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Yu GCF, Tay MK, Chen SPL, Leung MTS, Tung JYL. A Chinese girl with delayed puberty due to 17α-hydroxylase deficiency: the diagnosis, treatment and monitoring approach. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0047. [PMID: 37747283 PMCID: PMC10563631 DOI: 10.1530/edm-23-0047] [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: 04/19/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023] Open
Abstract
Summary 17α-hydroxylase deficiency (17α-OHD) is a rare form of congenital adrenal hyperplasia. We report the case of a teenage girl with 17α-OHD who presented with delayed puberty, hypergonadotropic hypogonadism and hypertension. We illustrate the clinical approach in workup, the subsequent management and monitoring of this rare condition. Learning points 17α-hydroxylase deficiency (17α-OHD) should be considered as a rare yet important differential diagnosis of girls with delayed puberty and elevated gonadotropins. Urine steroid profile, plasma aldosterone and renin levels should be assessed in adolescent girls with hypergonadotropic hypogonadism, after the exclusion of more common conditions, e.g. Turner syndrome. Inhibiting deoxycorticosterone (DOC) release by partial glucocorticoid replacement, counteracting DOC's mineralocorticoid effects by antagonists (such as eplerenone or spironolactone) as well as sex hormone replacements constitute the major backbone in the management of 17α-OHD.
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Affiliation(s)
- Geoffrey Chek Fei Yu
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Hong Kong
| | - Ming-kut Tay
- Department of Paediatrics and Adolescent Medicine, Tseung Kwan O Hospital, Hong Kong
| | - Sammy Pak-lam Chen
- Division of Chemical Pathology, Department of Pathology, Queen Elizabeth Hospital, Hong Kong
| | - Mei Tik Stella Leung
- Division of Chemical Pathology, Department of Pathology, Queen Elizabeth Hospital, Hong Kong
| | - Joanna Yuet-ling Tung
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong
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Alali M, Hajji S, Aljenaee K. Sertoliform endometrioid carcinoma of the right ovary. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0046. [PMID: 37767716 PMCID: PMC10563599 DOI: 10.1530/edm-23-0046] [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: 04/18/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Summary Endometrioid carcinomas of the ovary are a subtype of epithelial ovarian tumors, with sertoliform endometrioid carcinomas being a rare variant. We report a case of a previously healthy premenopausal woman presenting with androgenic symptoms in the form of hirsutism and male pattern alopecia. On further testing, she was found to have high levels of luteinizing hormone and total testosterone levels, and imaging revealed a large pelvic abdominal mass in the right ovary. She underwent total hysterectomy with bilateral salpingo-oophorectomy. Microscopy and histopathology confirmed the diagnosis of sertoliform endometrioid carcinoma. Her symptoms improved significantly on follow-up. Androgenic tumors might not be common in premenopausal women; however, it is important to maintain a high level of suspicion in patients presenting with virilizing symptoms especially of rapid progression. Learning points Our 47-year-old patient presented with virilizing symptoms that were rapidly progressing, which raises the suspicion of an underlying androgen secreting neoplasm. Sertoliform endometrioid carcinoma (SEC) is an extremely rare variant of endometrioid carcinomas and tend to present at an earlier stage as compared to most endometrioid carcinomas of the ovary. Recognition of SEC in virilizing patients is important as it is a well-differentiated, low-grade malignancy with a good prognosis when confined to the ovary.
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Affiliation(s)
- Mohammad Alali
- Kuwait Board of Internal Medicine, Kuwait City, Safat, Kuwait
| | - Sulaiman Hajji
- Department of Internal Medicine, Adan Hospital, Kuwait City, Kuwait
| | - Khalid Aljenaee
- Department of Internal Medicine, Adan Hospital, Kuwait City, Kuwait
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Mäkinen VN, Horskær Madsen S, Ji Riis-Vestergaard M, Bjerre M, Bønløkke Pedersen S, Asa SL, Rolighed L, Lunde Jørgensen JO, Ornstrup MJ. Ectopic Cushing's syndrome from a corticotropin-releasing hormone-secreting medullary thyroid carcinoma: a rare pitfall of inferior petrosal sinus sampling. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0057. [PMID: 37767685 PMCID: PMC10563613 DOI: 10.1530/edm-23-0057] [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: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Summary This case report describes a rare presentation of ectopic Cushing's syndrome (CS) due to ectopic corticotropin-releasing hormone (CRH) production from a medullary thyroid carcinoma (MTC). The patient, a 69-year-old man, presented with symptoms of muscle weakness, facial plethora, and easy bruising. An inferior petrosal sinus sampling test (IPSS) demonstrated pituitary adrenocorticotrophic hormone (ACTH) secretion, but a whole-body somatostatin receptor scintigraphy (68Ga-DOTATOC PET/CT) revealed enhanced uptake in the right thyroid lobe which, in addition to a grossly elevated serum calcitonin level, was indicative of an MTC. A 18F-DOPA PET/CT scan supported the diagnosis, and histology confirmed the presence of MTC with perinodal growth and regional lymph node metastasis. On immunohistochemical analysis, the tumor cell stained positively for calcitonin and CRH but negatively for ACTH. Distinctly elevated plasma CRH levels were documented. The patient therefore underwent thyroidectomy and bilateral adrenalectomy. This case shows that CS caused by ectopic CRH secretion may masquerade as CS due to a false positive IPSS test. It also highlights the importance of considering rare causes of CS when diagnostic test results are ambiguous. Learning points Medullary thyroid carcinoma may secrete CRH and cause ectopic CS. Ectopic CRH secretion entails a rare pitfall of inferior petrosal sinus sampling yielding a false positive test. Plasma CRH measurements can be useful in selected cases.
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Affiliation(s)
- Vivi-Nelli Mäkinen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Internal Medicine, Regional Hospital, Horsens, Denmark
| | | | - Mette Ji Riis-Vestergaard
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Internal Medicine, Gødstrup Hospital, Herning,Denmark
| | - Mette Bjerre
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital, Aarhus, Denmark
| | | | - Sylvia L Asa
- Department of Pathology, University Health Network, Toronto,Canada
| | - Lars Rolighed
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Otto Lunde Jørgensen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital, Aarhus, Denmark
| | - Marie Juul Ornstrup
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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Nakajima R, Idesawa H, Sato D, Ito J, Ito K, Fujii M, Suzuki T, Furuta T, Kawai H, Takayashiki N, Kurata M, Yagyu H. Continuous glucose monitoring in a patient with insulinoma presenting with unawareness of postprandial hypoglycemia. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0056. [PMID: 37767703 PMCID: PMC10563612 DOI: 10.1530/edm-23-0056] [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: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Summary Unawareness of postprandial hypoglycemia for 5 years was identified in a 66-year-old man at a local clinic. The patient was referred to our hospital because of this first awareness of hypoglycemia (i.e. lightheadedness and impaired consciousness) developing after lunch. In a 75 g oral glucose tolerance test, the plasma glucose concentration was decreased to 32 mg/dL (1.8 mmol/L) at 150 min with relatively high concentrations of insulin (8.1 μU/mL), proinsulin (70.3 pmol/L), and C-peptide (4.63 ng/mL). In a prolonged fasting test, the plasma glucose concentration was decreased to 43 mg/dL (2.4 mmol/L) at 66 h with an insulin concentration of 1.4 μU/mL and a C-peptide concentration of 0.49 ng/mL. Computed tomography showed an 18 mm hyperenhancing tumor in the uncinate process of the pancreas. A selective arterial calcium stimulation test showed an elevated serum insulin concentration in the superior mesenteric artery. The patient was then diagnosed with insulinoma and received pancreaticoduodenectomy. Continuous glucose monitoring (CGM) using the Dexcom G6 system showed unawareness of hypoglycemia mainly during the daytime before surgery. When the sensor glucose value was reduced to 55 mg/dL (3.1 mmol/L), the Dexcom G6 system emitted an urgent low glucose alarm to the patient four times for 10 days. Two months after surgery, an overall increase in daily blood glucose concentrations and resolution of hypoglycemia were shown by CGM. We report a case of insulinoma with unawareness of postprandial hypoglycemia in the patient. The Dexcom G6 system was helpful for assessing preoperative hypoglycemia and for evaluating outcomes of treatment by surgery. Learning points Insulinoma occasionally leads to postprandial hypoglycemia. The CGM system is useful for revealing the presence of unnoticed hypoglycemia and for evaluating treatment outcomes after surgical resection. The Dexcom G6 system has an urgent low glucose alarm, making it particularly suitable for patients who are unaware of hypoglycemia.
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Affiliation(s)
- Rikako Nakajima
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Hiroto Idesawa
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Daisuke Sato
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Jun Ito
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Kei Ito
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Masanao Fujii
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Takamichi Suzuki
- Department of Gastrointestinal Surgery, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Tomoaki Furuta
- Department of Gastrointestinal Surgery, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Hitomi Kawai
- Department of Pathology, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Norio Takayashiki
- Department of Pathology, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Masanao Kurata
- Department of Gastrointestinal Surgery, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Hiroaki Yagyu
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
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Wu YF, Ng HY, Namboodiri D, Lewis D, Davidson A, Champion B, Preda V. Thyrotropinoma with silent somatotroph and lactotroph adenoma during pregnancy. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0194. [PMID: 36137189 PMCID: PMC9513668 DOI: 10.1530/edm-21-0194] [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: 06/26/2022] [Accepted: 08/18/2022] [Indexed: 11/17/2022] Open
Abstract
Summary Thyrotropinomas are an uncommon cause of hyperthyroidism and are exceedingly rarely identified during pregnancy, with limited evidence to guide management. Most commonly they present as macroadenomas and may cause symptoms of mass effect including headache, visual field defects and hypopituitarism. We present a case of a 35-year-old woman investigated for headaches in whom a 13 mm thyrotropinoma was found. In the lead-up to planned trans-sphenoidal surgery (TSS), she spontaneously conceived and surgery was deferred, as was pharmacotherapy, at her request. The patient was closely monitored through her pregnancy by a multi-disciplinary team and delivered without complication. Pituitary surgery was performed 6 months post-partum. Isolated secondary hypothyroidism was diagnosed postoperatively and replacement thyroxine was commenced. Histopathology showed a double lesion with predominant pituitary transcription factor-1 positive, steroidogenic factor negative plurihormonal adenoma and co-existent mixed thyroid-stimulating hormone, growth hormone, lactotroph and follicle-stimulating hormone staining with a Ki-67 of 1%. This case demonstrates a conservative approach to thyrotropinoma in pregnancy with a successful outcome. This highlights the need to consider the timing of intervention with careful consideration of risks to mother and fetus. Learning points Thyrotropinomas are a rare cause of secondary hyperthyroidism. Patients may present with hyperthyroidism or symptoms of mass effect, including headaches or visual disturbance. Thyrotropinoma in pregnancy presents a number of pituitary-related risks including pituitary apoplexy and compression of local structures. Hyperthyroidism in pregnancy raises the risk of complications including spontaneous abortion, preeclampsia, low birthweight and premature labour. Timing of medical and surgical therapies must be carefully considered. A conservative approach requires careful monitoring in case emergent intervention is required.
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Affiliation(s)
- Yu-Fang Wu
- Department of Clinical Medicine, Endocrinology
| | - Hui Yi Ng
- Department of Clinical Medicine, Endocrinology
| | | | - David Lewis
- Department of Clinical Medicine, Endocrinology
| | - Andrew Davidson
- Department of Clinical Medicine, Neurosurgery, Macquarie University, Sydney, New South Wales, Australia
- Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Peter McCallum Cancer Centre, Department of Oncology, Melbourne, Victoria, Australia
| | - Bernard Champion
- Department of Clinical Medicine, Endocrinology
- School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
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Boharoon H, Navalkissoor S, Luong TV, Caplin M, Grossman A. Insulinoma: a quarter century of dietary control. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0270. [PMID: 36137190 PMCID: PMC9513657 DOI: 10.1530/edm-22-0270] [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: 07/15/2022] [Accepted: 08/19/2022] [Indexed: 11/12/2022] Open
Abstract
Summary Insulinomas are rare pancreatic neuroendocrine neoplasms (NENs) that are typically sporadic and solitary, with the majority being <2 cm in diameter at diagnosis. The median duration of symptoms before diagnosis is variable; however, this is usually in the region of 12-18 months. We report on an insulinoma diagnosed some 25 years following initial symptoms, having by that stage attained a diameter of 4 cm. We present a 50-year-old man who was reported with hypoglycaemic symptoms on his wedding 25 years prior to eventual confirmation of an insulinoma. He had since learned to live with the symptoms by eating frequently to manage his hypoglycaemia. However, over recent months, he reported a substantial deterioration in his symptoms, and indeed, had collapsed on two occasions. He had a fasting glucose of 2.9 mmol/L with grossly inappropriate elevated insulin and C-peptide levels. MRI demonstrated a 4.1 cm lesion at the body of pancreas and an indeterminate 9-mm liver lesion with a negative 68Gallium-DOTATATE PET scan. Accordingly, he was initiated on diazoxide and referred to the surgical team for distal pancreatectomy: histology confirmed a 4.4-cm well-differentiated pancreatic NEN of intermediate grade (NEN G2, Grade 2, 2017 World Health Organization (WHO) pancreatic-NEN classification), with positive immunohistochemistry for insulin. His hypoglycaemia episodes have ceased, and he remains under active surveillance. Our case demonstrates the possibility of dietary control of insulinoma-induced hypoglycaemia, and the likelihood that such a prolonged delay in diagnosis has led to the uncommonly large size of the apparently benign tumour which is usually 'small and indolent'. Learning points Most patients with insulinomas have lesions that are 1-2 cm in size, with 96% being less than 3 cm. The mean tumour size of insulinomas found in 3 of the largest reported series was 1.5 cm, with a range of 0.1-7.0 cm. It is not uncommon for patients to have symptoms for several months to years before diagnosis; however, no reported cases had the symptoms such long for 25 years, and the large size of the tumour in this case may reflect the very long history.
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Affiliation(s)
- Hessa Boharoon
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, London, UK
| | | | - Tu Vinh Luong
- Department of Pathology, Royal Free Hospital, London, UK
| | - Martyn Caplin
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, London, UK
| | - Ashley Grossman
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, London, UK
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Abass MK, Al Shamsi A, Jan I, Masalawala MSY, Deeb A. Combined SPINK1 mutations induce early-onset severe chronic pancreatitis in a child with severe obesity. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0273. [PMID: 36053195 PMCID: PMC9513635 DOI: 10.1530/edm-22-0273] [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: 05/30/2022] [Accepted: 06/06/2022] [Indexed: 11/25/2022] Open
Abstract
Summary The most frequent causes of pancreatitis classically have been known to be gallstones or alcohol. However, genetics can also play a key role in predisposing patients to both chronic and acute pancreatitis. The serine protease inhibitor Kazal type 1 (SPINK 1) gene is known to be strongly associated with pancreatitis. Patients with these underlying genetic mutations can have severe diseases with a high morbidity rate and frequent hospitalization. We report an Arab girl who presented with acute pancreatitis at the age of 7 years progressing to recurrent chronic pancreatitis over a few years. She had severe obesity from the age of 4 years and developed type 2 diabetes at the age of 12. She had a normal biliary system anatomy. Genetic analysis showed that she had combined heterozygous mutations in the SPINK1 gene (SPINK1, c.101A>G p.(Asn34Ser) and SPINK1, c.56-37T>C). Her parents were first-degree cousins, but neither had obesity. Mother was detected to have the same mutations. She had type 2 diabetes but never presented with pancreatitis. This case is the first to be reported from the Arab region with these combined mutations leading to recurrent chronic pancreatitis. It illustrates the importance of diagnosing the underlying genetic mutation in the absence of other known causes of pancreatitis. Considering the absence of pancreatitis history in the mother who did not have obesity but harboured the same mutations, we point out that severe obesity might be a triggering factor of pancreatitis in the presence of the mutations in SPINK1 gene in this child. While this is not an assumption from a single patient, we show that not all carriers of this mutation develop the disease even within the same family. Triggering factors like severe obesity might have a role in developing the disease. Learning points Acute recurrent pancreatitis and chronic pancreatitis are uncommon in children but might be underdiagnosed. Biliary tract anomalies and dyslipidaemias are known causative factors for pancreatitis, but pancreatitis can be seen in children with intact biliary system. Genetic diagnosis should be sought in children with pancreatitis in the absence of known underlying predisposing factors. SPINK1 mutations can predispose to an early-onset severe recurrent pancreatitis and acute pancreatitis.
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Affiliation(s)
- Maha Khalil Abass
- Pediatric Endocrinology Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Aisha Al Shamsi
- Clinical Genetics Department, Tawam Hospital, Al Ain, United Arab Emirates
| | - Iftikhar Jan
- Paediatric Surgery Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
- College of Medicine and Health Sciences, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | | | - Asma Deeb
- Pediatric Endocrinology Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
- College of Medicine and Health Sciences, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
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Dirven I, Bravenboer B, Raeymaeckers S, Andreescu CE. Lymphadenopathy after COVID-19 vaccination in patients with endocrine cancer: two case reports. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0258. [PMID: 36112088 PMCID: PMC9513633 DOI: 10.1530/edm-22-0258] [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: 07/02/2022] [Accepted: 08/22/2022] [Indexed: 11/08/2022] Open
Abstract
Summary The Covid-19 vaccination has been rapidly implemented among patients with cancer. We present two cases of patients with endocrine tumours who developed lymphadenopathy following a Covid-19 vaccination. In the case of a patient with multiple endocrine neoplasia (MEN) 1 syndrome, an 18-fluorodeoxyglucose (18FDG)-PET/CT showed positive axillary lymph nodes. Further work-up with fine needle aspiration showed a reactive pattern following a Covid-19 vaccination in the ipsilateral arm shortly before the 18FDG-PET/CT. A second patient, in follow-up for thyroid cancer, developed clinical supraclavicular lymphadenopathy after a Covid-19 vaccination. Follow-up ultrasound proved the lesion to be transient. These cases demonstrate lymphadenopathy in response to a Covid-19 vaccination in two patients susceptible to endocrine tumours and metastatic disease. With growing evidence about the pattern and occurrence of lymphadenopathy after mRNA Covid-19 vaccination, recommendations for scheduling and interpretation of imaging among cancer patients should be implemented to reduce equivocal findings, overdiagnosis, and overtreatment, while maintaining a good standard of care in oncological follow-up. Learning points Reactive lymphadenopathy is very common after an mRNA vaccination against Covid-19 and should be part of the differential diagnosis in patients with endocrine tumours who recently received a Covid-19 mRNA vaccination and present with an ipsilateral lymphadenopathy. A good vaccine history is essential in assessing the risk for lymphadenopathy and if possible, screening imaging in patients with endocrine tumours should be postponed at least 6 weeks after the previous vaccination. For now, a multidisciplinary care approach is recommended to determine the necessary steps in the diagnostic evaluation of lymphadenopathy in the proximity of a Covid-19 vaccination.
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Affiliation(s)
- Iris Dirven
- Department of Endocrinology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Bert Bravenboer
- Department of Endocrinology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Steven Raeymaeckers
- Department of Radiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Corina E Andreescu
- Department of Endocrinology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Correa LL, Medeiros de Sousa PA, Dinis L, Carloto LB, Nuñez-Garcia M, Sajoux I, Senhorini S. Severe type 2 diabetes (T2D) remission using a very low-calorie ketogenic diet (VLCKD). Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0295. [PMID: 36094136 PMCID: PMC9513631 DOI: 10.1530/edm-22-0295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/08/2022] Open
Abstract
Summary There is a close association between obesity and type 2 diabetes (T2D). The value of weight loss in the management of patients with T2D has long been known. Loss of 15% or more of body weight can have a disease-modifying effect in people with diabetes inducing remission in a large proportion of patients. Very low-carbohydrate ketogenic diets (VLCKDs) have been proposed as an appealing nutritional strategy for obesity management. The diet was shown to result in significant weight loss in the short, intermediate, and long terms and improvement in body composition parameters as well as glycemic and lipid profiles. The reported case is a 35-year-old man with obesity, dyslipidemia, and T2D for 5 years. Despite the use of five antidiabetic medications, including insulin, HbA1c was 10.1%. A VLCKD through a commercial multidisciplinary weight loss program (PnK method) was prescribed and all medications were discontinued. The method is based on high-biological-value protein preparations and has 5 steps, the first 3 steps (active stage) consist of a VLCKD (600-800 kcal/d) that is low in carbohydrates (<50 g daily from vegetables) and lipids. The amount of proteins ranged between 0.8 and 1.2 g/kg of ideal body weight. After only 3 months, the patient lost 20 kg with weight normalization and diabetes remission, and after 2 years of follow-up, the patient remained without the pathologies. Due to the rapid and significant weight loss, VLCKD emerges as a useful tool in T2D remission in patients with obesity. Learning points Obesity and type 2 diabetes (T2D) are conditions that share key pathophysiological mechanisms. Loss of 15% or more of body weight can have a disease-modifying effect in people with T2D inducing remission in a large proportion of patients. Diabetes remission should be defined as a return of HbA1c to <6.5% and which persists for at least 3 months in the absence of usual glucose-lowering pharmacotherapy. The very low-carbohydrate ketogenic diet (VLCKD) is a nutritional approach that has significant beneficial effects on anthropometric and metabolic parameters. Due to the rapid and significant weight loss, VLCKD emerges as a useful tool in T2D remission in patients with obesity.
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Affiliation(s)
- Livia Lugarinho Correa
- Department of Obesity, Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, Brazil
| | | | - Leticia Dinis
- Department of Obesity, Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, Brazil
| | - Luana Barboza Carloto
- Department of Obesity, Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, Brazil
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Opara NU. Diabetes mellitus-induced lower urinary tract symptoms and hepatic steatosis in an older male. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0290. [PMID: 36125050 PMCID: PMC9513662 DOI: 10.1530/edm-22-0290] [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: 07/11/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
Summary Diabetes mellitus type 2 (DM-2) is one of the important causes of low-grade chronic inflammation (meta inflammation) seen in almost all tissues in the body. Other possible mechanisms involved in the development of lower urinary tract symptoms (LUTS) with DM-2 are the hypertonicity of the peripheral sympathetic nerves and hyperinsulinemia effects on the autonomous nervous system activity. These further suggests that abnormalities in glucose homeostasis influence the hyperproliferation of the prostate cells resulting in benign prostatic hyperplasia (BPH). Similarly, hepatic steatosis, a form of non-alcoholic fatty liver disease (NAFLD) prevalence among patients with DM-2, is as high as 75%. NAFLD has no symptoms in most diabetic patients. In this study, we present a case of a 64-year-old Black male who had worsening urinary urgency and hesitancy for 4 months, with increasing abdominal girth. Patient was found to have symptoms, diagnostic studies, and physical exam findings indicative of BPH and fatty liver disease. He was treated with hepato-protective medications, tighter control of his blood glucose levels, and blood pressure meds for 13 months. Upon follow-up, most of his symptoms were resolved. Timeline of BPH resolution and decrease in liver size following treatment suggest that DM-2 has a strong correlation with the development of BPH and fatty liver disease in most patients living with diabetes. Learning points Men with type 2 diabetes mellitus (DM-2) tend to have significantly lower serum PSA level, lower testosterone levels, and larger prostate volume compared to non-diabetic male patients. Patients with DM-2 have higher prevalence of hepatic steatosis, liver cirrhosis, and end-stage liver failure. The role of metformin in reducing hepatic steatosis as stated by several studies is yet to be validated as our patient has been on metformin for 22 years for the management of DM-2 with fatty liver disease.
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Affiliation(s)
- Nnennaya U Opara
- Emergency Medicine, Charleston Area Medical Centre, Institute for Academic Medicine, Charleston, West Virginia, USA
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11
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Subki SH, Wadea Mohammed Hussain R, Al-Agha AE. Congenital lipoid adrenal hyperplasia in a Saudi infant. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0294. [PMID: 36053179 PMCID: PMC9513656 DOI: 10.1530/edm-22-0294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/11/2022] [Indexed: 11/08/2022] Open
Abstract
Summary Congenital lipoid adrenal hyperplasia (CLAH) is characterized by a defect in the STAR protein-encoding gene that attenuates all steroidogenesis pathways. Herein, we present the first reported case in Saudi Arabia of a 46 XY, phenotypically female infant with an unfamiliar, darkened complexion compared to the family's skin color. Based on the clinical and biochemical findings, CLAH was diagnosed and glucocorticoid replacement therapy was initiated. As a result, we suggest that pediatricians should always investigate the possibility of adrenal insufficiency when encountering unusual dark skin. Learning points Pediatricians should be prompted to rule out adrenal insufficiency in unexpectedly dark skin neonates. In such patients, pediatricians should not wait until the neonate develops an adrenal crisis. A low level of 17-hydroxyprogesterone does not always rule out the possibility of inherited adrenal gland disorders, and additional tests should be performed for early detection.
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Affiliation(s)
- Siham Hussein Subki
- Pediatrics Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Abdulmoein Eid Al-Agha
- Pediatrics Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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12
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Vieira IH, Mourinho Bala N, Ramos F, Dinis I, Cardoso R, Caetano JS, Rodrigues D, Paiva I, Mirante A. A serious and unusual presentation of congenital isolated ACTH deficiency due to TBX19 mutation, beyond the neonatal period. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0277. [PMID: 36070412 PMCID: PMC9513655 DOI: 10.1530/edm-22-0277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022] Open
Abstract
Summary Congenital isolated adrenocorticotrophic hormone (ACTH) deficiency due to T-box transcription factor-19 (TBX19 mutation) (MIM 201400; ORPHA 199296) usually presents in the neonatal period with severe hypoglycemia, seizures, and sometimes prolonged cholestatic jaundice. We report a case with an unusual presentation that delayed the diagnosis. A 9-month-old female patient with no relevant personal history was admitted to the emergency department due to a hypoglycemic seizure in the context of acute gastroenteritis. There was rapid recovery after glucose administration. At age 4, she presented with tonic-clonic seizures, fever, and gastrointestinal symptoms and came to need support in an intensive care unit. Low serum cortisol was documented and hydrocortisone was initiated. After normalization of inflammatory parameters, the patient was discharged with hydrocortisone. The genetic investigation was requested and compound heterozygous mutations in TBX19 were detected. This is a rare case of presentation of TBX19 mutation outside the neonatal period and in the setting of acute disease, which presented a diagnostic challenge. Learning points Congenital isolated adrenocorticotrophic hormone deficiency due to TBX19 mutation usually presents with neonatal hypoglycemia and prolonged cholestatic jaundice. An uneventful neonatal period, however, does not exclude the diagnosis as the disease may be asymptomatic at this stage. In the context of idiopathic hypoglycemia, even in the context of acute disease, hypocortisolism must always be excluded. Genetic evaluation should be performed in cases of congenital central hypocortisolism to allow proper counselling.
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Affiliation(s)
- Inês Henriques Vieira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Nádia Mourinho Bala
- Department of Endocrinology, Diabetes and Metabolism, Hospital Beatriz Ângelo, Loures, Portugal
| | - Fabiana Ramos
- Department of Medical Genetics, Diabetes and Growth, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Isabel Dinis
- Department of Endocrinology, Diabetes and Growth, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Rita Cardoso
- Department of Endocrinology, Diabetes and Growth, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Joana Serra Caetano
- Department of Endocrinology, Diabetes and Growth, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Dírcea Rodrigues
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Isabel Paiva
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Alice Mirante
- Department of Endocrinology, Diabetes and Growth, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
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13
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Casey C, Higgins T. Subacute thyroiditis post viral vector vaccine for COVID-19. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0193. [PMID: 36053182 PMCID: PMC9513652 DOI: 10.1530/edm-21-0193] [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: 06/17/2022] [Accepted: 08/17/2022] [Indexed: 11/08/2022] Open
Abstract
Summary Subacute thyroiditis is an inflammatory disorder of the thyroid gland that has previously been described following viral illnesses and occasionally post vaccination such as influenza vaccine. 2021 was a revolutionary year for the development of SARS-CoV-2 vaccinations with multiple different vaccines now available. There are increasing numbers of case reports of thyroiditis following these vaccinations. We report a case of a 50-year-old female who developed subacute thyroiditis 6 days post ChAdOx1 nCoV-19 vaccine (AZD1222 produced by AstraZeneca Vaxzevria). The initial thyrotoxic phase was followed by overt hypothyroidism. This resolved spontaneously within 5 months without levothyroxine replacement. We hope that our case will add to the growing literature of cases of thyroiditis occurring after multiple different types of SARS-CoV-2 vaccination and create awareness of this rare but treatable adverse effect. We also review the literature on the proposed mechanisms behind this adverse effect. Learning points Subacute thyroiditis is an inflammatory disorder of the thyroid gland that can occur after a viral illness or vaccination against certain infections. Subacute thyroiditis is a rare adverse effect that has been reported to occur after different types of SARS-CoV-2 vaccinations. Subacute thyroiditis post vaccination is relatively straightforward to manage, with some patients requiring non-steroidal anti-inflammatory drugs and beta-blockers, while more severe cases may require corticosteroid therapy. This adverse effect should not dissuade vaccination use at a population level. There are many postulated mechanisms for the development of subacute thyroiditis following vaccination including the presence of the ACE-2 receptor for SARS-CoV-2 on the thyroid gland, an inflammatory/immune response as is seen in COVID-19 infection itself and molecular mimicry between SARS-CoV-2 spike protein and healthy thyroid antigen.
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Affiliation(s)
- Caoimhe Casey
- University Hospital Kerry, Tralee, Co. Kerry, Ireland
| | - Tom Higgins
- University Hospital Kerry, Tralee, Co. Kerry, Ireland
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14
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Thewjitcharoen Y, Nakasatien S, Tsoi TF, Lim CKP, Himathongkam T, Chan JCN. Hypertriglyceridemia as a main feature associated with 17q12 deletion syndrome-related hepatocyte nuclear factor 1β-maturity-onset diabetes of the young. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0297. [PMID: 36106561 PMCID: PMC9513634 DOI: 10.1530/edm-22-0297] [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: 05/24/2022] [Accepted: 08/25/2022] [Indexed: 12/27/2022] Open
Abstract
Summary Hepatocyte nuclear factor 1β (HNF1B) gene is located on chromosome 17q12. It is a transcription factor implicated in the early embryonic development of multiple organs. HNF1B-associated disease is a multi-system disorder with variable clinical phenotypes. There are increasing reports suggesting that the 17q12 deletion syndrome should be suspected in patients with maturity-onset diabetes of the young type 5 (MODY5) due to the deletion of HNF1B gene. In contrast to classical 17q12 syndrome in childhood with neurological disorders and autism, patients with HNF1B-MODY deletion rarely had neuropsychological disorders or learning disabilities. The diagnosis of 17q12 deletion syndrome highlighted the phenotypic heterogeneity of HNF1B-MODY patients. In this study, we report the clinical course of a Thai woman with young-onset diabetes mellitus and hypertriglyceridemia as a predominant feature due to HNF1B deletion as part of the 17q12 deletion syndrome. Our findings and others suggest that hypertriglyceridemia should be considered a syndromic feature of HNF1B-MODY. Our case also highlights the need to use sequencing with dosage analyses to detect point mutations and copy number variations to avoid missing a whole deletion of HNF1B. Learning points Maturity-onset diabetes of the young type 5 (MODY5) may be caused by heterozygous point mutations or whole gene deletion of HNF1B. Recent studies revealed that complete deletion of the HNF1B gene may be part of the 17q12 deletion syndrome with multi-system involvement. The length of the deletion can contribute to the phenotypic variability in patients with HNF1B-MODY due to whole gene deletion. Using next-generation sequencing alone to diagnose MODY could miss a whole gene deletion or copy number variations. Specialized detection methods such as microarray analysis or low-pass whole genome sequencing are required to accurately diagnose HNF1B-MODY as a component of the 17q12 deletion syndrome. Molecular diagnosis is necessary to distinguish other acquired cystic kidney diseases in patients with type 2 diabetes which could phenocopy HNF1B-MODY. Hypertriglyceridemia is a possible metabolic feature in patients with HNF1B-MODY due to 17q12 deletion syndrome.
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Affiliation(s)
| | | | - Tsz Fung Tsoi
- Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity and Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Cadmon K P Lim
- Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity and Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | | | - Juliana C N Chan
- Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity and Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Asia Diabetes Foundation, Shatin, Hong Kong SAR, China
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15
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Beck AJ, Reddy VM, Sulkin T, Browne D. Management of severe and symptomatic primary hyperparathyroidism in the first trimester of unplanned pregnancy. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0203. [PMID: 36070416 PMCID: PMC9513675 DOI: 10.1530/edm-21-0203] [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: 05/23/2022] [Accepted: 08/17/2022] [Indexed: 11/08/2022] Open
Abstract
Summary Primary hyperparathyroidism (PHP) is the most common aetiology for hypercalcaemia. The incidence of PHP in pregnant women is reported to be 8/100 000 population/year. It presents a threat to the health of both mother (hyperemesis, nephrolithiasis) and fetus (fetal death, congenital malformations, and neonatal severe hypocalcaemia-induced tetany). However, there is a lack of clear guidance on the management of primary hyperparathyroidism in pregnancy. In this study, we describe the case of a 26-year-old female patient who presented with severe hypercalcaemia secondary to PHP and underwent successful parathyroid adenectomy under local anaesthesia. Learning points Primary hyperparathyroidism is a rare complication in pregnancy, but the consequences for mother and fetus can be severe. A perceived risk of general anaesthesia to the fetus in the first trimester has resulted in a general consensus to delay parathyroid surgery to the second trimester when possible - although the increased risk of fetal loss may occur before planned surgery. If the patient presents with severe or symptomatic hypercalcaemia, minimally invasive surgery under local anaesthetic should be considered regardless of the gestational age of the pregnancy.
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Affiliation(s)
- Adele J Beck
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Venkat M Reddy
- Royal Cornwall Hospitals NHS Trust, Endocrinology and Diabetes Mellitus, Treliske, Truro, UK
| | - Tom Sulkin
- Royal Cornwall Hospitals NHS Trust, Endocrinology and Diabetes Mellitus, Treliske, Truro, UK
| | - Duncan Browne
- Royal Cornwall Hospitals NHS Trust, Endocrinology and Diabetes Mellitus, Treliske, Truro, UK
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16
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Haridas K. Hypercalcemia in the setting of HTLV-1 infection and a normal PTHrP level. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0299. [PMID: 36137195 PMCID: PMC9513664 DOI: 10.1530/edm-22-0299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/05/2022] [Indexed: 11/25/2022] Open
Abstract
Summary Human T-cell lymphotropic virus-1 (HTLV-1) causes adult T-cell leukemia and lymphoma (ATLL) and is a rare but important cause of hypercalcemia. A 53-year-old male with HTLV-1-associated myelopathy presented with acute on chronic bilateral lower extremity weakness and numbness. Initial blood work revealed hypercalcemia with corrected calcium of 16.2 mg/dL (8.5-11.5) with normal levels of phosphorus and alkaline phosphatase. Workup for hypercalcemia revealed parathyroid hormone (PTH) of 14 pg/mL (10-65), 25 hydroxy vitamin D at 19.6 ng/mL (30-100), 1,25 dihydroxy vitamin D at 6.7 pg/mL (19.9-79.3), thyroid-stimulating hormone of 1.265 μIU/mL (0.5-5), undetectable PTH-related protein (PTHrP) and lactate dehydrogenase of 433 U/L (100-220). The urine calcium creatinine ratio was 0.388. Reverse transcriptase PCR was positive for HTLV-1 and negative for HTLV-2. Peripheral blood flow cytometry and lymph node biopsy confirmed ATLL. He received treatment with fluids, calcitonin and denosumab after which serum calcium levels fell (nadir: 7.7 mg/dL) and then normalized. Humoral hypercalcemia in this setting is mediated by receptor activator of nuclear factor-kappa B ligand (RANKL), PTHrP and other cytokines. PTHrP levels depend on levels of the TAX gene product, cell type and lymphocyte-specific factors. Thus, a low level, like in our patient, does not rule out HTLV-1 infection/ATLL as the cause of hypercalcemia. Hypercalcemia is known to be responsive to monoclonal antibodies against RANKL given the compound's role in mediating hypercalcemia in these cases. Learning points Human T-cell lymphotropic virus-1 infection and adult T-cell leukemia and lymphoma are associated with high rates of hypercalcemia and hypercalcemic crises. Hypercalcemia in these cases is mediated by osteoclastic bone resorption carried out by several agents including receptor activator of nuclear factor-kappa B ligand, parathyroid hormone-related protein (PTHrP), macrophage inflammatory protein 1 alpha, interleukins, etc. A normal PTHRrP does not rule out humoral hypercalcemia of malignancy in this setting, as indicated by this case. Hypercalcemia in such settings is highly responsive to monoclonal antibodies against RANKL given the role the ligand plays in resorptive hypercalcemia.
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Affiliation(s)
- Keerthana Haridas
- PGY2, Internal Medicine, Icahn School of Medicine, Mount Sinai St Luke’s/West, New York, New York, USA
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17
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Melzer F, Geisler C, Schulte DM, Laudes M. Rapid response to leptin therapy in a FPLD patient with a novel PPARG missense variant. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210082. [PMID: 34515658 PMCID: PMC8495725 DOI: 10.1530/edm-21-0082] [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: 08/04/2021] [Accepted: 08/24/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Familial partial lipodystrophy (FPLD) syndromes are rare heterogeneous disorders especially in women characterized by selective loss of adipose tissue, reduced leptin levels and severe metabolic abnormalities. Here we report a 34-year-old female with a novel heterozygotic c.485 thymine>guanine (T>G) missense variant (p.phenylalanine162cysteine; (Phe162Cys)) in exon 4 of the peroxisome proliferator-activated receptor gamma (PPARG) gene, developing a non-ketotic diabetes and severe hypertriglyceridemia with triglyceride concentrations >50 mmol/L. In this case, a particular interesting feature in comparison to other known PPARG mutations in FPLD is that while glycaemic control could be achieved through standard anti-diabetic medication, hypertriglyceridemia did neither respond to fibrate nor to omega-3-fatty acid therapy. This might suggest a lipid metabolism driven phenotype of the novel PPARG c.485T>G missense variant. Notably, recombinant leptin replacement therapy (metreleptin (Myalepta®)) was initiated showing a rapid and profound effect on triglyceride levels as well as on liver function tests and satiety feeling. Unfortunately, severe allergic skin reactions developed at the side of injection which could be covered by anti-histaminc treatment. We conclude that the heterozygous PPARG c.485T>G variant is a yet undescribed molecular basis underlying FPLD with difficulties predominantly to control hypertriglyceridemia and that recombinant leptin therapy may be effective in affected subjects. LEARNING POINTS Heterozygous c.485T>G variant in PPARG is most likely a cause for FPLD in humans. This variant results in a special metabolic phenotype with a predominant dysregulation of triglyceride metabolism not responding to standard lipid lowering therapy. Recombinant leptin therapy is effective in rapidly improving hypertriglyceridemia.
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Affiliation(s)
- Fiona Melzer
- Institute of Diabetes and Clinical Metabolic Research, Kiel, Germany
| | - Corinna Geisler
- Institute of Diabetes and Clinical Metabolic Research, Kiel, Germany
| | - Dominik M Schulte
- Institute of Diabetes and Clinical Metabolic Research, Kiel, Germany
- Department of Medicine 1, Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Matthias Laudes
- Institute of Diabetes and Clinical Metabolic Research, Kiel, Germany
- Department of Medicine 1, Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital of Schleswig-Holstein, Kiel, Germany
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18
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Kazakou P, Simeakis G, Alevizaki M, Saltiki K. Medullary thyroid carcinoma (MTC): unusual metastatic sites. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210063. [PMID: 34551391 PMCID: PMC8495720 DOI: 10.1530/edm-21-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Medullary thyroid carcinoma (MTC) has a varying clinical course; distant metastases are frequently present even at diagnosis. We present two MTC cases with unusual metastatic sites. Two female patients are presented with slow progressive MTC. The first case developed distant metastases 23 years after diagnosis and underwent locoregional therapies. At the same time a breast mass developed representing MTC metastasis. Treatment with vandetanib led to long-term disease stabilization. The second patient is presented with metastases in the pancreas 13 years after diagnosis. Shortly, a painful mass developed in the mandible and metastasis of MTC was diagnosed. Disease progression was recorded 20 months after the initiation of local and systemic therapy. Such cases have only rarely been reported in the literature and highlight the need for prompt recognition of unexpected MTC metastases. LEARNING POINTS Unusual sites of metastasis may appear in patients with medullary thyroid carcinoma (MTC) years after the initial diagnosis. Although rare, unexpected MTC metastases highlight the need for prompt recognition and appropriate treatment. Local recurrences accompanied by inappropriately low calcitonin levels should prompt further investigation for possible distant metastatic disease. Systemic treatment with tyrosine kinase inhibitors may be effective even in patients with unusual metastases from MTC.
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Affiliation(s)
- Paraskevi Kazakou
- Endocrine Unit, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George Simeakis
- Endocrine Unit, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Alevizaki
- Endocrine Unit, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina Saltiki
- Endocrine Unit, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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19
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Tudor D, Kolombo I, Tot A, Cikojevic D, Simunovic M, Skrabic V. Chronic hyponatremia based on maxillary sinus mass. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210068. [PMID: 34477110 PMCID: PMC8428015 DOI: 10.1530/edm-21-0068] [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: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY This is a case report of a child with chronic hyponatremia due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a paraneoplastic manifestation of olfactory neuroblastoma (OFN). We hereby report a clinical presentation as well as a pragmatic approach to one of the most common electrolytic disorders in the pediatric population and have emphasized the necessity of involving the sinonasal area in the diagnostic procedure while evaluating possible causes of SIADH. This report indicates that the chronicity of the process along with the gradual onset of hyponatremia occurrence is responsible for the lack of neurological symptoms at the moment of disease presentation. LEARNING POINTS Hyponatremia is not infrequently attributed to SIADH. Paraneoplastic syndromes are uncommon but they should be considered in the differential diagnosis of pediatric SIADH. Chronic insidious hyponatremia may not be associated with clear neurological symptoms despite its severity.
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Affiliation(s)
- Darija Tudor
- Department of Pediatrics, University Hospital of Split, Split, Croatia
| | - Iva Kolombo
- Department of Pediatrics, Šibenik General Hospital, Šibenik, Croatia
| | - Ana Tot
- Department of Pediatrics, University Hospital of Split, Split, Croatia
| | - Drasko Cikojevic
- Department of Otorhinolaryngology, University Hospital of Split, Split, Croatia
| | - Marko Simunovic
- Department of Pediatrics, University Hospital of Split, Split, Croatia
- Department of Pediatrics, University of Split School of Medicine, Split, Croatia
| | - Veselin Skrabic
- Department of Pediatrics, University Hospital of Split, Split, Croatia
- Department of Pediatrics, University of Split School of Medicine, Split, Croatia
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20
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Chhiba PD, Segal D. Lipoatrophy associated with daily growth hormone injections. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210087. [PMID: 34515656 PMCID: PMC8495724 DOI: 10.1530/edm-21-0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022] Open
Abstract
SUMMARY Recombinant human growth hormone therapy (rhGH) has been available since 1985 for a variety of conditions and has expanded the indications for rhGH therapy and the number of patients receiving therapy. The very nature of the therapy exposes individuals to years of injections. There are a number of well-known adverse events, however, a lesser-known and rarely reported adverse event of rhGH therapy is localized lipoatrophy. We report nine cases of localized lipoatrophy during rhGH therapy accounting for 14.5% of patients taking rhGH presenting to a single centre for routine follow-up over just a 2-month period. The development of localized lipoatrophy does not appear to be age, indication or dose-related but rather related to repeated administration of rhGH into a limited number of sites. The most likely putative mechanism is the local lipolytic action of growth hormone (GH) itself, although the possibility of an excipient-based interaction cannot be excluded. Given the high prevalence of this adverse event and the potential to prevent it with adequate site rotation, we can recommend that patients be informed of the possible development of localized lipoatrophy. Doctors and nurses should closely examine injection sites at each visit, and site rotation should be emphasized during injection technique education. LEARNING POINTS There are a number of well-known adverse events, however, a lesser-known and rarely reported adverse event of rhGH therapy is localized lipoatrophy. Examination of the injection sites at each visit by the treating healthcare practitioner. To advise the parents/caregivers/patients to change their injection site with each injection. To advise the parents/caregivers/patients to change the needles after every use. For parents, caregivers and patients to self-inspect their injection sites and have a high alert for the development of lipoatrophy and to then immediately report it to their doctor.
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Affiliation(s)
- Priya Darshani Chhiba
- University of the Witwatersrand, Wits Donald Gordon Medical Centre, Johannesburg, South Africa
| | - David Segal
- University of the Witwatersrand, Wits Donald Gordon Medical Centre, Johannesburg, South Africa
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21
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Warren AM, Ebeling PR, Grill V, Seeman E, Sztal-Mazer S. Bilateral atypical femoral fractures during denosumab therapy in a patient with adult-onset hypophosphatasia. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210096. [PMID: 34515659 PMCID: PMC8495717 DOI: 10.1530/edm-21-0096] [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: 08/03/2021] [Accepted: 08/19/2021] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Hypophosphatasia (HPP) is a rare and under-recognised genetic defect in bone mineralisation. Patients presenting with fragility fractures may be mistakenly diagnosed as having osteoporosis and prescribed antiresorptive therapy, a treatment which may increase fracture risk. Adult-onset HPPhypophosphatasia was identified in a 40-year-old woman who presented with bilateral atypical femoral fractures after 4 years of denosumab therapy. A low serum alkaline phosphatase (ALP) and increased serum vitamin B6 level signalled the diagnosis, which was later confirmed by identification of two recessive mutations of the ALPL gene. The patient was treated with teriparatide given the unavailability of ALP enzyme-replacement therapy (asfotase alfa). Fracture healing occurred, but impaired mobility persisted. HPP predisposes to atypical femoral fracture (AFF) during antiresorptive therapy; hence, bisphosphonates and denosumab are contraindicated in this condition. Screening patients with fracture or 'osteoporosis' to identify a low ALP level is recommended. LEARNING POINTS Hypophosphatasia (HPP) is a rare and under-recognised cause of bone fragility produced by impaired matrix mineralisation that can be misdiagnosed as a fragility fracture due to age-related bone loss. Antiresorptive therapy is contraindicated in HPP. Low serum alkaline phosphatase (ALP) provides a clue to the diagnosis. Elevated serum vitamin B6 (an ALP substrate) is indicative of HPP, while identification of a mutation in the ALPL gene is confirmatory. Enzyme therapy with recombinant ALP (asfotase alfa) is currently prohibitively costly. Treatment with anabolic bone agents such as teriparatide has been reported, but whether normally mineralized bone is formed requires further study.
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Affiliation(s)
- Annabelle M Warren
- Department of Endocrinology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Endocrinology, The Austin Hospital, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
| | - Vivian Grill
- Department of Endocrinology, Western Health, St Alban’s, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Ego Seeman
- Department of Endocrinology, The Austin Hospital, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Shoshana Sztal-Mazer
- Department of Endocrinology, The Alfred Hospital, Melbourne, Victoria, Australia
- Women’s Health Research Program, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
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Ioakim S, Constantinides V, Toumba M, Lyssiotis T, Kyriacou A. Microcalcifications without a thyroid nodule as the sole sign of papillary thyroid carcinoma. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210072. [PMID: 34515657 PMCID: PMC8495727 DOI: 10.1530/edm-21-0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/19/2021] [Indexed: 11/23/2022] Open
Abstract
SUMMARY Our objective is to demonstrate the importance of considering microcalcifications even without evidence of nodules as a potential sign of malignancy. Current guidelines, such as those of the British Thyroid Association, acknowledge the clinical significance of microcalcifications only when found within nodules. In this case, they are considered a suspicious feature, classifying the nodules as U5 (i.e. high risk) where fine-needle aspiration biopsy (FNAB) is warranted, following the high likelihood of cancer in these nodules. In addition, there is a dearth of evidence of ultrasound scan (USS) detection of microcalcifications in the thyroid gland outside of nodules, along with their associated clinical implications. Yet, this clinical manifestation is not so infrequent considering that we do encounter patients in the clinic showing these findings upon ultrasound examination. Three patients who presented to our clinic with thyroid-related symptoms were shown to have areas of microcalcifications without a nodule upon sonographic evaluation of their thyroid gland. These incidentally detected hyperechoic foci were later confirmed to correspond to areas of papillary thyroid carcinoma (PTC) on histopathological examination of resected tissue following thyroidectomy. Four more cases were identified with sonographic evidence of microcalcifications without nodules and given their clinical and other sonographic characteristics were managed with active surveillance instead. LEARNING POINTS Echogenic foci known as microcalcifications may be visible without apparent association to nodular structures. Microcalcifications without nodules may not be an infrequent finding. Microcalcifications are frequently indicative of malignancy within the thyroid gland even without a clearly delineated nodule. Empirically, the usual guidelines for the management of thyroid nodules can be applied to the management of microcalcifications not confined to a nodule, but such a finding per se should be classified as a 'high-risk' sign.
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Affiliation(s)
| | - Vasilis Constantinides
- Centre of Endocrine Surgery, Evangelistria Medical Centre, Nicosia, Cyprus
- University of Nicosia Medical School, Nicosia, Cyprus
| | - Meropi Toumba
- Child Endocrine Care, Department of Pediatrics, Aretaeio Hospital, Nicosia, Cyprus
- Department of Molecular Genetics, Function and Therapy, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | | | - Angelos Kyriacou
- CEDM, Centre of Endocrinology, Diabetes and Metabolism, Limassol, Cyprus
- Department of Diabetes, Endocrinology & Obesity Medicine, Salford Royal NHS Foundation & University Teaching Trust, Salford, UK
- Medical School, European University of Cyprus, Nicosia, Cyprus
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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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Al-Sharafi BA, Askar F, Qais AA. Management of a patient with Sheehan's syndrome and diabetes insipidus complicated by recurrent hyponatremia. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210078. [PMID: 34515663 PMCID: PMC8495719 DOI: 10.1530/edm-21-0078] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/17/2021] [Indexed: 11/11/2022] Open
Abstract
SUMMARY A 38-year-old female was initially seen in the intensive care unit after severe postpartum hemorrhage. She was initially diagnosed to have Sheehan's syndrome and after discharge, she was diagnosed to have a vesicovaginal fistula which initially caused a delay in diagnosing diabetes insipidus in the patient because she was having urinary incontinence. The patient had the vesicovaginal fistula repaired and was on replacement with levothyroxine, prednisone, and desmopressin. Years after her diagnosis, the patient experienced recurrent episodes of hyponatremia in the setting of desmopressin therapy. This case highlights the challenges of diagnosing diabetes insipidus in a patient with Sheehan's syndrome and a vesicovaginal fistula, as well as the long-term management of central diabetes insipidus in a resource-limited setting. LEARNING POINTS Sheehan's syndrome is rarely associated with diabetes insipidus, and in our patient, it was initially missed due to a vesicovaginal fistula which caused urinary incontinence. Water intoxication is more common in young children and older adults but can occur years after initiating treatment with desmopressin in adults and should be kept in mind when treating patients with hyponatremia who have hypopituitarism associated with diabetes insipidus. Water intoxication is much more common in patients with diabetes insipidus being treated with intranasal desmopressin than in those using the oral preparations.
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Affiliation(s)
- Butheinah A Al-Sharafi
- Department of Internal Medicine, School of Medicine and Health Sciences, Sana’a University, Sana’a, Yemen
| | - Faiza Askar
- Department of Internal Medicine, School of Medicine and Health Sciences, Sana’a University, Sana’a, Yemen
| | - Ahmed A Qais
- Department of Internal Medicine, School of Medicine and Health Sciences, Sana’a University, Sana’a, Yemen
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Maudhoo A, Maharaj A, Buonocore F, Martos-Moreno GA, Argente J, Achermann JC, Chan LF, Metherell LA. Missplicing due to a synonymous, T96= exonic substitution in the T-box transcription factor TBX19 resulting in isolated ACTH deficiency. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM21-0128. [PMID: 34564059 PMCID: PMC8495723 DOI: 10.1530/edm-21-0128] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/03/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Congenital isolated ACTH deficiency (IAD) is a rare condition characterised by low plasma ACTH and serum cortisol with normal production of other pituitary hormones. TBX19 (also known as TPIT) is a T-box pituitary restricted transcription factor important for POMC gene transcription and terminal differentiation of POMC-expressing cells. TBX19 gene mutations have been shown to cause neonatal-onset congenital IAD. We report a neonate of Romanian origin, who presented at 15 h of life with respiratory arrest and hypoglycaemia which recurred over the following 2 weeks. Biochemical investigations revealed IAD, with undetectable serum cortisol (cortisol < 1 μg/dL; normal range (NR): 7.8-26.2) and plasma ACTH levels within the normal range (22.1 pg/mL; NR: 4.7-48.8). He responded to hydrocortisone treatment. Patient DNA was analysed by a HaloPlex next-generation sequencing array targeting genes for adrenal insufficiency. A novel homozygous synonymous mutation p.Thr96= (Chr1:168260482; c.288G>A; rs376493164; allele frequency 1 × 10-5, no homozygous) was found in exon 2 of the TBX19 gene. The effect of this was assessed by an in vitro splicing assay, which revealed aberrant splicing of exon 2 giving rise to a mutant mRNA transcript whereas the WT vector spliced exon 2 normally. This was identified as the likely cause of IAD in the patient. The predicted protein product would be non-functional in keeping with the complete loss of cortisol production and early presentation in the patient. LEARNING POINTS Synonymous variants (a nucleotide change that does not alter protein sequence) usually thought to be benign may still have detrimental effects on RNA and protein function causing disease. Hence, they should not be ignored, especially if very rare in public databases. In vitro splicing assays can be employed to characterise the consequence of intronic and exonic nucleotide gene changes that may alter splicing. Establishing a diagnosis due to a TBX19 mutation is important as it defines a condition of isolated ACTH deficiency not associated with additional pituitary deficiencies.
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Affiliation(s)
- Ashwini Maudhoo
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Avinaash Maharaj
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Federica Buonocore
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Gabriel Angel Martos-Moreno
- Department of Endocrinology, Hospital Infantil Universitario Niño Jesús, Instituto de Investigación La Princesa, Madrid, Spain
- Department of Pediatrics, Universidad Autónoma de Madrid, Madrid, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Argente
- Department of Endocrinology, Hospital Infantil Universitario Niño Jesús, Instituto de Investigación La Princesa, Madrid, Spain
- Department of Pediatrics, Universidad Autónoma de Madrid, Madrid, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- CEI UAM + CSIC, IMDEA Food Institute, Madrid, Spain
| | - John C Achermann
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Li F Chan
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Lou A Metherell
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Katsamakas M, Tzitzili E, Boudina M, Kiziridou A, Valeri R, Zafeiriou G, Chrisoulidou A. Thyroid sarcoidosis: a rare entity in the differential diagnosis of thyroid cancer. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210095. [PMID: 34515660 PMCID: PMC8495726 DOI: 10.1530/edm-21-0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
SUMMARY We present two cases of thyroid sarcoidosis that were misdiagnosed as thyroid cancer. In the first patient, fine needle aspiration cytology (FNAc) of a suspicious thyroid nodule indicated the presence of papillary thyroid cancer, and the patient underwent thyroid surgery. However, histopathology identified a sarcoid granuloma, without any sign of malignancy. The second patient had a history of papillary microcarcinoma with suspicious lymph nodes diagnosed years after the initial diagnosis and was referred for assessment of cervical lymphadenopathy. Fine needle aspiration cytology (FNAc) of the suspicious lymph nodes erroneously indicated metastasis from thyroid cancer, and lateral modified lymph node dissection was performed, based on FNAc and ultrasonographic features. Histopathology excluded malignancy and identified non-caseating granulomas. Sarcoidosis of the thyroid may have a clinical presentation similar to well-differentiated thyroid carcinoma and, although rare, should be considered in the differential diagnosis, especially when other signs of the disease are already present. In these cases, FNAc provided a false diagnosis of papillary thyroid carcinoma and lymph node metastases that led to unnecessary surgery. LEARNING POINTS Sarcoidosis may share clinical and ultrasonographic features with papillary thyroid carcinoma. Fine needle aspiration cytology is helpful in the diagnosis of both conditions; however, the overlapping cytological characteristics may lead to erroneous diagnosis. The present cases illustrate the importance of cytological identification of these difficult cases. Every piece of information provided by the clinician is essential to the cytologist.
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Affiliation(s)
| | | | | | | | - Rosalia Valeri
- Cytology Department, Theageneio Cancer Hospital, Thessaloniki, Greece
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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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Keen F, Iqbal F, Owen P, Christian A, Kumar N, Kalhan A. Metastatic insulinoma presenting 14 years after benign tumour resection: a rare case and management dilemma. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200065. [PMID: 33434180 PMCID: PMC7576662 DOI: 10.1530/edm-20-0065] [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: 07/13/2020] [Revised: 07/13/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022] Open
Abstract
SUMMARY We present a 60-year-old woman who underwent successful surgical resection (partial pancreatectomy) for a low grade non-functioning pancreatic neuroendocrine tumour (pNET), with no biochemical or radiological features of recurrence on follow-up visits for 5 years. Fourteen years after the initial surgery, she developed spontaneous severe hypoglycaemic episodes which required hospitalisation, with subsequent investigations confirming the diagnosis of a metastatic insulin-secreting pNET (insulinoma). Medical management of her severe spontaneous hypoglycaemic episodes remained challenging, despite optimum use of diazoxide and somatostatin analogue therapy. Based on a discussion at the regional neuroendocrine tumour multidisciplinary team meeting, she underwent an elective hepatic trans-arterial embolization which was unfortunately unsuccessful. She ended up requiring an emergency right hemihepatectomy and left retroperitoneal mass resection which finally stabilised her clinical condition. LEARNING POINTS Ours is only the seventh case report of a previously benign pNET presenting as a functional insulin secreting metastatic tumour. However, it is the first case report, in which the metastatic functional pNET presented after such a long hiatus (14 years). There is currently no clear consensus regarding the length of follow-up of non-functional pNET which are deemed cured post-surgical resection, with most guidelines advocating a median follow up of 5 years (1). The delayed presentation in our case suggests additional considerations should be made regarding optimal post-operative surveillance duration based on the age of the patient, location of the tumour, lymph node spread and Ki-67 index. Hepatic artery embolization and/or partial hepatectomy remains a treatment option for pNET patients with significant hepatic metastasis.
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Affiliation(s)
- F Keen
- Department of Diabetes and Endocrinology, Royal Glamorgan Hospital, Llantrisant, UK
| | - F Iqbal
- Morriston Hospital, Swansea, UK
| | - P Owen
- Department of Diabetes and Endocrinology, Royal Glamorgan Hospital, Llantrisant, UK
| | | | - N Kumar
- University Hospital of Wales, Cardiff, UK
| | - A Kalhan
- Department of Diabetes and Endocrinology, Royal Glamorgan Hospital, Llantrisant, UK
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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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Stütz B, Korbonits M, Kothbauer K, Müller W, Fischli S. Identification of a TMEM127 variant in a patient with paraganglioma and acromegaly. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200119. [PMID: 33416299 PMCID: PMC7576664 DOI: 10.1530/edm-20-0119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/03/2020] [Indexed: 02/03/2023] Open
Abstract
SUMMARY The coincidence of a pheochromocytoma or paraganglioma and a pituitary adenoma in the same patient is a rare condition. In the last few years SDHx and MAX mutations have been identified and discussed as a potential causal connection in cases of coincidence. We describe a case of a middle-aged female patient which presented with acromegaly, a growth hormone-secreting pituitary adenoma and a symptomatic neck paraganglioma. The patient was cured by surgery from both the pituitary tumour and the paraganglioma and is well after ten years follow-up. Due to the unusual coexistence of two neuroendocrine tumours, further molecular genetic testing was performed which revealed a variant in the TMEM127 gene (c245-10C>G). LEARNING POINTS Pheochromocytoma/paraganglioma and coexisting functioning pituitary adenoma are a very rare condition. An appropriate treatment of each tumour entity with a multi-disciplinary approach and regular follow-up is needed. The possibility of a hereditary disease should be considered and genetic workup is recommended. Genetic testing should focus primarily on the genes with mutations related to pheochromocytomas and paragangliomas. Next-generation sequencing with multi-gene panel testing is the currently suggested strategy. Genes associated with paragangliomas and pituitary adenomas are SDHA, SDHB, SDHC, SDHD, SDHAF2, MAX and MEN1, while case reports with VHL, RET and NF1 may represent coincidences. Variants of uncertain significance may need ongoing vigilance, in case novel data become available of these variants.
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Affiliation(s)
- Beryl Stütz
- Department of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, Luzern, Switzerland
| | - Marta Korbonits
- Department of Endocrinology, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Karl Kothbauer
- Department of Neurosurgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Werner Müller
- Department of Otorhinolarnygology, Head and Neck Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Stefan Fischli
- Department of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, Luzern, Switzerland
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Mohammadian Khonsari N, Hakak-Zargar B, Voth T, Noorian S. Late infantile form of multiple sulfatase deficiency. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200128. [PMID: 33434174 PMCID: PMC7576665 DOI: 10.1530/edm-20-0128] [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: 07/30/2020] [Accepted: 09/03/2020] [Indexed: 01/05/2023] Open
Abstract
SUMMARY Multiple sulfatase deficiency (MSD) is a lysosomal storage disorder (LSD) that results in the accumulation of sulfate esters which go on to cause neurological deterioration and mental delay, skin changes, and dysmorphism. The disease can be categorized into three subtypes based on the age of onset: neonatal, late infantile, or juvenile. Our patient is a 2.5-year-old girl, the only child of a healthy couple. Prior to the presentation of the disease, she had not been noted to have any previous health complications. The condition began at the age of 6 months with developmental regression and global hypotonia. Following thorough evaluation and testing, the patient was diagnosed with severe late infantile MSD, although some features, such as minimal mental deterioration, minimal dysmorphic facial features, and minimal organ enlargement, did not fully correlate with the diagnosis, since in cases of severe forms of the condition these features are almost always quite marked. The unexpected minimalism of some of the patient's MSD signs in spite of the severity of her MSD condition made her case worth further studying. LEARNING POINTS Treating dermatologic signs and symptoms greatly eased our patient's discomfort. We would suggest the use of appropriate supportive treatment for symptom management regardless of the life expectancy of the patient. As regards the diagnosis of MLD, given that in some cases the patient may present with irregular features of the condition, a genetic evaluation may be useful for accurate diagnosis. If motor function impairment is followed by dermatologic involvement, as seen in our patient and in many cases in the literature, MSD must be considered, and additional tests should be done to rule it out.
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Affiliation(s)
| | - Benyamin Hakak-Zargar
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Tessa Voth
- Department of Biomedical Physiology and Kinesiology, Faculty of Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Shahab Noorian
- Department of Pediatrics, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
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Profka E, Rodari G, Giacchetti F, Berrettini A, Manzoni G, Daccò V, Arosio M, Giavoli C, Colombo C. A case of testicular atrophy associated with cystic fibrosis. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200095. [PMID: 33434179 PMCID: PMC7576656 DOI: 10.1530/edm-20-0095] [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: 07/30/2020] [Revised: 07/30/2020] [Accepted: 08/25/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY An 8-year-old boy with cystic fibrosis came to our attention for an empty scrotum. General physical examination showed a normal penis and hypoplastic scrotum with non-palpable testes bilaterally. Routine blood investigations showed low levels of LH, testosterone, inhibin B and antiMullerian hormone and elevated levels of FSH. Karyotype was normal. An abdominal ultrasound confirmed the absence of the testes into the scrotum, in the inguinal region and abdomen. At laparoscopy were noted bilaterally hypotrophic spermatic vessels, absence of the vas deferens and a closed inner ring. Inguinal exploration found out a small residual testis and histological examination showed fibrotic tissue. This is the first case of testicular atrophy associated to CFTR mutation described. The process that led to bilateral testicular and vas deferens atrophy remains unexplained, a possible influence of CFTR dysfunction cannot be ruled out, although it is possible that these conditions are independently associated. LEARNING POINTS Cystic fibrosis produces a multisystemic disease which can affect also the reproductive tract. Nearly 97-98% of male patients are infertile because of congenital bilateral absence of vas deferens. A correlation between cystic fibrosis and bilateral testicular atrophy could be possible.
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Affiliation(s)
- Eriselda Profka
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giulia Rodari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Giacchetti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alfredo Berrettini
- Pediatric Urology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianantonio Manzoni
- Pediatric Urology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Daccò
- Cystic Fibrosis Centre, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maura Arosio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Giavoli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carla Colombo
- Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Sagi SV, Joshi H, Trotman J, Elsey T, Swamy A, Rajkanna J, Bhat NA, Haddadin FJS, Oyibo SO, Park SM. A novel CASR variant in a family with familial hypocalciuric hypercalcaemia and primary hyperparathyroidism. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200084. [PMID: 33434173 PMCID: PMC7576638 DOI: 10.1530/edm-20-0084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 08/10/2020] [Accepted: 08/25/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Familial hypocalciuric hypercalcaemia (FHH) is a dominantly inherited, lifelong benign disorder characterised by asymptomatic hypercalcaemia, relative hypocalciuria and variable parathyroid hormone levels. It is caused by loss-of-function pathogenic variants in the calcium-sensing receptor (CASR) gene. Primary hyperparathyroidism (PHPT) is characterised by variable hypercalcaemia in the context of non-suppressed parathyroid hormone levels. Unlike patients with FHH, patients with severe hypercalcaemia due to PHPT are usually symptomatic and are at risk of end-organ damage affecting the kidneys, bone, heart, gastrointestinal system and CNS. Surgical resection of the offending parathyroid gland(s) is the treatment of choice for PHPT, while dietary adjustment and reassurance is the mainstay of management for patients with FHH. The occurrence of both FHH and primary hyperparathyroidism (PHPT) in the same patient has been described. We report an interesting case of FHH due to a novel CASR variant confirmed in a mother and her two daughters and the possible coexistence of FHH and PHPT in the mother, highlighting the challenges involved in diagnosis and management. LEARNING POINTS Familial hypocalciuric hypercalcaemia (FHH) and primary hyperparathyroidism (PHPT) can coexist in the same patient. Urinary calcium creatinine clearance ratio can play a role in distinguishing between PHPT and FHH. Genetic testing should be considered in managing patients with PHPT and FHH where the benefit may extend to the wider family. Family segregation studies can play an important role in the reclassification of variants of uncertain significance. Parathyroidectomy has no benefit in patients with FHH and therefore, it is important to exclude FHH prior to considering surgery. For patients with coexisting FHH and PHPT, parathyroidectomy will reduce the risk of complications from the severe hypercalcaemia associated with PHPT.
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Affiliation(s)
- Satyanarayana V Sagi
- Department of Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, UK
| | - Hareesh Joshi
- Department of Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, UK
| | - Jamie Trotman
- East Midlands and East of England NHS Genomic Laboratory Hub, Cambridge University Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Terence Elsey
- East Midlands and East of England NHS Genomic Laboratory Hub, Cambridge University Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Ashwini Swamy
- Department of Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, UK
| | - Jeyanthy Rajkanna
- Department of Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, UK
| | - Nazir A Bhat
- Department of Ear, Nose and Throat, Peterborough City Hospital, Peterborough, UK
| | - Firas J S Haddadin
- Department of Diabetes and Endocrinology, Queen Elizabeth Hospital, King’s Lynn, UK
| | - Samson O Oyibo
- Department of Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, UK
| | - Soo-Mi Park
- Department of Clinical Genetics, Cambridge University Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
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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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J Orrego J, A Chorny J. Aldosterone- and cortisol-cosecreting adrenal adenoma, ovarian hyperthecosis and breast cancer. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200121. [PMID: 33434176 PMCID: PMC7576653 DOI: 10.1530/edm-20-0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 08/09/2020] [Accepted: 08/25/2020] [Indexed: 11/25/2022] Open
Abstract
SUMMARY We describe a 56-year-old postmenopausal woman with hypertension, hypokalemia and severe alopecia who was found to have a 4.5-cm lipid-poor left adrenal mass on CT scan performed to evaluate her chronic right-sided abdominal pain. Hormonal studies revealed unequivocal evidence of primary aldosteronism and subclinical hypercortisolemia of adrenal origin. Although a laparoscopic left adrenalectomy rendered her normotensive, normokalemic and adrenal insufficient for 2.5 years, her alopecia did not improve and she later presented with facial hyperpigmentation acne, worsening hirsutism, clitoromegaly, and an estrogen receptor-positive breast cancer. Further testing demonstrated markedly elevated serum androstenedione and total and free testosterone and persistently undetectable DHEAS levels. As biochemical and radiologic studies ruled out primary adrenal malignancy and obvious ovarian neoplasms, a bilateral salpingo-oophorectomy was undertaken, which revealed bilateral ovarian hyperthecosis. This case highlights how the clinical manifestations associated with hyperaldosteronism and hypercortisolemia masqueraded the hyperandrogenic findings. It was only when her severe alopecia failed to improve after the resolution of hypercortisolism, hyperandrogenic manifestations worsened despite adrenal insufficiency and an estrogen receptor-positive breast cancer was found, did it becomes apparent that her symptoms were due to ovarian hyperthecosis. LEARNING POINTS As cortisol cosecretion appears to be highly prevalent in patients with primary aldosteronism, the term 'Connshing' syndrome has been suggested. The associated subclinical hypercortisolemia could be the driver for the increased metabolic alterations seen in patients with Conn syndrome. The identification of these dual secretors before adrenal venous sampling could alert the clinician about possible equivocal test results. The identification of these dual secretors before unilateral adrenalectomy could avoid unexpected postoperative adrenal crises. Hyperfunctioning adrenal and ovarian lesions can coexist, and the clinical manifestations associated with hypercortisolemia can masquerade the hyperandrogenic findings.
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Affiliation(s)
- John J Orrego
- Departments of Endocrinology and Metabolism, Kaiser Foundation Health Plan of Colorado, Denver, Colorado, USA
| | - Joseph A Chorny
- Pathology, Kaiser Foundation Health Plan of Colorado, Denver, Colorado, USA
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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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