Endocrine Abstracts

Introduction: There has been much interest recently in measuring both salivary cortisol and cortisone due to the presence of 11β-hydroxysteroid dehydrogenase type 2 enzyme in the salivary glands. This enzyme facilitates the conversion of cortisol to cortisone; hence the concentration of cortisone in saliva may also be of interest. Studies have shown recently that salivary cortisone and cortisol are good markers of serum free cortisol status.Methods:...

Liquid chromatography tandem mass spectrometry (LC–MS/MS) methods are considered superior to immunoassay for the analysis of serum 25-hydroxy vitamin D (25-OHD) due to improved performance and potential cost benefits. As LC–MS/MS is appropriate for the analysis of other clinically relevant hormones tandem mass spectrometers are becoming commonplace in UK clinical laboratories. However, like immunoassay, LC–MS/MS methods are not foolproof and inappropriate use of...

Testosterone in serum may be unbound (free), or bound to either sex hormone binding globulin (SHBG) or albumin. Consequently, ‘total’ serum testosterone analysis may be misleading in situations where binding protein concentrations are abnormal. Current methods for estimating the biologically active (bio-available) serum testosterone concentration involve physical separation of testosterone fractions and are not amenable to high-throughput analysis. The use of automat...

A 74-year-old man was referred urgently for investigation of recurrent phaeochromocytoma.In 2006, he was referred to another hospital with nocturnal sweating and tremors. He was found to have a left sided phaeochromocytoma which was removed laparoscopically with uneventful follow up. Unfortunately no initial results or histology were available on referral to our department.Follow up in primary care had involved annual 24 h urinary ...

Objective: Vitamin D deficiency is common among women despite abundant sunshine in Saudi Arabia. No local study has evaluated the seasonal vitamin D level among hospitalized menopausal and postmenopausal Saudi women. The aim of this study was to estimate the prevalence of vitamin D deficiency among menopausal and postmenopausal in Saudi Arabia during summer and winter.Methods: Data were retrospectively collected for 1556 female patients (>19 years) d...

Background: Insulin, derived from a single chain precursor pro-insulin, is cleaved by convertases to form insulin (t1/2 – 4 min) and C-peptide (t1/2 – 30 min). The ratio of insulin to C-peptide levels, which is usually less than one, is reversed in presence of exogenous insulin and insulin autoimmune syndrome. We present the significance of insulin-C-peptide ratio (ICR) in the diagnostic algorithm for the investigation of endogenous hyperinsulinaemia.<p class="ab...

Introduction: Hirsutism, the presence of terminal (coarse) hairs that appear in a male-like pattern, affects 5–10% of women and may cause concern for an underlying endocrine disorder or malignancy. Spironolactone compete for the androgen receptor in the hair follicle, therefore, it is frequently used in treatment of hirsutism. We report a case, in which treatment of hirsutism with Spironolactone interfered with androstenedione immunoassay and raised unnecessary concern ab...

Both diabetes and Addisons’ are conditions which can be associated with muscle weakness and altered potassium levels. This is a case of recurrent muscle paralysis in a patient with both conditions with the underlying abnormality being the neurological condition of hypokalaemic periodic paralysis.A 23-year-old Caucasian gentleman was admitted to medical admissions with sudden onset weakness of his lower legs. On examination he had reduced power of hi...

The short Synacthen test (SST) is used to evaluate adrenal glucocorticoid secretion in response to synthetic ACTH (also known as tetracosactide or Synacthen). Traditionally, after a baseline cortisol and ACTH, two plasma cortisol samples have been taken after i.v. or i.m. administration of Synacthen 250 μg, one at 30 min and one at 60 min. However practice varies and some physicians only take one cortisol measurement at 30 min.Hypothesis: A protocol...

The accurate measurement of cortisol by immunoassay is compromised by the potential for cross-reactivity of reagent antibodies with structurally-related steroid compounds present in patient serum. This susceptibility is potentiated when normal steroid metabolism is altered pharmacologically by anti-steroidogenic drugs. This class of drug is utilised in the management of Cushing’s syndrome to moderate cortisol production. To investigate the effect of the 11β-hydroxyla...

Background: Testosterone replacement therapy has been shown to produce a wide range of benefits for men with hypogonadism with studies showing improvement in libido, bone density, muscle mass, body composition, mood, cognition, and erythopoiesis. The risks associated with testosterone replacement therapy are less well characterised and there is a lack of larger randomised trials. One recognised risk is polycythaemia. The aim of this study is to assess the frequency of polycyth...

Aim: To determine whether cases of hypocalcaemia presenting via an emergency medical admissions unit (EAU) are appropriately investigated.Background: Hypocalcaemia is a potentially life threatening abnormality, with a prevalence of 18% among hospital inpatients.1,2 Risk factors include vitamin D deficiency, renal disease, hypoparathyroidism (typically post-neck surgery) and hypomagnesaemia. A reasonable investigational dataset comprises U+Es a...

A 29-year-old woman was admitted at 33 weeks gestation with pre-eclampsia (BP 145/107 mmHg, 3+ proteinuria and significant oedema). On admission her Na was 133 mmol/l and urinary Na 49 mmol/day (ref range 130–260). Twenty-four hours urine protein was 4.43 g/day. Foetal assessment revealed intra uterine growth retardation. She was started on labetolol and the dose titrated upwards to control her blood pressure.Her serum sodium level gradually fell re...

Introduction: Hyponatraemia is the commonest inpatient electrolyte disturbance, and its severity has been shown to correlate with in-patient mortality, length of stay, and use of hospital resources. Unfortunately, hyponatraemia goes frequently unrecognised. The purpose of this audit was to see how a tertiary health centre manages hyponatraemia and how patient journey is affected.Goals: To identify hyponatraemic patients in a tertiary centre in a 2-week t...

Primary adrenal failure is a rare condition with an incidence during pregnancy of around 1 case in 12 000 gestations.A 31 years old primi gravida presented 10 days after giving birth to a healthy child at full term with postural dizziness and severe fatigue. There was no history of excessive blood loss during delivery and her past medical history was unremarkable, but low blood pressure (BP) was reported throughout pregnancy. She mentioned increased body...

Poor transitional care leads to increased loss to follow up, non-adherence to treatment, high morbidity and mortality. The paediatric and adult endocrinology teams in our Trust have been running a joint transition service since 10/2000. A review of this service was undertaken, in order to examine its effectiveness and to aid its improvement.The details of all 81 patients, who had been through transitional care between 10/00-09/09 were acquired. Their rec...

A 61-year-old man was referred to the Endocrinology clinic with a 5-month history of hyponatraemia. It was first detected as part of a routine test, which revealed a serum sodium of 124 mmol/l. His serum osmolality was 253 mOsmol/kg, urine sodium was 32 mmol/l and urine osmolality 317 mOsmol/kg. His results suggested SIADH. He already had a chest X-ray and brain MRI scan done which were reported as normal. His thyroid function test and short synacthen test were normal. He had ...

Introduction: Thyrotropinomas are rare pituitary tumour accounting for 0.5–1.0% of all pituitary tumours. There are only seven reported cases of mixed TSH/LH/FSH producing adenoma. We report a patient with secondary hyperthyroidism due to TSH producing adenoma co-secreting FSH and LH.Case report: A 75-year-old Caucasian male was seen with 2-year history of tiredness, anxiety and palpitations along with 7-month history of weight loss. He also complai...

Introduction: Adrenal incidentaloma is defined as a clinically inapparent adrenal mass that is incidentally detected after imaging studies conducted for reasons other than the evaluation of the adrenal glands. Existing guidance suggests that excess catecholamine and cortisol secretion should be ruled out all cases and excess aldosterone secretion should be ruled out hypertensive patients. Certain features on CT scanning such as a Hounsfield value of over 10 are useful in diffe...

Introduction: Di George’s syndrome is a rare congenital disease that is usually diagnosed in childhood due to its presentation with velo-cardio-facial abnormalities.Case report: A 42-year-old man was incidentally found to be hypocalcaemic (corrected calcium 1.71 mmol/l) during a ‘well-man check’. A subsequent parathyroid hormone (PTH) was inappropriately low at 0.8 pmol/l (reference range 0.5–4.4 pmol/l).He was ...

An 81-year-old lady was referred with a 2-month history of frontal balding and hirsutism over the face and chest that required daily shaving. Her symptoms were progressing weekly. She did not have any history of hot flushes, voice changes or weight loss. Clinical examination revealed marked hirsutism over the face, neck, upper back, thorax and abdomen with a fullness in the right iliac fossa. She had a past medical history of hypertension and hypercholesterolemia.<p class=...

Case report: A 67-year-old female with untreated congenital adrenal hyperplasia (21-hydoxylase deficiency) was diagnosed with bilateral vulval carcinomata. She was referred to another unit with serum sodium of 121 mmol/l, potassium 4.6 mmol/l and 17-hydroxyprogesterone of 714 nmol/l (0–14 nmol/l). A short synacthen test performed in the evening demonstrated a baseline cortisol of 558 nmol/l, rising to 643 nmol/l at 80 min. The baseline cortisol was deemed adequate but in ...

Introduction: Hyponatraemia is not uncommon in primary care and its management can be complex. It is vital that initial assessment is carried out properly as mismanagement can have serious consequences.Aim: To investigate general practitioners’ views and perceptions on the management of hyponatraemia encountered in primary care.Method: Local general practitioners were surveyed with a questionnaire via email and at local postgr...

Background: According to western literature aerobic Gram-positive cocci are the predominant microorganisms that are isolated from diabetic foot ulcers. In contrast, whatever limited data is available from India Gram-negative aerobic bacteria were most frequently isolated.Aims and objectives: To know the clinical and microbiological profile of patients with infected diabetic foot ulcers.Patients and methods: A descriptive cross-sect...

A 29-year-old man of South Asian descent presented with pancreatitis. Adjusted calcium was 3.10 mmol/l and PTH 9.8 μmol/l. Of note was that his parents were first cousins, and a cousin had undergone parathyroidectomy for hypercalcaemia.Pituitary, adrenal and thyroid function, calcitonin, prolactin, phosphate, magnesium, alkaline phosphatase and urinary catecholamines were all normal. 25-Hydroxyvitamin D was 20 nmol/l (15–100) The patient was th...

Objective: To present an unusual case of a goitre co-existing with bilateral thryoglossal fistula.Introduction: AF, a 32-year-old male presented with 4 years history of an anterior neck swelling associated with palpitations, heat intolerance, protrusion of the eyeballs, weight loss, tremors of the hands and generalized weakness.Prior to onset of the neck swelling, he had noticed since childhood that whenever he drinks any fluid, so...

Background: The use of high dose Ergot derived dopamine agonists in patients with Parkinson’s disease has been associated with an increased risk of cardiac valvular fibrosis. The UK Medicines and Health products Regulatory Agency (MHRA) currently advises baseline Echocardiogram within 3–6 months and follow up Echocardiogram at 6–12 monthly intervals in all patients taking ergot derived dopamine agonists. However, the risk of cardiac valvulopathy with lower doses...

Background: Adrenal incidentalomas (AI) are a common radiological finding (estimated prevalence 4%). Guidelines from the American Association of Clinical Endocrinologists (AACE) and the American Association of Endocrine Surgeons (AAES) recommend radiological evaluation at 3–6 months then annually for 1–2 years, and hormonal evaluation by measurement of plasma aldosterone/renin (ARR) activity, 24 h catecholamines/metanephrines (CATS), and 1 mg overnight dexamethasone ...

Hypoadrenalism and bilateral adrenal haemorrhage are rare manifestations of lymphoma. We present a case of diffuse large B cell non-Hodgkins lymphoma (NHL) in whom the main manifestations of relapse included hypoadrenalism and then bilateral adrenal haemorrhage.A 75-year-old male presented with a 2-week history of severe left sided abdominal pain. He was known to have NHL predominantly involving the right maxillary sinus, which had been treated with chem...

Aim: An increasing proportion of patients are referred to endocrine clinics for assessment of an endocrine reason for obesity. The aim of our study was to assess the hormone profiles of patients referred for bariatric surgery.Methods: Patients referred to bariatric surgery clinic were investigated for hypothyroidism (TSH, T4), Cushing’s disease (2 mg-overnight dexamethasone suppression test), acromegaly (IGF1) and Vitamin D deficiency (PT...

A 22-year-old woman with hypophosphataemic rickets was diagnosed at age four when she presented with short stature and valgus deformity of the lower limbs. Biochemical testing, genetic screening and radiological investigation of her family showed no abnormality and it was concluded that she had a de novo mutation.She was treated with 1α-calcidol and phosphate Sandoz with regularly monitored biochemistry. She had poor adherence to her medicati...

Background: Phaeochromocytomas (PHAEOs) and paragangliomas (PGLs) are rare catecholamine producing tumours which are potentially lethal if left untreated and may be associated with a wide variety of complications. Optimum management demands multidisciplinary input from endocrinologists, biochemists, geneticists and endocrine surgeons.Objective: A retrospective audit into the management of PHAEOs/PGLs at our institution against the 2005 recommendations ma...

Background: The screening investigation of choice for phaeochromocytomas (PHAEO) and paragangliomas (PGL) in the UK is usually a 24 h urine collection for fractionated metadrenalines +/− free catecholamines. These assays have high diagnostic sensitivity (approaching 98%) but lower specificity.Aim: To review causes of false positive (FP) catecholamine and metabolite results in our centre over a 12-year period.Methods: Data wer...

A 65-year-old female, with a 4 month history of left upper quadrant discomfort, was identified as having a multi-loculated para-renal ‘cyst’ on ultrasound scanning. CT identified a 13×11×10 cm heterogeneous mass arising from the left adrenal. An enlarged ill-defined left retro-crural ‘lymph node’ was also noted. There was no history of weight loss. Past medical history was unremarkable. She was no medication. Examination was unremarkable apart fro...

Pituitary MRI is widely used in endocrine practice, and is regarded as entirely safe. We report here a life-threatening outcome from a routine pituitary MRI scan.A 23-year-old female with a 3-year history of microprolactinoma confirmed by MRI underwent a routine repeat MRI scan with gadolinium. During injection of Gadovist she experienced minimal chest tightness which rapidly resolved. Four hours after the injection she rapidly became very breathless. On...

Aim: To find out all Acromegalic patients above the age of 40 years had their colonoscopic screening or not.Reason for colonoscopy screening: There is 13 to 14 fold increased risk of colorectal cancer in Acromegaly patients and 2.5 fold increase in mortality from Colonic cancer.Standards: i) Patientts with acromegaly should be offered regular colonoscopy from the age of 40 years.ii) ...

Adrenal haemorrhage is rarely associated with anticoagulation according to a large American series. We present 2 cases in whom there was no evidence of over anticoagulation, both of whom developed a degree of hypoadrenalism.Case 1: A 72-year-old-male presented with severe non-pleuritic left flank pain. He had been seen the previous day with possible deep venous thrombosis (DVT) and had received a single dose of enoxaparin (1.5 mg/kg). He was tender in th...

Hyponatremia complicates 1% of hospital admissions and can be associated with serious CNS effects. We report a case of an 84-year-old woman with longstanding hyponatremia resulting in several hospital admissions because of acute confusion due to severe hypoatremia. This case emphasizes the need to consider selective vasopressin V2-receptor antagonist (Tolvaptan) as a potential therapy for hyponatremia secondary to the syndrome of inappropriate antidiuretic hormone (SIADH)....

Introduction: Proton pump inhibitors (PPIs) were until very recently perceived to be safe, effective and inexpensive. As a result they are widely prescribed empirically, beyond their core indications. However dose-dependent adverse reactions increasingly reported include diarrhoea, resistant hypomagnesaemia/hypocalcaemia and interstitial nephritis. Moreover, they are associated with increased rates of vertebral and wrist fractures, and increased C. difficile carriage rate....

A 32-year-old lady was referred to our centre with thyrotoxicosis and elevated FT4 and TSH levels. She was already on carbimazole. Interestingly, her symptoms started at childhood. She was nicknamed ‘shaky’ by her school friends because of her tremors. There was no family history of thyroid disease.She was clinically and biochemically thyrotoxic with FT4 of 12.4–38.8 pmol/l and TSH of 7.24–38.8 mIU/l.<p class...

A 76-year-old man with history of oesophageal carcinoma was successfully treated by surgery and radiotherapy 4 years previously. He presented with anorexia and 4 stones weight loss associated with abdominal discomfort. He was not on any medication. On examination blood pressure 100/60, no peripheral oedema, systemic examination otherwise was unremarkable. Soon after admission, he developed a generalised tonic clonic seizure requiring a Lorazepam and Phenytoin infusion to contr...

Introduction and aim: An e-mail based GP advisory service was launched by the authors’ centre in 2005. The PCT commissioned the service in July 2009. Enquiries are handled by specialist registrars with consultant supervision. The charge is £23/enquiry.Pre-commissioning, annual audits demonstrated an efficient and popular service, enhancing communication links between primary and secondary/tertiary care.We re-audited the s...

A 31-year-old male presented to A&E with confusion, lethargy, polyuria and blurred vision. The previous month he had been diagnosed with diabetes and started on metformin by his GP. On examination he was cachectic (BMI 17 kg/m2), dehydrated and hypotensive (88/56). Baseline investigations revealed a metabolic acidosis (pH 7.30), with capillary glucose 20 mmol/l and moderate ketonuria. Treatment for diabetic ketoacidosis was commenced. Further results revealed he...

A 30-year-old female reported a 2-year history of excessive sweating / flushing affecting the right hand side of the face and scalp along with the right arm. These symptoms were generally related to exercise and demonstrated a sharp midline demarcation, being present only on the right hand side.Past medical history included hypothyroidism secondary to Hashimoto’s Thyroiditis. She was euthyroid on levothyroxine. She also reported unequal pupils since...

Supervised 72 h fast is historically the gold standard screen for spontaneous hypoglycaemia. Consensus guidelines published in 2009 suggested that β-hydroxy-butyrate levels be measured every 6 h, and the glucose response to an i.v. injection of glucagon be assessed at the time of documented hypoglycaemia, or at the end of the 72 h fast. We incorporated these recommendations into our protocol, and here examine the results of the first 10 cases.A rise...

A 28-year old Lithuanian woman presented with a 6-week history of firm anterior neck swelling. There were no symptoms of local obstruction, invasion, or thyroid dysfunction, and no past medical history, medication use or relevant family history. On initial assessment, she was euthyroid, with a 6 cm hard mass replacing the right lobe of the thyroid, a 2 cm lymph node lateral to it, but no other lymphadenopathy. No cellular material could be obtained on initial clinical and ultr...

Background: Length-of-stay (LOS) after various surgical procedures varies greatly between centres and countries. In the US there is increasing tendency towards day-case thyroid and parathyroid surgery but their model of care cannot be easily extrapolated. In the UK the average LOS for such operations is 3–4 days.Methods: Retrospective review of data retrieved from hospital-based software regarding the surgical activity during a decade in a large Uni...

We present a case of a 71-year-old gentleman who presented with a clivoid mass to the opthalmologists.The patient presented with left retro-orbital pain. He was generally fit and well, but his past medical history included cancer of the prostate and gout. An MRI brain was performed, which demonstrated a lesion between the left internal carotid artery and the clivus. CT chest/abdomen/pelvis confirmed no evidence of metastatic prostate cancer.<p class=...

Aims: Endocrine deficiencies are common complications of thalassaemia major. Our haematology department serves one of the UK’s largest populations of thalassaemia patients. We assessed our thalassaemia major patients’ endocrine status and factors associated with endocrinopathies.Methods: Retrospective analysis of our thalassaemia major patients on active follow-up in April 2010. Parameters such as age, gender, hepatitis C infection, compliance ...

Introduction: A 28-year-old primigravida developed increasing hairgrowth in androgen sensitive areas in the first trimester of her first pregnancy. She was previously well with menarche at 14 years, normal periods thereafter and no difficulty in conceiving. She took no medication. Clinically, at 34 weeks gestation she had significant hirsutism of her face, arms, legs and a prominent male escutcheon. She was obese but not Cushingoid.Investigations and res...

A 55-year-old lady was admitted with sudden onset headache, diplopia, photophobia and confusion. CT brain showed SAH with hydrocephalus. Coiling of the aneurysm with EVD insertion was done on the same day. On day 5 post-operatively she developed hyponatremia and dropped her GCS to 10/15.On examination she was volume depleted with dry mucous membranes and loss of skin turgor. Urine output over the previous 4 days had been 2.5–4 l/day, urinary sodium ...

A 50-year-old woman with learning difficulties and schizophrenia presented to accident and emergency with 5 days of epigastic pain and vomiting.Initially, she was peripherally shut down, with a pulse of 120 and blood pressure of 115/80. Chest examination was normal. Abdominal examination showed epigastric tenderness with guarding.Blood tests confirmed a diagnosis of acute pancreatitis (Amylase 1972 IU/l), with hypercalcaemia (corre...

A 22-year-old pregnant lady presented to the Emergency Department (ED) at 36 weeks of gestation with sudden onset of severe headache and blurring of vision. On examination, she was alert, conscious (GCS: 15/15) and had bitemporal hemianopia, confirmed on formal visual field assessment. MRI brain scan (limited views due to pregnancy) showed a pituitary mass extending into the suprasellar region and reaching the optic chiasm. Serum prolactin (PRL) was elevated at 3876 μ/l (...

The British Thyroid Association recommends that a specialist multidisciplinary team (MDT) is responsible for thyroid cancer management. In accordance with this recommendation, a team was formed to manage thyroid carcinoma in a tertiary referral centre. The team included endocrinology, general surgery, ENT, cytology, radiology and radiation oncology consultants.This audit was performed to assess management of thyroid carcinoma before the establishment of ...

Introduction: Hyponatraemia is common biochemical abnormality in hospitalised patients and is difficult to manage in some cases. Tolvaptan is presently licensed in the UK for the treatment of hyponatraemia secondary to SIADH. We present our experience of using Tolvaptan.Cases: Patient 1 was admitted with sagittal sinus thrombosis. Over 9 days serum sodium dropped from normal to 121 mmol/l with biochemical evidence of SIADH. The patient was treated with T...

Case: A 41-year-man presented to his GP with a pruritic skin rash affecting the whole body but sparing the face. He was treated with antihistamines with no improvement. On investigation thyroid function tests showed free T4 48 pmol/l, free T3 11.6 pmol/l with suppressed TSH<0.1 mU/l. He was started on carbimazole and referred to endocrinology. At the clinic it was noted that he has lost weight, felt hot all the time. There was no past history of rash....

A 76-year-old man with recent history of diet control diabetes and hypertension presented to his GP with change in his voice and biochemical T3 toxicosis. He had no further assessment and received no treatment. Few months later he presented with right side goitre and found to have right vocal cord palsy and medullary thyroid cancer and hyperthyroidism. He had evidence of local nodal and distant metastases. Soon after biochemical euthyroidism he underwent total thyro...

Background: The effect of long term opioids on the hypothalamo-pituitary–adrenal (HPA) axis is conflicting. We present a case of a 21-year-old female who presented with adrenal insufficiency (AI) secondary to chronic tramadol use.Case summary: Our patient presented with a three year history of non-specific abdominal pain, lethargy and dizziness. No cause was found for these symptoms despite thorough investigations. One month before referral to Endoc...

A 73-year-old man was referred to the general medical clinic with a 3-year history of shortness of breath and wheeze. During assessment he commented that over the same period he had also had intermittent sweats, flushing and redness of the face especially after eating and taking red wine. Echocardiogram and urinary 24-h 5-hydroxyindoleacetic acid (5-HIAA) were arranged. Surprisingly two of three urinary 24-h urinary 5-HIAA were positive (43 and 47.5 μmol/24 h and 30 &#956...

Medullary thyroid cancers (MTC) account for about 5% of thyroid cancers. The biochemical hallmark of MTC is the secretion of calcitonin (CT). CT levels are both a key feature of pre-operative diagnosis and post-operative follow up. CT screening in a cohort of over 10 000 patients with thyroid nodular disease has demonstrated that a positive CT test has a higher diagnostic sensitivity and specificity for MTC than fine needle aspiration (FNA). They may also secrete carcinoembryo...

Introduction: Complete androgen insensitivity syndrome (CAIS) is an X-linked genetic disorder characterised by normal female appearance, including external genitalia and the presence of 46XY karyotype. We report a case of CAIS, diagnosed in adulthood, and discuss ethical issues surrounding the disclosure of diagnosis and associated difficulties in further management.Case history: A 33-year-old Nigerian lady was referred to our endocrine service with Prim...

A 31-year gentleman presented with a four day history of anxiety and confusion. Over several months, he had noticed red eyes and a ‘stomach-ache’. A collateral history revealed a previous episode of confusion and concern about excessive alcohol intake. He denied any current medication. On examination, he had bilateral conjunctivitis. Investigations demonstrated severe hypercalcaemia of 3.54 mmol/l (NR 2.15–2.6 mmol/l). He was treated with intravenous fluids and ...

We present the case of a woman who first presented at age 18 with hirsutism. Menarche had been normal and she had regular menses. She gave no past medical history except that at age 6 she had been admitted to hospital with tonsillitis that was complicated by diarrhoea and vomiting, drowsiness and hypotension. At that time, Na+ was 130 mmol/l and K+5.8 mmol/l. She was treated with antibiotics and fluids and improved; electrolytes returned to normal.<p ...

MM, a 51-year-old female was reviewed in the Endocrinology clinic for the assessment of hypercalcaemia, hyperprolactinaemia, and an adrenal mass. Bipolar depression had been diagnosed 24 years previously with continuous use of Lithium Carbonate since. An acute deterioration in mental state 3 years previously prompted Risperidone treatment which was ongoing. Hypercalcaemia (calcium=2.78 mmol/l, PTH=13.8 pmol/l, vitamin D=33 nmol/l) was recorded. Polyuria and nocturia was noted....

In Central and Eastern Cheshire, Secondary Care endocrinology/diabetes clinicians can now access a summary of the patient’s primary care electronic patient record (EPR), using a secure Web browser for GP data held by the GP provider EMIS. This improves decision making at the point of care.The clinicians, including consultants, SpRs, dieticians and specialist nurses can access details of medication, allergies, and previous diagnoses, available for 95...

Introduction: Amiodarone is a commonly prescribed antiarrythmic drug. It can cause potentially serious adverse effects involving the thyroid gland, lungs, liver and eyes. It is recommended that patients on amiodarone have regular monitoring tests.Methods: We conducted an audit of patients who were prescribed amiodarone by various physicians in our hospital between January 2007 and March 2008. The data was obtained from the patients case notes. We looked ...

A 54-year-old lady with a 27-year history of schizoaffective disorder presented with shaking episodes, polyuria and polydipsia. She was found to have a serum sodium of 157 mmol/l. Of note, she had been on lithium for several years but this had been stopped three months previously as her serum sodium was raised at 156 mmol/l.On admission her lithium level was undetectable, confirming no recent use. Serum osmolality was 343 mOsm/kg and urine osmolality 82 ...

A 52-year-old man was referred in June 2009 with weakness, unsteadiness, diarrhoea and weight loss of 14 kg in the last 4 months. His past medical history included hypertension, ischaemic heart disease and chronic obstructive pulmonary disease. He was a heavy smoker and admitted to drinking heavily for the past 9 months. His serum sodium was 126 mmol/l, serum potassium 2.0 mmol/l, serum bicarbonate 31 mmol/l. His chest X-ray was normal. He had had persistent hypokalaemia for 4...

A 30-year-old Caucasian lady was diagnosed with type 2 diabetes in July 2005 on an oral glucose tolerance test and was treated with metformin. Sixteen months later she presented with urinary symptoms and was noted to have 2+ ketonuria. Her blood glucose was 13.4 mmol/l. Her BMI was 26 kg/m2 and she was noted to have Cushingoid habitus and acanthosis nigricans. Her blood pressure was normal. Her serum sodium was 130 mmol/l, potassium 3.7 mmol/l and bicarbonate 8 mmol...

A young fit male readmitted with three weeks history of malaise, pale stool, dark urine, pruritus with recent travel to Greece. He denied alcohol, illicit drug abuse. Examination revealed jaundice.Investigation showed cholestatic liver impairment with Bilirubin: 448 μmol/l (7-35), ALT: 134 IU/l (17–63), ALP: 190 IU/l (32–91), HDL 0.34 mmol/l (>0.9). Viral Screen, autoantibody, porphyria and tumour markers were negative. CT Abdomen show...

We present a 20-year-old lady who was known to have MEN-1 and had previously been treated for hyperparathyroidism at a different hospital in 2003 with excision of right upper and lower and left lower parathyroid glands and left thyroid lobectomy, resulting in normalisation of adjusted calcium (adjCa) levels.She presented to our department with persistently elevated adjusted calcium levels (adjCa 2.69 mmol/l) along with raised parathyroid hormone (PTH 16 ...

After adrenal insufficiency is confirmed by synacthen testing, lifelong steroid replacement is expected. We report a case of apparent reversal of adrenal insufficiency. Case details: a 66-year-old man was referred for oral pigmentation, and a random cortisol level of 184 nmol/l. He reported a 2-year history of tiredness, nocturia, dry mouth and reduced libido. There was no dizziness, salt-craving, or weight loss. He denied taking any form of steroid or over-the-counter drugs. ...

Introduction: Insulinoma is a tumour, derived from the beta cells of the pancreas. The incidence in the general population is 4 cases per million a year. 80 to 90% of insulinomas are benign and <10% are malignant.Case presentation: A 67-year-old lady was admitted via the emergency department after being found unresponsive at home. She was found to be hypoglycaemic and responded to i.v. dextrose. She was diagnosed with type 2 diabetes mellitus a year ...

Somatostatin analogues (SA) represent the most effective medical treatment for the control of neuroendocrine tumour (NET) symptoms, like carcinoid syndrome. Recently there has been evidence of lengthened time to tumour progression in patients with midgut carcinoid treated with octreotide. Nevertheless, a number of new therapeutic indications and the clinical effectiveness of SA for other clinical conditions are appearing. A 69-year-old man was investigated for anaemia (haemogl...

A 43-year-old woman presented acutely with Graves disease and hyperthyroidism. She had thyroid eye disease and a large diffuse goitre with pressure symptoms. She reported hearing a bruit herself without a stethoscope. She was tachycardic, with capillary nail fold pulsation and a positive Pemberton’s sign. Initial T4 was 78.6, TSH not detected.Betablockers to control the patients tachycardia were contraindicated due to a history of asthma,...

A 59-year-old Caucasian heterosexual man presented with malaise and dizziness. General examination revealed no peripheral oedema, no clubbing or lymphadenopathy and systemic examination was otherwise normal. His initial investigations showed hyponatremia with serum sodium 121 mmol/l, potassium 3.4 mmol/, serum osmolality 255 mOsml/kg, and urine osmolality 672 mOsml/kg. The rest of blood tests including; thyroid function, short Synacthen test, full blood count, liver functions,...

Background: There is a close association between low testosterone and metabolic syndrome. Testosterone replacement therapy (TRT) has beneficial effects on cardiovascular (CV) risk factors in men with hypogonadism.Aim: This is a retrospective audit of CV parameters in hypogonadal men treated with testosterone undecanoate (Nebido) in standard clinical practice.Methods: Patients with hypogonadism on testosterone undecanoate injections...

We present the case of an 80-year-old man found to have a non-functioning pituitary macroadenoma causing secondary adrenal insufficiency and hypogonadism in 2006. Thyroid function and prolactin levels were normal. With hydrocortisone replacement he was doing well. There was no visual field defect and he continued with conservative management. On enquiring about testosterone treatment, it had been started in Oct 2008, but discontinued within a month as there was no change in hi...

Background: Adrenal masses discovered incidentally during imaging studies (adrenal incidentalomas – AIs) are common and prompt investigations to exclude secretory lesions and malignancy. Uncertainty exists over the best management strategy of AI.Objective: To monitor the current practice against the local protocol and existing guidelines; to identify the biochemical and imaging outcomes in a single centre cohort.Methods: Retro...

GLP-1 stimulates β-cell proliferation, it also enhances the differentiation of new beta cells from progenitor cells in the pancreatic duct epithelium and it is capable of inhibiting apoptosis of β cells. GLP-1 also exhibits other effects of importance for glucose homeostasis, such as, inhibiting glucagon secretion, delaying gastric emptying, and stimulating insulin biosynthesis. These effects come along with a potential increase in peripheral insulin action. Type 2 d...

Background: Prolactin is an identified marker associated with atherosclerosis. Atherosclerotic process and hence the macrovascular complications are causes for high mortality and morbidity rates among people with diabetes.Aim: To assess the relationship between serum prolactin and cardiovascular risk in patients with acute myocardial infarction (AMI) and patients with type 2 diabetes mellitus.Subjects and methods: A case–contr...

Introduction: Familial hypercholesterolaemia (FH) is a severe form of hyperlipidaemia resulting in early coronary heart disease (CHD). It has autosomal dominant inheritance with a prevalence of 1 in 500.Aim: Given this prevalence we would expect 1000 cases in our local catchment area of East and North Hertfordshire. Far fewer cases are know about. We tried to find out where potential cases were and assess the management of all cases.<p class="abstext...