years prior, enlargement of the pituitary gland and stalk along with panhypopituitarism and polyuria developed in a 73-year-old male. A high serum IgG4 level and biopsy of the submandibular gland showing infiltration of IgG4-positive plasma cells led to a clinical diagnosis of IgG4-related hypophysitis. Prednisolone treatment reduced the swelling of the pituitary gland and stalk and improved anterior pituitary function. Although arginine vasopressin secretion remained insufficient, polyuria was relieved and kept in remission even after prednisolone treatment was completed. This is the first reported case in which prednisolone was able to maintain both normal anterior pituitary function and remission of polyuria caused by IgG4-related hypophysitis. IgG4-related hypophysitis has previously been associated with a relapse of symptoms during treatment. However, the patient reported in this case study remained in remission for over 3 months after completion of steroid treatment and should be monitored closely for changes in pituitary function. Learning points Steroid therapy is the first-line therapy for pituitary dysfunction and pituitary stalk swelling in IgG4-related hypophysitis. In this case, although posterior pituitary function remained insufficient, polyuria was relieved and kept in remission for over 3 months even after prednisolone treatment was completed. IgG4-related hypophysitis has been associated with the relapse of symptoms during steroid tapering, and changes in pituitary function and symptoms should be monitored closely. When we encounter cases of adrenal insufficiency and polyuria during observation of autoimmune pancreatitis or other IgG4-related disease, we should consider the possibility of IgG4-related hypophysitis in mind.
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Affiliation(s)
- Motohiro Kubori
- Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Megumi Fujimoto
- Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yukiyoshi Okauchi
- Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Kanae Matsuno
- Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Eri Yamabayashi
- Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Ryuki Sakamoto
- Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Shinya Inada
- Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Hiromi Iwahashi
- Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
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Hirose R, Tannai H, Nakai K, Makita K, Matsui S, Saito J. High aldosterone levels in the renal capsular vein from the left aldosterone-producing adenoma on adrenal venous sampling. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0041. [PMID: 37530458 PMCID: PMC10448587 DOI: 10.1530/edm-23-0041] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023] Open
Abstract
Summary A 42-year-old female patient was referred to our hospital with hypertension and hypokalemia and was diagnosed with primary aldosteronism. Dynamic contrast-enhanced computed tomography images revealed a 13-mm nodule on the lateral segment of the left adrenal gland and a fine venous connection between the nodule and the prominent renal capsular vein running nearby. The venograms in the left lateral tributary with a microcatheter confirmed alternative drainage to the left renal capsular vein during adrenal venous sampling, and the left renal capsular vein sampling was added. The patient was diagnosed with a left aldosterone-producing adenoma (APA) using the lateralization index (48.3) and a higher plasma aldosterone concentration (PAC) of the left lateral tributary (66 700 pg/mL) than other tributary samples after adrenocorticotropic hormone stimulation. Furthermore, markedly higher PAC (224 000 pg/mL) was observed in the left renal capsular vein blood than in the left adrenal central vein (45 000 pg/mL) and tributaries, confirming the diagnosis. Laparoscopic left partial adrenalectomy and following histopathological analysis revealed a CYP11B2-positive adrenocortical adenoma. Complete clinical and biochemical success for primary aldosteronism was achieved after 6 months. Direct evidence of APA blood venous drainage into the renal capsular vein has been demonstrated. Sampling from an alternative drainage pathway could be beneficial for APA diagnosis if such APA blood drainage is assumed. Learning points Aldosterone-producing adenomas may drain blood into an alternative pathway but for the adrenal vein. The presence of alternative venous drainage could be assumed by contrast-enhanced computed tomography or venogram during adrenal venous sampling. Sampling in the alternative drainage veins and demonstrating elevated aldosterone levels could help in diagnosing aldosterone-producing adenoma.
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Affiliation(s)
- Rei Hirose
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Hiromitsu Tannai
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuki Nakai
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Kohzoh Makita
- Department of Radiology, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Seishi Matsui
- Department of Interventional Radiology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
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Sugito E, Tanabe A, Maruyama K, Nohara K, Enomoto N, Bouchi R, Ohsugi M, Ueki K, Yamada K, Kajio H. False-positive 123I-metaiodobenzylguanidine scintigraphy in a patient with a gastrointestinal stromal tumor presenting as a left adrenal incidentaloma. Endocrinol Diabetes Metab Case Rep 2023; 2023:22-0390. [PMID: 36815698 PMCID: PMC9986376 DOI: 10.1530/edm-22-0390] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/30/2023] [Indexed: 02/24/2023] Open
Abstract
Summary A 47-year-old man was diagnosed with a left adrenal incidentaloma at 40 years of age. The tumor had irregular margins and grew from 18 mm to 30 mm in maximum diameter over 7 years. On computed tomography scan, the mass appeared to localize within the tip of the lateral limb of the left adrenal gland, and between the left adrenal gland and the posterior wall of the stomach. The plasma corticotropin and cortisol concentrations and the 24-h urine fractionated metanephrine levels were normal. 123I-metaiodobenzylguanidine scintigraphy showed tumor avidity consistent with a hormonally inactive pheochromocytoma. A laparoscopic left adrenalectomy was performed; however, no tumor was present in the resected specimen. Abdominal computed tomography postoperatively showed that the tumor remained intact and appeared to connect to the posterior wall of the stomach. A laparotomy was performed and the tumor was removed. The tumor was localized to the intraperitoneal space and isolated from the posterior wall of the stomach. The pathological diagnosis was a gastrointestinal stromal tumor. Clinicians need to be aware of the limitations of diagnostic imaging studies in diagnosing non-functioning adrenal incidentalomas, which require a pathological analysis for the final diagnosis. Moreover, clinicians need to provide patients with sufficient informed consent when deciding on treatment strategies. Learning points Anatomic structures and tumors that develop in neighboring tissues to the adrenal glands may be confused with primary adrenal tumors. 123I- metaiodobenzylguanidine (MIBG) scintigraphy is specific for diagnosing pheochromocytomas and paragangliomas; however, it has been reported that 123I-MIBG may accumulate in neuroendocrine tumors as well as other tumors. Clinicians should recognize the limitations of imaging studies and the uncertainty of an imaging-based preoperative diagnosis.
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Affiliation(s)
- Erika Sugito
- Department of Diabetes, Endocrinology, and Metabolism, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology, and Metabolism, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
| | - Koji Maruyama
- Department of Diabetes, Endocrinology, and Metabolism, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kyoko Nohara
- Department of Surgery, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naoki Enomoto
- Department of Surgery, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ryotaro Bouchi
- Department of Diabetes, Endocrinology, and Metabolism, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
- Diabetes and Metabolism Information Center, Diabetes Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsuru Ohsugi
- Department of Diabetes, Endocrinology, and Metabolism, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
- Diabetes and Metabolism Information Center, Diabetes Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kohjiro Ueki
- Department of Diabetes, Endocrinology, and Metabolism, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
- Department of Molecular Diabetic Medicine, Diabetes Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuhiko Yamada
- Department of Surgery, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroshi Kajio
- Department of Diabetes, Endocrinology, and Metabolism, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
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Morishita A, Hozumi Y, Ishii H, Hokazono Y, Manuel Yosei Kikuchi C, Shimasaki M, Itaya M, Oura M, Kuriki K, Hishida A, Seki G. Effect of early dose increase of evocalcet for intractable hypercalcemia caused by parathyroid carcinoma. Endocrinol Diabetes Metab Case Rep 2023; 2023:22-0269. [PMID: 36602916 PMCID: PMC9875064 DOI: 10.1530/edm-22-0269] [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: 04/08/2022] [Accepted: 12/12/2022] [Indexed: 01/06/2023] Open
Abstract
Summary Hypercalcemia due to parathyroid carcinoma (PC) is safely and quickly controlled with rapidly increasing evocalcet doses. Most parathyroid carcinomas are detected because of hypercalcemia due to primary hyperparathyroidism (PHPT). Hypercalcemia becomes more severe in patients with PC than those with parathyroid adenoma or hyperplasia. Hypercalcemia often causes renal dysfunction, gastrointestinal symptoms, and psychiatric symptoms. Consequently, the serum calcium level needs to be promptly corrected. Here, we report a case of PC with remarkably persistent hypercalcemia, which we safely and quickly controlled with rapidly increasing evocalcet doses. A 77-year-old female presented with renal dysfunction. Her serum calcium (Ca) and intact parathyroid hormone serum levels were 13.9 mg/dL and 1.074 pg/mL, respectively. Her renal function worsened because of hypercalcemia due to PHPT. Technetium-99 m methoxy-isobutyl-isonitrile parathyroid scintigraphic examination revealed an accumulation below the right thyroid lobe. CT examination showed a 35-mm mass. Hypercalcemia needed to be immediately corrected because of the patient's worsening renal function. Evocalcet treatment at a gradually increasing dose of up to 20 mg over 3 weeks allowed her serum Ca level to be maintained below 11 mg/dL. Only mild nausea was observed at the beginning of the treatment. The mass was suspected as PC because the hypercalcemia was refractory to high-dose evocalcet. The patient was treated with parathyroidectomy and ipsilateral thyroidectomy. PC was diagnosed based on the pathological findings of capsular and venous invasion. The patient's renal function improved and surgery could be safely performed by promptly correcting hypercalcemia. Learning points Hypercalcemia due to parathyroid carcinoma (PC) is often more severe than that caused by parathyroid adenoma or hyperplasia. PC is a rare disease, but it should be considered if the patient has intractable hypercalcemia due to primary hyperparathyroidism (PHPT). Evocalcet, which is used to treat hypercalcemia due to PHPT, does not interact with P450 (CYP) and causes few side effects. Complications, including renal dysfunction, were improved and the surgery could be safely performed by promptly correcting hypercalcemia. PC has a high recurrence rate. En-block excision is necessary when PC is suspected.
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Affiliation(s)
- Azusa Morishita
- Department of Nephrology, Yaizu City Hospital, Dobara, Yaizu, Shizuoka, Japan
| | - Yasuo Hozumi
- Department of Breast and Endocrine Surgery, Ibaraki Prefectural Central Hospital, Koibuchi, Kasama, Ibaraki, Japan
| | - Hiroaki Ishii
- Department of Nephrology, Yaizu City Hospital, Dobara, Yaizu, Shizuoka, Japan
| | - Yukio Hokazono
- Department of Pathology, Yaizu City Hospital, Dobara, Yaizu, Shizuoka, Japan
| | | | - Megumi Shimasaki
- Department of Nephrology, Yaizu City Hospital, Dobara, Yaizu, Shizuoka, Japan
| | - Mikiko Itaya
- Department of Nephrology, Yaizu City Hospital, Dobara, Yaizu, Shizuoka, Japan
| | - Masaharu Oura
- Department of Nephrology, Yaizu City Hospital, Dobara, Yaizu, Shizuoka, Japan
| | - Ken Kuriki
- Department of Pathology, Yaizu City Hospital, Dobara, Yaizu, Shizuoka, Japan
| | - Akira Hishida
- Department of Nephrology, Yaizu City Hospital, Dobara, Yaizu, Shizuoka, Japan
| | - George Seki
- Department of Nephrology, Yaizu City Hospital, Dobara, Yaizu, Shizuoka, Japan
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Toyoda M, Suganuma N, Takahashi A, Masuda T, Goda M, Yoshida T, Yukawa N, Yamanaka S, Rino Y, Masuda M. Parathyroid carcinoma with pancreatitis causing hypercalcaemic emergency treated with extracorporeal membrane oxygenation-assisted parathyroid resection. Endocrinol Diabetes Metab Case Rep 2023; 2023:22-0323. [PMID: 36606579 PMCID: PMC9874956 DOI: 10.1530/edm-22-0323] [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: 07/01/2022] [Accepted: 10/27/2022] [Indexed: 01/07/2023] Open
Abstract
Summary Emergencies due to malignancies usually have a severe clinical course and require urgent treatment. These scenarios are dubbed 'oncologic emergencies'. Parathyroid tumours often cause hypercalcaemia but not oncologic emergencies. We present a case of parathyroid carcinoma with severe hypercalcaemia and pancreatitis, resolved by surgical resection of the tumour assisted by extracorporeal membrane oxygenation (ECMO). A 66-year-old woman presented to our hospital because of haematuria. Laboratory findings were as follows: white blood cell count: 30 000, C-reactive protein: 17.7, calcium: 21.9, creatine kinase: 316, creatine kinase-myoglobin binding: 20, troponin I: 1415.8, amylase: 1046, lipase: 499, blood urea nitrogen: 57, and creatinine: 2.42. ECG was unremarkable. CT revealed a 4-cm low-density irregular tumour in the left lobe of the thyroid gland and severe pancreatitis. We diagnosed hypercalcaemia and pancreatitis due to parathyroid carcinoma. Volume expansion with isotonic saline was started immediately. Calcitonin, followed by denosumab, calcimimetic agents, and continuous hemodiafiltration were administered. The patient's general condition worsened due to uncontrolled hypercalcaemia. Urgent tumour resection was planned, assisted with ECMO for cardiopulmonary support and surgical field venous pressure reduction. Tumour histology was suggestive of parathyroid carcinoma. Hypercalcaemia and the patient's general condition improved gradually postoperatively. Hypercalcaemia is one of the oncologic emergency symptoms, commonly occurring because of lytic bone metastasis. However, reports about parathyroid carcinoma-causing life-threatening hypercalcaemia and pancreatitis are scarce; the fatality of this condition is estimated to be 30-70%. We report a case of survival of hypercalcaemia of malignancy. Learning points Parathyroid carcinoma is relatively rare and sometimes causes emergent conditions such as hypercalcaemia and severe pancreatitis. General therapy for hypercalcaemia including aggressive saline dehydration, administration of furosemide, calcitonin, zoledronic acid, and evocalcet, and dialysis is sometimes ineffective for parathyroid carcinoma. Therefore, careful planning of therapy in case of exacerbation is important. During an emergency, rapid surgical treatment despite high calcium level is the best potential therapeutic strategy.
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Affiliation(s)
- Madoka Toyoda
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | | | - Akari Takahashi
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Taku Masuda
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Masami Goda
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Tatsuya Yoshida
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Norio Yukawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Shoji Yamanaka
- Department of Surgical Pathology, Yokohama City University, Yokohama, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Munetaka Masuda
- Department of Surgery, Yokohama City University, Yokohama, Japan
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10
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Kobayashi T, Iwata T, Handa K, Arima H. Pyogenic spondylitis due to Streptococcus agalactiae with paraspinal abscess and vertebral destruction in a diabetic patient: time course of imagings. Endocrinol Diabetes Metab Case Rep 2023; 2023:22-0305. [PMID: 36602911 PMCID: PMC9875033 DOI: 10.1530/edm-22-0305] [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: 06/06/2022] [Accepted: 12/12/2022] [Indexed: 01/06/2023] Open
Abstract
Summary A 76-year-old female with type 2 diabetes mellitus presented with hematuria, low back pain, and intermittent fever for 7 days. She was admitted to our hospital and diagnosed with Streptococcus agalactiae (GBS) bacteremia. CT showed an air density within the right iliopsoas muscle, and an MRI of the spine revealed hyperintensity in the right half of the L1-L2 intervertebral disk, leading to the diagnosis of a paraspinal abscess and L1-L2 pyogenic spondylitis. Antibiotic therapy was started and the clinical symptoms, as well as serologic biomarkers and radiologic images of the paraspinal abscess, were improved. The therapy was stopped on day 72 despite vertebral destruction progression. Vertebral endplate ossification was observed on day 108, and further bone formation was noted on day 177. Our case study with radiologic findings over 6 months demonstrated how bone destruction with pyogenic spondylitis, which had been treated with antibiotic therapy, improved after cessation of antibiotics. Learning points Although GBS is a rare cause of spondylitis, diabetic mellitus is a risk factor for the development of invasive GBS infections, especially under poor glycemic control. Bone destruction of pyogenic spondylitis can improve after discontinuation of antibiotic therapy. It may be important to decide the period of antibiotic therapy based on clinical conditions, serologic biomarkers, and soft tissue findings rather than bone findings. When elderly diabetic patients present with back pain and fever, spondylitis should be considered in the differential diagnosis to avoid potential diagnostic delays or misdiagnosis.
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Affiliation(s)
- Tomoko Kobayashi
- Department of Endocrinology and Diabetes, Nagoya University Hospital, Nagoya, Japan
| | - Takuya Iwata
- Department of Endocrinology and Diabetes, Nagoya University Hospital, Nagoya, Japan
| | - Katsunari Handa
- Department of Endocrinology and Diabetes, Nagoya University Hospital, Nagoya, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Hospital, Nagoya, Japan
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Wada N, Miyoshi A, Baba S, Sugawara H, Obara S. A case of subacute thyroiditis after influenza vaccination. Endocrinol Diabetes Metab Case Rep 2023; 2023:22-0364. [PMID: 37931407 PMCID: PMC9986373 DOI: 10.1530/edm-22-0364] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/11/2022] [Indexed: 11/08/2023] Open
Abstract
Summary A 40-year-old Japanese woman presented to the outpatient clinic with fever and palpitations 2 days after receiving the influenza vaccine (Influenza HA Vaccine 'KMB'®) following the second dose of coronavirus disease 2019 (COVID-19) vaccine (COVID-19 vaccine Moderna intramuscular injection®). At the first visit, the patient presented with a swollen thyroid gland with mild tenderness, and she was diagnosed with subacute thyroiditis (SAT) based on the presence of thyrotoxicosis (free T3: 5.42 pg/mL; free T4: 2.34 ng/dL; and thyroid-stimulating hormone (TSH): <0.01 μIU/mL), a high C-reactive protein level (5.77 mg/dL), a negative TSH receptor antibody, and characteristic ultrasound findings. The patient's human leukocyte antigen types were A2, A11, B35, B51, DR4, and DR1403. Prednisolone (15 mg/day) was given as an initial dose, after which the fever subsided, and the dose was tapered and discontinued after 6 weeks. The patient was thought to have developed SAT due to influenza vaccination. SAT after influenza vaccination may be overlooked. For patients with SAT, it is necessary to obtain information regarding their vaccination history. Learning points After influenza vaccination, subacute thyroiditis (SAT) may develop. If persistent fever, anterior neck pain, swelling, tenderness of the thyroid gland, and symptoms of thyrotoxicosis are observed immediately after vaccination for several viruses, including influenza, an examination to rule out the onset of SAT is recommended. Human leukocyte antigen type A2 (HLA-A2) and HLA-B35 may be linked to the development of SAT following influenza vaccination. The two doses of the coronavirus disease 2019 (COVID-19) vaccine given before the influenza vaccine may affect the onset of SAT.
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Affiliation(s)
- Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Arina Miyoshi
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Shuhei Baba
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Hajime Sugawara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Shinji Obara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
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12
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Nakajima R, Sekiya M, Furuta Y, Miyamoto T, Sato M, Fukuda K, Hattori K, Suehara Y, Sakata-Yanagimoto M, Chiba S, Okajima Y, Matsuzaka T, Takase S, Takanashi M, Okazaki H, Takashima Y, Yuhara M, Mitani Y, Matsumoto N, Murayama Y, Ohyama Osawa M, Ohuchi N, Yamazaki D, Mori S, Sugano Y, Osaki Y, Iwasaki H, Suzuki H, Shimano H. A case of NASH with genetic predisposition successfully treated with an SGLT2 inhibitor: a possible involvement of mitochondrial dysfunction. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0368. [PMID: 36571472 PMCID: PMC9874953 DOI: 10.1530/edm-22-0368] [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: 09/19/2022] [Accepted: 12/06/2022] [Indexed: 12/27/2022] Open
Abstract
Summary In this study, we herein describe a 47-year-old Japanese woman who manifested inheritable non-alcoholic steatohepatitis (NASH) and severe dyslipidemia. Interestingly, her NASH progression was ameliorated by treatment with a sodium-glucose co-transporter 2 (SGLT2) inhibitor. This inheritability prompted us to comprehensively decode her genomic information using whole-exome sequencing. We found the well-established I148M mutation in PNPLA3 as well as mutations in LGALS3 and PEMT for her NASH. Mutations in GCKR may contribute to both NASH and dyslipidemia. We further mined gene mutations potentially responsible for her manifestations that led to the identification of a novel M188fs mutation in MUL1 that may be causally associated with her mitochondrial dysfunction. Our case may provide some clues to better understand this spectrum of disease as well as the rationale for selecting medications. Learning points While the PNPLA3 I148M mutation is well-established, accumulation of other mutations may accelerate susceptibility to non-alcoholic steatohepatitis (NASH). NASH and dyslipidemia may be intertwined biochemically and genetically through several key genes. SGLT2 inhibitors emerge as promising treatment for NASH albeit with interindividual variation in efficacy. Genetic background may explain the mechanisms behind the variation. A novel dysfunctional mutation in MUL1 may lead to metabolic inflexibilities through impaired mitochondrial dynamics and function.
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Affiliation(s)
- Rikako Nakajima
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Motohiro Sekiya
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Yasuhisa Furuta
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Takafumi Miyamoto
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Masashi Sato
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba
| | - Kuniaki Fukuda
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba
- Department of Gastroenterology, Kasumigaura Medical Center, 2-7-14 Shimotakatsu, Tsuchiura, Ibaraki, Japan
| | - Keiichiro Hattori
- Department of Hematology, Faculty of Medicine, University of Tsukuba
| | - Yasuhito Suehara
- Department of Hematology, Faculty of Medicine, University of Tsukuba
| | | | - Shigeru Chiba
- Department of Hematology, Faculty of Medicine, University of Tsukuba
| | - Yuka Okajima
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Takashi Matsuzaka
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
- Transborder Medical Research Center, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Satoru Takase
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, the University of Tokyo, Bunkyo, Tokyo, Japan
| | - Mikio Takanashi
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, the University of Tokyo, Bunkyo, Tokyo, Japan
| | - Hiroaki Okazaki
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, the University of Tokyo, Bunkyo, Tokyo, Japan
| | - Yusuke Takashima
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Mikiko Yuhara
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Yuta Mitani
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Nako Matsumoto
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Yuki Murayama
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Mariko Ohyama Osawa
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Nami Ohuchi
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Daichi Yamazaki
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Sayuri Mori
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Yoko Sugano
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Yoshinori Osaki
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Hitoshi Iwasaki
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Hiroaki Suzuki
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Hitoshi Shimano
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
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Sawamura T, Karashima S, Ohmori A, Sawada K, Aono D, Kometani M, Takeda Y, Yoneda T. Hiccups as the first presentation of secondary adrenal insufficiency associated with advanced cervical cancer. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0286. [PMID: 36017819 PMCID: PMC9422230 DOI: 10.1530/edm-22-0286] [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: 07/16/2022] [Accepted: 07/21/2022] [Indexed: 11/30/2022] Open
Abstract
Summary Hiccups are a common symptom characterized by intermittent spasmodic contraction of the diaphragm. Most hiccups are transient, but some are refractory. Patients with intractable hiccups often have abnormalities of the diaphragm, medulla oblongata, and lesions affecting nerve fibers connecting them. Moreover, electrolyte abnormalities, including hyponatremia, are frequently observed in patients with intractable hiccups. Adrenal insufficiency (AI) is one of the causes of hyponatremia. However, hiccups are not commonly the first presentation. Herein, we describe a case of a 45-year-old woman complaining of refractory hiccups. The patient was initially diagnosed with hiccups associated with cervical cancer metastasis to the liver and peritoneum. The administration of chlorpromazine did not have a beneficial effect on her hiccup. Fasting hypoglycemia and hyponatremia were later found. Her serum cortisol level was low without an elevation of adrenocorticotropic hormone level. MRI of the pituitary gland showed metastatic lesion in the pituitary gland and stalk. Thus, the patient was diagnosed with secondary AI due to cervical cancer metastasis to the pituitary gland and stalk. Administration of hydrocortisone improved her hiccups with the normalization of serum sodium level. Therefore, differential diagnosis in advanced cancer patients with hiccups should include AI-induced hyponatremia. Learning points Hiccups could be the first manifestation of adrenal insufficiency (AI). Hiccups in patients with AI are often mediated by hyponatremia. Hyponatremia is less frequent in secondary AI than in primary AI. However, hyponatremia can result from increased antidiuretic hormone due to loss of cortisol. The differential diagnosis should include AI-induced hyponatremia if hiccups occur in patients with advanced cancer, as metastasis to adrenal gland or pituitary gland could cause AI.
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Affiliation(s)
- Toshitaka Sawamura
- Department of Internal Medicine, Asanogawa General Hospital, Kanazawa, Ishikawa, Japan
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan
| | - Shigehiro Karashima
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Ai Ohmori
- Department of Internal Medicine, Asanogawa General Hospital, Kanazawa, Ishikawa, Japan
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan
| | - Kei Sawada
- Department of Internal Medicine, Asanogawa General Hospital, Kanazawa, Ishikawa, Japan
| | - Daisuke Aono
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Mitsuhiro Kometani
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Yoshiyu Takeda
- Department of Internal Medicine, Asanogawa General Hospital, Kanazawa, Ishikawa, Japan
| | - Takashi Yoneda
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
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14
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Sekiya M, Yuhara M, Murayama Y, Ohyama Osawa M, Nakajima R, Ohuchi N, Matsumoto N, Yamazaki D, Mori S, Matsuda T, Sugano Y, Osaki Y, Iwasaki H, Suzuki H, Shimano H. A case of early-onset diabetes with impaired insulin secretion carrying a PAX6 gene Gln135* mutation. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0271. [PMID: 35979842 PMCID: PMC9422263 DOI: 10.1530/edm-22-0271] [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: 06/24/2022] [Accepted: 07/07/2022] [Indexed: 11/08/2022] Open
Abstract
Summary A paired homeodomain transcription factor, PAX6 (paired-box 6), is essential for the development and differentiation of pancreatic endocrine cells as well as ocular cells. Despite the impairment of insulin secretion observed in PAX6-deficient mice, evidence implicating causal association between PAX6 gene mutations and monogenic forms of human diabetes is limited. We herein describe a 33-year-old Japanese woman with congenital aniridia who was referred to our hospital because of her uncontrolled diabetes with elevated hemoglobin A1c (13.1%) and blood glucose (32.5 mmol/L) levels. Our biochemical analysis revealed that her insulin secretory capacity was modestly impaired as represented by decreased 24-h urinary C-peptide levels (38.0 μg/day), primarily explaining her diabetes. Intriguingly, there was a trend toward a reduction in her serum glucagon levels as well. Based on the well-recognized association of PAX6 gene mutations with congenital aniridia, we screened the whole PAX6 coding sequence, leading to an identification of a heterozygous Gln135* mutation. We tested our idea that this mutation may at least in part explain the impaired insulin secretion observed in this patient. In cultured pancreatic β-cells, exogenous expression of the PAX6 Gln135* mutant produced a truncated protein that lacked the transcriptional activity to induce insulin gene expression. Our observation together with preceding reports support the recent attempt to include PAX6 in the growing list of genes causally responsible for monogenic diabetes. In addition, since most cases of congenital aniridia carry PAX6 mutations, we may need to pay more attention to blood glucose levels in these patients. Learning points PAX6 Gln135* mutation may be causally associated not only with congenital aniridia but also with diabetes. Blood glucose levels may deserve more attention in cases of congenital aniridia with PAX6 mutations. Our case supports the recent attempt to include PAX6 in the list of MODY genes, and Gln135* may be pathogenic.
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Affiliation(s)
- Motohiro Sekiya
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mikiko Yuhara
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yuki Murayama
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mariko Ohyama Osawa
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Rikako Nakajima
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Nami Ohuchi
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Nako Matsumoto
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Daichi Yamazaki
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Sayuri Mori
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takaaki Matsuda
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yoko Sugano
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yoshinori Osaki
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hitoshi Iwasaki
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroaki Suzuki
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hitoshi Shimano
- 1Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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15
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Kadowaki Y, Nishiyama M, Nakamura M, Morisaka H, Fujimoto S, Terada Y, Kojima K. Adult-onset Langerhans cell histiocytosis changing CNS lesion from pituitary to suprasellar extension. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0232. [PMID: 35642690 PMCID: PMC9175615 DOI: 10.1530/edm-22-0232] [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: 05/05/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022] Open
Abstract
Summary Langerhans cell histiocytosis (LCH) is a rare disease characterized by the proliferation of abnormal Langerhans cells in various tissues and organs, including bone, skin, the lungs, and the pituitary gland. Hypothalamic-pituitary lesions in LCH often cause central diabetes insipidus (CDI), but the natural course of LCH in the CNS remains to be elucidated. In this study, we report an interesting case of altered LCH lesions in the CNS from the pituitary to the hypothalamus in a 45-year-old woman. She developed symptoms of polyuria and was diagnosed with CDI with lymphocytic hypophysitis due to an enlarged pituitary gland with stalk thickening shown on MRI. Short-term glucocorticoid therapy cured pituitary enlargement, but serum prolactin levels gradually increased. Six years later, the immunohistological findings of a skin biopsy revealed positive for leukocyte common antigen, S-100, and CD1a expression, indicating a diagnosis of LCH. MRI revealed a new lesion in the hypothalamus without pituitary involvement, likely due to LCH. Chemotherapy improved LCH lesions both in the skin and hypothalamus, but therapy was stopped on the patient's request. Although adult-onset LCH is rare, it should be considered as a differential diagnosis in cases of CDI as the primary disease. The clinical course in the present case indicated that LCH lesion was altered from pituitary to suprasellar extension; where such changes were observed, the possibility of LCH should be considered. Learning points Diagnosing the primary disease of CDI is challenging; therefore, careful observation is necessary in pathologically unknown cases. Enhanced MRI should be performed in cases with suspected hypothalamic lesions, such as elevated serum prolactin. Although adult-onset LCH is rare, it should be considered a differential diagnosis in cases of CDI as the primary disease. The direction of changing CNS lesion from pituitary to suprasellar extension might be a unique MRI finding in LCH.
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Affiliation(s)
- Yuji Kadowaki
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Mitsuru Nishiyama
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
- Health Care Center, Kochi University, Kochi City, Kochi, Japan
| | - Makoto Nakamura
- Department of Hematology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Hiroyuki Morisaka
- Department of Dermatology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Shimpei Fujimoto
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Kensuke Kojima
- Department of Hematology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
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16
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Murashita M, Wada N, Baba S, Sugawara H, Miyoshi A, Obara S. Subacute thyroiditis associated with thyrotoxic periodic paralysis after COVID-19 vaccination: a case report. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0236. [PMID: 35578985 PMCID: PMC9175599 DOI: 10.1530/edm-22-0236] [Citation(s) in RCA: 1] [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: 04/13/2022] [Accepted: 04/25/2022] [Indexed: 12/18/2022] Open
Abstract
Summary We report a 26-year-old Japanese man who visited our outpatient clinic presenting fever immediately after i.m. injection of the second dose of a coronavirus disease 2019 (COVID-19) vaccine (Moderna®). At the first visit, the patient had a fever of 37.7°C and a swollen thyroid gland with mild tenderness. He was diagnosed with subacute thyroiditis (SAT) based on the presence of thyrotoxicosis (free tri-iodothyronine, 32.3 pg/mL; free thyroxine, >7.77 ng/dL; and thyroid-stimulating hormone (TSH) < 0.01 μIU/mL), high C-reactive protein level (7.40 mg/dL), negative TSH receptor antibody, and characteristic ultrasound findings. His HLA types were A*02:01/24:02, B*15:11/35:01, Cw*03:03, DRB1*09:01/12:01, DQB1*03:03, and DPB1*05: 01/41:01. He was initially administered prednisolone 15 mg/day, following which the fever subsided. After 10 days, he developed limb weakness and could not walk. The serum potassium level decreased to 1.8 mEq/L, which confirmed the diagnosis of thyrotoxic periodic paralysis (TPP). Potassium supplementation was initiated. The muscle weakness gradually decreased. Prednisolone therapy was terminated 6 weeks after the first visit. His thyroid function returned to normal 5 months after the first visit, through a hypothyroid state. To our knowledge, this is the first reported case of TPP-associated SAT following COVID-19 vaccination. Persistent fever following vaccination should be suspected of SAT. Additionally, TPP may be associated with SAT in Asian male patients. Learning points Following coronavirus disease 2019 (COVID-19) vaccination, subacute thyroiditis may develop regardless of the vaccine type. If persistent fever, anterior neck pain, swelling and tenderness of thyroid gland, and symptoms of thyrotoxicosis are observed immediately after the COVID-19 vaccination, examination in consideration of the onset of subacute thyroiditis is recommended. HLA-B35 may be associated with the onset of subacute thyroiditis after the COVID-19 vaccination. Although rare, subacute thyroiditis can be associated with thyrotoxic periodic paralysis, especially in Asian men. Glucocorticoid therapy for subacute thyroiditis may induce thyrotoxic periodic paralysis through hypokalemia.
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Affiliation(s)
- Mone Murashita
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Shuhei Baba
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Hajime Sugawara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Arina Miyoshi
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Shinji Obara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
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Takahashi H, Nishimata S, Kumada A, Yamanaka G, Kashiwagi Y, Kawashima H. A 17-year-old boy with lymphocytic infundibuloneurohypophysitis who developed non-alcoholic steatohepatitis effectively treated with growth hormone. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0148. [PMID: 35319489 PMCID: PMC9002206 DOI: 10.1530/edm-21-0148] [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: 02/12/2022] [Accepted: 02/21/2022] [Indexed: 11/17/2022] Open
Abstract
Summary We encountered a case of childhood-onset lymphocytic infundibuloneurohypophysitis, based on the MRI and endocrinological findings, with decreased function of the anterior and posterior lobes of the pituitary. Three years after the diagnosis, the patient developed non-alcoholic steatohepatitis (NASH), which was effectively treated by growth hormone (GH) supplementation. The present case demonstrated that NASH can be effectively treated by short-term GH supplementation, even in late childhood. Learning points In recent years, the efficacy of growth hormone replacement therapy in normalizing the liver function of adult-onset growth hormone deficiency patients with non-alcoholic steatohepatitis (NASH) has been reported. Lymphocytic infundibuloneurohypophysitis is a very rare disease, particularly in childhood. We here presented a rare case of a child with lymphocytic infundibuloneurohypophysitis who developed NASH and showed substantial improvement in liver function after growth hormone treatment.
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Affiliation(s)
- Hidekuni Takahashi
- Department of Pediatrics and Adolescent Medicine, Tokyo Medical University, Tokyo, Japan
| | - Shigeo Nishimata
- Department of Pediatrics and Adolescent Medicine, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Kumada
- Department of Pediatrics and Adolescent Medicine, Tokyo Medical University, Tokyo, Japan
| | - Gaku Yamanaka
- Department of Pediatrics and Adolescent Medicine, Tokyo Medical University, Tokyo, Japan
| | - Yasuyo Kashiwagi
- Department of Pediatrics and Adolescent Medicine, Tokyo Medical University, Tokyo, Japan
| | - Hisashi Kawashima
- Department of Pediatrics and Adolescent Medicine, Tokyo Medical University, Tokyo, Japan
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Jazdarehee A, Huget-Penner S, Pawlowska M. Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0100. [PMID: 35212265 PMCID: PMC8897593 DOI: 10.1530/edm-21-0100] [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: 12/17/2021] [Accepted: 02/02/2022] [Indexed: 11/11/2022] Open
Abstract
SUMMARY Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting. LEARNING POINTS Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.
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Key Words
- adolescent/young adult
- adult
- geriatric
- neonatal
- paediatric
- pregnant adult
- female
- male
- american indian or alaska native
- asian - bangladeshi
- asian - chinese
- asian - filipino
- asian - indian
- asian - japanese
- asian - korean
- asian - pakistani
- asian - vietnamese
- asian - other
- black - african
- black - caribbean
- black - other
- hispanic or latino - central american or south american
- hispanic or latino - cuban
- hispanic or latino - dominican
- hispanic or latino - mexican, mexican american, chicano
- hispanic or latino - puerto rican
- hispanic or latino - other
- native hawaiian/other pacific islander
- white
- other
- afghanistan
- aland islands
- albania
- algeria
- american samoa
- andorra
- angola
- anguilla
- antarctica
- antigua and barbuda
- argentina
- armenia
- aruba
- australia
- austria
- azerbaijan
- bahamas
- bahrain
- bangladesh
- barbados
- belarus
- belgium
- belize
- benin
- bermuda
- bhutan
- bolivia
- bosnia and herzegovina
- botswana
- bouvet island
- brazil
- british indian ocean territory
- brunei darussalam
- bulgaria
- burkina faso
- burundi
- cambodia
- cameroon
- canada
- cape verde
- cayman islands
- central african republic
- chad
- chile
- china
- christmas island
- cocos (keeling) islands
- colombia
- comoros
- congo
- congo, the democratic republic of the
- cook islands
- costa rica
- côte d'ivoire
- croatia
- cuba
- cyprus
- czech republic
- denmark
- djibouti
- dominica
- dominican republic
- ecuador
- egypt
- el salvador
- equatorial guinea
- eritrea
- estonia
- ethiopia
- falkland islands (malvinas)
- faroe islands
- fiji
- finland
- france
- french guiana
- french polynesia
- french southern territories
- gabon
- gambia
- georgia
- germany
- ghana
- gibraltar
- greece
- greenland
- grenada
- guadeloupe
- guam
- guatemala
- guernsey
- guinea
- guinea-bissau
- guyana
- haiti
- heard island and mcdonald islands
- holy see (vatican city state)
- honduras
- hong kong
- hungary
- iceland
- india
- indonesia
- iran, islamic republic of
- iraq
- ireland
- isle of man
- israel
- italy
- jamaica
- japan
- jersey
- jordan
- kazakhstan
- kenya
- kiribati
- korea, democratic people's republic of
- korea, republic of
- kuwait
- kyrgyzstan
- lao people's democratic republic
- latvia
- lebanon
- lesotho
- liberia
- libyan arab jamahiriya
- liechtenstein
- lithuania
- luxembourg
- macao
- macedonia, the former yugoslav republic of
- madagascar
- malawi
- malaysia
- maldives
- mali
- malta
- marshall islands
- martinique
- mauritania
- mauritius
- mayotte
- mexico
- micronesia, federated states of
- moldova, republic of
- monaco
- mongolia
- montenegro
- montserrat
- morocco
- mozambique
- myanmar
- namibia
- nauru
- nepal
- netherlands
- netherlands antilles
- new caledonia
- new zealand
- nicaragua
- niger
- nigeria
- niue
- norfolk island
- northern mariana islands
- norway
- oman
- pakistan
- palau
- palestinian territory, occupied
- panama
- papua new guinea
- paraguay
- peru
- philippines
- pitcairn
- poland
- portugal
- puerto rico
- qatar
- réunion
- romania
- russian federation
- rwanda
- saint barthélemy
- saint helena
- saint kitts and nevis
- saint lucia
- saint martin
- saint pierre and miquelon
- saint vincent and the grenadines
- samoa
- san marino
- sao tome and principe
- saudi arabia
- senegal
- serbia
- seychelles
- sierra leone
- singapore
- slovakia
- slovenia
- solomon islands
- somalia
- south africa
- south georgia and the south sandwich islands
- spain
- sri lanka
- sudan
- suriname
- svalbard and jan mayen
- swaziland
- sweden
- switzerland
- syrian arab republic
- taiwan, province of china
- tajikistan
- tanzania, united republic of
- thailand
- timor-leste
- togo
- tokelau
- tonga
- trinidad and tobago
- tunisia
- turkey
- turkmenistan
- turks and caicos islands
- tuvalu
- uganda
- ukraine
- united arab emirates
- united kingdom
- united states
- united states minor outlying islands
- uruguay
- uzbekistan
- vanuatu
- vatican city state
- venezuela
- viet nam
- virgin islands, british
- virgin islands, u.s.
- wallis and futuna
- western sahara
- yemen
- zambia
- zimbabwe
- maylaysia
- adipose tissue
- adrenal
- bone
- duodenum
- heart
- hypothalamus
- kidney
- liver
- ovaries
- pancreas
- parathyroid
- pineal
- pituitary
- placenta
- skin
- stomach
- testes
- thymus
- thyroid
- andrology
- autoimmunity
- cardiovascular endocrinology
- developmental endocrinology
- diabetes
- emergency
- endocrine disruptors
- endocrine-related cancer
- epigenetics
- genetics and mutation
- growth factors
- gynaecological endocrinology
- immunology
- infectious diseases
- late effects of cancer therapy
- mineral
- neuroendocrinology
- obesity
- ophthalmology
- paediatric endocrinology
- puberty
- tumours and neoplasia
- vitamin d
- 17ohp
- acth
- adiponectin
- adrenaline
- aldosterone
- amh
- androgens
- androstenedione
- androsterone
- angiotensin
- antidiuretic hormone
- atrial natriuretic hormone
- avp
- beta-endorphin
- big igf2
- brain natriuretic peptide
- calcitonin
- calcitriol
- cck
- corticosterone
- corticotrophin
- cortisol
- cortisone
- crh
- dehydroepiandrostenedione
- deoxycorticosterone
- deoxycortisol
- dhea
- dihydrotestosterone
- dopamine
- endothelin
- enkephalin
- epitestosterone
- epo
- fgf23
- fsh
- gastrin
- gh
- ghrelin
- ghrh
- gip
- glp1
- glp2
- glucagon
- glucocorticoids
- gnrh
- gonadotropins
- hcg
- hepcidin
- histamine
- human placental lactogen
- hydroxypregnenolone
- igf1
- igf2
- inhibin
- insulin
- kisspeptin
- leptin
- lh
- melanocyte-stimulating hormone
- melatonin
- metanephrines
- mineralocorticoids
- motilin
- nandrolone
- neuropeptide y
- noradrenaline
- normetanephrine
- oestetrol (e4)
- oestradiol (e2)
- oestriol (e3)
- oestrogens
- oestrone (e1)
- osteocalcin
- oxyntomodulin
- oxytocin
- pancreatic polypeptide
- peptide yy
- pregnenolone
- procalcitonin
- progesterone
- prolactin
- prostaglandins
- pth
- relaxin
- renin
- resistin
- secretin
- somatostatin
- testosterone
- thpo
- thymosin
- thymulin
- thyroxine (t4)
- trh
- triiodothyronine (t3)
- tsh
- vip
- 17-alpha hydroxylase/17,20 lyase deficiency
- 17-beta-hydroxysteroid dehydrogenase type 3 deficiency
- 3-m syndrome
- 22q11 deletion syndrome
- 49xxxxy syndrome
- abscess
- acanthosis nigricans
- acromegaly
- acute adrenocortical insufficiency
- addisonian crisis
- addison's disease
- adenocarcinoma
- aip gene mutation
- adrenal insufficiency
- adrenal salt-wasting crisis
- adrenarche
- adrenocortical adenoma
- adrenocortical carcinoma
- adrenoleukodystrophy
- aip gene variant
- amenorrhoea (primary)
- amenorrhoea (secondary)
- amyloid goitre
- amyloidosis
- anaplastic thyroid cancer
- anaemia
- aneuploidy
- androgen insensitivity syndrome
- anti-phospholipid antibody syndrome
- asthma
- autoimmune disorders
- autoimmune polyendocrine syndrome 1
- autoimmune polyendocrine syndrome 2
- autoimmune polyglandular syndrome
- autoimmune hypophysitis
- autosomal dominant hypophosphataemic rickets
- autosomal dominant osteopetrosis
- bardet-biedl syndrome
- bartter syndrome
- bilateral adrenal hyperplasia
- biliary calculi
- breast cancer
- brenner tumour
- brown tumour
- burkitt's lymphoma
- casr gene mutation
- catecholamine secreting carotid body paraganglionoma
- cancer-prone syndrome
- carcinoid syndrome
- carcinoid tumour
- carney complex
- carotid body paraganglioma
- c-cell hyperplasia
- cerebrospinal fluid leakage
- chronic fatigue syndrome
- circadian rhythm sleep disorders
- congenital adrenal hyperplasia
- congenital hypothyroidism
- congenital hyperinsulinism
- conn's syndrome
- corticotrophic adenoma
- craniopharyngioma
- cretinism
- crohn's disease
- cryptorchidism
- cushing's disease
- cushing's syndrome
- cystolithiasis
- de quervain's thyroiditis
- denys-drash syndrome
- desynchronosis
- developmental abnormalities
- diabetes - lipoatrophic
- diabetes - mitochondrial
- diabetes - steroid-induced
- diabetes insipidus - dipsogenic
- diabetes insipidus - gestational
- diabetes insipidus - nephrogenic
- diabetes insipidus - neurogenic/central
- diabetes mellitus type 1
- diabetes mellitus type 2
- diabetic foot syndrome
- diabetic hypoglycaemia
- diabetic ketoacidosis
- diabetic muscle infarction
- diabetic nephropathy
- diverticular disease
- donohue syndrome
- down syndrome
- eating disorders
- ectopic acth syndrome
- ectopic cushing's syndrome
- ectopic parathyroid adenoma
- empty sella syndrome
- endometrial cancer
- endometriosis
- eosinophilic myositis
- euthyroid sick syndrome
- familial hypocalciuric hypercalcaemia
- familial dysalbuminaemic hyperthyroxinaemia
- familial euthyroid hyperthyroxinaemia
- fat necrosis
- female athlete triad syndrome
- fetal demise
- fetal macrosomia
- follicular thyroid cancer
- fractures
- frasier syndrome
- friedreich's ataxia
- functional parathyroid cyst
- galactorrhoea
- gastrinoma
- gastritis
- gastrointestinal perforation
- gastrointestinal stromal tumour
- gck mutation
- gender identity disorder
- gestational diabetes mellitus
- giant ovarian cysts
- gigantism
- gitelman syndrome
- glucagonoma
- glucocorticoid remediable aldosteronism
- glycogen storage disease
- goitre
- goitre (multinodular)
- gonadal dysgenesis
- gonadoblastoma
- gonadotrophic adenoma
- gorham's disease
- granuloma
- granulosa cell tumour
- graves' disease
- graves' ophthalmopathy
- growth hormone deficiency (adult)
- growth hormone deficiency (childhood onset)
- gynaecomastia
- hamman's syndrome
- haemorrhage
- hajdu-cheney syndrome
- hashimoto's disease
- hemihypertrophy
- hepatitis c
- hereditary multiple osteochondroma
- hirsutism
- histiocytosis
- huntington's disease
- hürthle cell adenoma
- hyperaldosteronism
- hyperandrogenism
- hypercalcaemia
- hypercalcaemic crisis
- hyperglucogonaemia
- hyperglycaemia
- hypergonadotropic hypogonadism
- hypergonadotropism
- hyperinsulinaemia
- hyperinsulinaemic hypoglycaemia
- hyperkalaemia
- hyperlipidaemia
- hypernatraemia
- hyperosmolar hyperglycaemic state
- hyperparathyroidism (primary)
- hyperparathyroidism (secondary)
- hyperparathyroidism (tertiary)
- hyperpituitarism
- hyperprolactinaemia
- hypersexuality
- hypertension
- hyperthyroidism
- hypoaldosteronism
- hypocalcaemia
- hypoestrogenism
- hypoglycaemia
- hypoglycaemic coma
- hypogonadism
- hypogonadotrophic hypogonadism
- hypoinsulinaemia
- hypokalaemia
- hyponatraemia
- hypoparathyroidism
- hypophosphataemia
- hypophosphatasia
- hypophysitis
- hypopituitarism
- hypothyroidism
- iatrogenic disorder
- idiopathic bilateral adrenal hyperplasia
- idiopathic pituitary hyperplasia
- igg4-related systemic disease
- inappropriate tsh secretion
- incidentaloma
- infertility
- insulin autoimmune syndrome
- insulin resistance
- insulinoma
- intracranial vasospasm
- intrauterine growth retardation
- iodine allergy
- ischaemic heart disease
- kallmann syndrome
- ketoacidosis
- klinefelter syndrome
- kwashiorkor
- kwashiorkor (marasmic)
- leg ulcer
- laron syndrome
- latent autoimmune diabetes of adults (lada)
- laurence-moon syndrome
- left ventricular hypertrophy
- leukocytoclastic vasculitis
- leydig cell tumour
- lipodystrophy
- lipomatosis
- liver failure
- lung metastases
- luteoma
- lymphadenopathy
- macronodular adrenal hyperplasia
- macronodular hyperplasia
- macroprolactinoma
- marasmus
- maturity onset diabetes of young (mody)
- mccune-albright syndrome
- mckittrick-wheelock syndrome
- medullary thyroid cancer
- meigs syndrome
- membranous nephropathy
- men1
- men2a
- men2b
- men4
- menarche
- meningitis
- menopause
- metabolic acidosis
- metabolic syndrome
- metastatic carcinoma
- metastatic chromaffin cell tumour
- metastatic gastrinoma
- metastatic melanoma
- metastatic tumour
- microadenoma
- microprolactinoma
- motor neurone disease
- myasthenia gravis
- myelolipoma
- myocardial infarction
- myositis
- myotonic dystrophy type 1
- myotonic dystrophy type 2
- myxoedema
- myxoedema coma
- nelson's syndrome
- neonatal diabetes
- nephrolithiasis
- neuroblastoma
- neuroendocrine tumour
- neurofibromatosis
- nodular hyperplasia
- non-functioning pituitary adenoma
- non-hodgkin lymphoma
- non-islet-cell tumour hypoglycaemia
- noonan syndrome
- oculocerebrorenal syndrome
- osteogenesis imperfecta
- osteomalacia
- osteomyelitis
- osteoporosis
- osteoporosis (pregnancy/lactation-associated)
- osteosclerosis
- ovarian cancer
- ovarian dysgenesis
- ovarian hyperstimulation syndrome
- ovarian tumour
- paget's disease
- paget's disease (juvenille)
- pancreatic neuroendocrine tumour
- pancreatitis
- panhypopituitarism
- papillary thyroid cancer
- paraganglioma
- paranasal sinus lesion
- paraneoplastic syndromes
- parasitic thyroid nodules
- parathyroid adenoma
- parathyroid adenoma (ectopic)
- parathyroid carcinoma
- parathyroid cyst
- parathroid hyperplasia
- pcos
- periodontal disease
- phaeochromocytoma
- phaeochromocytoma crisis
- pickardt syndrome
- pituitary abscess
- pituitary adenoma
- pituitary apoplexy
- pituitary carcinoma
- pituitary cyst
- pituitary haemorrhage
- pituitary hyperplasia
- pituitary hypoplasia
- pituitary tumour (malignant)
- plurihormonal pituitary adenoma
- poems syndrome
- polycythaemia
- porphyria
- pneumonia
- posterior reversible encephalopathy syndrome
- post-prandial hypoglycaemia
- prader-willi syndrome
- prediabetes
- pre-eclampsia
- pregnancy
- premature ovarian failure
- premenstrual dysphoric disorder
- premenstrual syndrome
- primary hypertrophic osteoarthropathy
- prolactinoma
- prostate cancer
- pseudohypoaldosteronism type 1
- pseudohypoaldosteronism type 2
- pseudohypoparathyroidism
- psychosocial short stature
- puberty (delayed or absent)
- puberty (precocious)
- pulmonary oedema
- quadrantanopia
- rabson-mendenhall syndrome
- rhabdomyolysis
- rheumatoid arthritis
- rickets
- schwannoma
- sellar reossification
- sertoli cell tumour
- sertoli-leydig cell tumour
- sexual development disorders
- sheehan's syndrome
- short stature
- siadh
- small-cell carcinoma
- small intestine neuroendocrine tumour
- solitary fibrous tumour
- solitary sellar plasmacytoma
- somatostatinoma
- somatotrophic adenoma
- squamous cell thyroid carcinoma
- stiff person syndrome
- struma ovarii
- subcutaneous insulin resistance
- systemic lupus erythematosus
- takotsubo cardiomyopathy
- tarts
- testicular cancer
- thecoma
- thyroid adenoma
- thyroid carcinoma
- thyroid cyst
- thyroid dysgenesis
- thyroid fibromatosis
- thyroid hormone resistance syndrome
- thyroid lymphoma
- thyroid nodule
- thyroid storm
- thyroiditis
- thyrotoxicosis
- thyrotrophic adenoma
- traumatic brain injury
- tuberculosis
- tuberous sclerosis complex
- tumour-induced osteomalacia
- turner syndrome
- unilateral adrenal hyperplasia
- ureterolithiasis
- urolithiasis
- von hippel-lindau disease
- wagr syndrome
- waterhouse-friderichsen syndrome
- williams syndrome
- wolcott-rallison syndrome
- wolfram syndrome
- xanthogranulomatous hypophysitis
- xlaad/ipex
- zollinger-ellison syndrome
- abdominal adiposity
- abdominal distension
- abdominal cramp
- abdominal discomfort
- abdominal guarding
- abdominal lump
- abdominal pain
- abdominal tenderness
- abnormal posture
- abdominal wall defects
- abrasion
- acalculia
- accelerated growth
- acne
- acrochorda
- acroosteolysis
- acute stress reaction
- adverse breast development
- aggression
- agitation
- agnosia
- akathisia
- akinesia
- albuminuria
- alcohol intolerance
- alexia
- alopecia
- altered level of consciousness
- amaurosis
- amaurosis fugax
- ambiguous genitalia
- amblyopia
- amenorrhoea
- ameurosis
- amnesia
- amusia
- anasarca
- angiomyxoma
- anhedonia
- anisocoria
- ankle swelling
- anorchia
- anorectal malformations
- anorexia
- anosmia
- anosognosia
- anovulation
- antepartum haemorrhage
- anuria
- anxiety
- apathy
- aphasia
- aphonia
- apnoea
- appendicitis
- appetite increase
- appetite reduction/loss
- apraxia
- aqueductal stenosis
- arteriosclerosis
- arthralgia
- articulation impairment
- ascites
- asperger syndrome
- asphyxia
- asthenia
- astigmatism
- asymptomatic
- ataxia
- atrial fibrillation
- atrial myxoma
- atrophy
- adhd
- autism
- autonomic neuropathy
- avulsion
- babinski's sign
- back pain
- bacteraemia
- behavioural problems
- belching
- bifid scrotum
- biliary colic
- bitemporal hemianopsia
- blindness
- blistering
- bloating
- bloody show
- boil(s)
- bone cyst
- bone fracture(s)
- bone lesions
- bone pain
- bony metastases
- borborygmus
- bowel movements - bleeding
- bowel movements - increased frequency
- bowel movements - pain
- bowel obstruction
- bowel perforation
- brachycephaly
- brachydactyly
- bradycardia
- bradykinesia
- bradyphrenia
- bradypnea
- breast contour change
- breast enlargement
- breast lump
- breast reduction
- breast tenderness
- breastfeeding difficulties
- breathing difficulties
- bronchospasms
- brushfield spots
- bruxism
- buffalo hump
- cachexia
- calcification
- cardiac fibrosis
- cardiac malformations
- cardiac tamponade
- cardiogenic shock
- cardiomegaly
- cardiomyopathy
- cardiopulmonary arrest
- carpal tunnel syndrome
- caruncle - inflammation
- cataplexy
- cataract(s)
- catathrenia
- central obesity
- cerebrospinal fluid rhinorrhoea
- cervical pain
- cheeks - full
- cheiloschisis
- chemosis
- chest pain
- chest pain (pleuritic)
- chest pain (precordial)
- cheyne-stokes respiration
- chills
- cholecystitis
- cholestasis
- chondrocalcinosis
- chordee
- chorea
- choroidal atrophy
- chronic pain
- circulatory collapse
- cirrhosis
- citraturia
- claudication
- clitoromegaly
- cloacal exstrophy
- clonus
- club foot
- clumsiness
- coagulopathy
- coarctation
- coeliac disease
- cognitive problems
- cold intolerance
- collapse
- colour blindness
- coma
- concentration difficulties
- confusion
- congenital heart defect
- conjunctivitis
- constipation
- convulsions
- coordination difficulties
- coughing
- crackles
- cramps
- craniofacial abnormalities
- craniotabes
- cutaneous ischaemia
- cutaneous myxoma
- cutaneous pigmentation
- cyanosis
- dalrymple's sign
- deafness
- deep vein thrombosis
- dehydration
- delayed puberty
- delirium
- dementia
- dental abscess(es)
- dental problems
- depression
- diabetes insipidus
- diabetic neuropathy
- diabetic foot infection
- diabetic foot neuropathy
- diabetic foot ulceration
- diarrhoea
- diplopia
- dizziness
- duodenal atresia
- duplex kidney(s)
- dysarthria
- dysdiadochokinesia
- dysgraphia
- dyslexia
- dyslipidaemia
- dysmenorrhoea
- dyspareunia
- dyspepsia
- dysphagia
- dysphonia
- dysphoria
- dyspnoea
- dystonia
- dysuria
- ear, nose and/or throat infection
- early menarche
- ears - low set
- ears - pinna abnormalities
- ears - small
- ecchymoses
- ectopic ureter
- emotional immaturity
- encopresis
- endometrial hyperplasia
- enlarged bladder
- enlarged prostate
- eosinophilia
- epicanthic fold
- epilepsy
- epistaxis
- erectile dysfunction
- erythema
- euphoria
- eyebrows - bushy
- eyelid retraction
- eyelid swelling
- eyelids - redness
- eyes - almond-shaped
- eyes - dry
- eyes - feeling of grittiness
- eyes - inflammation
- eyes - irritation
- eyes - itching
- eyes - pain (gazing down)
- eyes - pain (gazing up)
- eyes - redness
- eyes - watering
- face - change in appearance
- face - coarse features
- face - numbness
- facial fullness
- facial palsy
- facial plethora
- facial weakness
- facies - abnormal
- facies - hippocratic
- facies - moon
- faecal incontinence
- failure to thrive
- fallopian tube hyperplasia
- fasciculation
- fatigue
- fatigue (post-exertional)
- feet - cold
- feet - increased size
- feet - large
- feet - pain
- feet - small
- fingers - thick
- flaccid paralysis
- flatulence
- flushing
- fontanelles - enlarged
- frontal bossing
- fungating lesion
- fungating mass
- funny turns
- gait abnormality
- gait unsteadiness
- gallbladder calculi
- gallstones
- gangrene
- gastro-oesophageal reflux
- genital oedema
- genu valgum
- genu varum
- gestational diabetes
- glaucoma
- glucose intolerance
- glucosuria
- growth hormone deficiency
- growth retardation
- haematemesis
- haematochezia
- haematoma
- haematuria
- haemoglobinuria
- haemoptysis
- hair - coarse
- hair - dry
- hair - temporal balding
- hairline - low
- hallucination
- hands - enlargement
- hands - large
- hands - single palmar crease
- hands - small
- head - large
- headache
- hearing loss
- heart failure
- heart murmur
- heat intolerance
- height loss
- hemiballismus
- hemianopia
- hemiparesis
- hemispatial neglect
- hepatic cysts
- hepatic metastases
- hepatomegaly
- hidradenitis suppurativa
- high-arched palate
- hip dislocation
- hippocampal dysgenesis
- hirschsprung's disease
- hot flushes
- hydronephrosis
- hypolipidaemia
- hyperactivity
- hyperacusis
- hyperandrogenaemia
- hypercalciuria
- hypercapnea
- hypercholesterolaemia
- hypercortisolaemia
- hyperflexibility
- hyperglucagonaemia
- hyperhidrosis
- hyperhomocysteinaemia
- hypernasal speech
- hyperopia
- hyperoxaluria
- hyperpigmentation
- hyperplasia
- hyperpnoea
- hypersalivation
- hyperseborrhea
- hypersomnia
- hyperthermia
- hypertrichosis
- hypertrophy
- hyperuricaemia
- hyperventilation
- hypoadrenalism
- hypoalbuminaemia
- hypocalciuria
- hypocitraturia
- hypomagnesaemia
- hypopigmentation
- hypoplastic scrotum
- hypopotassaemia
- hypoprolactinaemia
- hyporeflexia
- hyposmia
- hypospadias
- hypotension
- hypothermia
- hypotonia
- hypoventilation
- hypovitaminosis d
- hypovolaemia
- hypovolaemic shock
- hypoxia
- immunodeficiency
- impulsivity
- inattention
- infections
- inflexibility
- insomnia
- instability
- intussusception
- irritability
- ischaemia
- ischuria
- itching
- jaundice
- keratoconus
- ketonuria
- ketotic odour
- kidney dysplasia
- kidney stones
- kyphoscoliosis
- kyphosis
- labioscrotal fold abnormalities
- laceration
- late dentition
- learning difficulties
- leg pain
- legs - increased length
- leukaemia
- leukocytosis
- libido increase
- libido reduction/loss
- lichen sclerosus
- lips - dry
- lips - thin
- little finger - in-curved
- little finger - short
- liver masses
- lordosis
- lordosis (loss of)
- lymphadenectomy
- lymphadenitis
- lymphocytosis
- lymphoedema
- macroglossia
- malaise
- malaise (post-exertional)
- malodorous perspiration
- mania
- marcus gunn pupil
- mastalgia
- meckel's diverticulum
- melena
- menorrhagia
- menstrual disorder
- mesenteric ischaemia
- metabolic alkalosis
- microalbuminuria
- microcephaly
- micrognathia
- micropenis
- milk-alkali syndrome
- miscarriage
- mood changes/swings
- mouth - down-turned
- mouth - small
- movement - limited range of
- mucosal pigmentation
- muscle atrophy
- muscle freezing
- muscle hypertrophy
- muscle rigidity
- myalgia
- myasthaenia
- mydriasis
- myelodysplasia
- myeloma
- myoclonus
- myodesopsia
- myokymia
- myopathy
- myopia
- myosis
- nail clubbing
- nail dystrophy
- nasal obstruction
- nausea
- neck - loose skin (nape)
- neck - short
- neck mass
- neck pain/discomfort
- necrolytic migratory erythema
- necrosis
- nephrocalcinosis
- nephropathy
- neurofibromas
- night terrors
- nipple change
- nipple discharge
- nipple inversion
- nipple retraction
- nipples widely spaced
- nocturia
- normochromic normocytic anaemia
- nose - depressed bridge
- nose - flat bridge
- nose - thickening
- nystagmus
- obsessive-compulsive disorder
- obstetrical haemorrhage
- obstructive sleep apnoea
- odynophagia
- oedema
- oesophageal atresia
- oesophagitis
- oligomenorrhoea
- oliguria
- onychauxis
- oophoritis
- ophthalmoplegia
- optic atrophy
- orbital fat prolapse
- orbital hypertelorism
- orthostatic hypotension
- osteoarthritis
- osteopenia
- otitis media
- ovarian cysts
- ovarian hyperplasia
- palatoschisis
- pallor
- palmar erythema
- palpebral fissure (downslanted)
- palpebral fissure (extended)
- palpebral fissure (reduced)
- palpebral fissure (upslanted)
- palpitations
- pancreatic fibrosis
- pancytopaenia
- panic attacks
- papilloedema
- paraesthesia
- paralysis
- paranoia
- patellar dislocation
- patellar subluxation
- pedal ulceration
- pellagra
- pelvic mass
- pelvic pain
- penile agenesis
- peptic ulcer
- pericardial effusion
- periodontitis
- periosteal bone reactions
- peripheral oedema
- personality change
- pes cavus
- petechiae
- peyronie's disease
- pharyngitis
- philtrum - long
- philtrum - short
- phosphaturia
- photophobia
- photosensitivity
- pleurisy
- poikiloderma
- polydactyly
- polydipsia
- polyphagia
- polyuria
- poor wound healing
- postmenopausal bleeding
- post-nasal drip
- postprandial fullness
- postural instability
- prehypertension
- premature birth
- premature labour
- prenatal growth retardation
- presbyopia
- pretibial myxoedema
- proctalgia fugax
- prognathism
- proptosis
- prosopagnosia
- proteinuria
- pruritus
- pruritus scroti
- pruritus vulvae
- pseudarthrosis
- psoriatic arthritis
- psychiatric problems
- psychomotor retardation
- psychosis
- pterygium colli
- ptosis
- puberty (delayed/absent)
- puberty (early/precocious)
- puffiness
- pulmonary embolism
- purpura
- pyelonephritis
- pyloric stenosis
- pyrexia
- pyrosis
- pyuria
- rash
- rectal pain
- rectorrhagia
- refractory anemia
- reluctance to weight-bear
- renal agenesis
- renal clubbing
- renal colic
- renal cyst
- renal failure
- renal insufficiency
- renal phosphate wasting (isolated)
- renal tubular acidosis
- respiratory failure
- reticulocytosis
- retinitis pigmentosa
- retinopathy
- retrobulbar pain
- retrograde ejaculation
- retroperitoneal fibrosis
- salivary gland swelling
- salpingitis
- salt craving
- salt wasting
- sarcoidosis
- schizophrenia
- scoliosis
- scotoma
- seborrhoeic dermatitis
- seizures
- sensory loss
- sepsis
- septic arthritis
- septic shock
- shivering
- singultus
- sinusitis
- sixth nerve palsy
- skeletal deformity
- skeletal dysplasia
- skin - texture change
- skin infections
- skin necrosis
- skin pigmentation - spotty
- skin thickening
- skin thinning
- sleep apnoea
- sleep difficulties
- sleep disturbance
- sleep hyperhidrosis
- slow growth
- slurred speech
- social difficulties
- soft tissue swelling
- somnambulism
- somniloquy
- somnolence
- sore throat
- spasms
- spastic paraplegia
- spasticity
- speech delay
- spider naevi
- splenomegaly
- sputum production
- steatorrhoea
- stomatitis
- strabismus
- strangury
- striae
- stridor
- stroke
- subfertility
- suicidal ideation
- supraclavicular fat pads
- supranuclear gaze palsy
- sweating
- syncope
- syndactyly
- tachycardia
- tachypnoea
- teeth gapping
- telangiectasias
- telecanthus
- tetraparesis
- t-reflex (absent)
- t-reflex (depressed)
- tetany
- thermodysregulation
- thrombocytopenia
- thrombocytosis
- thrombophilia
- thrush
- tics
- tinnitus
- toe clubbing
- toe deformities
- toes - thick
- toes - widely spaced
- tongue - protruding
- tracheo-oesophageal compression
- tracheo-oesophageal fistula
- tremulousness
- tricuspid insufficiency
- umbilical hernia
- uraemia
- ureter duplex
- uricaemia
- urinary frequency
- urinary incontinence
- urogenital sinus
- urticaria
- uterine hyperplasia
- uterus duplex
- vagina duplex
- vaginal bleeding
- vaginal discharge
- vaginal dryness
- vaginal pain/tenderness
- vaginism
- ventricular fibrillation
- ventricular hypertrophy
- vertigo
- viraemia
- virilisation (abnormal)
- vision - acuity reduction
- vision - blurred
- visual disturbance
- visual field defect
- visual impairment
- visual loss
- vitiligo
- vocal cord paresis
- vomiting
- von graefe's sign
- weight gain
- weight loss
- wheezing
- widened joint space(s)
- xeroderma
- xerostomia
- 3-methoxy 4-hydroxy mandelic acid
- 17-hydroxypregnenolone (urine)
- 17-ketosteroids
- 25-hydroxyvitamin-d3
- 5hiaa
- aberrant adrenal receptors
- acid-base balance
- acth stimulation
- activated partial thromboplastin time
- acyl-ghrelin
- adrenal antibodies
- adrenal function
- adrenal scintigraphy
- adrenal venous sampling
- afp tumour marker
- alanine aminotransferase
- albumin
- albumin to creatinine ratio
- aldosterone (24-hour urine)
- aldosterone (blood)
- aldosterone (plasma)
- aldosterone (serum)
- aldosterone to renin ratio
- alkaline phosphatase
- alkaline phosphatase (bone-specific)
- alpha-fetoprotein
- ammonia
- amniocentesis
- amylase
- angiography
- anion gap
- anti-acetylcholine antibodies
- anticardiolipin antibody
- anti-insulin antibodies
- anti-islet cell antibody
- anti-gh antibodies
- antinuclear antibody
- anti-tyrosine phosphatase antibodies
- asvs
- barium studies
- basal insulin
- base excess
- apolipoprotein h
- beta-hydroxybutyrate
- bicarbonate
- bilirubin
- biopsy
- blood film
- blood pressure
- bmi
- body fat mass
- bone age
- bone biopsy
- bone mineral content
- bone mineral density
- bone mineral density test
- bone scintigraphy
- bone sialoprotein
- bound insulin
- brca1/brca2
- c1np
- c3 complement
- c4 complement
- ca125
- calcifediol
- calcium (serum)
- calcium (urine)
- calcium to creatinine clearance ratio
- carcinoembryonic antigen
- cardiac index
- catecholamines (24-hour urine)
- catecholamines (plasma)
- cd-56
- chemokines
- chest auscultation
- chloride
- chorionic villus sampling
- chromatography
- chromogranin a
- chromosomal analysis
- clomid challenge
- clonidine suppression
- collagen
- colonoscopy
- colposcopy
- continuous glucose monitoring
- core needle biopsy
- corticotropin-releasing hormone stimulation test
- cortisol (9am)
- cortisol (plasma)
- cortisol (midnight)
- cortisol (salivary)
- cortisol (serum)
- cortisol day curve
- cortisol, free (24-hour urine)
- c-peptide (24-hour urine)
- c-peptide (blood)
- c-reactive protein
- creatinine
- creatine kinase
- creatinine (24-hour urine)
- creatinine (serum)
- creatinine clearance
- crh stimulation
- ctpa scan
- ct scan
- c-telopeptide
- cytokines
- deoxypyridinoline
- dexa scan
- dexamethasone suppression
- dexamethasone suppression (high dose)
- dexamethasone suppression (low dose)
- dhea sulphate
- discectomy
- dldl cholesterol
- dmsa scan
- dna sequencing
- domperidone
- down syndrome screening
- ductal lavage
- echocardiogram
- eeg
- electrocardiogram
- electrolytes
- electromyography
- endoscopic ultrasound
- endoscopy
- endosonography
- enzyme immunoassay
- epinephrine (plasma)
- epinephrine (urine)
- erythrocyte sedimentation rate
- estimated glomerular filtration rate
- ethanol ablation
- ewing and clarke autonomic function
- exercise tolerance
- fbc
- ferritin
- fine needle aspiration biopsy
- flow cytometry
- fludrocortisone suppression
- fluticasone-propionate-17-beta carboxylic acid
- fmri
- folate
- ft3
- ft4
- gada
- gallium nitrate
- gallium scan
- gastric biopsy
- genetic analysis
- genitography
- gh day curve
- gh stimulation
- gh suppression
- glp-1
- glp-2
- glucose suppression test
- glucose (blood)
- glucose (blood, fasting)
- glucose (blood, postprandial)
- glucose (urine)
- glucose tolerance
- glucose tolerance (intravenous)
- glucose tolerance (oral)
- glucose tolerance (prolonged)
- gluten sensitivity
- gnrh stimulation
- gonadotrophins
- growth hormone-releasing peptide-2 test
- gut hormones (fasting)
- haematoxylin and eosin staining
- haemoglobin
- haemoglobin a1c
- hcg (serum)
- hcg (urine)
- hcg stimulation
- hdl cholesterol
- hearing test
- heart rate
- hepatic venous sampling with arterial stimulation
- high-sensitivity c-reactive protein
- histopathology
- hla genotyping
- holter monitoring
- homa
- homocysteine
- hyaluronic acid
- hydrocortisone day curve
- hydroxyproline
- hydroxyprogesterone
- hysteroscopy
- igfbp2
- igfbp3
- igg4/igg ratio
- immunocytochemistry
- immunohistochemistry
- immunoglobulins
- immunoglobulin g2
- immunoglobulin g4
- immunoglobulin a
- immunoglobulin m
- immunostaining
- inferior petrosal sinus sampling
- inhibin b
- insulin (fasting)
- insulin suppression
- insulin tissue resistance tests
- insulin tolerance
- intracranial pressure
- irm imaging
- ketones (plasma)
- ketones (urine)
- kidney function
- lactate
- lactate dehydrogenase
- laparoscopy
- laparoscopy and dye
- laparotomy
- ldl cholesterol
- leuprolide acetate stimulation
- leukocyte esterase (urine)
- levothyroxine absorption
- lipase (serum)
- lipid profile
- liquid-based cytology
- liquid chromatography-mass spectrometry
- liver biopsy
- liver function
- lumbar puncture
- lung function testing
- luteinising hormone releasing hormone test
- macroprolactin
- magnesium
- mag3 scan
- mammogram
- mantoux test
- metanephrines (plasma)
- metanephrines (urinary)
- methoxytyramine
- metoclopramide
- metyrapone cortisol day curve
- metyrapone suppression
- metyrapone test dose
- mibg scan
- microarray analysis
- molecular genetic analysis
- mri
- myocardial biopsy
- nerve conduction study
- neuroendocrine markers
- neuron-specific enolase
- norepinephrine
- ntx
- oct
- octreotide scan
- octreotide suppression test
- osmolality
- ovarian venous sampling
- p1np
- palpation
- pap test
- parathyroid scintigraphy
- pentagastrin
- perchlorate discharge
- percutaneous umbilical blood sampling
- peripheral blood film
- pet scan
- ph (blood)
- phosphate (serum)
- phosphate (urine)
- pituitary function
- plasma osmolality
- plasma viscosity
- platelet count
- pneumococcal antigen
- pneumococcal pcr
- polymerase chain reaction
- polysomnography
- porter-silber chromogens
- potassium
- pregnancy test
- proinsulin
- prostate-specific antigen
- protein electrophoresis
- protein fingerprinting
- protein folding analysis
- psychiatric assessment
- psychometric assessment
- pulse oximetry
- pyelography
- pyridinium crosslinks
- quicki
- plasma renin activity
- radioimmunoassay
- radionuclide imaging
- raiu test
- red blood cell count
- renal biopsy
- renin (24-hour urine)
- respiratory status
- renin (blood)
- renin plasma activity
- rheumatoid factor
- salt loading
- sdldl cholesterol
- secretin stimulation
- selective parathyroid venous sampling
- selective transhepatic portal venous sampling
- semen analysis
- serotonin
- serum osmolality
- serum free insulin
- sestamibi scan
- sex hormone binding globulin
- shbg
- skeletal muscle mass
- skin biopsy
- sleep diary
- sodium
- spect scan
- supervised 72-hour fast
- surgical biopsy
- sweat test
- synaptophysin
- systemic vascular resistance index
- tanner scale
- thoracocentesis
- thyroid transcription factor-1
- thyroglobulin
- thyroid antibodies
- thyroid function
- thyroid scintigraphy
- thyroid ultrasonography
- total cholesterol
- total ghrelin
- total t3
- total t4
- trabecular thickness
- transaminase
- transvaginal ultrasound
- trap 5b
- trh stimulation
- triglycerides
- triiodothyronine (t3) suppression
- troponin
- tsh receptor antibodies
- type 3 precollagen
- type 4 collagen
- ultrasound-guided biopsy
- ultrasound scan
- urea and electrolytes
- uric acid (blood)
- uric acid (urine)
- urinalysis
- urinary free cortisol
- urine 24-hour volume
- urine osmolality
- vaginal examination
- vanillylmandelic acid (24-hour urine)
- visual field assessment
- vitamin b12
- vitamin e
- waist circumference
- water deprivation
- water load
- weight
- western blotting
- white blood cell count
- white blood cell differential count
- x-ray
- zinc
- abscess drainage
- acetic acid injection
- adhesiolysis
- adrenalectomy
- amputation
- analgesics
- angioplasty
- arthrodesis
- assisted reproduction techniques
- bariatric surgery
- bilateral salpingo-oophorectomy
- blood transfusion
- bone grafting
- caesarean section
- cardiac transplantation
- cardiac pacemaker
- cataract extraction
- chemoembolisation
- chemotherapy
- chemoradiotherapy
- clitoroplasty
- continuous renal replacement therapy
- contraception
- cordotomy
- counselling
- craniotomy
- cryopreservation
- cryosurgical ablation
- debridement
- dialysis
- diazoxide
- diet
- duodenotomy
- endonasal endoscopic surgery
- exercise
- external fixation
- extracorporeal shock wave lithotripsy
- extraocular muscle surgery
- eye surgery
- eyelid surgery
- fasciotomy
- fluid repletion
- fluid restriction
- gamma knife radiosurgery
- gastrectomy
- gastrostomy
- gender reassignment surgery
- gonadectomy
- heart transplantation
- hormone replacement
- hormone suppression
- hypophysectomy
- hysterectomy
- inguinal orchiectomy
- internal fixation
- intra-cardiac defibrillator
- islet transplantation
- ivf
- kidney transplantation
- laparoscopic adrenalectomy
- laryngoplasty
- laryngoscopy
- laser lithotripsy
- light treatment
- liver transplantation
- lumpectomy
- lymph node dissection
- mastectomy
- molecularly targeted therapy
- neuroendoscopic surgery
- oophorectomy
- orbital decompression
- orbital radiation
- orchidectomy
- orthopaedic surgery
- osteotomy
- ovarian cystectomy
- ovarian diathermy
- oxygen therapy
- pancreas transplantation
- pancreatectomy
- pancreaticoduodenectomy
- parathyroidectomy
- percutaneous adrenal ablation
- percutaneous nephrolithotomy
- pericardiocentesis
- pericardiotomy
- physiotherapy
- pituitary adenomectomy
- plasma exchange
- plasmapheresis
- psychotherapy
- radiofrequency ablation
- radionuclide therapy
- radiotherapy
- reconstruction of genitalia
- resection of tumour
- right-sided hemicolectomy
- salpingo-oophorectomy
- small bowel resection
- speech and language therapy
- spinal surgery
- splenectomy
- stereotactic radiosurgery
- termination of pregnancy
- thymic transplantation
- thyroidectomy
- tracheostomy
- transcranial surgery
- transsphenoidal surgery
- transtentorial surgery
- vaginoplasty
- vagotomy
- 5-alpha-reductase inhibitors
- 17?-estradiol
- abiraterone
- acarbose
- acetazolamide
- acetohexamide
- adalimumab
- albiglutide
- alendronate
- alogliptin
- alpha-blockers
- alphacalcidol
- alpha-glucosidase inhibitors
- amiloride
- amlodipine
- amoxicillin
- anastrozole
- angiotensin-converting enzyme inhibitors
- angiotensin receptor antagonists
- anthracyclines
- antiandrogens
- antibiotics
- antiemetics
- antiepileptics
- antipsychotics
- antithyroid drugs
- antiseptic
- antivirals
- aripiprazole
- aromatase inhibitors
- aspirin
- astragalus membranaceus
- ativan
- atenolol
- atorvastatin
- avp receptor antagonists
- axitinib
- azathioprine
- bendroflumethiazide
- benzodiazepines
- beta-blockers
- betamethasone
- bexlosteride
- bicalutamide
- bisphosphonates
- bleomycin
- botulinum toxin
- bromocriptine
- cabergoline
- cabozantinib
- calcimimetics
- calcitonin (salmon)
- calcium
- calcium carbonate
- calcium chloride
- calcium dobesilate
- calcium edta
- calcium gluconate
- calcium-l-aspartate
- calcium polystyrene sulphonate
- canagliflozin
- capecitabine
- captopril
- carbimazole
- carboplatin
- carbutamide
- carvedilol
- ceftriaxone
- chlorothiazide
- chlorpropamide
- cholecalciferol
- cholinesterase inhibitors
- ciclosporin
- cinacalcet
- cisplatin
- clodronate
- clomifene
- clomiphene citrate
- clopidogrel
- co-cyprindiol
- codeine
- colonic polyps
- combined oral contraceptive pill
- conivaptan
- cortisone acetate
- continuous subcutaneous hydrocortisone infusion
- continuous subcutaneous insulin infusion
- coumadin
- corticosteroids
- cortisol
- cyproterone acetate
- dacarbazine
- danazol
- dapagliflozin
- daunorubicin
- deferiprone
- demeclocycline
- denosumab
- desmopressin
- dexamethasone
- diazepam
- diethylstilbestrol
- digoxin
- diltiazem
- diphenhydramine
- diuretics
- docetaxel
- dopamine agonists
- dopamine antagonists
- dopamine receptor agonists
- doxazosin
- doxepin
- doxorubicin
- dpp4 inhibitors
- dutasteride
- dutogliptin
- eflornithine
- enoxaparin
- empagliflozin
- epinephrine
- epirubicin
- eplerenone
- epristeride
- equilenin
- equilin
- erlotinib
- ethinylestradiol
- etidronate
- etomidate
- etoposide
- everolimus
- exenatide
- fenofibrate
- finasteride
- fluconazole
- fluticasone
- fludrocortisone
- fluorouracil
- fluoxetine
- flutamide
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- gaba receptor antagonists
- gefitinib
- gemcitabine
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- ginkgo biloba
- glibenclamide
- glibornuride
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- glimepiride
- glipizide
- gliquidone
- glisoxepide
- glp1 agonists
- glucose
- glyclopyramide
- gnrh analogue
- gnrh antagonists
- heparin
- hrt (menopause)
- hydrochlorothiazide
- hydrocortisone
- ibandronate
- ibuprofen
- idarubicin
- idebenone
- imatinib
- immunoglobulin therapy
- implanon
- indapamide
- infliximab
- iron supplements
- isoniazid
- insulin aspart
- insulin glargine
- insulin glulisine
- insulin lispro
- interferon
- intrauterine system
- iopanoic acid
- ipilimumab
- ipragliflozin
- irbesartan
- izonsteride
- ketoconazole
- labetalol
- lactulose
- lanreotide
- leuprolide acetate
- levatinib
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- levothyroxine
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- liothyronine
- liraglutide
- lithium
- lisinopril
- lixivaptan
- loperamide
- loprazolam
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- losartan
- low calcium formula
- magnesium glycerophosphate
- magnesium sulphate
- mecasermin
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- medroxyprogesterone acetate
- meglitinides
- menotropin
- metformin
- methadone
- methimazole
- methylprednisolone
- metoprolol
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- miglitol
- mitotane
- mitoxantrone
- mozavaptan
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- multivitamins
- naproxen
- natalizumab
- nateglinide
- nelivaptan
- neridronate
- nifedipine
- nilutamide
- nitrazepam
- nivolumab
- nsaid
- octreotide
- oestradiol valerate
- olanzapine
- olpadronate
- omeprazole
- opioids
- oral contraceptives
- orlistat
- ornipressin
- otelixizumab
- oxandrolone
- oxidronate
- oxybutynin
- paclitaxel
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- pancreatic enzymes
- pantoprazole
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- paroxetine
- pasireotide
- pegvisomant
- perindopril
- phenobarbital
- phenoxybenzamine
- phosphate binders
- phosphate supplements
- phytohaemagglutinin induced interferon gamma
- pioglitazone
- plicamycin
- potassium chloride
- potassium iodide
- pramlintide
- prazosin
- prednisolone
- prednisone
- premarin
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- protease inhibitors
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- pyridostigmine
- quetiapine
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- romidepsin
- rosiglitazone
- salbutamol
- saline
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- salt supplements
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- saxagliptin
- selective progesterone receptor modulators
- selenium
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- somatostatin analogues
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- streptozotocin
- steroids
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- terazosin
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- testosterone enanthate esters
- tetrabenazine
- thalidomide
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- tibolone
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- tolazamide
- tolbutamide
- tolvaptan
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- trastuzumab
- trazodone
- triamcinolone
- triamterene
- trimipramine
- troglitazone
- tryptophan
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- valproic acid
- valrubicin
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- vaptans
- vildagliptin
- vinorelbine
- voglibose
- vorinostat
- warfarin
- zaleplon
- z-drugs
- zoledronic acid
- zolpidem
- zopiclone
- cardiology
- dermatology
- gastroenterology
- general practice
- genetics
- geriatrics
- gynaecology
- nephrology
- neurology
- nursing
- obstetrics
- oncology
- otolaryngology
- paediatrics
- pathology
- podiatry
- psychology/psychiatry
- radiology/rheumatology
- rehabilitation
- surgery
- urology
- insight into disease pathogenesis or mechanism of therapy
- novel diagnostic procedure
- novel treatment
- unique/unexpected symptoms or presentations of a disease
- new disease or syndrome: presentations/diagnosis/management
- unusual effects of medical treatment
- error in diagnosis/pitfalls and caveats
- february
- 2022
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Affiliation(s)
- Aria Jazdarehee
- Department of Medicine and Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Sawyer Huget-Penner
- Division of Endocrinology and Metabolism, Fraser Health Authority, British Columbia, Canada
| | - Monika Pawlowska
- Division of Endocrinology and Metabolism, University of British Columbia, British Columbia, Canada
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Nakajima H, Niida Y, Hamada E, Hirohito K, Ota M, Okada S, Mohri T, Kurematsu Y, Hontsu S, Muro S, Takahashi Y. Adrenal insufficiency in immunochemotherapy for small-cell lung cancer with ectopic ACTH syndrome. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM200218. [PMID: 34582361 PMCID: PMC8495718 DOI: 10.1530/edm-20-0218] [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: 08/11/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022] Open
Abstract
SUMMARY Ectopic ACTH (adrenocorticotrophic hormone) syndrome (EAS) is rarely associated with small-cell lung cancer (SCLC). Although chemotherapy is initially effective for SCLC, complicated EAS scarcely improves. Recently, immune checkpoint inhibitors have been used to treat SCLC. Atezolizumab plus chemotherapy for SCLC improved progression-free survival compared to conventional chemotherapy. However, little has been reported on the efficacy of the combination therapy for SCLC with EAS. We report a 72-year-old male who presented with 4-week history of leg oedema, proximal myopathy, weight loss, and worsened symptoms of diabetes and hypertension. Laboratory findings revealed hypokalaemia, increased plasma ACTH, and serum cortisol levels. Cortisol levels were not suppressed by the high-dose dexamethasone test. Chest and abdominal CT revealed a right lower lobe tumour with multiple metastases on the hilar lymph nodes, liver, lumbar spine, and bilateral enlarged adrenal glands. The patient was diagnosed with stage 4B SCLC with EAS. Hypercortisolaemia was then treated with metyrapone and atezolizumab plus chemotherapy, which was started for SCLC. After 10 days, the tumour shrank noticeably, and the ACTH level drastically decreased concomitantly with low cortisol levels with symptoms of fever, appetite loss, and general fatigue. Hydrocortisone treatment was initiated, and the symptoms resolved immediately. We describe a case of SCLC with EAS treated with atezolizumab plus chemotherapy, presenting with adrenal insufficiency. Close observation is required for patients with adrenal insufficiency receiving atezolizumab plus chemotherapy because of its stronger effect. Furthermore, advances in cancer therapy and care for endocrine paraneoplastic syndrome needs to be adapted. LEARNING POINTS The immune checkpoint inhibitor atezolizumab has recently been approved for the treatment of small-cell lung cancer (SCLC). Approximately 1-6% of tumour ectopically produce ACTH and cause ectopic ACTH syndrome (EAS) as an endocrine paraneoplastic syndrome. The use of combined chemotherapy and atezolizumab in the ectopic ACTH syndrome secondary to small-cell lung cancer may cause a precipitous fall in circulating ACTH/cortisol, resulting in symptomatic adrenal insufficiency The advances in cancer therapy and treatment for endocrine paraneoplastic syndrome need to be adapted.
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Affiliation(s)
- Hiroki Nakajima
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
| | - Yasuhiro Niida
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
| | - Eriko Hamada
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Japan
| | - Kuwata Hirohito
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
| | - Masahide Ota
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Japan
| | - Sadanori Okada
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
| | - Takako Mohri
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
| | - Yukako Kurematsu
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
| | - Shigeto Hontsu
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Japan
| | - Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
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20
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Nishi N, Takeshima K, Morita S, Iwakura H, Nishi M, Matsuoka T. Deterioration of pituitary function without relapse after steroid therapy for IgG4-related hypophysitis. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210029. [PMID: 34236042 PMCID: PMC8284956 DOI: 10.1530/edm-21-0029] [Citation(s) in RCA: 2] [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: 05/31/2021] [Accepted: 06/07/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY IgG4-related hypophysitis is an autoimmune hypophysitis associated with IgG4-related disease. Swelling of the pituitary gland is responsive to steroid therapy, but the prognosis of pituitary function after the treatment remains unclear. The present case implies that transiently improved pituitary function can re-worsen during long-term follow-up in IgG4-related hypophysitis. A 71-year-old male patient with IgG4-related hypophysitis visited a nearby hospital with malaise, anorexia, and polyuria. Pituitary dysfunction was suspected, so he was referred to our hospital for further examination. Imaging studies and laboratory data showed swelling of the pituitary gland and panhypopituitarism, which dramatically improved following steroid therapy. There was no evidence of relapsing IgG4-related disease during prednisolone tapering. Pituitary function was examined after 4 years under treatment with low-dose prednisolone; surprisingly, anterior pituitary function had worsened again. Our case suggests a need for continuous monitoring of pituitary function after steroid therapy for IgG4-related hypophysitis. This report illustrates the natural course of pituitary function in IgG4-related hypophysitis and may be informative when considering the introduction of steroid therapy. LEARNING POINTS Steroid therapy is an effective first-line therapy for pituitary dysfunction and pituitary swelling in IgG4-related hypophysitis. Pituitary function can worsen again during follow-up, despite transient improvement after steroid therapy in IgG4-related hypophysitis. Continuous monitoring of pituitary function is necessary for IgG4-related hypophysitis, regardless of disease activity.
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Affiliation(s)
- Nobuyuki Nishi
- First Department of Internal Medicine, Wakayama Medical University, Kimiidera, Wakayama City, Wakayama, Japan
| | - Ken Takeshima
- First Department of Internal Medicine, Wakayama Medical University, Kimiidera, Wakayama City, Wakayama, Japan
| | - Shuhei Morita
- First Department of Internal Medicine, Wakayama Medical University, Kimiidera, Wakayama City, Wakayama, Japan
| | - Hiroshi Iwakura
- First Department of Internal Medicine, Wakayama Medical University, Kimiidera, Wakayama City, Wakayama, Japan
| | - Masahiro Nishi
- First Department of Internal Medicine, Wakayama Medical University, Kimiidera, Wakayama City, Wakayama, Japan
- Division of Clinical Nutrition and Metabolism, Wakayama Medical University, Kimiidera, Wakayama City, Wakayama, Japan
| | - Takaaki Matsuoka
- First Department of Internal Medicine, Wakayama Medical University, Kimiidera, Wakayama City, Wakayama, Japan
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Ito K, Ito J, Yamamoto Y, Nakajima R, Fujii M, Katakura Y, Muramatsu A, Takayashiki N, Toyama K, Kurokawa M, Yagyu H. Serial assessments of anterior pituitary hormones in a case of mixed histiocytosis representing Langerhans cell histiocytosis overlapping with Erdheim-Chester disease. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210030. [PMID: 33982663 PMCID: PMC8185526 DOI: 10.1530/edm-21-0030] [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: 04/08/2021] [Accepted: 04/26/2021] [Indexed: 12/04/2022] Open
Abstract
SUMMARY A 61-year-old man developed central diabetes insipidus caused by mixed histiocytosis (MH) representing Langerhans cell histiocytosis overlapping with Erdheim-Chester disease. Bone, skin, vascular, and retroperitoneal involvements were also observed. Dynamic hormonal testing showed normal responses for anterior pituitary hormones, except for impaired secretion of growth hormone (GH). MRI of the brain showed thickening of the pituitary stalk with slightly reduced signal hyperintensity in the posterior pituitary lobe on T1-weighted imaging. During 2 years of follow-up without radical treatment for MH, imaging studies suggested extension of vascular and retroperitoneal involvements. In contrast, brain MRI did not show any particular interval changes, except for the disappearance of hyperintense signalling in the posterior pituitary lobe. Moreover, no other anterior pituitary dysfunctions beyond GH deficiency emerged during the 2 years of follow-up. The natural history of MH in this case is described, focusing on serial assessments of pituitary functions using dynamic tests. LEARNING POINTS Erdheim-Chester disease and Langerhans cell histiocytosis overlapping as MH was described, focusing on pituitary functions. MH caused both GH deficiency and central diabetes insipidus. Despite a lack of radical therapy for MH, no other anterior pituitary dysfunctions emerged for 2 years. Radiological images showed no particular interval changes in pituitary stalk lesions, while vascular and retroperitoneal involvements extended.
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Affiliation(s)
- Kei Ito
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito-shi, Ibaraki, Japan
| | - Jun Ito
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito-shi, Ibaraki, Japan
| | - Yuki Yamamoto
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito-shi, Ibaraki, Japan
| | - Rikako Nakajima
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito-shi, Ibaraki, Japan
| | - Masanao Fujii
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito-shi, Ibaraki, Japan
| | - Yukino Katakura
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito-shi, Ibaraki, Japan
| | - Aiko Muramatsu
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito-shi, Ibaraki, Japan
| | - Norio Takayashiki
- Department of Pathology, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito-shi, Ibaraki, Japan
| | - Kazuhiro Toyama
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hiroaki Yagyu
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito-shi, Ibaraki, Japan
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Tao K, Awazu M, Honda M, Shibata H, Mori T, Uchida S, Hasegawa T, Ishii T. An infant with congenital nephrogenic diabetes insipidus presenting with hypercalcemia and hyperphosphatemia. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM200189. [PMID: 33899745 PMCID: PMC8115416 DOI: 10.1530/edm-20-0189] [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: 11/13/2020] [Accepted: 03/23/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY We report a male infant with congenital nephrogenic diabetes insipidus (NDI) who presented with hypercalcemia and hyperphosphatemia since birth. Serum sodium started to increase at 39 days. Although there was no polyuria, urine osmolality was 71 mOsm/kg, when serum osmolality was 296 mOsm/kg with plasma arginine vasopressin 22.5 pg/mL. He was thus diagnosed as NDI. An undetectable level of urine calcium and unsuppressed intact parathyroid hormone suggested hyperparathyroidism including calcium-sensing receptor mutations that could cause hypercalcemia-induced NDI. Polyuria became apparent after the initiation of i.v. infusion for the treatment of hypernatremia. Low calcium and low sodium formula with hypotonic fluid infusion did not correct hypernatremia, hypercalcemia, or hyperphosphatemia. Hydrochlorothiazide and subsequently added celecoxib effectively decreased urine output and corrected electrolytes abnormalities. Normal serum electrolytes were maintained after the discontinuation of low calcium formula. The genetic analysis revealed a large deletion of the arginine vasopressin receptor-2 (AVPR2) gene but no pathogenic variant in the calcium-sensing receptor (CASR) gene. Whether hypercalcemia and hyperphosphatemia were caused by dehydration alone or in combination with other mechanisms remains to be clarified. LEARNING POINTS Congenital NDI can present with neonatal hypercalcemia and hyperphosphatemia. Hypercalcemia and hyperphosphatemia can be treated with low calcium and low sodium formula, hydration, hydrochlorothiazide, and celecoxib. Genetic testing is sometimes necessary in the differentiating diagnosis of hypercalcemia associated with NDI.
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Affiliation(s)
- Katsuo Tao
- Department of Pediatrics, Fukui Aiiku Hospital, Fukui, Japan
| | - Midori Awazu
- Department of Pediatrics, Keio University School of Medicine, shinjyuku, Tokyo, Japan
| | - Misa Honda
- Department of Pediatrics, Keio University School of Medicine, shinjyuku, Tokyo, Japan
| | - Hironori Shibata
- Department of Pediatrics, Keio University School of Medicine, shinjyuku, Tokyo, Japan
| | - Takayasu Mori
- Department of Nephrology, Tokyo Medical and Dental University, Fukui, Japan
| | - Shinichi Uchida
- Department of Nephrology, Tokyo Medical and Dental University, Fukui, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, shinjyuku, Tokyo, Japan
| | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, shinjyuku, Tokyo, Japan
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Taguchi T, Kimizuka S, Takano K. Improved AcroQoL scores in acromegaly after sagittal split ramus osteotomy with Le Fort I osteotomy. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210001. [PMID: 33960325 PMCID: PMC8185529 DOI: 10.1530/edm-21-0001] [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: 03/06/2021] [Accepted: 04/12/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Acromegaly is associated with a low quality of life (QoL), which is partially attributable to appearance. However, appearance changes are only partially reversible with treatments of growth hormone excess. This case study describes a 41-year-old Japanese man who presented with mandibular prognathism. Acromegaly was suspected because of the patient's facial features. Subsequent examination revealed a pituitary tumour with elevated levels of growth hormone and insulin-like growth factor 1 (IGF1), confirming a diagnosis of acromegaly. We assessed his QoL with the acromegaly QoL questionnaire (AcroQoL) before transsphenoidal surgery, and all AcroQoL scores were low. Although the pituitary adenoma was resected, his serum IGF1 levels started to increase again and MRI identified a residual pituitary lesion. After lanreotide and pegvisomant injection therapies improved his serum IGF1 levels, we reassessed his AcroQoL scores, however, the results showed worsening scores regarding appearance and personal relationships, and the patient expressed interest in surgery for mandibular prognathism. We performed sagittal split ramus osteotomy (SSRO) with Le Fort I osteotomy, thus, the patient's AcroQoL scores improved. This case shows that SSRO with Le Fort I osteotomy for mandibular prognathism, rather than control of serum IGF1 level alone, improved the patient's AcroQoL score, especially for both psychological well-being and approval of appearance. Acromegaly has many complications, including its negative impact on patients' perception of their appearance and patients' QoL can be improved using multiple options, in addition to controlling growth hormone levels. LEARNING POINTS The patient's AcroQoL scores worsened despite biochemical normalization of IGF-1 levels. Mandibular prognathism due to acromegaly can be successfully operated by performing sagittal split ramus osteotomy with Le Fort I osteotomy. Frequent monitoring of AcroQoL scores and appropriate response to negative results can improve the overall QoL.
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Affiliation(s)
- Tomomi Taguchi
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine
| | - Sachiko Kimizuka
- Department of Plastic and Aesthetic Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Koji Takano
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine
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Wakabayashi T, Takei A, Okada N, Shinohara M, Takahashi M, Nagashima S, Okada K, Ebihara K, Ishibashi S. A novel SOX10 nonsense mutation in a patient with Kallmann syndrome and Waardenburg syndrome. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM200145. [PMID: 33913437 PMCID: PMC8115407 DOI: 10.1530/edm-20-0145] [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: 03/24/2021] [Accepted: 04/02/2021] [Indexed: 11/23/2022] Open
Abstract
SUMMARY The underlying genetic drivers of Kallmann syndrome, a rare genetic disorder characterized by anosmia and hypogonadotropic hypogonadism due to impairment in the development of olfactory axons and in the migration of gonadotropin-releasing hormone (GNRH)-producing neurons during embryonic development, remain largely unknown. SOX10, a key transcription factor involved in the development of neural crest cells and established as one of the causative genes of Waardenburg syndrome, has been shown to be a causative gene of Kallmann syndrome. A 17-year-old male patient, who was diagnosed with Waardenburg syndrome on the basis of a hearing impairment and hypopigmented iris at childhood, was referred to our department because of anosmia and delayed puberty. As clinical examination revealed an aplastic olfactory bulb and hypogonadotropic hypogonadism, we diagnosed him as having Kallmann syndrome. Incidentally, we elucidated that he also presented with subclinical hypothyroidism without evidence of autoimmune thyroiditis. Direct sequence analysis detected a nonsense SOX10 mutation (c.373C>T, p.Glu125X) in this patient. Since this nonsense mutation has never been published as a germline variant, the SOX10 substitution is a novel mutation that results in Kallmann syndrome and Waardenburg syndrome. This case substantiates the significance of SOX10 as a genetic cause of Kallmann syndrome and Waardenburg syndrome, which possibly share a common pathway in the development of neural crest cells. LEARNING POINTS Kallmann syndrome and Waardenburg syndrome possibly share a common pathway during neural crest cell development. SOX10, a key transcription factor involved in the development of neural crest cells, is a common causative gene of Kallmann syndrome and Waardenburg syndrome. Careful evaluation about various phenotypic features may reveal the unknown genetic drivers of Kallmann syndrome.
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Affiliation(s)
- Tetsuji Wakabayashi
- Division of Endocrinology and MetabolismDepartment of Internal Medicine, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Akihito Takei
- Division of Endocrinology and MetabolismDepartment of Internal Medicine, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Nobukazu Okada
- Division of Endocrinology and MetabolismDepartment of Internal Medicine, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Miki Shinohara
- Division of Endocrinology and MetabolismDepartment of Internal Medicine, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Manabu Takahashi
- Division of Endocrinology and MetabolismDepartment of Internal Medicine, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shuichi Nagashima
- Division of Endocrinology and MetabolismDepartment of Internal Medicine, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Kenta Okada
- Division of Endocrinology and MetabolismDepartment of Internal Medicine, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Ken Ebihara
- Division of Endocrinology and MetabolismDepartment of Internal Medicine, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shun Ishibashi
- Division of Endocrinology and MetabolismDepartment of Internal Medicine, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Tatsushima K, Takeshita A, Fukata S, Fukuhara N, Yamaguchi-Okada M, Nishioka H, Takeuchi Y. Challenges in the functional diagnosis of thyroid nodules before surgery for TSH-producing pituitary adenoma. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM200221. [PMID: 33929339 PMCID: PMC8115409 DOI: 10.1530/edm-20-0221] [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: 02/21/2021] [Accepted: 04/06/2021] [Indexed: 11/24/2022] Open
Abstract
SUMMARY A 50-year-old woman with thyroid-stimulating hormone (TSH)-producing pituitary adenoma (TSHoma) was diagnosed due to symptoms of thyrotoxicosis. Preoperatively, she showed thyrotoxicosis with the syndrome of inappropriate secretion of TSH (SITSH) and had a 5 cm nodule in her thyroid gland. Octreotide was administered preoperatively, which helped lower her serum TSH level but not her thyroid hormone level. These findings were atypical for a patient with TSHoma. The TSHoma was completely resected, and the TSH level dropped below the sensitivity limit shortly after surgery. Interestingly, however, thyroid hormone levels remained high. A clear clue to the aetiology was provided by consecutive thyroid scintigraphy. Although preoperative thyroid scintigraphy did not show a hot nodule and the mass was thought to be a non-functional thyroid nodule, the nodule was found to be hot in the postoperative phase of TSH suppression. By focusing on the atypical postoperative course of the TSHoma, we were able to conclude that this was a case of TSHoma combined with an autonomously functioning thyroid nodule (AFTN). LEARNING POINTS The diagnosis of autonomously functioning thyroid nodules (AFTNs) depends on suppressed serum TSH levels. If thyroid hormones are resistant to somatostatin analogue therapy or surgery for TSHoma, complications of AFTN as well as destructive thyroiditis need to be considered. It is important to revisit the basics when facing diagnostic difficulties and not to give up on understanding the pathology.
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Shimazaki S, Kazukawa I, Mori K, Kihara M, Minagawa M. Acute kidney injury caused by ammonium acid urate crystals in diabetic ketoacidosis at the onset of type 1 diabetes mellitus. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM200143. [PMID: 33865236 PMCID: PMC7923033 DOI: 10.1530/edm-20-0143] [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: 01/22/2021] [Accepted: 02/02/2021] [Indexed: 11/30/2022] Open
Abstract
SUMMARY Ammonium acid urate (AAU) crystals are rare in industrialized countries. Furthermore, the number of children with diabetic ketoacidosis (DKA) who develop severe acute kidney injury (AKI) after hospitalization is small. We encountered two patients with AKI caused by AAU crystals during the recovery phase of DKA upon admission. They were diagnosed with severe DKA and hyperuricemia. Their urine volume decreased and AKI developed several days after hospitalization; however, acidosis improved in both patients. Urine sediment analysis revealed AAU crystals. They were treated with urine alkalization and diuretics. Excretion of ammonia in the urine and urine pH levels increased after treatment of DKA, which resulted in the formation of AAU crystals. In patients with severe DKA, the urine and urine sediment should be carefully examined as AAU can form in the recovery phase of DKA. LEARNING POINTS Ammonium acid urate crystals could be formed in the recovery phase of diabetic ketoacidosis. Diabetic ketoacidosis patients may develop acute kidney injury caused by ammonium acid urate crystals. Urine and urine sediment should be carefully checked in patients with severe DKA who present with hyperuricemia and volume depletion.
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Affiliation(s)
| | - Itsuro Kazukawa
- Department of Endocrinology, Chiba Children’s Hospital, Chiba, Japan
| | - Kyoko Mori
- Department of Endocrinology, Chiba Children’s Hospital, Chiba, Japan
| | - Makiko Kihara
- Department of Endocrinology, Chiba Children’s Hospital, Chiba, Japan
| | - Masanori Minagawa
- Department of Endocrinology, Chiba Children’s Hospital, Chiba, Japan
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Kometani M, Yoneda T, Maeda Y, Oe M, Takeda Y, Higashitani T, Aono D, Yoshino A, Karashima S, Takeda Y. Pheochromocytoma crisis with cyclic fluctuation in blood pressure mimics acute coronary syndrome. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200115. [PMID: 33434177 PMCID: PMC7577022 DOI: 10.1530/edm-20-0115] [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: 07/14/2020] [Accepted: 09/03/2020] [Indexed: 11/18/2022] Open
Abstract
SUMMARY Pheochromocytoma crisis results from the sudden release of large quantities of catecholamines and leads to progressive multiple organ dysfunction. Here we report a case of pheochromocytoma crisis with symptoms associated with acute coronary syndrome (ACS) and severe fluctuations in blood pressure (BP). A 43-year-old Japanese man with hypertension (240/120 mmHg) visited a general hospital for chest pain. Echocardiogram showed ST segment depression and blood test demonstrated elevated troponin T. However, emergent coronary angiography revealed normal findings. CT showed a large adrenal mass on the left side, which was suspected as the cause of chest pain and BP elevation. After the patient was transported to our hospital, his BP was found to oscillate between 70 and 240 mmHg, and level of consciousness was decreased. After hospitalization, he had a further decrease in consciousness, a rise in body temperature, and a gradual increase in the interval between the upper and lower systolic BP. His systolic BP varied between 30 mmHg and 300 mmHg at the intervals of 20-30 min. After a multimodality therapy, including α-blocker and high dose fluid replacement, the fluctuation in his BP was gradually decreased and got stabilized after approximately 24 h. Approximately 3 weeks later, he underwent left adrenalectomy. This case showed that pheochromocytoma with internal necrosis might be misdiagnosed as ACS. Furthermore, in cases with a large adrenal tumor and severe elevation or fluctuations of BP, pheochromocytoma should be suspected and treated with α-blockers and fluid replacements as soon as possible prior to surgery. LEARNING POINTS High catecholamine levels due to pheochromocytoma crisis might cause symptoms associated with acute coronary syndrome. Adrenal tumor with internal necrosis and the elevation or fluctuations of blood pressure should be suspected to be pheochromocytoma. If pheochromocytoma crisis is suspected, the specialist, such as an endocrinologist or a urologist, should intervene, and an α-blocker treatment with adequate fluid replacement therapy should be initiated as soon as possible. Pheochromocytoma multisystem crisis (PMC) is a fatal condition characterized by multiple organ failure, severe blood pressure variability, high fever, and encephalopathy. This is an extremely rare subtype of a very rare disease such as pheochromocytoma. However, because the fatality rate of PMC is high, clinicians should be aware of the symptoms that mark its onset.
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Affiliation(s)
- Mitsuhiro Kometani
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Takashi Yoneda
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
| | - Yuji Maeda
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
- Department of Urology, Public Central Hospital of Matto Ishikawa, Hakusan, Japan
| | - Masashi Oe
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Yoshimichi Takeda
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Takuya Higashitani
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Daisuke Aono
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Asuka Yoshino
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Shigehiro Karashima
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Yoshiyu Takeda
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
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Baba S, Miyoshi A, Obara S, Usubuchi H, Terae S, Sunahara M, Oshima T, Misawa K, Tsuji T, Takahashi B, Yamazaki Y, Sasano H, Wada N. A case of Williams syndrome with suspected coexisting ectopic aldosterone-producing tumor in the liver. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200057. [PMID: 33434178 PMCID: PMC7576637 DOI: 10.1530/edm-20-0057] [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: 06/17/2020] [Revised: 06/17/2020] [Accepted: 08/25/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY A 31-year-old man with Williams syndrome (WS) was referred to our hospital because of a 9-year history of hypertension, hypokalemia, and high plasma aldosterone concentration to renin activity ratio. A diagnosis of primary aldosteronism (PA) was clinically confirmed but an abdominal CT scan showed no abnormal findings in his adrenal glands. However, a 13-mm hypervascular tumor in the posterosuperior segment of the right hepatic lobe was detected. Adrenal venous sampling (AVS) subsequently revealed the presence of an extended tributary of the right adrenal vein to the liver surrounding the tumor. Segmental AVS further demonstrated a high plasma aldosterone concentration (PAC) in the right superior tributary vein draining the tumor. Laparoscopic partial hepatectomy was performed. The resected tumor histologically separated from the liver was composed of clear cells, immunohistochemically positive for aldesterone synthase (CYP11B2), and subsequently diagnosed as aldosterone-producing adrenal adenoma. After surgery, his blood pressure, serum potassium level, plasma renin activity and PAC were normalized. To the best of our knowledge, this is the first report of WS associated with PA. WS harbors a high prevalence of hypertension and therefore PA should be considered when managing the patients with WS and hypertension. In this case, the CT findings alone could not differentiate the adrenal rest tumor. Our case, therefore, highlights the usefulness of segmental AVS to distinguish adrenal tumors from hepatic adrenal rest tumors. LEARNING POINTS Williams syndrome (WS) is a rare genetic disorder, characterized by a constellation of medical and cognitive findings, with a hallmark feature of generalized arteriopathy presenting as stenoses of elastic arteries and hypertension. WS is a disease with a high frequency of hypertension but the renin-aldosterone system in WS cases has not been studied at all. If a patient with WS had hypertension and severe hypokalemia, low PRA and high ARR, the coexistence of primary aldosteronism (PA) should be considered. Adrenal rest tumors are thought to arise from aberrant adrenal tissues and are a rare cause of PA. Hepatic adrenal rest tumor (HART) should be considered in the differential diagnosis when detecting a mass in the right hepatic lobe. Segmental adrenal venous sampling could contribute to distinguish adrenal tumors from HART.
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Affiliation(s)
- Shuhei Baba
- Departments of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Arina Miyoshi
- Departments of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Shinji Obara
- Departments of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | | | - Satoshi Terae
- Radiology, Sapporo City General Hospital, Sapporo, Japan
| | | | | | | | - Takahiro Tsuji
- Pathology, Sapporo City General Hospital, Sapporo, Japan
| | - Bunya Takahashi
- Department of Diagnostic Imaging, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Norio Wada
- Departments of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
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Fujita Y, Tanaka D, Tatsuoka H, Matsubara M, Hyo T, Hamamoto Y, Komiya T, Inagaki N, Seino Y, Yamazaki Y. A novel splice-site mutation of the HNF1B gene in a family with maturity onset diabetes of the young type 5 (MODY5). Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200092. [PMID: 33434175 PMCID: PMC7576636 DOI: 10.1530/edm-20-0092] [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: 07/25/2020] [Revised: 07/25/2020] [Accepted: 08/25/2020] [Indexed: 12/31/2022] Open
Abstract
SUMMARY Maturity-onset diabetes of the young (MODY) is a form of monogenic diabetes mellitus characterised by early onset and dominant inheritance. Delayed diagnosis or misdiagnosis as type 1 or type 2 diabetes mellitus is common. Definitive genetic diagnosis is essential for appropriate treatment of patients with MODY. The hepatocyte nuclear factor 1-beta (HNF1B) gene is responsible for MODY type 5 (MODY5), which has distinctive clinical features including renal disease. MODY5 should always be considered by clinicians in patients with early onset diabetes and renal anomalies. We report a case of a 30-year-old Japanese male with early-onset diabetes mellitus, renal anomalies and family history of diabetes that was suggestive of MODY5. Renal histology showed no evidence of diabetic nephropathy. Genetic testing revealed a novel heterozygous splice-site mutation of the HNF1B gene in the family members. It was strongly suggested that the mutation could underlie our patient's MODY5. LEARNING POINTS Genetic diagnosis of MODY is relevant for appropriate treatment. Dominantly inherited early-onset diabetes mellitus with renal cysts suggests MODY5. Scanning the non-coding regions is important for not missing a mutation in HNF1B.
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Affiliation(s)
- Yuki Fujita
- Center for Diabetes, Endocrinology & Metabolism, Kansai Electric Power Hospital, Osaka, Japan
- Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
| | - Daisuke Tanaka
- Department of Diabetes, Endocrinology and Clinical Nutrition, Graduate School ofMedicine, Kyoto University, Kyoto, Japan
| | - Hisato Tatsuoka
- Department of Diabetes, Endocrinology and Clinical Nutrition, Graduate School ofMedicine, Kyoto University, Kyoto, Japan
| | - Miho Matsubara
- Center for Diabetes, Endocrinology & Metabolism, Kansai Electric Power Hospital, Osaka, Japan
- Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
| | - Takanori Hyo
- Center for Diabetes, Endocrinology & Metabolism, Kansai Electric Power Hospital, Osaka, Japan
| | - Yoshiyuki Hamamoto
- Center for Diabetes, Endocrinology & Metabolism, Kansai Electric Power Hospital, Osaka, Japan
- Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
| | - Toshiyuki Komiya
- Center for Nephrology, Kansai Electric Power Hospital, Osaka, Japan
- Division of Renal Disease and Blood Purification, Kansai Electric Power Medical Research Institute, Kobe, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Clinical Nutrition, Graduate School ofMedicine, Kyoto University, Kyoto, Japan
| | - Yutaka Seino
- Center for Diabetes, Endocrinology & Metabolism, Kansai Electric Power Hospital, Osaka, Japan
- Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
| | - Yuji Yamazaki
- Center for Diabetes, Endocrinology & Metabolism, Kansai Electric Power Hospital, Osaka, Japan
- Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
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Nakao T, Takeshima K, Ariyasu H, Kurimoto C, Uraki S, Morita S, Furukawa Y, Iwakura H, Akamizu T. Thyroid storm with delayed hyperbilirubinemia and severe heart failure: indication and contraindication of plasma exchange. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200036. [PMID: 33434181 PMCID: PMC7487178 DOI: 10.1530/edm-20-0036] [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: 06/27/2020] [Accepted: 08/11/2020] [Indexed: 11/22/2022] Open
Abstract
SUMMARY Thyroid storm (TS) is a life-threatening condition that may suffer thyrotoxic patients. Therapeutic plasma exchange (TPE) is a rescue approach for TS with acute hepatic failure, but it should be initiated with careful considerations. We present a 55-year-old male patient with untreated Graves' disease who developed TS. Severe hyperthyroidism and refractory atrial fibrillation with congestive heart failure aggregated to multiple organ failure. The patient was recovered by intensive multimodal therapy, but we had difficulty in introducing TPE treatment considering the risk of exacerbation of congestive heart failure due to plasma volume overload. In addition, serum total bilirubin level was not elevated in the early phase to the level of indication for TPE. The clinical course of this patient instructed delayed elevation of bilirubin until the level of indication for TPE in some patients and also demonstrated the risk of exacerbation of congestive heart failure by TPE. LEARNING POINTS Our patient with thyroid storm could be diagnosed and treated promptly using Japan Thyroid Association guidelines for thyroid storm. Delayed elevation of serum bilirubin levels could make the decision of introducing therapeutic plasma exchange difficult in cases of thyroid storm with acute hepatic failure. The risk of worsening congestive heart failure should be considered carefully when performing therapeutic plasma exchange.
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Affiliation(s)
- Tomomi Nakao
- First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Ken Takeshima
- First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Hiroyuki Ariyasu
- First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Chiaki Kurimoto
- First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Shinsuke Uraki
- First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Shuhei Morita
- First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Yasushi Furukawa
- First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Hiroshi Iwakura
- First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Takashi Akamizu
- First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan
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Higashitani T, Karashima S, Aono D, Konishi S, Kometani M, Oka R, Demura M, Furukawa K, Yamazaki Y, Sasano H, Yoneda T, Takeda Y. A case of renovascular hypertension with incidental primary bilateral macronodular adrenocortical hyperplasia. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM190163. [PMID: 33434182 PMCID: PMC7424347 DOI: 10.1530/edm-19-0163] [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: 05/16/2020] [Accepted: 06/15/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Renovascular hypertension (RVHT) is an important and potentially treatable form of resistant hypertension. Hypercortisolemia could also cause hypertension and diabetes mellitus. We experienced a case wherein adrenalectomy markedly improved blood pressure and plasma glucose levels in a patient with RVHT and low-level autonomous cortisol secretion. A 62-year-old Japanese man had been treated for hypertension and diabetes mellitus for 10 years. He was hospitalized because of a disturbance in consciousness. His blood pressure (BP) was 236/118 mmHg, pulse rate was 132 beats/min, and plasma glucose level was 712 mg/dL. Abdominal CT scanning revealed the presence of bilateral adrenal masses and left atrophic kidney. Abdominal magnetic resonance angiography demonstrated marked stenosis of the left main renal artery. The patient was subsequently diagnosed with atherosclerotic RVHT with left renal artery stenosis. His left adrenal lobular mass was over 40 mm and it was clinically suspected the potential for cortisol overproduction. Therefore, laparoscopic left nephrectomy and adrenalectomy were simultaneously performed, resulting in improved BP and glucose levels. Pathological studies revealed the presence of multiple cortisol-producing adrenal nodules and aldosterone-producing cell clusters in the adjacent left adrenal cortex. In the present case, the activated renin-angiotensin-aldosterone system and cortisol overproduction resulted in severe hypertension, which was managed with simultaneous unilateral nephrectomy and adrenalectomy. LEARNING POINTS Concomitant activation of the renin-angiotensin-aldosterone system and cortisol overproduction may contribute to the development of severe hypertension and lead to lethal cardiovascular complications. Treatment with simultaneous unilateral nephrectomy and adrenalectomy markedly improves BP and blood glucose levels. CYP11B2 immunohistochemistry staining revealed the existence of aldosterone-producing cell clusters (APCCs) in the adjacent non-nodular adrenal gland, suggesting that APCCs may contribute to aldosterone overproduction in patients with RVHT.
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Affiliation(s)
- Takuya Higashitani
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Shigehiro Karashima
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Daisuke Aono
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Seigoh Konishi
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Internal Medicine, Keiju Medical Center, Nanao, Ishikawa, Japan
| | - Mitsuhiro Kometani
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Rie Oka
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Masashi Demura
- Department of Hygiene, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Kenji Furukawa
- Health Care Center, Japan Advanced Institute of Science and Technology, Nomi, Ishikawa, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Takashi Yoneda
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Yoshiyu Takeda
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
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