Endocrine Abstracts

Aim: To study distribution and magnitude of morbidities (cardiovascular, renal, endocrine, CNS, hypertension, dyslipidemia) in North Indian adult obese patients.Methods: We assessed 100 obese patients based on BMI criteria for asian adults (BMI>27) attending endocrine and metabolic clinic and subjected for quantification of various morbidities in the form cardiovascular, renal, endocrine, CNS, hypertension, dyslipidemia.Results...

Diabetes mellitus is a serious health problem that requires continuous medical care to reduce the risk of its long-term complications. Although several guidelines have been developed to improve diabetes care, the compliance with diabetes clinical practice recommendations remains inadequate in some primary care clinics.The objective of this study was to assess the effectiveness of an intervention targeted at primary care physicians to improve the screenin...

Adrenal incidentaloma is a clinically silent adrenal mass detected on imaging performed for unrelated reasons. The concern is whether the incidentaloma is malignant or hypersecreting. The most comprehensive existing guidelines on investigation and management come from NIH Consensus Development Programme.We aimed to determine how many are identified by radiology over 12 months; how many of these are referred to endocrinology; how many are appropriately in...

We present a 59-year-old lady referred to us with worsening fatigue, arthralgia and dizziness over several years. Other symptoms included sleep disturbance, headaches, occasional palpitations and sore eyes. There was no family history of thyroid illness. Her medications included Vitamin B, Vitamin C, Hi 5 vitamin supplement, calcium, and zinc. On further questioning, she was taking kelp supplement (2 tablets per day) as recommended by a nutritionist, for treatment of ‘slu...

Background: Phaeochromocytoma are rare catecholamine secreting tumours and may present with hypertension, orthostatic hypotension, tachycardia and even cardiogenic shock. These tumours can easily be missed particularly in patients presenting with other disorders. We present a case of a patient with severe community acquired pneumonia who despite overwhelming sepsis was severely hypertensive.The case: JP was a 33-year-old man who was previously fit and we...

A 58-year-old previously fit and well man presented with sudden onset severe epigastric pain associated with frequent episodes of vomiting. The pain was constant and relieved only with morphine. He was febrile otherwise systemic examination was normal. Serum sodium 132 mmol/l and serum potassium 4.4 mmol/l. The rest of blood testes including; full blood count, liver functions, glucose, amylase, corrected calcium, D-dimer, troponin, urea and creatinine were all normal. ECG, che...

I would like to present a case of autoimmune poly glandular syndrome who first presented as profround hypothyroidism and secondary amenorrhea 8 years after her first baby. TSH was >100 and LH and FSH 44.3 and 27 at diagnosis with oestradiol of 18. As patient remained symptomatic after being on thyroxine replacement she went on to undergo a synacthen test which showed a much blunted response (baseline cortisol 264, 30 min 273 and 60 min 264). While being investigated as an ...

A 45-year-old woman was diagnosed with hypothyroidism at 26, Addison’s disease at 35 and primary ovarian insufficiency at 42. She is positive for adrenal and thyroid microsomal antibodies but negative for ovarian antibodies. She has a strong family history of autoimmunity. Interestingly, her mother has pernicious anaemia and hypothyroidism and her sister has hypothyroidism. A diagnosis of autoimmune polyglandular syndrome (APS) type 2 has been supported by the HLA haploty...

We report the case of a 77-year-old lady who presented to hospital with confusion, agitation and polyuria. She had type 2 diabetes mellitus but was otherwise well with no history of weight loss, nephrolithiasis or fractures. There was no relevant family history. There were no abnormal findings on examination apart from dehydration and no focal neurological signs or lymphadenopathy. Investigations revealed a serum corrected calcium level of 4.71 nmol/l (normal 2.1–2.6). He...

Historically, many endocrine specialist nurses (ESN) worked in ‘isolation’, with little peer support, ‘learning on the job’, there were few external training opportunities and their roles developed according to local expectations and needs.In 1997, a small group of ESN met to establish a support network for themselves and their colleagues. Within a year they had successfully developed links with the Society for Endocrinology (S for E)...

Introduction: Glargine is a recombinant human insulin analogue, used in the treatment of diabetes mellitus. Although widely used, information regarding the altered time-effect profile of glargine taken in overdose is scarce. We describe a case which highlights this phenomenon.Case report: An 82-year-old female was found by her neighbour, 18 h after attempting suicide by injecting herself with 600 units of glargine at multiple sites. Her capillary blood g...

Polymyalgia Rheumatica (PMR) is a condition of widespread inflammation which mainly affects large muscles manifesting as muscle pain, stiffness and weakness, usually associated with elevated circulating inflammatory markers. Typically PMR responds briskly to the introduction of glucocorticoids but hasty withdrawal can precipitate re-activation of the condition, a message illustrated by our case report in a patient identified with Cushing’s syndrome....

Introduction: Hyperprolactinaemia may be associated with weight gain and obesity, suggesting that prolactin may modulate body composition and weight. Treatment that normalises prolactin levels using dopamine agonists frequently leads to weight loss and provides further evidence for the association.Case: A 28-year-old South Asian male with a body mass index of 27.2 kg/m2 was referred to a weight management clinic with a five year history of wei...

Background: Hypoglycaemia frequently occurs in hospital inpatients with diabetes mellitus. With better vigilance amongst healthcare staff, episodes of hypoglycaemia could be prevented and with better awareness of the treatment process, early reversal of hypoglycaemia could avert the development of adverse events in these patients. This study aimed to assess the management of hypoglycaemia in hospital inpatients.Methods: This was a retrospective study of ...

A 46-year-old gentleman presented with a history of general lethargy, weight gain, limb weakness, easy bruising and severe back ache. Examination showed central obesity, proximal myopathy, with marked thinning and extensive bruising of the skin. His blood pressure and glycemic control were suboptimal and resistant to treatment. Routine blood tests including a chest X-ray were normal. An overnight dexamethasone suppression test showed failed serum cortisol suppression (749 nmol...

Background: Hyperadrogenemia is one of the most commonly encountered endocrine disorders in reproductive-aged women. By far the most common causes of androgen excess are functional which account for more than 90% of cases. Androgen and ovarian tumours producing excess androgen are however very rare and only account for about 0.2% of cases.Case history: A 62-year-old lady admitted to hospital with pneumonia was found to have an ill defined, firm, non-tend...

Elevated serum prolactin (PRL) is common, with many potential causes. We performed a retrospective audit of patients with hyperprolactinaemia from 2006 to 2008, aiming to identify the clinical indications for prolactin testing, the aetiology identified and the treatment instigated. Medical notes for 83 patients (55 female, mean age 41 years (range 17–95)) with PRL >700 mU/l were retrospectively reviewed. Indications for testing included: seizure or suspected seizure (...

Introduction: Benign prostatic hypertrophy is common amongst elderly men, and usually treated with the testosterone blocker, finasteride. However, the treatment of such a condition alongside hypo-pituitarism and low testosterone levels presents with a therapeutic dilemma.Case report: An 88-year-old gentleman who was admitted following recurrent episodes of confusion and falls was found to have a serum sodium level of 114 mmol/l, serum osmolality of 258 m...

Introduction: Cerebral ischaemic events in young patients due to patent foramen ovale are rare. A more plausible diagnosis had clouded the initial management and diagnosis of such a case in a young male patient.Case report: A 19-year-old gentleman was admitted with vomiting and profound hyponatraemia of 99 mmol/l. He was diagnosed to have Addison’s disease (with positive adrenal antibodies) following a flat short synacthen test. He warranted ITU adm...

Objectives: The long-term outcome of bariatric surgery on renal function in the morbidly obese renal transplant recipient is still unknown. We describe three cases of morbidly obese renal transplant recipients who have subsequently undergone bariatric surgery.Patient 1: A 44-year-old man (BMI 42.2 kg/m2) had received a renal transplant for chronic renal disease secondary to childhood reflux nephropathy. Laparoscopic Roux-en-Y gastric bypass re...

Introduction: Epilepsy and anti-epileptic medications can be associated with various endocrine disorders namely, polycystic ovary syndrome, premature ovarian failure, hypothalamic amenorrhoea, functional hyperprolactinaemia and rarely galactorrhoea. Here, we present a lady who developed intermittent episodes of galactorrhoea suspected to be due to primary generalized seizures.Case report: A 50-year-old lady was referred for investigation of elevated prol...

Introduction: Osteoporosis poses a significant public health issue, causing significant morbidity and mortality. It leads to an increased fracture risk through a reduction in the bone mineral density (BMD), disruption of bone microarchitecture, and alteration of the amount and variety of non-collagenous proteins in bone. Treatment aims are to prevent fractures and maintain the quality of life of the aging adult. The advent of the WHO assessment tool ‘Fractur...

A 51-year-old female presented with a 9 month history of symptoms suggestive of hypoglycaemia and associated episodes of unconsciousness, which were prevented by frequent food intake but with subsequent weight gain. She reported a history of lactose-induced anaphylaxis and the use of lactose-free subcutaneous prednisolone since sustaining a traumatic cardiac injury in 1987.Two supervised prolonged fasts demonstrated hypoglycaemia with elevated insulin le...

We present a 52-year-old lady with type 2 diabetes mellitus, referred by her GP with poor glycaemic control. Her past medical history included haemochromatosis, undifferentiated connective tissue disorder, depression, hypothyroidism, pernicious anaemia and alcohol abuse. Relevant medications were metformin 1 g bd, novorapid 28 units tds, levemir 30 mg od and prednisolone 5 mg od. Her HbA1c was 8.1%, renal function and baseline pituitary function was normal. Following an admiss...

Hypocalcaemia following thyroidectomy may be temporary or permanent, usually occurring within 14–72 h. The British Association of Endocrine Surgeons 2009 audit reported long-term hypocalcaemia rates of 7%. Total thyroidectomy for Graves’s disease carries the greatest risk (reported in 6–30% of cases) and currently there is no national consensus on management of this complication.We present three healthy young women who underwent total thyr...

A 45-year-old man was found wandering in the streets by the Ambulance Service. He complained of productive cough with haemoptysis. On examination he was cachectic with clubbing, and he was confused (abbreviated mental test score 1/10). Chest XR showed left hilar and perihilar air space shadowing. He was treated for a community acquired pneumonia. A CT scan of the head showed a mass lesion in the pituitary fossa, confirmed on an MRI scan.Assessment of his...

Hyponatraemia is the commonest electrolyte abnormality observed in clinical practise. It is a potential cause of substantial morbidity and mortality. Drug history, fluid volume status in addition to serum and urine biochemistry is essential for optimal management.We report a case of a 50-year-old female with known psychosis admitted to the Mental Health Unit and treated with Citalopram, Mirtazepine, Risperidone, Clonazepam and Procyclidine. Admission pla...

A 52-year-old gentleman was referred for the evaluation of hypercalcaemia. He gave a four week history of feeling generally unwell with dizziness, abdominal discomfort, weight loss, nausea and vomiting. He was an ex-heavy smoker and was on Lithium for about 20 years for bipolar disorder. He had had a recent admission to hospital with sepsis, secondary to chest infection, with a brief ITU stay and was discharged only 3 weeks prior to the onset of current illness.<p class="a...

A 25-year-old lady with poorly controlled type I diabetes presented acutely with vomiting, peripheral oedema and abdominal distention.She was diagnosed with type I diabetes at the age of 12 and her glycaemic control has always been suboptimal predominantly due to poor compliance with the treatment. She had had numerous admissions with diabetic ketoacidosis in the past.On examination a tender hepatomegaly was noted. The investigatio...

A 31-year-old Caucasian male with chronic fatigue syndrome and additional symptoms of abdominal pain and diarrhoea, was referred by his neuro-gastroenterologist for investigation of possible carcinoid tumour after finding a raised 24 h urinary 5HIAA level – 220 μmol/24 h (normal range <50 μmol/24 h).Full blood count, urea and electrolytes, liver function tests, plasma and urinary catecholamines were all within normal range.<p class...

A 39-year-old rugby league player was admitted with back pain to an Endocrinology/General Medicine ward. He was diagnosed with osteomyelitis of the spine and was treated with antibiotic. During his prolonged in-patient stay (6 weeks i.v. antibiotic treatment), the presence of purple striae on his lower abdomen was noted. Although he did not have other classical features of a Cushing’s syndrome including proximal myopathy, he had an increased BMI (38 kg/m2) and ...

Pituitary sarcoidosis is a rare form of neurosarcoid, commonly associated with multisystemic sarcoidosis. The most common intracranial site of sarcoidosis leading to endocrine involvement is the hypothalamus and the pituitary gland. The prevalence of hypothalamic–pituitary involvement in multisystemic sarcoiosis is reported to be around 5%.Granulomatous infiltration of the hypothalamus and the pituitary gland always results in endocrine disorder, GH...

Background: The insulin stress test (IST) is accepted as the gold standard investigation of the hypothalamio-pituitary–adrenal axis (HPA). The test has been shown to be reliable though potentially unpleasant for the patient and has been associated with complications such as loss of consciousness, seizures, arrythmias, angina, myocardial infarction and death. To this effect close medical supervision is always required when an IST is performed.Methods...

Background: The insulin stress test (IST) is accepted as the gold standard investigation of the hypothalamio-pituitary–adrenal axis (HPA). The short synacthen test (SST) has been advocated as an alternative to the IST. Fatigue can be a common presenting symptom of patients suffering from abnormalities in the HPA axis.Methods: We audited the results of ISTs following failed SSTs for the assessment of patients who present with symptoms of fatigue. We ...

Low potassium and magnesium are common findings found in patients seen on acute medical take which is often not followed up.A 23-year-old previously well Asian lady, presented with history of fatigue, weight loss and palpitations. She has been always thirsty and polyuric at night. There was history of tetany in childhood. There was a family history of an aunt who had Barter’s syndrome and her parents were first cousins.She had...

A 55-year-old female presented to her General Practitioner with hirsutism, male pattern baldness, weight gain and a deepening of voice. Her past medical history included well controlled type 2 diabetes on gliclazide, and hysterectomy for menorrhagia. She had an elevated serum testosterone after solvent extraction (18 nmol/l) and free androgen index (17.6). The patient was referred for further investigation.17-Hydroxyprogesterone and dehydroepiandrosteron...

We present a case of a 25-year-old male with no significant past medical history presenting with extensive bilateral cervical lymphadenopathy, thirst and polyuria. He denied night sweats, weight loss or a change in appetite. There was no reported previous contact with tuberculosis and he had not travelled to high risk areas. A water deprivation test was consistent with a diagnosis of diabetes insipidus.Computerised Tomography scanning of the chest demons...

Androgen secreting ovarian tumours account for 0.1% of ovarian tumours. They can appear at any age (mean, 42 years) and can be slow growing.We report a case of androgen secreting ovarian tumour diagnosed at a delayed stage. It is unusual as it evaded diagnosis because of various factors, which we believe should be learning lesions.A 56-year-old lady with medical history of sub-arachnoid haemorrhage (SAH), presented with features of...

A 63-year-old phenotypic male presented with absent testis and enlarged adrenal glands. He had attended the urology clinic for persistent microscopic haematuria. He was found to have an empty scrotum and hypospadias. The patient recalled having genital surgery in childhood but could not recall any endocrine assessment. He was taller than his peers in early childhood but stopped growing after age 13 years. He described himself as ‘potent’. He was unmarried and did not...

A 31-year-old female presented with menstrual irregularities, weight gain and hirsutism.She was recently diagnosed with type 2 diabetes requiring Metformin therapy.Investigations: Serum cortisol levels failed to suppress on overnight dexamethasone suppression test (ODST) and low dose dexamethasone suppression tests (LDDST) (ODST: unsuppressed cortisol at 343 nmol/l, LDDST 48 h post dexamethasone cortisol of 397 nmol/l). The serum c...

We would like to present a case which, through unexpected results, caused us to examine the communication, both written and verbal, that is provided to patients prior to undergoing dynamic tests in our unit, and which subsequently led to a change in our practice.A 48-year-old lady was referred from the GP with a raised testosterone of 5.0 nmol/l (reference range 0.2–2.9 nmol/l), irregular periods and late onset hirsutism. A low dose dexamethasone te...

A 45-year-old woman presented with a 6-week history of constipation and generalised abdominal pains. Blood biochemistry revealed a corrected serum calcium of 4.99 mmol/l, phosphate 0.82 mmol/l, and intact parathyroid hormone (i-PTH) of 0.2 pmol/l (normal range 1–6.1 pmol/l). Serum parathyroid hormone related peptide (PTH-rP) was 5.3 pmol/l (normal range <1.8 pmol/l). Computed tomography demonstrated an 11.0×11.6 cm ovarian tumour with cystic and solid areas and h...

A 61-year-old gentleman, with a background of chronic schizophrenia, presented with hyponatraemia in 2008 and was diagnosed with Addison’s disease. He had two previous admissions with hyponatraemia in 2002 and 2006. During his first admission his hyponatraemia was attributed to volume depletion secondary to vomiting, and he responded to fluid resuscitation. On the second occasion, SIADH (syndrome of inappropriate antidiuretic hormone) was diagnosed secondary to antipsycho...

Case report: A 52-year-old woman presented with an 11-month history of increasing hirsutism and deepening voice. She had a past history of total abdominal hysterectomy (ovaries preserved) with adjuvant chemotherapy and radiotherapy for cervical carcinoma. She was on no medication. Examination revealed evidence of virilisation with no other abnormality.Investigations: Total testosterone=10.7 nmol/l (<2.9).FSH=31.7 U/l (37–1...

Background: Insulin autoimmune syndrome (IAS) is characterised by spontaneous hypoglycaemia in the absence of exogenous insulin administration and high serum levels of immunoreactive insulin along with high titres of insulin antibodies. Although it is the third leading cause of hypoglycaemia in Japan, it is very rare in the western world. We present the first reported case of IAS in UK.Case report: A 27-year-old lady from south east-Asian background pres...

Background and aims: Antithyroid medications are first line treatment for thyrotoxicosis in the UK. The risk of agranulocytosis is ~1:2000 cases. Between 1963 and 2003, 809 adverse reactions related to antithyroid medications were reported. Of these 179 were due to agranulocytosis. Forty-two fatal events were recorded and half of these were related to agranulocytosis.Patient awareness is vital in preventing drug associated morbidity and mortality. We con...

A 25-year-old Asian man presented with a 6 month history of erectile dysfunction, loss of libido and reduced exercise tolerance. His past medical history included ulcerative colitis, treated with long-term prednisolone and mesalazine for 8 years. He weighed 116 kg and his BP was 144/86 mmHg. He had bilateral gynaecomastia but no galactorrhea. Testicular volumes were 8 ml bilaterally and secondary sexual characteristics were normal. He was clinically euthyroid.<p class="abs...

Pituitary apoplexy is uncommon and the incidence is quoted to be between 5 and 16% in pre-existing pituitary adenomas. Recurrent pituitary apoplexy is rarer; we report 2 such cases.A 22-year-old female underwent transsphenoidal resection of an expanding intrasellar lesion in 1987. She was commenced on hydrocortisone for cortisol deficiency and on subsequent follow-up, on thyroxine. She required repeated surgery in 2003 and 2005 after she presented with h...

A 24-year-old Pakistani woman presented one day after returning from a 6-week holiday in Pakistan with a 3-day history of generalised weakness, difficulty in walking and left flank pain. She was known to have mixed connective tissue disease (MCTD). Clinically she was pyrexial and had generalised muscular weakness (power 3/5), and hypotonia. Biochemically, she was found to have hypokalaemia (1.8 mmol/l), raised serum urea (8.1 mmol/l), and creatinine (160 μmol/l), high ESR...

A 59-year-old lady with headaches and malaise was found to be hypertensive with a blood pressure (BP) 210/105. An MRI brain revealed a haemorrhagic lesion in the right temporal lobe. There were no other signs of end organ damage. Her medications included atenolol 25 mg OD, ramipril 10 mg OD and bendroflumethiazide 2.5 mg OD. It transpired that she has been drinking 5 cups of liquorice tea per day over the last 18 months. Following a vomiting illness she stopped liquorice tea c...

A 60-year-old woman presented with 2 months of aching limbs and 2 weeks of nausea and a left sided neck mass. She was clinically euthyroid with a 5 cm non-tender left thyroid nodule. There was no cervical lymphadenopathy and the remainder of the examination was unremarkable. There was no family history of any endocrine disorder.Investigations showed serum TSH concentration 5.94 μ/l and serum free T4 concentration 12 pmol/l. Thyroid peroxi...

A 24-year-old Asian lady with no past medical history was admitted under the surgical team with right sided abdominal pain, nausea and vomiting, postural dizziness and weight loss. She was give trimethoprim for a possible urinary tract infection along with paracetamol, tramadol and diclofenac. Blood tests on admission demonstrated normal renal, liver and thyroid function, a normal C-reactive protein and full blood count and a low sodium of 131 mmol/l. An abdominal ultrasound w...

A 68-year-old female was found to have a supra sellar mass on CT scanning for investigation of long-standing tremor. She had experienced thirst, polydipsia, polyuria, nocturia and malaise for 1 year. Primary hypothyroidism had been diagnosed 5 years earlier. A left temporal visual field defect found 3 years earlier had been attributed to a structural anomaly of the optic nerve head. MR scanning confirmed the presence of a mass lesion of the infundibulum with displacement of th...

A 34-year-old female presented with an 18 months history of secondary amenorrhoea, hirsutism, weight gain and low mood. Examination confirmed typical stigmata of Cushing’s syndrome with skin thinning, purpura, acne, facial plethora, central adiposity and hypertension. Investigations revealed fT4 14.7 pmol/l, fT4 4.1 pmol/l, TSH 0.71 μ/l, prolactin 377 μIU/ml, FSH 3.5 μ/l, LH 2.2 μ/l, oestradiol 140 pmol/l, testosterone 5.1 nmol/l,...

A 41-year-old lady presented with a long history of very severe premenstrual dysphoria, commencing 2 weeks prior menstruation. Her symptoms included behavioural problems and in particular aggression, impaired memory, palpitation, bloating and diarrhoea. She also experience cyclical left head and left eye pain without visual symptoms. She was para 3+0 with a past medical history of polycystic ovary syndrome, eventually treated by ovarian diathermy. During pregnancy her symptoms...

A 36-year-old man, presenting to his GP with severe intermittent headaches, was found to have a blood pressure of 210/110 mmHg. He had been diagnosed with familial adenomatous polyposis (FAP) in early childhood, and had had a total colectomy with ileo-rectal anastamosis at the age of 17. Routine surveillance CT imaging the following month revealed an incidental finding of bilateral adrenal masses (right 4×2 cm, left 2.7×2.9 cm).On assessment in...

A 40-year-old female presented with lethargy, poor mobility and blurred vision for 2 weeks and 6 months of amenorrhoea. On examination she was markedly Cushingoid with proximal myopathy and normal visual fields. She was hypertensive, with peripheral oedema and leg ulcers. Bloods revealed leucocytosis, hyperglycemia, and ketonuria. She was commenced on insulin. CXR was clear.Endocrine review diagnosed Cushings syndrome. Cortisol did not suppress overnight...

Introduction: Hypothyroidism in pregnancy may be associated with neurodevelopmental delay of the unborn baby. Timely management of abnormal thyroid function tests (TFTs) in pregnancy is important. In our centre, some patients attend an Endocrinology-led dedicated antenatal thyroid clinic, whilst others attend an Obstetrician-led general antenatal clinic.Objectives: The management of hypothyroid pregnant patients attending our centre was audited against T...

Hypomagnesaemia usually occurs secondary to decreased intestinal absorption or excessive renal excretion. There have been a few reports recently suggesting an association between PPIs and hypomagnesaemia.A 65-year-old lady was referred to the endocrine clinic for investigation of hypomagnesaemia found on routine testing. Serum magnesium was 0.27 mmol/l (normal 0.7–1.0), with corrected serum calcium of 2.0 mmol/l (2.12–2.63), and normal PTH and ...

Gitelman’s syndrome (GS) is a rare autosomal recessive renal tubular disorder caused by defects of thiazide sensitive Na-Cl co-transporter due to mutations of the SLC12A3 gene.We report a case of a 23-year-old woman, who presented with excessive tiredness in her second pregnancy. She had a past history of hypokalaemia in a previous pregnancy (attributed to ‘vomiting’), which required multiple admissions for i.v. potassium replacement despi...

A 28-year-old man presented to his GP in Turkey complaining of fatigue. As part of his work up, serum PTH was assessed and was found to be markedly elevated at 29.9 pmol/l (normal range 1.6–6.8), with normal calcium, phosphate, alkaline phosphatase, renal function, 1,25- and 25-hydroxy vitamin D3 levels. A DEXA scan was normal and a Sestamibi scan did not reveal any parathyroid adenoma. Prior to any further investigations or treatment, he moved to the UK.<p class="abs...

A 34-year-old primi gravida, 11 weeks into pregnancy, presented with hypertension (blood pressure 170/110 mmHg) proteinuria and hypokalaemia. She gave a 6-week history of tiredness, weight gain, and easy bruising. On examination, there was marked facial puffiness, non pitting oedema, thin skin with multiple bruises, marked proximal myopathy and no pigmented striae. Pregnancy associated Cushing’s was suspected.Investigations: Hypokalaemia (K+</s...

A 30-year-old Eritrean female presented with a 1 month history of nausea and vomiting, with 15 kg weight loss but no bowel disturbance. Past medical history included an open cholecystectomy. There was no family history of mineral or bone disorders. She denied any prescribed/over-counter medication and abstained from alcohol. Examination revealed marked cachexia (BMI 16.1 kg/m2). ECG revealed ST depression and T wave inversion.Investigations in...

A 19-year-old student was referred with a history of increasing anxiety attacks, palpitations and breathlessness. Blood pressure and urinary catecholamine levels were elevated. MRI imaging confirmed a para-aortic paraganglionoma and MIBG scan highlighted bony metastases. The patient underwent surgery for the primary lesion and targeted MIBG therapy for metastases.Age of onset, malignant disease and metastases increase the likelihood of a genetic cause an...

Introduction: PHPT is reported to be rare in pregnancy, with 150 cases described in the literature. Its incidence is 8/100 000 in childbearing women/year. PHPT may lead to a loss of up to 50% of pregnancies through miscarriage or stillbirth, dehydration, hyperemesis, nephrolithiasis, pre-eclampsia, fractures and pancreatitis in mothers; and death, hypocalcaemia and tetany in neonates. Intrauterine growth retardation, low birth weight and pre-term labour were described. Rate of...

This lady with a background of schizophrenia and depression, on long term lithium therapy, initially presented in 2002, at the age of 53, with acute renal failure and symptoms of lithium toxicity secondary to sepsis. Lithium level measured at the time was 2.5 mEq/l and her creatinine 314 μmol/l. She was normocalcaemic on admission. The patient was hospitalized on ICU and the treatment included ventilation, haemofiltration and inotropic support.On 10...

A 48-year-old woman presented to her GP with polyuria and proximal muscle weakness. She was found to have newly developed hypertension at 180/96 and her serum potassium was 2.7 mmol/l. Lisinopril 40 mg od and Slow-K 1 tablet bd were started and she was referred for further investigation.On clinic review blood pressure was 188/110 supine and 190/110 standing. Serum sodium was 147 mmol/l, potassium 3.7 mmol/l and total bicarbonate 29 mmol/l. Her Lisinopril...

A 70-year-old woman was referred to the endocrine clinic with recently diagnosed diabetes mellitus and poorly controlled systemic hypertension. At presentation she had clinical features of Cushing’s syndrome including central obesity, Cushingoid facies and marked proximal myopathy. BP was 220/190. Initial biochemistry revealed plasma sodium 140 mmol/l, potassium 3.6 mmol/l and creatinine 82 mmol/l. Overnight 1 mg dexamethasone suppression test revealed cortisol 1148 mmol/...

Aims: Treatment regimes for low testosterone are well established but reasons for treatment change and patient preferences are less well known. We looked at the type of testosterone replacement, subsequent modification of replacement and reason for that change.Methods: Data were collected from the electronic case notes of 50 patients on testosterone replacement for at least 6 months attending endocrine clinics in a University Teaching Hospital.<p cla...

Background: Obese young people are likely to suffer significant morbidity in adult life. Successful intervention during adolescence may have far-reaching benefits. Evidence is emerging that patient-responsive clinical services may deliver improved outcomes.Aims: To assess the perceptions of obese young people about weight and weight-management services.Method: Annonymised, postal questionnaire survey of 116 obese young people (9&#1...

Insulin induced hypoglycaemia is a life threatening complication in T1DM. Sub-optimal counter regulatory response, with hypocortisolemia, threatens the recovery from insulin induced hypoglycaemia. We present a 28-year-old man with polyglandular autoimmune syndrome type 2 and life threatening hypoglycaemia, whose severe hypoglycaemic events were improved following introduction of CSII.The patient was diagnosed with Addison’s disease in 2000 and T1DM ...

A 51-year-old woman with no significant past medical history presented with left flank pain, accelerated hypertension, progressive deterioration in renal function and left sided pleuritic chest pain. CTPA revealed pulmonary oedema and left adrenal haemorrhage. Urinary catecholamines were marginally elevated (24 h Urinary Metadrenalines 7.58 μmol/24 h) raising the possibility of an underlying phaeochromocytoma. Short synacthen test showed a sub-optimal response (0 min cort...

Up-to-date, there have been 7 case reports of hypomagnesaemia associated with hypocalcaemia and hypokalaemia in patients on long-term treatment with proton-pump inhibitors (PPIs). The suggestion is that these reports present a tip of an iceberg in clinical practice. Inspired by a case of severe symptomatic electrolyte loss, which was corrected by discontinuation of PPIs, we performed an audit of a potential relationship between hypomagnesaemia and PPIs in our hospital.<p c...

Despite rarer in children than in adults, GH-secreting pituitary adenomas are often more aggressive, being challenging cases during childhood. Somatic changes (tall stature and acromegalic features), optic chiasma syndrome or metabolic and cardiovascular impact of GH excess trigger diagnosis and requires aggressive management. Treatment options are surgery, radiotherapy and medical therapy using somatostatin analogues, dopamine agonists and recently, GH receptor antagonists &#...

Context: Bariatric surgery can lead to vitamin deficiencies.Objective: To assess changes in blood vitamin concentrations after gastric bypass surgery.Design: Twenty-nine patients underwent gastric bypass and 24 unmatched controls underwent lifestyle intervention in a prospective, non-randomised trial. Patients in the surgical group received multivitamin, iron, calcium, vitamin D, and vitamin B-12 supplements. No supplements were pr...

A 60-year-old HIV positive man was referred from the genitourinary physicians for investigation of hypercalcaemia (calcium 3.20 mmol/l). He described non-specific symptoms of tiredness and polyuria. Past medical history included well-controlled HIV with an undetectable viral load, secondary syphilis and a history of renal stones. Medications included Didanosine, Emtricitabine, Darunavir and Ritonavir.Initial investigations demonstrated a suppressed parat...

Non-islet cell tumour hypoglycaemia (NICTH) is a rare paraneoplastic phenomenon and there is limited guidance regarding different treatment modalities.We present two cases of NICTH focusing on the combined methods used to control hypoglycaemia.The first involves an 89-year-old gentleman diagnosed with a pelvic leiomyoma in 2003. For several years, he had experienced recurrent collapses which briefly improved following tumour emboli...

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is regarded as a precursor to the development of carcinoid tumorlets. It is confined to the neuroendocrine cell of the airway mucosa without penetration through the basement membrane and appears in a diffuse pattern, typically in association with obliterative bronchiolar fibrosis. DIPNECH belongs to the preinvasive lesions defined by the 1999 World Health Organization classification, along with atypical ade...

Background: Anorexia is a problem of paramount importance in patients with advanced liver cirrhosis contributing to malnutrition. In turn, malnutrition is a risk factor for the development of life-threatening complications and increased mortality. Ghrelin hormone; an important orexigenic agent has been postulated to integrate anabolic changes in the body.Aim: To assess ghrelin level in Egyptian patients with liver cirrhosis and hepatocellular carcinoma.<...

Introduction: Neuroendocrine tumors (NET) are very rare and often present a diagnostic challenge. They are often misdiagnosed due to non-specific symptoms. We report a rare case of NET presenting to a non endocrine unit.Case: A 72-year-old Caucasian female was referred for refractory diarrhoea with hypokalaemia. In addition, there was history of significant weight loss over few months.She had past medical history of diabetes, hyper...

Background: The high prevalence of metabolic syndrome (MS) in schizophrenia has been increasingly recognized in the mental health literature in recent years. The MS is a cluster of the most dangerous known cardiac risk factors (diabetes and prediabetes, abdominal obesity, high cholesterol level, and high blood pressure ‘BP’; according to the International Diabetes Federation Criteria, 2007). The existence of an increased mortality risk among people with...

Introduction: Hypocalcaemia secondary to post-operative hypoparathyroidism is a recognised complication of thyroid surgery with reported rates of up to 75%. Little guidance exists on the appropriate management of post-operative hypocalcaemia and individual clinicians may develop their own preferred management strategies based on past experience. However, delay in restoring normocalcaemia may increase length of hospital stay and patient morbidity.Aims: i)...

Background: Contrast procedures are frequently performed in diabetic patients and are the third most common cause of hospital-acquired renal failure1. Diabetic patients are at risk of Metformin associated lactic acidosis in the presence of renal failure2.Standards: RCR guidelines3 recommend:• Recent serum creatinine should be available for patients with renal disease or diabetes<p class="ab...

Introduction: Hypoparathyroidism is normally treated with calcium salts and activated vitamin D. Here we report a case where synthetic 1–34 PTH (teriparatide) and i.m. vitamin D was successful in treating a case of primary hypoparathyroidism resistant to conventional treatment.Case report: A 16-year girl presented to the emergency department with vacant episodes and mild confusion. Her childhood was uneventful until the age of 12 when she developed ...

The current paradigm for management of acromegaly includes surgery as primary treatment regardless of whether or not this is likely to be curative. There is increasing evidence that somatostatin analogue medical therapy may produce shrinkage of growth hormone producing pituitary tumours. This study tests the hypothesis that primary medical therapy may produce clinically significant tumour shrinkage prior to surgery.Eleven treatment naïve subjects wi...

Background: Hypothyroidism is reported to be associated with mild insulin resistance though severe insulin resistance is rare. We report the case of a man presented with reversible severe insulin resistance in hypothyroidism.Case report: A 23-year-old obese man with autism was presented with poor responsiveness (GCS 7/15). He had general malaise for 2 days prior to admission. On admission, his test results showed random glucose – 60.8 mmol/l, potass...

A 17-year-old female was referred to the adult endocrine clinic with a history of primary amenorrhoea. She was short in stature with a height below the 4th centile for her age. Her BMI was 24 kg/m2 with a weight below the 25th centile and there was delay in bone-age 2 years.She had an interesting past medical history of late-onset central nocturnal hypoventilation from the age of 8 years when she presented with apnoeic episodes and weight gain...

Introduction: Gastric endocrine tumors (GET) are rare. Type 1 tumors are non-functioning, almost exclusively benign lesions, usually presenting as multiple polyps, usually <1 cm in diameter, which arise from gastric enterochromaffin-like cells in response to chronically elevated gastrin, secondary to (auto-immune) atrophic fundic gastritis. These tumors were traditionally treated with total gastrectomy, like adenocarcinomas. Currently, surveillance or endoscopic treatment ...

Introduction: A short-synacthen test (SST) is routinely used to diagnose hypoadrenalism, however, some authors suggest using morning serum cortisol as an initial screening test to rule out hypoadrenalism. We assessed the utility of a morning cortisol as a screening test when compared with the outcome of SST.Methods: We retrospectively analysed SSTs carried out in our endocrine outpatient clinic in the last 3 years (649 results). Of these, 113 were identi...

Over the last 10 years there have been significant advances in stem cell transplantation (SCT) in adults for haematological malignancies leading to improved survival. Conditioning regimes prior to transplantation often utilise high dose chemotherapy and/or total body irradiation (TBI). Significant endocrinopathies have been reported amongst children undergoing SCT. We report the effect of SCT during adult life on endocrine function.Basal hormone levels w...

Thalassaemia patients are transfusion dependent and at risk of iron overload with end organ damage. Iron deposition is reduced by chelation treatment. We present the data on endocrinopathy and bone density in the adult patients under our care with thalassaemia. In addition, we will discuss therapeutic approaches to these problems including the use of newer chelation agents and possible reversal of endocrine end organ damage. We will also review the correlation in our patients ...

Introduction and aim: Long-term unemployment leads to poorer health and increased inequalities. The Welfare Reform Bill, published on 14 January 2009, supports the progression back to work for incapacity benefit claimants.Due to the chronic nature of endocrine conditions, affected patients may be at an increased risk of long-term unemployment. We do not currently hold data describing the unemployment or return to work rate for this group. Our aim is to d...

Background: Hypercalcaemia is defined as an elevated serum calcium level above 2.6 mmol/l and occurs in 1 in 1000 of the population. It commonly results from primary hyperparathyroidism (PHP) which is usually treated with parathyroidectomy. A less common cause of hypercalcaemia is familial hypocalciuric hypercalcaemia (FHH) which is caused by mutations inactivating the calcium-sensing receptor; however FHH is relatively benign and requires no treatment. It is clearly important...

Context: Hydrocortisone day curves (HCDC) are used to monitor hydrocortisone replacement by obtaining serum samples to measure cortisol levels throughout the day. Salivary measurement of free cortisol offers a non-invasive alternative to serum measurements.Objective: To validate salivary cortisol measurement as an alternative method to assess the adequacy of hydrocortisone replacement in patients with hypoadrenalism.Setting, patien...

Introduction and aims: Women with polycystic ovary syndrome (PCOS) are at significantly increased risk of developing impaired glucose tolerance (IGT; prevalence 9–35%) and type 2 diabetes (T2DM; prevalence 2–10%), hence screening for these complications is recommended. The American Androgen Excess Society (AAES) recommends a biannual oral glucose tolerance test (OGTT) in all women with PCOS but this is costly and inconvenient. Alternative strategies which minimise th...

Hyperaldosteronism is a significant cause of secondary hypertension, but there are often delays in obtaining the diagnosis. The recent BES publication of Guidelines for the investigation and management of this condition represent a move to standardise the work-up of these patients.We present an audit of cases, dating back to 2000, with confirmed biochemical hyperaldosteronism (on the basis of plasma aldosterone/renin activity ratio or lack of aldosterone...