Endocrine Abstracts

Background: Hypocalcaemia is a common electrolyte disorder and it can occur following parathyroidectomy or thyroidectomy. It has been suggested that some post-operative hypocalcaemic crises may reflect severe vitamin D deficiency and vitamin D supplementation may have a protective effect.Objectives: To establish the prevalence of severe post-operative hypocalcaemia (as defined by the requirement for i.v. calcium gluconate) following parathyroid surgery a...

Background: Short Synacthen tests (SST) are both inconvenient and expensive, especially since the cost of tetracosactide recently increased 15-fold to over £45/ampule. A retrospective review was performed to see whether the number of SST’s could be reduced in our institution.Methods: All 76 adult inpatient (mean age 67) and 106 adult outpatient SST’s (mean age 50) from a 12-month period were reviewed for indication and whether a preceding ...

Patients with thyroid dysfunction require frequent clinic follow-up, but are often young and have difficulty taking time off work or college, leading to non-attendance and disruption to their treatment. The did not attend (DNA) rate of our endocrine clinic was 21.3%, of whom 44% comprised patients with thyroid disorders. Skype has already been used very successfully for follow-up in the Newham diabetes clinics for our young and ethnically diverse population. We wished to explo...

Background: Turner syndrome (TS) is associated with significant morbidity and a reduction in life expectancy. National guidelines have been developed to support the management of adult patients with TS but little is known about their implementation. We therefore sought to compare the management of patients with TS seen within a single tertiary referral centre by endocrinology, either general-purpose or Turner-specific clinics (TSC), or by other specialties.<p class="abstex...

A 19-year-old Cushingoid lady was referred with significant hirsutism requiring daily facial shaving despite previous laser epilation and regular waxing. She had a background history of PCOS, polycythaemia, hypertension and had been labelled as having a ‘Cushingoid appearance’. Extensive investigations elsewhere (UFCs, MR pituitary, and CT adrenals) had failed to diagnose the syndrome. She was taking metformin to regulate menses and lercanidipine and bisprolol. Spiro...

Background: Malignant paragangliomas are rare. Predictors of malignant potential include high levels of normetadrenaline and/or dopamine, and the presence of a germline mutation in the succinate dehydrogenase B gene (SDHB). Prognosis is poor and treatment options are limited, with only short-term responses observed after 131I-MIBG therapy or chemotherapy.Aim: To report response to the oral tyrosine kinase inhibitor sunitinib.<p cl...

Adrenal incidentalomas are a common clinical dilemma with increasing utilisation of cross-sectional imaging modalities. The aims of management include: i) exclusion of possible malignancy and ii) identification of hormonally active lesions.Our unit has adopted AACE guidelines, including a screen for adrenal androgen hypersecretion. This audit aimed to review the utility of such an approach.We identified case notes of 145 consecutiv...

Introduction: Primary hyperaldosteronism (PHA) accounts for 5–13% of all hypertension and up to 20% of resistant hypertension. Aldosterone producing adenomas (APA) account for 60% of PHA and surgical resection in these patients can be curative. There is no consensus on the need for and duration of follow-up after adrenalectomy. This study assessed the immediate effect of unilateral adrenalectomy for APA on the serum potassium, renin and aldosterone levels. Acute effects o...

An 84-year-old lady with hypertension, bladder cancer, and chronic kidney disease, presented with a 3-day history of diplopia on looking to the right, abnormal eye movements, right-sided peri-orbital headache, and diarrhoea. Clinical examination revealed right-sided sixth cranial nerve palsy with normal pupillary light reaction, visual acuity, and visual fields. There were no other neurological deficits. The patient did not have features of hypercortisolism, GH excess, or adre...

Introduction: Foot disease in diabetes is associated with significant morbidity and mortality. Diabetic foot disease requires complex care with input from a range of healthcare professionals. Scottish Intercollegiate Guidelines Network guideline 116 recommends that all patients with diabetes and foot ulceration are seen at a multidisciplinary foot clinic. Our aim was to assess the impact on patient outcomes of introducing a multidisciplinary foot clinic within NHS Fife.<p ...

Introduction: The provision of out-of-hours (OOH) care for hospital inpatients is currently a hot political topic with aspirations for ‘seven day working’ and earlier specialist involvement. Care for patients with diabetes or endocrine problems OOH (which accounts for 75% of each week) is variable and often falls as a default to the general medical team. Our centre (over 1000 beds, all major specialities) has, for many years, provided a 24/7 service for GPs and hospi...

A 37-year-old man presented with persistent right hip pain and night sweats. CT of chest, abdomen, and pelvis revealed a right iliopsoas abscess from which mycobacterium species tuberculosis isolated. He commenced quadruple agent anti tuberculous chemotherapy. Repeat CT 1 year later showed complete resolution of the abscess but a 3.3×1.7 cm mass replacing the right adrenal gland. Considered likely to represent healed tuberculous lesion, treatment completed, and patient di...

Introduction: Polyendocrine autoimmune syndrome is a group of disorder involving endocrine glands as a consequence of autoimmunity. Non-endocrine organs also may be affected. An association between autoimmunity and immunodeficiency has also been recognized. We report a case of polyglandular autoimmune disease associated with common variable immunodeficiency.Case report: A 26-year-old was diagnosed with Addison disease at the age of 4 following recurrent ...

Phaeochromocytoma during pregnancy is extremely rare with a frequency of 0.002% pregnancies. However, the risks for the pregnant patient with this tumour are extremely high: with maternal and foetal mortality up to 50% if undiagnosed. In contrast, early diagnosis and treatment during pregnancy decrease the maternal and foetal mortality to <5 and 15% respectively.A 37-year-old female underwent abdominal imaging to investigate iron deficiency anaemia. ...

Objectives: Insulin pumps were introduced in the late 1970s. Their use has continued to grow and the technology has continued to improve along with the development of insulin substrates. They are however a costly therapy, thus NICE recommend pump therapy in the following circumstances; when patients are undergoing regular episodes of severe and sometimes unpredictable episodes of hypoglycaemia, have HbA1c levels over 8.5% despite attempts to lower it, difficult control during ...

End stage renal disease (ESRD) is characterised by decreased renal synthesis of 1,25-dihydroxyvitamin D (1,25D). Therapeutic use of 1,25D analogues for the management of renal bone disease is routine. However ESRD patients are also deficient in 25D (the immediate precursor of 1,25D). Since 2014 UK guidelines recommend diagnosis and treatment of 25D deficiency/insufficiency in people with chronic kidney disease, but make no recommendations for dosage or monitoring. This, togeth...

A 48-year-old non-smoking female was seen in the chest clinic for cough and breathlessness on a background of asthma type symptoms for 20 years. Her cough was exacerbated by inhalers, productive of yellow sputum and intermittent streaks of blood. On examination, her lungs were clear but coughed continuously with an unusual duration of five minutes. Pulmonary function test showed an obstructive picture. CT scan showed bronchiectasis with multiple small nodules scattered through...

Sodium–glucose co-transporter 2 (SGLT2)-inhibitors represent a new class of drugs that inhibit glucose re-uptake in the proximal renal tubule resulting in glycosuria, with concomitant weight loss and improved glycaemic control in patients with type 2 diabetes mellitus (T2DM). Since becoming available, SGLT2 inhibitors have been implicated in over 20 reported cases of diabetic ketoacidosis or ketosis. In many cases there was an antecedent period of decreased oral intake, a...

We present a patient with Gitelman’s syndrome who had marked symptoms of myalgia and lethargy secondary to electrolyte imbalances. Initial management with oral potassium and magnesium replacements failed and she had five to six hospital admissions a month via the emergency department for worsening symptoms and needing i.v. electrolyte replacement. Therefore, she had planned i.v. potassium replacement three times a week via the day unit instead. Although this significantly...

Introduction: Hyponatraemia is defined as serum sodium concentration <135 mmol/l. It is the most common electrolyte disorder encountered in clinical practise. It is associated with an increase in mortality and length of stay, independent of diagnosis and clinical variables. Despite this it is often inadequately investigated and poorly managed.Methods: A retrospective audit was performed of patients admitted to The Great Western Hospital (GWH) serum s...

Introduction: X-linked adrenoleucodystrophy (XALD) is a progressive disorder affecting adrenal glands, testis, and myelin stability, that normally caused by mutations in ABCD1 (NM_000033) gene There is a failure of β-oxidation of fatty acids within peroxisomes due to reduced activity of very long chain acyl-CoA synthetase and can be diagnosed by the demonstration of elevated very long chain fatty acid.Case report: We report a case of a 32-y...

Case 1: A 65-year-old man was admitted with symptomatic hypocalcaemia (corrected calcium of 1.65 mmol/l, PTH 46.6 (1.6–6.8) pmol/l, and vitamin D 51.4 (50–150) nmol/l)) 5 days following denosumab initiation. He had a diagnosis of probable urothelial carcinoma with associated osteoblastic metastases, and 10 days prior to this admission had been treated for hypercalcaemia (corrected calcium of 3.04 (2.20–2.60) mmol/l) with i.v. fluids following which denosumab was...

A 58-year-old lady presented to hospital with abdominal pain, nausea, and tiredness, and was referred to endocrinology with symptomatic hyponatraemia (serum Na+ 112 mmol/l). Six months previously her serum sodium was normal. She was euvolaemic, and adrenal insufficiency and thyroid dysfunction were excluded. Laboratory investigations were suggestive of syndrome of inappropriate antidiuretic hormone (SIADH) and no causative medications were identified. A CT of her th...

Background: Transition is an important stage in the care of a young person with a long term endocrine condition.Objective: To explore current services for young people (YP) with endocrine conditions from the perspective of paediatric and adult endocrinologists, and YP and their parents using their services.Methods: There were two components: i) service questionnaire for completion by paediatric and adult endocrinologists. ii) &#145...

A 57-year-old gentleman presented with bilateral painless submandibular swelling, and flu like symptoms. A biopsy from the enlarged submandibular gland showed chronic sclerosing sialadenitis with lymphocytic infiltration. Immunohistochemistry showed plasma cells positive for CD79a and IgG4, and a combination of CD4 and CD8 positive lymphocytes. IgG4 levels were significantly raised (3.16 g/l, NR <1.3 g/l). A diagnosis of IgG4 syndrome was made. Chest and abdominal CT imagi...

Background: Thyroid disease in pregnancy is common with hypothyroidism predominating.Objectives: To determine the aetiology of thyroid disease in patients attending an antenatal thyroid clinic, their baseline biochemical and therapeutic characteristics as well as subsequent management.Subjects/setting: 114 women with a mean 31 years (±5) age were seen by a consultant endocrinologist in the antenatal thyroid clinic, between Sep...

Endometrial hyperplasia has been reported in up to 15% of transmen. For this reason the current clinical practice suggest that the uterus should be scanned every 2 years.This is the single centre retrospective audit study at the largest UK Gender Identity Clinic to examine the incidence of endometrial hyperplasia in transmen.Between 2006 and 2012. 200 patients having been maintained on testosterone therapy for 2 years, of those 108...

Introduction: We present a case of a gentleman with non-islet cell tumor hypoglycemia (NICTH), a rare cause of spontaneous hypoglycemia that presents clinical challenges in maintaining euglycaemia.Case report: A 76-year-old gentleman not known to be diabetic presented with confusion and agitation. On admission he had a blood glucose reading of 2.1 mmol/l and clinical examination confirmed an abdominal mass. He was initially resuscitated with i.v. dextros...

Aim: To investigate the relationship between baseline and stimulated cortisol responses in relation to the habitual time of rising and time of test.Method: The self-reported habitual rising time and time of cortisol testing were recorded in 63 consecutive patients (47F, 17M, age 18–94) undergoing standard stimulation testing with tetracosactide (SynActhen) 250 μg i.v. In total, 75 tests were analysed. A normal response was defined as a 30 min p...

Introduction: The commonest metastases to the thyroid are from renal cell carcinomas (RCC) and 23–48% of all thyroid metastases are RCCs. They may occur many years after RCC excision, the longest reported latent period being 20 years. Sunitinib (SUN), a multiple targeted anti-cancer drug, is increasingly used for RCC therapy but may cause thyroid dysfunction in some – usually hypothyroidism. We report a patient who presented with thyroid metastases 21 years after RCC...

Immobilisation is a recognised but rare cause of hypercalcaemia. Most reported cases are patients with spinal cord injury or trauma.Case 1: A 26-year-old female experienced a 5½ months admission to the intensive care unit (ITU) with complications following small bowel resection for Crohn’s disease. At 16 weeks she developed hypercalcaemia. Investigations confirmed calcium 3.24 mmol/l, parathyroid hormone (PTH) <0.6 pmol/l (1.6–6.9), 24...

Hyponatremia, defined as a serum sodium concentration below 135 mmol/l is acknowledged to be the most common electrolyte disturbance within hospital environment. Hyponatremia, specifically severe hyponatremia, is associated with an increase in morbidity and mortality.Aim: Audit aim was to evaluate the diagnosis, investigation, and management of hyponatremia in our district general hospital. This is a retrospective audit using lab data and clinical notes....

Nerve sheath tumours originate from myelin that surrounds peripheral nerves and include schwannomas and neurofibromas. They can occur sporadically or as part of neurofibromatosis 1 or 2. Very rarely, they have been described to arise from the viscera including the adrenal gland. It is thought that they arise from Schwann cells around nerve fibres that supply the adrenal medulla. These are rather slow growing and non-functioning adrenal tumours that can be found incidentally or...

Background: Hypogonadotropic hypogonadism (HH) is commonly associated with morbidly obesity. Gynaecomastia is associated feature of hypogonadism and can be deteriorated by testosterone therapy.History: A 49-year-old gentleman with a BMI of 53.2 kg/m2 was referred for management of obesity. He has two children (age 18 and 22). He had obesity associated comorbidities including obstructive sleep apnoea and impaired fasting glucose. He reported le...

Phaeochromocytoma (PCC) and paragangliomas (PGL) are neuroendocrine tumours derived from the embryonic neural crest, located either within the adrenal gland or at extra-adrenal sites.Objective: To study the clinical, biochemical, imaging characteristics, and mutational profile of patients with PCC/PGL treated at our institution.Methods: We collected data of patients with PCC/PGLs managed at Christian Medical College, Vellore, India...

Pituicytomas are rare tumours, originating from modified glial cells called pituicytes. The lineage of these tumours remains a topic of debate. Approximately 65 cases have been reported in the literature to date, since being formally recognised in 2007. We report a case where the final diagnosis was made after second surgery for late recurrence.Case: A 54-year-old man presented with left sided visual disturbances in 1998 and underwent transcranial resect...

Background: Although, the diagnostic accuracy of magnetic resonance imaging (MRI) has increased in recent years, it may fail to detect secretory adenoma in a few patients with GH excess. Managing such patients with acromegaly can be challenging. We present a case where 11C-methionine PET/CT co-registered with SPGR/volume MRI proved to be helpful in identifying GH secreting pituitary adenoma.Case history: A 42-year-old male was referred by surg...

A 30-year-old lady presented with three episodes of generalised seizures, paraesthesiae, irritability, and intermittent confusion since her first delivery 5 months ago. Over the past 3 weeks, she had developed exertional dyspnoea and easy fatigue. She was previously fit and well and the recent delivery was eventless. On examination, she demonstrated carpopedal spasm and other typical features of hypocalcaemia. Serum calcium was 0.88 mmol/l (2.10–2.55), magnesium 0.63 mmol...

We present the case of a 27-year-old man who was first diagnosed with type 1 diabetes mellitus when he presented with diabetic ketoacidosis (DKA) and during later admissions was found to have grossly abnormal liver function tests. Following diagnosis, his diabetic control has been a challenge to manage despite the patient’s claim he had been taking his insulin ‘religiously’. He has had repeated admissions with DKA and has failed to attend clinic follow-ups on se...

Background: Short Synacthen tests (SSTs) are used to assess adrenal function by injecting tetracosactide and measuring blood cortisol after 30 and 60 min. Many SSTs at Royal Bournemouth Hospital (RBH) are undertaken externally to the Bournemouth Diabetes and Endocrine Centre (BDEC). There is an increasing cost-implication for undertaking SSTs exacerbated by recent problems with Synacthen supply. A 0900 h cortisol or random cortisol on acutely unwell patients can be sufficient ...

Pseudohypoglycemia has been reported in patients with Raynaud’s phenomenon, peripheral vascular disease and shock and may result from increased glucose extraction by the tissues because of low capillary flow and increased glucose transit time. We present a frail and comorbid 76-year-old lady with a long standing history of Rheumatoid arthritis/systemic sclerosis/systemic lupus erythematosis overlap syndrome complicated by Raynaud’s phenomenon. She was on long-term st...

A 70-year-old lady with known hypothyroidism and ischaemic heart disease (previous CABG) presented with tonic clonic seizures. Her BP was 245/110. She was admitted to the intensive care unit. MRI brain showed subcortical oedema with subarachnoid bleed in the left temporal parietal region. Investigation for malignant hypertension showed a solid mass measuring 17×17×11 cm completely replacing the left kidney on CT-scanning. She was discharged home on sodium valproate w...

We present a 33-year-old lady who was diagnosed with primary hyperparathyroidism in 2004 (aged 22). Investigations showed parathyroid hyperplasia and she underwent a parathyroidectomy of three glands with one parathyroid gland implanted into each thigh. She then presented in 2013 with symptoms in keeping with hypercalcaemia. Initial investigations included ultrasound of thyroid and parathyroid glands which showed no evidence of parathyroid adenoma and incidental tiny cysts on ...

Introduction: Hyponatraemia is a common cause of morbidity and mortality affecting 15–28% of inpatients. Tolvaptan is a competitive vasopressin 2 antagonist licensed to treat hyponatraemia secondary to the syndrome of inappropriate anti-diuretic hormone secretion (SIADH). There has been concern that tolvaptan treatment may lead to rapid overcorrection of sodium in a minority of patients, thus potentially leading to osmotic demyelination syndrome.Met...

Background: Given the technically challenging nature of adrenal venous sampling (AVS) there is a drive to centralise services to improve successful outcomes. This has potential implications for patients living in remote and rural areas.Methods: We retrospectively reviewed the case notes of 15 patients who underwent AVS in our hospital, for investigation of primary hyperaldosteronism between 2002 and 2015. We assessed the success rate of cannulation of th...

Background: Treating life-threatening diabetic ketoacidosis (DKA) with a pH of <6.9 is extremely challenging and often refractory to treatment using standard fixed dose insulin DKA management protocols which may not work effectively at this low pH because of increased insulin resistance. I.v. bicarbonate (HCO3) use in this situation can be considered but remains controversial due to the risk of significant side effects as well as limited evidence in literature. ...

Primary adrenal lymphoma is rare and accounts for <1% of extra-nodal non-Hodgkin’s lymphoma cases. It presents with B symptoms, bilateral adrenal masses and hypoadrenalism; and thought to have a poor prognosis. We describe a patient that was diagnosed with and successfully treated for primary adrenal diffuse large B cell lymphoma (DLBCL).Case: A 62-year-old gentleman with longstanding hypertension presented with a 5-month history of weight loss,...

Background: Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder characterised by impaired cortisol synthesis. In the CaHASE study, a surprisingly low number of cases were identified as attending adult endocrine clinics. It has been suggested that patients with CAH are lost to follow up around the time of transition to adult services.In our service, there is a transition clinic that has a lead paediatric and adult Consultant who attend...

Background: Patients with adrenal insufficiency sometimes complain of excessive weight gain or feeling unwell on standard hydrocortisone despite dose optimisation. Prednisolone can be used in adrenal insufficiency but has a more prolonged duration of action and blood tests to monitor prednisolone levels are not readily available. Conventional glucocorticoid replacement can lead to over-replacement particularly in the evening which is thought to increase the risk of obesity. Pl...

Background: Severe hypocalcaemia is a life threatening metabolic emergency which must be identified and treated properly to prevent mortality.Objective: To highlight a rare finding of severe hypocalcaemia due to hypovitaminosis D in a Nigerian female on anti-tuberculous therapy.Case presentation: A 30-year-old Nigerian female who wears purdah presented to the medical emergency on account of perioral numbness, generalised muscle spa...

Background: Dapagliflozin was the first SGLT2 inhibitor licensed in UK to improve glycaemic control in type 2 diabetes. Whilst it has not been studied for use in combination with GLP1 agonists the modes of action of the two therapies suggest they would be a logical therapeutic combination. We aimed to evaluate clinical experience with this regimen.Methods: Observational retrospective data was collected from electronic patient records (SCI–diabetes) ...

Introduction: Hyponatraemia is common and associated with significant morbidity and mortality. However, it’s often not recognised as a serious diagnosis and therefore inadequately investigated and poorly managed. An audit of the management of patients admitted to The Great Western Hospital (GWH) with hyponatraemia confirmed these problems. A hyponatraemia guideline was produced in order to improve diagnosis, investigation, and management of patients with hyponatraemia.</p...

Introduction: Diaphoresis, or excessive sweating, is well recognised as a presenting complaint for endocrine disorders such as hyperthyroidism, acromegaly, and phaeochromocytoma. However, diaphoresis is an unusual presenting complaint for Cushing’s syndrome.Case: We present the case of a 35-year-old lady who first presented to health services for symptoms of excessive sweating, and feeling hot most of the time. Whilst initial investigations such as ...

Background: Phaeochromocytoma represents a rare cause of hypercortisolism, accounting for <5% of ectopic Cushing’s syndrome while <1% of phaeochromocytomas are accompanied by Cushing’s syndrome.Case presentation: We present a case of a 51-year-old lady admitted to the surgical ward for bowel surgery for severe long-standing constipation. She was referred to the endocrine team for recent-onset severe hypokalaemia and the presence of left...

Background: Short Synacthen tests (SSTs) are used to assess adrenal function by injecting tetracosactide and measuring blood cortisol after 30 and 60 min. Accuracy of timing helps enable successful interpretation of results. A SST is an invasive test although it is normally well tolerated. There is an increasing cost-implication for undertaking SSTs exacerbated by recent problems with Synacthen supply.Method: We undertook a retrospective audit of 333 pat...

Background: Hyponatremia is the commonest electrolyte abnormality encountered in clinical practice. It is associated with increased mortality and prolonged length of stay. Errors in establishing the aetiology of hyponatremia can lead to inappropriate treatment with adverse outcomes. An accurate diagnosis requires a careful clinical and biochemical assessment. An audit was undertaken to determine current practice at University Hospitals Bristol.Method: A ...

A 57-year-old female who was previously healthy was admitted to hospital with a 2-week history of abdominal pain. On admission, she was tachycardic, tachypnoeic, hypotensive, and had abdominal tenderness. Her initial investigations revealed a neutrophilia with her biochemistry showing hyponatraemia (sodium of 124 mmol/l (135–145)) and normokalaemia (potassium of 4.7 mmol/l (3.5–5.5)). She had an urgent abdominal CT scan which showed evidence of a tubo-ovarian abscess...

Xerostomia can be classified into two different types. One type is associated with severely reduced salivary secretion. The other involves normal salivary function yet reduced viscosity of saliva or reduced mucin concentration within the saliva, a common finding in elderly people. Studies show that xerostomia is the most common oral side-effect of cardiovascular medication. Statins are common cardiovascular drugs used to treat hypercholesterolemia. A 55-year-old Asian lady, no...

Objective: We report the rare case of a 45-year-old male with multiple endocrine neoplasm 1 (MEN1) with simultaneous occurrence characteristic tumours leading to a delicately balanced metabolic homeostasis.Methods: Clinical, biochemical, and radiological data of this patient diagnosed to have MEN1 were analysed and the challenges in the management of these neuroendocrine tumours are discussed.Case illustration: A 45-year-old gentle...

Background: HDL is a plasma lipid-protein complex of lipids and alphalipoproteins (apolipoproteins A-I and A-II). It is involved in reverse transport of cholesterol from peripheral tissue to liver, allowing cholesterol degradation. HDL cholesterol (HDL-C) levels are inversely associated with cardiovascular risk. HDL-C levels can be elevated due to genetic causes or drugs. We present a case where significantly raised HDL levels caused some concern at the outset.<p class="ab...

Splenunculi or accessory spleens are congenital foci of normal splenic tissue that are separate from the main body of the spleen. They are common, with a prevalence of 16% on contrast-enhanced abdominal CT, and present in 10–30% of post mortem examinations. They are benign, and important to recognise to avoid unnecessary investigations and surgery for suspected malignancies.Splenunculi are usually asymptomatic and found incidentally. Typically on CT...

Background: Primary hyperparathyroidism (PHPT) is a common endocrine disorder which affects 3/1000 of the general population and is associated with excess morbidity and mortality. Clinical practice tends to vary in terms of investigations, monitoring, decisions on intervention, and follow up. Audits in several European countries have previously demonstrated marked variation and divergence from best practice recommendations.Methods: This project used the ...

Pregnancy and lactation-associated osteoporosis (PAO) is a rare syndrome of spontaneous fragility fractures, most commonly vertebral, occurring in late pregnancy or lactation. The aetiology and pathogenesis of this osteoporosis are unknown, and early diagnosis and management are essential because of the severity of the morbidity associated with these fractures. The management includes cessation of breastfeeding, use of specific osteoporosis drugs, and adequate analgesia.<p...

A 65-year-old Caucasian gentleman was admitted with weight loss and generally feeling unwell. X ray chest done a week before admission as part of routine investigation by the General Practitioner, showed healing rib fractures with diffuse sclerosis. Malignancy was initially suspected due to the bony changes in the chest X-ray. Hence a full body CT scan was done and was normal. Incidentally he was noted to have low adjusted calcium of 2.16 mmol/l (2.20–2.60), raised parath...

Opiate use is a well-recognised cause of hypogonadotrophic hypogonadism. Adrenocorticotrophic hormone and growth hormone deficiencies are much rarer.A 56-year-old female presented with weight loss, lethargy, and nausea of ~3 years duration. She had received treatment with morphine sulphate 100 mg twice daily for ~15 years for back pain due to disc prolapse and osteoarthritis. A 0900 h cortisol of 110 nmol/l requested by her general practitioner had resul...

Ipilimumab, pembrolizumab, and nivolumab – novel immune checkpoint blockade drugs – are increasingly used in the treatment of metastatic melanoma and other cancers. Ipilimumab is an anti-cytotoxic T-lymphocyte antigen 4 (CTLA4) MAB and the first drug shown to improve overall survival in metastatic melanoma. Hypophysitis is a widely described side-effect linked with both lymphocytic inflammation and a direct toxic effect on the pituitary in mouse studies, but has been...

A 71-year-old male patient with no significant past medical history was admitted to hospital with acute hepatitis in July 2014 with bilirubin 98 μmol/l, ALT 1703 IU/l, and ALP 223 IU/l. Liver ultrasound showed a normal sized liver with normal echotexture. Liver screen including hepatitis A, B, C, E, and autoantibody screen was negative. Liver biopsy revealed acute hepatitis with patchy necrosis and inflammatory infiltrate consistent with inflammation, drugs, or autoimmune...

We present the case history of a 33-year-old male with Noonan syndrome diagnosed at 2 months of age, as he had typical facial features (hypertelorism, ptosis, low set ears, and small pointed chin), a heart murmur and bilateral cryptorchidism. At 22 months he underwent patent ductus arteriosus closure and at 24 months, the left testis was excised, for testicular torsion. He had learning difficulties and attended a special needs school and was intermittently reviewed in the paed...

An 18-year-old female presented to acute services with polydipsia and lower back pain. Routine blood tests revealed hypercalcaemia 3.67 mmol/l with significantly raised parathyroid hormone levels 2986 ng/l (10–65), alkaline phosphatase (ALP) 3330 IU/l (30–130), and low vitamin D 10.3 nmol/l (50–220). A CT scan revealed a 3.5 cm parathyroid adenoma and very osteopenic bones with multiple lucencies in keeping with primary hyperparathyoidism. The parathyroid subtra...

We present two cases, with apparently confirmed Cushing’s. Detailed clinical evaluation did not support the diagnosis, and carbamezepine interference was finally confirmed in both patients.Case 1: A 44-year-old man presented to a nephrologist with malignant hypertension. Routine investigation for secondary causes revealed hyperreninaemia with marked disparity of kidney size suggestive of renal infarction. 24 h urinary free cortisols (UFCs) were also...

We describe the case of a 32-year-old lady Polish lady, who presented to the surgical team at Leeds Teaching Hospitals NHS Trust in July 2012 with abdominal pain and vomiting. The previous year she had undergone a private ‘banded bypass’ operation in Poland resulting in 60 kg weight loss. On admission she was diagnosed with a slipped gastric band, to be confirmed by laparoscopy. Surprisingly the ‘band’ was in fact a length of surgical drain sutured to the m...

Introduction: Macroprolactin is a physiologically inactive form of prolactin, usually composed of a prolactin monomer and an IgG or anti-prolactin antibody molecule. Whilst clinically non-reactive, it interferes with immunological assays used for prolactin detection. It is identified by polyethylene glycol (PEG) precipitation, and levels of macroprolactin are generally believed to remain stable over time.Case: We present the case of a 36-year-old gentlem...

Introduction: Guidelines for the use of GH in GH deficient adults were issued by the UK National Institute for Clinical Excellence (NICE). To assess current practice in relation to these guidelines, a review of patients receiving GH treatment was performed. The aims were to i) assess if adults with GH deficiency met NICE criteria for GH therapy and ii) identify reasons for initiating or continuing GH treatment if NICE criteria were not met.Methods: Retro...

Background: Hypogonadism and erectile dysfunction have diverse causes. Hypogonadotrophic hypogonadism results from pituitary dysfunction, often caused by pituitary adenoma, pituitary surgery, radiotherapy, or use of prescription/non-prescription drugs. Rarer causes should be considered during initial investigation of patients with erectile dysfunction. We present a case of secondary hypogonadism and how further investigations eventually led to the underlying diagnosis.<p c...

Hypertension is the most commonly recognised cardiac manifestation of a phaeochromocytoma. There are however a variety of other cardiac presentations including arrhythmias and the increasingly reported Takotsubo cardiomyopathy. We present the case of a female patient presenting acutely to the general medical take who was found to have cardiac arrhythmias and transient left ventricular dysfunction.The initial presentation was breathlessness, chest pain, s...

Introduction: Patients with adrenal insufficiency (AI) lack endogenous cortisol and require oral hydrocortisone. In primary AI (PAI) endogenous aldosterone synthesis is also lost and patients require oral fludrocortisone. Important long-term issues include wearing MedicAlert jewellery (MAJ) and adequacy of steroid replacement including fludrocortisone, assessed by plasma–renin activity (PRA).We identified patients with AI attending our unit and aime...

Background: Adult spontaneous hypoglycaemia in non-diabetic patients is not a diagnosis per se but a manifestation of a disease and is often a diagnostic challenge. Although rare, it’s important to exclude endogenous hyperinsulinemia, because treatment can be curative. The aim of our audit was to assess the usefulness of various investigations done for spontaneous hypoglycaemia in diagnosing Insulinoma.Methods: Data on 98 non-diabetic patie...

Introduction: Cyclophosphamide is known to cause gonadal dysfunction. Specifically, it has been reported to cause damage to the seminiferous tubules causing raised FSH>LH with low testosterone levels. We present the case of a gentleman with raised FSH and LH following treatment with R-CHOP therapy. Interestingly, the testosterone level was high, signifying adequate physiological response.Case history: A 63-year-old gentleman was referred to endocrine...

Tumour induced hypoglycaemia is a rare disorder occurring in cancer patients caused by variety of tumours including islet and non-islet tumours. Non-islet cell tumour induced hypoglycaemia (NICTH) is rare paraneoplastic disorders normally associated with pleural solitary fibrous tumour but can also rarely occur in extra thoracic site.We describe an 86-year-old man not known to have diabetes mellitus who presented with 3-month history of early morning hea...

In recent years, there is increased interest in using maggot debridement therapy (MDT) for ulcer treatment. MDT has shown beneficial effects on ulcers’ rate of healing, need for surgical intervention, and number of antibiotic-free days. In this retrospective study, we looked into the effects of MDT on the length of inpatient stay and need for surgical intervention.Data were collected from 33 randomly selected patients admitted into hospital with pri...

A 72-year-old man, otherwise fit and well, with treated hypertension presented to our hospital with abdominal pain and vomiting. He was febrile with deranged liver function tests and elevated inflammatory markers. Abdominal ultrasound showed a right suprarenal mass, and a normal gallbladder.CT confirmed a 37×31×24 mm right adrenal mass with no significant contrast enhancement, and bilateral pneumonia responsible for the septic picture. Thrombus...

Introduction: Graves’ disease is an autoimmune disorder which may lead to thyroid overactivity and eye disease. Oestrogen and progesterone are thought to be immunomodulatory and have been postulated to play an important role in the difference in prevalence of autoimmune disorders between men and women. Autoimmune disorders, including autoimmune thyroid disease, are often quiescent during pregnancy with an increased prevalence postpartum. The increase in immune mediated th...

Serum androgen levels are commonly suppressed in patients with benign cortisol-secreting adrenocortical adenomas due to ACTH suppression. Associated androgen co-secretion usually indicates malignancy. Here, we present a case a very large benign androgen and cortisol-secreting adrenocortical neoplasm.Case: A 24-year-old female was referred with a 1-year history of secondary amenorrhea associated with hirsutism and acne. She reported irregular menstrual cy...

Adrenal haemorrhage is a relatively rare phenomenon which can often present non-specifically. In the case of bilateral haemorrhages, if unrecognised the endocrine sequelae may prove to be fatal. These three cases highlight very different clinical presentations of this important condition.Case 1: A 74-year-old male was admitted following a fall and fractured neck of femur. His post-operative recovery was complicated by acute myocardial infarction, pneumon...

Introduction: Paget’s disease of the bone is a rare endocrine disease especially among Africans and Asians. Hence the detection of a case in a middle-aged Nigerian is of interest.Case presentation: A 62-year-old Nigerian man in apparent good health was found to have markedly elevated alkaline phosphatase (ALP) of 1179 U/l during a routine medical check-up. He had no history suggestive of Paget’s disease of the bone and also had no known family ...

We present the case of a 50-year-old lady who initially presented to the endocrine department at Royal Bolton Hospital in 2011 with symptoms of tiredness and lethargy following hysterectomy and bilateral salpingo-oophorectomy in 2003. Hormone replacement therapy was not commenced in view of a strong family history of breast cancer. There is a family history of both autoimmune hypothyroidism and hyperthyroidism. Thyroid function tests were normal, with a positive thyroid peroxi...