Explaining Long COVID: A Pioneer Cross-Sectional Study Supporting the Endocrine Hypothesis

Context

In some patients, symptoms may persist after COVID-19, defined as long COVID. Its pathogenesis is still debated and many hypotheses have been raised.

Objective

Our primary objective was to evaluate the corticotroph and somatotroph functions of patients previously infected with SARS-CoV-2 and experiencing post-COVID-19 syndrome to detect any deficiencies that may explain long COVID.

Methods

A cross-sectional study was conducted including patients who had previously contracted SARS-CoV-2 with a postinfection period of 3 months or less to 15 months, divided into 2 groups. The first group (G1) comprised fully recovered patients, while the second group (G2) included patients experiencing long COVID. The primary outcome was the comparison of corticotroph and somatotroph functions.

Results

A total of 64 patients were divided into 2 groups, each consisting of 32 patients. G2 exhibited more frequently anterior pituitary deficits compared to G1 (P = .045): for the corticotroph axis (G1: 6.3% vs G2: 28.1%) and for the somatotroph axis (G1: 31.3% vs G2: 59.4%). Baseline cortisol level was significantly lower in G2 (G1: 13.37 µg/dL vs G2: 11.59 µg/dL) (P = .045). The peak cortisol level was also lower in G2 (G1: 23.60 µg/dL vs G2: 19.14 µg/dL) (P = .01). For the somatotroph axis, the insulin growth factor-1 level was lower in G2 (G1: 146.03 ng/mL vs G2: 132.25 ng/mL) (P = .369). The peak growth hormone level was also lower in G2 (G1: 4.82 ng/mL vs G2: 2.89 ng/mL) (P = .041).

Conclusion

The results showed that long COVID patients in our cohort were more likely to have anterior pituitary deficiencies. The endocrine hypothesis involving anterior pituitary insufficiency can be considered to explain long COVID.

Uncovering the alarming rise of diabetic ketoacidosis during COVID-19 pandemic: a pioneer African study and review of literature

Introduction

Reports around the world indicate that COVID-19 pandemic may be contributing to an increase in the incidence of new onset diabetic ketoacidosis (DKA). This has yet to be studied in Africa. We aimed to compare the incidence trend of new onset DKA before and during the COVID-19 pandemic, with a focus on the type of diabetes mellitus (DM).Materials and methodsThis was a cross sectional analytical study, over a 4-year period, between March 2018 until February 2022 conducted in the referral center: diabetology department of university hospital Farhat Hached Sousse, Tunisia. The study population included patients hospitalized for new onset DKA divided in two groups: G1: before COVID-19 pandemic and G2: during COVID-19 pandemic. Patients younger than 14, new onset DM not presenting with DKA, other types of diabetes (monogenic, secondary or pancreatic diabetes) were not included. A statistical analysis of the monthly incidence trend was conducted using the Jointpoint software providing the average monthly percentage of change (AMPC).

Results

a total of 340 patients were included:137 registered before the pandemic and 203 during the pandemic, representing a 48.17% increase. The mean monthly incidence of new onset DKA during COVID-19 pandemic was statistically higher than that before COVID-19 pandemic (8.42 ± 4.87 vs 5.75 ± 4.29 DKA per month) (p=0.049). The temporal trend of DKA during the 4-year study showed a significant upward trend with a change in AMPC of +0.2% (p=0.037). The incidence of type 1 diabetes (T1D) and type 2 diabetes (T2D) increased by 50% and 44% respectively during COVID-19 pandemic. Anti-glutamic acid decarboxylase (anti-GAD) antibodies' titers significantly increased in G2 compared with G1 (median of 330[Q1-Q3]=[58.5-1795]vs 92.5[Q1-Q3]=[22.5-1074] respectively)(p=0.021).

Discussion

The incidence trend of DKA showed an increase during the COVID-19 pandemic along with an increase of T1D and T2D implying that the pandemic may have been the underlying factor of this upward trend.

Gastrointestinal manifestations in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) patient: major effect on treatment and prognosis

Summary

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive inherited syndrome caused by mutations in autoimmune regulator (AIRE) gene. The three clinical components of this syndrome are mucocutaneous candidiasis, hypoparathyroidism, and primary adrenal insufficiency. In addition to these frequent symptoms, many other components have been reported including gastrointestinal manifestations.We report a case of a 17-year-old Caucasian female patient diagnosed with APECED who presented with acute abdominal pain. Her medical history revealed chronic digestive discomfort without bowel movement disorders. The patient needed a significant increase in doses of calcium supplementation and hydrocortisone which appeared to be partially inefficient. Investigation with esophagogastroduodenoscopy and biopsy showed autoimmune atrophic gastritis. The patient eventually needed increasing doses of treatment received in order to achieve desired clinical and biological therapeutic goals.

Learning points

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive inherited syndrome caused by mutations in the autoimmune regulator (AIRE) gene. The three clinical components of this syndrome that appear in early childhood are mucocutaneous candidiasis, hypoparathyroidism, and primary adrenal insufficiency. In addition to these frequent symptoms, many other components have been reported including gastrointestinal manifestations like atrophic gastritis. They can be caused by many abnormalities including atrophic gastritis and the modification of intestinal biofilm and microbiota. Early diagnosis and treatment of gastrointestinal manifestations associated with APECED prevent multiple life-threatening consequences like acute adrenal crisis and severe symptomatic hypocalcemia.

AB1064 HYPERURICEMIA IN PATIENTS WITH PRIMARY HYPERTENSION: PREVALENCE AND ASSOCIATED FACTORS

Background

Hypertension and hyperuricemia (HU) are both cardivascular risk factors. HU is frequently associated with hypertension even without the use of treatments that potentially cause elevations of uric acid levels.

Objectives

To determine the prevalence of HU in patients diagnosed with primary hypertension and its associated factors.

Methods

A cross-sectional study was conducted in the rheumatology and endocrinology departments of Farhat Hached Hospital of Tunisia over a period of 6 months. Patients diagnosed with primary hypertension were included. HU was defined by uric acid levels ≥ 360 µmol/L in women and ≥ 420 µmol/L in men.

Results

One hundred patients were included. Study population was mainly made of women (65%). The median of age was 63 years [min:34, max:89]. The prevalence of HU was 26%. HU was more common in women (19%) compared to men (7%) without statistical significance (p= 0.315). The median values of systolic and diastolic blood pressure values were 140 mmHg and 80 mmhg, respectively. Elevated diastolic blood pressure was associated with HU (p=0.043).

All patients presented other comorbidities. Type 2 diabetes was the most common one (83%) followed by obesity (56.7%). Forty three percent of patients had dyslipidema, 21% renal failure, 16.9% proteinuria, 9% gout, 8% hypothyroidism and 30% osteoarthritis. HU was significantly associated with hypothyroidism (p=0.027), renal failure (p= 0.000), obesity (p=0.038) and proteinuria (p=0.02). HU was not associated with disturbance of lipid and glycemic status.

High uric acid levels were associated with the use of thiazide diuretics (p= 0.048) and ACE inhibitors (p= 0.037). Nonetheless, no association was found with the use of low dose aspirin (p= 0.412) nor other antihypertensive treatments.

Conclusion

Prevalence of HU is high in patients diagnosed with primary hypertension and is associated with hypothyroidism, obesity, renal failure, proteinuria and diastolic hypertension. HU is also associated with the use of thiazide diuretics and ACE inhibitors.

References

[1]Clarson LE, Hider SL, Belcher J, Heneghan C, Roddy E, Mallen CD. Increased risk of vascular disease associated with gout: a retrospective, matched cohort study in the UK clinical practice research datalink. Ann Rheum Dis. 2015;74(4):642–7. doi: 10.1136/annrheumdis-2014-205252

[2]Deléaval, P., Burnier, M. (2005). ‘L’hyperuricémie dans l’hypertension artérielle: quelle implication?’, Rev Med Suisse 2005; volume -9. no. 032, 2072 - 2079

Disclosure of Interests

None declared

AB1069 URIC ACID LEVELS IN RELATION TO FASTING BLOOD GLUCOSE AND HbA1c

Background

Hyperuricemia is reported to be a risk factor for the development of type 2 diabetes (T2D) and prediabetes.

Objectives

To determine the prevalence of HU and gout in T2D and prediabetes and to study the relationship between HU, gout, T2D and prediabetes.

Methods

A cross-sectional study was conducted beween January 2021 and June 2021 in the Rheumatology and endocrinology departments of Farhat Hached Hospital. Patients who fulfilled the diagnosis of diabetes or prediabetes according to the American Diabetes Association guidelines of 2021 were included. Uric acid levels were also assessed and HU was defined as uric acid levels ≥ 360 µmol/l in women and ≥ 420 µmol/l in men. Diagnosis of gout was based on the ACR/EULAR 2015 classification.

Results

One hundred fifty-one patients having T2D and 46 prediabetic patients were included. The mean of age in both groups was 61 and 54 years respectively.

Prevalence of HU was 26.1% in prediabetic while it was 17.2% in the group of T2D with no statistical relevance (p=0.182). No difference related to gender was observed in both groups. The prevalence of gout was higher in the prediabetes group (15.2%) compared to the T2DM group (6%) but without significant difference (p=0.062).

Uric acid levels were remarkably higher in prediabetic patients (mean=324,3 µmol/l) compared to patients having T2D (median=278 µmol/l) with a significant statistical difference (p=0.022).

No association was identified between HU, fasting blood glucose and HbA1C in the two groups. However, uric acid levels are inversely proportional to fasting blood glucose (p=0,001) and HBA1C (p=0.001) in all patients.

Conclusion

Individuals with moderately elevated HbA1c and fasting glucose levels (prediabetes) may be at a higher risk of HU, whereas individuals with diabetes or elevated HbA1c levels may have a normal uricemia. This could be explained by the GLUT-9 transporter regulation in the renal proximal tubule that blocks the absorption of uric acid when glycosuria is present.

References

[1]Choi HK, Ford ES. Haemoglobin A1c, fasting glucose, serum C-peptide and insulin resistance in relation to serum uric acid levels--the Third National Health and Nutrition Examination Survey. Rheumatology. 29 janv 2008;47(5):713-7.

[2]van der Schaft N, Brahimaj A, Wen K, Franco OH, Dehghan A. The association between serum uric acid and the incidence of prediabetes and type 2 diabetes mellitus: The Rotterdam Study. Hribal ML, éditeur. PLOS ONE. 20 juin 2017;12(6):e0179482.

Disclosure of Interests

None declared

AB1058 IS HYPERURICEMIA ASSOCIATED WITH TYPE 2 DIABETES DEGENERATIVE COMPLICATIONS?

Background

Prevalence of hyperuricemia (HU) is constantly increasing around the world and HU is now identified as an independant cardiovascular risk factor.

Objectives

To determine the prevalence of HU in patients with type 2 diabetes (T2D) and to identify degenerative complications of T2D associated with HU.

Methods

A cross-sectional descriptive study was conducted in the rheumatology and endocrinology departments of Farhat Hached University Hospital of Tunisia over a period of 6 months. Patients diagnosed with T2D according to the 2021 guidelines of the American Diabetes Association were included. A cut-off of uric acid ≥ 360 µmol/L in females and ≥ 420 µmol/L in males was used to define HU.

Results

One hundred fifty-one patients were included. Sex ratio F/M was 1.4. The median of age was 61 years. The prevalence of HU was 17.2%. Only 6 % of patients had gout. Degenerative complications of T2D were encountered in 74.2% of cases. Diabetic neuropathy was the most common (51.7%) and was significantly associated with HU (p=0.049). Diabetic nephropathy was reported in 38.4% of patients and was also associated with HU (p= 0.008). HU was associated with renal failure (p < 0.01), microalbuminuria (<0.01), proteinuria (p=0.001) and history of ischemic stroke (p=0.048). Diabetic feet problems were reported in 15.9 % of patients and were associated with HU (p=0.008). Nevertheless, diabetic retinopathy (39.7%), peripheral arteriopathy of lower limbs (27.2%) and myocardiopathy (15.2%) were not associated with HU.

Conclusion

HU is common in patients with T2D. Our study raises the question whether HU could be a risk factor for the development of degenerative complications in T2D patients. Screening for HU could be recommended in T2D patients for a holistic assessment of the disease.

References

[1]Zhu Y, Pandya BJ, Choi HK. Prevalence of gout and hyperuricemia in the US general population: The National Health and Nutrition Examination Survey 2007-2008: Prevalence of Gout and Hyperuricemia in the US. Arthritis Rheum. oct 2011;63(10):3136-41.

[2]Xiong Q, Liu J, Xu Y. Effects of Uric Acid on Diabetes Mellitus and Its Chronic Complications. Int J Endocrinol. 13 oct 2019;2019:1-8.

Disclosure of Interests

None declared

Clinical, immunological, and genetic investigations in a rare association of type 1 diabetes with xeroderma pigmentosum

Xeroderma pigmentosum (XP) is a rare genodermatosis predisposing to skin cancers. Autoimmune diseases related to XP are rarely discussed in the literature. Type 1 diabetes (T1D) has been associated with other genodermatoses like Cockayne syndrome, but it has never been described in XP. In the present study, we report the rare occurrence of T1D in XP patients. Five XP patients belonging to 4 consanguineous families originating from different regions of Tunisia were investigated. Their ages ranged between 8 and 18 years. All the patients had a severe hypovitaminosis D. All the patients had positive GAD antibody levels, and 4 of them had familial history of other autoimmune diseases. The spectrum of XP was variable in all the patients, with dermatological and neurological symptoms, and the occurrence of some cancers. Various hypotheses have been proposed to explain this association, among of which we cite the role of immunomodulation and down-regulation of ATP-dependent DNA excision repair protein genes, implying that impaired DNA repair may contribute to the development of some autoimmune diseases. Vitamin D3 deficiency secondary to sun protective measures was found in all patients and thus may play a role in increasing T1D risk in these patients.

Positive myositis-specific autoantibodies during COVID-19: a case report

Viral infection is known to be a trigger of autoimmune diseases. Numerous cases of coronavirus disease 2019 (COVID-19) with autoimmune manifestations have been reported and several authors have highlighted the relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and autoimmune diseases. Autoimmune myopathies being one of these manifestations. A 27-year-old diabetic woman was admitted for management of acido-ketosis decompensation of her diabetes secondary to SARS-CoV-2 infection. During hospitalization, she developed muscle weakness and increased creatine kinase levels, which led us to assay the autoimmunity pattern which became positive for myositis-specific autoantibodies against single recognition particle (anti-SRP). The patient was treated with intense hydration with clinical and biological improvement and anti-SRP disappeared two months later. Positive myositis auto-antibodies are one of the autoimmune complications that could be seen during and after the SARS-CoV-2 infection.

Disorders of sodium balance in COVID-19 patients: two Tunisian patients report

Coronavirus disease 2019 (COVID-19) was first reported in December 2019. The disease is caused by severe acute respiratory syndrome virus corona virus 2 (SARS-CoV-2). Mild respiratory symptoms are the most common manifestations of SARS-CoV-2, but new signs are constantly being discovered as it spreads. Disorders of sodium balance are increasingly described in patients with SARS-CoV-2. We report, here, the cases of two patients presented with COVID-19 and in whom we discovered sodium disorders. The first patient is a 74-year-old man who presented with fatal hypernatremia. The second patient is a 66-years-old man presented with COVID-19 and euvolemic hyponatremia attributed to syndrome of inappropriate anti-diuretic hormone secretion (SIADH). This hyponatremia persisted long after the respiratory signs disappeared. Sodium balance disorders are increasingly described in the literature; special attention should be paid to the electrolyte status of COVID-19 patients. Pathophysiological mechanisms associating SARS-CoV-2 with these disorders are being studied.

Impact de la période du confinement sur la prise en charge des patients diabétiques

Introduction

Pour éviter la propagation du virus lors de la pandémie du COVID-19, un confinement était imposé. Pendant cette période, les patients atteints de maladies chroniques, tel que le diabète, ont eu des difficultés à l’accès aux soins. L’objectif de cette étude est d’évaluer le retentissement de la période de confinement sur la prise en charge des patients diabétiques et sur leur qualité de vie.

Patients et méthodes

Il s’agit d’une étude descriptive transversale, réalisée au service d’endocrinologie CHU Farhat Hached de Sousse et au Centre de santé de base Bouhssina, sur 3 mois (février mars avril 2020) (après le premier confinement en Tunisie).

Résultats

On a interrogé 100 patients diabétiques avec une prédominance féminine (66 %). L’âge moyen était de 56,2 ± 5,6 ans. Pendant le confinement, 69 % des patients n’ont pas pu accéder aux soins, 62 % ont déjà raté un RDV, 20 % des patients n’ont pas pu accéder aux médicaments, 57 % avaient des mesures de glycémie plus élevées et 60 % des patients sentaient plus à risque à cause du diabète. Le score de la qualité de vie était au-dessus de la moyenne sur le plan mental chez 20 % et sur le plan physique chez 14 % des patients interrogés.

Conclusion

Le diabète est connu être associé à des formes graves de COVID-19, ce qui rend ces patients plus vulnérables. Vu la situation sanitaire un accompagnement plus rapproché parait nécessaire basé sur le développement de la télémédecine.

Retentissement du confinement sur l’équilibre glycémique chez les personnes âgées diabétiques pendant la pandémie du coronavirus

Introduction

Matériels et méthodes

Résultats

Conclusion

Pituitary apoplexy of a giant prolactinoma during pregnancy

AIMS AND METHODS

Prolactinomas are a common cause of sexual dysfunction and infertility. We aimed, through this case report, to illustrate the difficulties of management of women with giant prolactinoma, especially in cases of desire of pregnancy.

RESULTS

A 30-year-old woman was referred to our department for secondary amenorrhea. Investigations showed a prolactin level of 5168 ng/mL and giant pituitary adenoma of 4 cm in diameter. Cytoreductive surgery was performed after failure to normalize prolactin levels during three years with medical treatment by cabergoline. After seven months, menstrual cycles have resumed, and after 13 months, the patient became pregnant. At 22nd week of gestation, she was admitted in our hospital for pituitary apoplexy. Medical treatment with bromocriptine was chosen. The vaginal premature delivery at 28 weeks gave birth to twins weighing 1 Kg each who died on the 7th day of life.

CONCLUSION

This is a relevant clinical case that illustrates the efficacy of cytoreductive surgery in case of insufficient response to dopamine agonists to restore gonadal function. The possibility of a pregnancy should be considered in these patients since it can be associated with high maternal and fetal risks.

Safety assessment and potential risks of the glucagon stimulation test in the diagnosis of secondary adrenal insufficiency

BACKGROUND

Although it takes more time, the glucagon stimulation test (GST) is a reliable measure for assessing growth hormone (GH) and adrenocorticotropic hormone (ACTH) secretion. The GST is considered to be a safe test, however, it still has mild side effects and potential risks.

OBJECTIVE

The objective of this study was to analyze the side effects of the GST while testing adrenal insufficient patients.

METHODS

This was a prospective study in which GST was performed in eighty-one patients (44 men, 37 women, mean age: 35.83±19.62 years) with pituitary disorder. The GST consisted in an intramuscular injection of 1 mg of glucagon. Blood samples were collected at baseline, and 30, 60, 90, 120, 150, 180 and 210 min after glucagon injection for cortisol measurements. All patients were asked to report side-effects associated with this test.

RESULTS

The mean peak blood glucose level under GST was 9.01±2.03 mmol/L and the mean glycemic nadir was 4.34±1.75 mmol/L was found most frequently during the 30th minute (p <10-3). During the test, 35 subjects (43.2%) had side effects with a mean age of 42.89 ± 19.75 years. Frequent side effects included: nausea (29.62%), vomiting (27.16%), abdominal cramps (18.51%) and hunger (13.58%). All patients tolerated the test until the end. Adverse effects were significantly more prevalent in patients older than 50 years (p=0.012).

CONCLUSIONS

The GST is a reliable alternative to assess hypothalamic pituitary adrenal axis but should be cautiously used especially in the elderly although its minor side effects.

Association of an empty sella and grave´s disease in a patient with acromegaly: a case report

Acromegaly is, in most cases, caused by growth hormone secreting pituitary adenomas. Those patients often develop different pathologies of the thyroid gland, however, the occurrence of Grave´s disease is quite a rare situation. We report a case of a 64-year-old female patient who presented with signs of hyperthyroidism and imbalance of her diabetes mellitus. On physical examination, she had facial features of acromegaly. Biochemical testing confirmed the suspicion of acromegaly and Grave´s disease, with an elevated insulin-like growth factor-1 and a suppressed thyroid stimulation hormone (TSH) with positive TSH-receptor antibodies. A pituitary Magnetic Resonance Imaging (MRI) was performed, revealing a macro-adenoma and an empty sella. The patient successfully underwent a transsphenoidal surgery and obtained a remission of her hyperthyroidism under anti-thyroid drugs.

Three Successful Pregnancies in a Patient with Recurrent Cushing's Disease

The association of pregnancy and Cushing's disease (CD) is rare. A 28-year-old woman was admitted for clinical suspicion of Cushing's syndrome. The investigations confirmed the diagnosis of CD with secondary hypogonadotropic hypogonadism due to an invasive pituitary macroadenoma. The patient underwent transsphenoidal adenomectomy, and histopathology showed an adrenocorticotropic hormone pituitary adenoma. Initial remission of CD ensued, and fertility was restored as the patient had 2 uncomplicated pregnancies. Five years and 10 months after surgery, a third spontaneous pregnancy was confirmed with underlying recurrent CD. Having mild hypercortisolism, CD was managed expectantly. The outcome was a healthy full-term neonate with no maternal complications during pregnancy or labor. Our case highlights the challenge faced by physicians of choosing the optimal approach to active CD in pregnancy. In cases where maternal and fetal complications are mild, conservative approach may be used and specific treatment can be postponed until after delivery.

Clinical patterns of third nerve palsies in diabetic patients

BACKGROUND

Neuropathy is a frequent complication in diabetic patients with variable clinical presentations and evolutions.

AIM

The purpose of the study was to specify the clinical features of diabetic third nerve palsy, to assess the risk factors and to observe its evolution.

METHODS

We report a series of 11 diabetic patients with oculomotor paralysis collected in the department of endocrinology and diabetology of FarhatHached Hospital of Sousse between 1996 and 2005.

RESULTS

Our study was about 6 men and 5 women with an average age of 63.6 ± 13.7 years. All patients had type 2 diabetes.  Eight patients presented with diplopia, three with periocular pain and 6 with headache. The oculomotor palsy was unilateral in all cases. All patients were in glycemic imbalance at the time of the diagnosis of ptosis and they were at high cardiovascular risk. The evolution under optimal equilibrium of diabetes and control of cardiovascular risk factors was marked by regression and disappearance in 4 patients, homo or contralateral recurrence in 4 patients and persistence of the palsy in 1 patient.

CONCLUSION

Glycemic equilibrium and ischemic phenomena due to cardiovascular risk factors are at the root of these oculomotor paralyses in diabetic patients. The evolution of diabetic mononevritis remains unpredictable despite the control of blood glucose levels and cardiovascular risk factors.

Correlation between superficial and intra-operative specimens in diabetic foot infections: results of a cross-sectional Tunisian study

Objective

To determine the correlation between superficial, and intra-operative specimens in diabetic foot infections (DFIs).

Methods

We conducted a cross-sectional study in patients with DFIs hospitalized in a Tunisian teaching hospital. Superficial specimens were collected for all patients, and intra-operative specimens were collected in operated patients. The specimens were processed using standard microbiology techniques. Antimicrobial susceptibility testing was carried out according to the protocol established by the European Committee on Anti-microbial Susceptibility Testing. Intra-operative and superficial specimens were considered correlated if they isolated the same microorganism(s), or if they were both negative.

Results

One hundred twelve patients, 81 males and 31 females, mean age 56 years, were included. Superficial samples were positive in 77% of cases, and isolated 126 microorganisms. Among the positive samples, 71% were monomicrobial. The most frequently isolated microorganisms were Enterobacteriaceae (53%), followed by streptococci (21%) and Staphylococcus aureus (17%). Nine microorganisms (7%) were multi-drug resistant. Intra-operative samples were positive in 93% of cases. Superficial specimens were correlated to intra-operative specimens in 67% of cases. Initial antibiotic therapy was appropriate in 70% of cases. The lower-extremity amputation and the mortality rates were 41% and 1%, respectively.

Conclusion

In our study, DFIs were most frequently caused by Enterobacteriaceae and superficial specimens were correlated to intra-operative specimens in only two thirds of cases. Clinicians should emphasize on the systematic practice of intraoperative specimens in all patients with DFIs treated surgically, while well-performed superficial specimens could be useful for prescribing appropriate antibiotic therapy in other patients.

[Posttraumatic type 1 diabetes in an army soldier]

L'influence du stress comme facteur précipitant l'apparition du diabète de type 1 est un sujet largement étudié dans la littérature. La relation entre les traumatismes physiques et psychologiques et le diabète ont été un sujet rarement étudié en milieu militaire. Le diabète post-traumatique reste toujours un sujet controversé. Nous rapportons le cas d'un soldat tunisien, sans antécédents personnels ou familiaux d’auto-immunité, qui a été diagnostiqué pour un diabète de type 1 au décours d’une agression physique lors de conflits sociaux entre les forces de l’ordre et les citoyens.

[Study of acute inaugural ketosis-prone diabetes in a Hospital in Central-Eastern Tunisian]

Ketosis-prone diabetes is an acute complication of diabetes resulting from ketone accumulation in the blood. Despite the high rate of ketosis-prone diabetes described, there is very little information on the epidemiology of this inaugural complication of diabetes in Tunisia. This study aims to determine the epidemiological and clinical features and the laboratory tests parameters of inaugural ketoses in a Hospital in Tunisian. We conducted a retrospective, cross-sectional exhaustive study of patients admitted with inaugural ketosis over the period January 2010 - August 2016. The study population was divided into 2 groups according to the presence or not of anti-pancreatic autoimmunity: the DAI group consisted of all patients with autoimmunity, the DNAI group consisted of all patients without autoimmunity. Our study included 391 patients, with a sex ratio of 226 men/125 women, the average age was 34 ± 14.33 years. There was a male predominance (68%) in the general population. The age of disease onset was significantly lower in the DAI group. A factor that contributed to ketosis onset was found in 77.7% of the overall study population, it was significantly more frequent in the DAI group than in the DNAI group. The most common factor was viral infections. Thyroid antibodies were significantly higher in the DAI group. Ketosis is a common factor leading to inaugural decompensation of diabetes in Tunisia. Young adult male is the most affected group of population reported in the literature, with the absence of autimmunity, and a clinical profile of type 2 diabetes.

Cortisol cut-points for the glucagon stimulation test in the evaluation of hypothalamic pituitary adrenal axis

Diagnosis of adrenal insufficiency requires evaluation by dynamic stimulation tests. The insulin tolerance test (ITT) is accepted as the gold-standard test for the evaluation of hypothalamo-pituitary-adrenal (HPA) axis but the test is unpleasant and dangerous. Although it takes more time, glucagon stimulation test (GST) is a good alternative to ITT. The primary aim of this study was to compare the ITT and GSTs in the evaluation of HPA axe in patients with pituitary disorders. We conducted a prospective study in which ITT and GST were performed within 7 days in 81 patients. Serum cortisol was measured. We divided our population in Group 1 (G1): Adrenal Insufficiency (Peak cortisol under ITT <200 ng/mL) and Group 2 (G2): normal response (Peak cortisol under ITT >200 ng/mL). Receiver-operating characteristic (ROC) analysis was performed to identify the thresholds for GST. The mean peak of cortisol under GST was not significantly different from that obtained after ITT in the whole cohort (182.67 ± 89.07 ng/mL vs. 179.75 ± 79.01 ng/mL), and it was significantly reduced in patients of G1 (p < 10^-3). ROC curve analysis showed that the best diagnostic accuracy was obtained with a peak cortisol cut-off to GST of 167 ng/mL (sensitivity, 89%; specificity, 79%). Using this cut-off, 86.4% of the patients were correctly classified. In our prospective series, GST is a potential accurate and safe alternative test for the assessment HPA. Test-specific cut-offs should be applied to avoid misinterpretation.

[Prolactin-secreting microadenoma in menopausal women]

Prolactin-secreting adenoma is rare in elderly women. Patient's clinical picture may be confused with that of menopause, making diagnosis sometimes difficult. We report the case of a 57-year old woman with a 2-year history of secondary amenorrhea without hot flushes associated with galactorrhea in order to highlight the peculiarities of prolactin-secreting microadenomas. Physical examination confirmed the diagnosis of galactorrhoea and biology showed hyperprolactinemia at mIU/L, FSH = 15.1 IU/L and LH = 4,1 IU/L. Pituitary MRI showed left adenoma measuring 8 mm. Patient's evolution under dopaminergic treatment was marked by the recovery, for a transitional period, of mestrual cycles and the occurrence of hot flushes, normalization of prolactin levels and reduction of adenoma size.

Macroprolactinemia and Empty Sella Syndrome

Macroprolactinemia is a polymeric form of prolactin-release, causing mildly symptomatic clinical pictures. The former can be isolated or associated with other causes of hyperprolactinemia. The association with an empty sella syndrome is rare. We report a case of a female patient discovered with this association. It’s about a female patient 47 years old, followed up since the age of 31 years for bilateral galactorrhea and a spaniomenorrhea. There has been no associated drug intake. Her exploration has showed a serum prolactin level of 635 mIU/L. Thyroid test results were normal T4 = 10,2ng/L and TSH = 1.76 mIU/L. A brain scan has showed an empty sella turcica. Despite the unchanged levels of prolactinemia, the evolution under dopaminergic 5 mg /D has been marked by the occurrence of a pregnancy with persistent moderate hyperprolactinemia in the postpartum. Chromatography has showed a predominance of the macroprolactin form with: Prolactin monomer at 4.8%, Big Prolactin at 5% and Big Big Prolactin at 83%, thus stopping bromocriptine. Our observation suggests that macroprolactinemia can be associated with conventional etiologies of moderate hyperprolactinemia as the empty sella syndrome. Its detection would prevent the use of dopaminergic therapy which seems not useful.

Lipid management in ramadan

During Ramadan fast, Muslims must refrain from smoking, eating, drinking, having sexual activity, and consuming oral medications from sunrise to sunset. It has been previously shown that Ramadan fasting induces favourable changes on metabolic parameters, reduces oxidative stress and inflammation and promotes cardiovascular benefits. Although ill people are exempted from fasting, most patients with chronic diseases are keen on performing this Islamic-ritual. During recent years, Risk stratification and treatment adjustment during Ramadan are well known and structured in several guidelines for patients with diabetes mellitus. Data related to the effect of Ramadan fast on lipid profiles are less known and several controversies have been reported. Here, we focus on lipid profile and lipid management during Ramadan taking into account comorbidities and cardiovascular risk.

[Place of pelvic ultrasonography using transabdominal technique in the investigation of premature ovarian failure]

OBJECTIVES

The aim of the present study was to characterize women with premature ovarian failure (POF) by their ovarian ultrasonographic appearances using transabdominal technique to establish the relationship to clinical, hormonal status, and genetic analysis.

PATIENTS AND METHODS

We studied a cohort of 80 patients suffering from POF. The surface of the ovary was calculated and we identified the detection or not of follicles.

RESULTS

The detection of the two ovaries by ultrasound was positive in 33 patients; only one ovary was identified in seven patients; none was noted in 40 patients. The surface of the ovaries ranged between 0.74 et 5.92 cm(2) (2.2+/-1.13 cm(2)). Ultrasonography identified follicles in 23 patients (28.75%). The presence of follicles suggested at ultrasonography was detected in 14 cases (70%) in normal-sized ovaries (> or =2 cm(2)) and in nine cases (45%) in small-sized ovaries (p=0.1). No significative statistical difference was found between the ultrasonographic appearances and the type of amenorrhea, pubertal development, hormonal status (estradiol, testosterone and delta-4-androstendione) and the chromosomal analysis.

CONCLUSION

The clinical and hormonal status and the genetic analysis can't predict the presence or not of follicles in the ovaries of patients with POF.

Non-traumatic fractures following seizures: two case reports

INTRODUCTION

Seizures with or without trauma may cause fractures that occur commonly in epileptic seizures. Fracture risk is less reported in non-epileptic seizures. Some metabolic conditions leading to a decrease in bone mineral density may cause fractures secondary to non-epileptic seizure.

CASE PRESENTATION

We describe two cases of non-traumatic acetabular and vertebrae fractures following seizures without history of epilepsy. They occurred in two male patients, 18 and 48 years old suffering respectively from hypercorticism and poorly controlled diabetes mellitus. Seizures, occurring inside hospital, were secondary to hypertensive encephalopathy crisis with hypokaliemia in the first case and severe hypoglycaemia in the second one. Fracture was promoted by a decrease in mineral bone density caused respectively by hypercorticism and diabetic chronic renal failure.

CONCLUSION

These observations emphasize that fracture prevention among patients with decreased mineral bone density should include the avoidance of metabolic causes of seizure.

Diabetes mellitus as an early symptom of pancreatic cancer diagnosed three years later

We present a case of a 40-year-old man with strong family history of diabetes. His pancreatic ultrasonography was normal at the discovery of his diabetes. Anti-pancreatic antibodies were negative. The patient was treated by insulin and continued to loose weight. His diabetes remained unstable during the follow-up. Three years later, a pancreatic adenocarcinoma was diagnosed which was locally advanced and could not be removed surgically. This observation argues among several mechanisms explaining diabetes in subjects with pancreatic cancer, in favor of tumor-derived diabetogenic substance and suggests that diabetes mellitus could reveal pancreatic cancer even in the presence of conventional risk factors of type 2 diabetes.

Retroperitonial liposarcoma mimicking pheochromocytoma

The authors report the case of a 46-year-old woman who presented with a 4 month history of paroxystic and recent hypertension accompagned by headaches, tachycardia and sweating. The patient had decreased appetite with epigastric discomfort and abdominal distension. Physical examination was initially normal with mainly normal tension and no abdominal or lombar mass in palpation. While hospitalised, she developed paroxystic crisis of flush, headaches and hypertension of 190/100 mmHg. Biological findings revealed hypokaliemia and normal kaliuria on 3 day samples, with normal glycaemia and normal creatininaemia. Hormonal investigation revealed elevated metanephrines (3 mg/24 hours). Magnetic resonance imaging showed an 11 cm x 8.5 cm retroperitoneal mass with an enhanced signal in T2, a hypotrophic non-functional left kidney and no adrenal adenoma. Clinical and hormonal features suggested a diagnosis of pheochromocytoma. After preoperative medication, open excision, including left radical nephrectomy and adrenalectomy, normalized the catecholamine urinary level, resolved hypokalemia, and improved hypertension. Pathologic examination revealed a well-differentiated liposarcoma, without any pheochromocytoma component, and left adrenal hyperplasia. The tumour cells were immunonegative for chromogranin A. No metastatic lesion was identified by thoraco-abdominal computed tomography.

[MRI and pituitary adenoma]

Pituitary is the most important gland of the organism which can be affected by many diseases, especially by adenomatous processes. Classically macroadenoma, microadenoma and picoadenoma are described, according to the size of the pituitary adenoma. The diagnosis of microadenoma was long considered a highly difficult task and that of picoadenoma was impossible by computed tomography. Recently, the high resolution of multiplanar MRI has enabled the diagnosis of microadenomas measuring less than 3 mm (picoadenoma). For macroadenoma, MRI not only contributes to diagnosis but is particularly important to assess the extension and to detect possible complications. The aim of our study is to illustrate MRI features in pituitary adenoma.

Le syndrome de Cushing factice : deux observations

INTRODUCTION

Search of corticosteroid use is an important precaution before any exploration of hypercorticism. Nevertheless, this use may be factitious leading to serious misdiagnosis and pitfalls.

EXEGESIS

We report two cases of 29 and 60 years old male patients, referred for hypercorticism with patent features including metabolic and trophical signs. Laboratories findings revealed unelevated urinary cortisol values (40 and 27 microg/ day) in both cases with normal ACTH and normal plasmatic cortisol response to synacthène (32,5 and 35 microg/dl). Corticosteroid use, initially denied, was finally approved by the patients (hydrocortisone and dexamethasone for the first patient and betametasone for the second). So, they were assigned to psychiatric therapy.

CONCLUSION

Our cases emphasize that corticosteroid misuse must be evoked in patients with unexpected hormonal assessment of pituitary adrenal axis despite patent clinical features of hypercorticism. Several specific tests are actually available for detect factitious Cushing syndrome. However, differential diagnostic remains difficult mainly with pseudo Cushing and cyclical Cushing syndromes.

Rhinorrhée par fistule ethmoïdale spontanée compliquant un syndrome de Sheehan

INTRODUCTION

Treatment of pituitary macroadenoma frequently leads to nontraumatic cerebrospinal fistula and rhinorrhea. We report an unusual case of rhinorrhea in a woman with Sheehan's syndrome.

CASE

A 39-year-old woman receiving hormone replacement therapy for hypothyroidism diagnosed 13 years earlier (Sheehan's syndrome) developed metabolic syndrome, which combining obesity, type 2 diabetes, hypertension and mixed hyperlipidemia. Cerebrospinal fluid rhinorrhea was confirmed by measurement of the glucose concentration in her nasal discharge and by cerebral MRI, which revealed a fistula of the ethmoid bone and an empty sella. Etiological screening was negative, and normal bone densitometry as well as the absence of trauma ruled out any bone defects. Conversely, the metabolic syndrome, notably obesity, suggested a nontraumatic mechanism for the empty sella.

DISCUSSION

Onset of empty sella syndrome during treatment for Sheehan's syndrome may be the cause of the CSF rhinorrhea. The role of obesity requires further investigation.

Histiocytose langerhansienne multiviscérale associée à un syndrome d'interruption de la tige pituitaire

Clinical manifestations of hypothalamic-pituitary Langerhans'cell histiocytosis are commonly, diabetes insipidus and sometimes growth hormone deficiency. Their morphologic characteristics on magnetic resonance imaging are absence of posterior pituitary hyperintensity and thickening of the pituitary stalk. Pituitary stalk transection is characterized on magnetic resonance imaging by the absence of pituitary stalk visibility, hypoplasia of the anterior hypophysis and ectopic posterior pituitary hyperintense signal. This syndrome has been shown to be associated with either isolated growth hormone deficiency or multiple anterior pituitary hormone deficiency, but normal posterior pituitary function.

CASE REPORT

We report our experience with a six-year-old boy who had been treated for three years for a multisystem Langerhans'cell histiocytosis with diabetes insipidus and who was admitted because of short stature. Endocrinological examinations demonstrated a profound growth hormone deficiency and a partial central hypocorticism. Magnetic resonance imaging showed pituitary stalk transection and a midline anomaly of the brain (Arnold Chiari type I malformation).

CONCLUSION

Although, some events of his perinatal history lead to the hypothesis of a malformative origin, the progression of Langerhans' cell histiocytosis affected tissues to fibrosis, suggest that this disease is the cause of the patient's hypothalamohypophyseal lesions.