Highlighted Cases

Section 1: Case History: We present the case of a 52-year-old found female found collapsed at home with a three-week history of polyuria, polydipsia and lassitude on a background of primary hypothyroidism and non-insulin-dependent diabetes. On examination, she was hypothermic at 32°C, hypotensive (blood pressure 90/60 mmHg), newly oliguric, and had a Glasgow coma scale (GCS) of 9/15. A diagnosis of severe diabetic ketoacidosis (DKA) was made on admission. <p class="ab...

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ea0074ncc2 | Highlighted Cases | SFENCC2021

Recognizing chronic hypoxaemia as a risk factor for non-hereditary Paraganglioma

Abdul Rasheed Althaf , Ball Steve , Hunter Louise

Case history: Hereditary paragangliomas (PGLs) associated with loss of function mutations in SDHx and VHL genes have revealed a remarkable connection between these conditions and the hypoxia signalling pathway: with a pseudohypoxic profile driving hypoxia inducible factor (HIF) activity and tissue-limited cellular proliferation. We present a case of sporadic, multiple PGL mediated by HIF activation through true hypoxia. A 32 year old female was re...

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ea0074ncc3 | Highlighted Cases | SFENCC2021

Agranulocytosis & contrast – a perfect storm

Neely Andrew , Virtej Ioana , Black Neil

A 77 year old female was admitted two weeks after an out-patient CT Pulmonary Angiogram showed a subsegmental pulmonary embolism and retrosternal goitre. History was of ten days of confusion, breathlessness, diarrhoea and reduced intake. On admission, she was febrile, tachypnoeic and in new, rate controlled, AF. Burch-Wartofsky Point Scale: 45, this being highly suggestive of a thyroid storm. TFTs were normal one year prior. Thyroid USS showed a multi-nodular goitre. She was c...

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ea0074ncc4 | Highlighted Cases | SFENCC2021

A rare case of multiple thrombi and left adrenal haemorrhage following COVID-19 vaccination

Boyle Luke D , Morganstein Daniel L , Mitra Indu , Nogueira Edson F

Case history: A 55 year-old female presented to A&E with left iliac fossa pain and vomiting, 8 days following her first dose of the AstraZeneca COVID-19 vaccine. She had a background of hypothyroidism, hypertension and hysterectomy for menorrhagia at age 25 no prior thrombotic history. She underwent emergency laparoscopy for suspected torsion, which was converted to laparotomy for ovarian necrosis secondary to left ovarian vein thrombosis. Post-operatively, isolated...

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ea0074ncc5 | Highlighted Cases | SFENCC2021

Grave’s orbitopathy – Metastatic breast cancer presenting as orbitopathy, not previously recorded in the endocrine literature

Isand Kristina , Wass John , Norris Jonathan , Heleen Noor Inger

Case history: A 67-year-old lady was referred to an endocrinologist for autoimmune hypothyroidism diagnosed in 2004. A treatment combination of levothyroxine and liothyronine was used. She had a history of recurrent metastatic ER-positive HER-2 negative lobular breast cancer with liver and bony metastatic involvement. She commenced with Letrozole (aromatase inhibitor) and Palbociclib (CDK inhibitor), later Fulvestrant (antioestrogen) and Crizotinib (tyrosine kinase inhibitor)....

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ea0074ncc6 | Highlighted Cases | SFENCC2021

An unusual cause of hypokalaemia: Itraconazole induced apparent mineralocorticoid excess syndrome

Abdalraheem Ali , Seetho Ian

Case history: 81 year-old female was admitted to hospital with pneumonia. Past medical history included laryngeal cancer (1996), laryngectomy, iatrogenic hypoparathyroidism, hypothyroidism, and pulmonary tuberculosis (2007). She was treated with different antibiotics without improvement. She had positive aspergillus serology, but cultures were negative. She was started on voriconazole which was later changed to itraconazole 100 mg twice daily and discharged home. She was seen ...

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ea0074ncc7 | Highlighted Cases | SFENCC2021

A rare case of metastatic prolactinoma presenting with cervical myelopathy

Bashiti Hazem , Broughton Chloe , Nelson Richard

Case History: A 52 year old man presented in 2009 with a gradual loss of peripheral vision associated with headaches. Examination confirmed bi-temporal hemianopia. Further investigation revealed elevated prolactin levels and pituitary MRI showed evidence of large pituitary tumour. A diagnosis of macroprolactinoma was made and cabergoline was commenced. Given resistance to medical treatment, the patient required two surgical resections (2011 and 2013) and radical radiotherapy (...

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ea0074ncc8 | Highlighted Cases | SFENCC2021

Invoking Occam’s razor: A case of familial partial lipodystrophy unifying multiple diagnoses

Sullivan Heather , Westall Sam , Khan Abidullah , Khan Ahtisha , Khan Alikhan , McNulty Sid , Furlong Niall , Narayanan Prakash , Balafshan Tala , Bujawansa Sumudu

Case history: A 25 year old primigravid woman was referred through to the Joint Antenatal clinic with a 15-year history of Diabetes Mellitus Type 2 treated with metformin. Her past medical history included polycystic ovarian syndrome, (causing significant hirsutism and amenorrhoea), non-alcoholic fatty liver disease, dyslipidaemia and hypertension (previously investigated for secondary causes). Her HbA1c was well controlled at 30 mmol/mol, and her Metformin had been discontinu...

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ea0074ncc9 | Highlighted Cases | SFENCC2021

A rare case of Hypocalcaemia – A diagnostic dilemma

Abeyaratne Dayakshi , Healy Ultan , Naziat Auditi , Tomlinson Jeremy , Pal Aparna , Hannan Fadil , Thakker Rajesh , Shine Brian , Jafar-Mohammadi Bahram

Case history: A 38-year-old woman presented with blepharospasm, cramping of the hands, and paraesthesia primarily affecting the face and hands. Symptoms had been present for 10 years but had been progressive over the previous 12 months. Symptoms were consistent with neuromuscular instability. Hypocalcaemia and elevated Parathyroid hormone (PTH) were confirmed. Past medical history was notable for anorexia nervosa in remission. Family history was non-contributary. Hypocalcaemia...

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ea0074ncc10 | Highlighted Cases | SFENCC2021

PVLSA – A rare cause of thyroid abscess

Tyndall Victoria , Arunagirinathan Ganesh

Case History: We present a case of a 24 year old music teacher and who attended our medical assessment unit. The gentleman described a twelve day history of neck pain, malaise, and odynophagia having received treatment one month previously for a PVL positive Staphylococcus aureus (PVLSA) lip abscess for which he did not complete eradication therapy. He described associated difficulty swallowing, rigors, vomiting and weight loss. On examination he had a tender, hot goi...

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ea0074ncc11 | Highlighted Cases | SFENCC2021

A spoonful of sugar helps the lactate stay down

Fawdry Helena , Gorrigan Rebecca , Ramachandran Radha , Drake William

Section 1: Case history: A 30-year-old Romanian male presented to A&E with symptomatic hypoglycaemia (point-of-care venous glucose 1.8 mmol/l, laboratory value 2.0). He reported 2 days of intermittent left-sided abdominal pain and frequent food craving. Despite eating, he developed dysarthria, hyperhidrosis, somnolence and asthenia, associated with epigastric pain and vomiting. He was recently diagnosed with hepatitis C, discovered incidentally during investigations for ch...

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ea0074ncc12 | Highlighted Cases | SFENCC2021

A rare presentation of parathyroid carcinoma and brown tumours in a young woman with no associated genetic condition

de Bray Anne , Jones Sharon , Ahmad Ijaz , Juszczak Agata

Case history: A 34-year old Caucasian nurse presented to her GP with a 7 month history of abdominal pain. She was found to have PTH-dependent hypercalcaemia with Stage 3A chronic kidney disease (corrected calcium 3.43 mmol/l, phosphate 0.62 mmol/l, total vitamin D 32 nmol/l, PTH 214.9 pmol/l, creatinine 117 μmol/l and eGFR 45 ml/min/1.73m2). On direct questioning, she reported fatigue, generalised weakness and intermittent joint pains affecting her lower back and bo...

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ea0074ncc13 | Highlighted Cases | SFENCC2021

Refractory Graves’ disease following total thyroidectomy caused by concurrent ectopic thyroid tissue in the anterior mediastinum

Sathyanarayan Sheela , Li Adrian , Arshad Sobia , Dimitriadis Georgios K

Case History :A 34-year-old Caucasian female patient presented in May 2015 to A&E with symptoms of overt thyroid dysfunction. She was managed medically until June 2016 when thionamide treatment was withdrawn. Unfortunately, this lady had a first disease relapse in July 2018 whilst she was pregnant at 35 weeks of gestation and then further disease relapse in January 2020 during her second pregnancy. Investigations: Initial biochemistry in 2015 confirm...

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ea0074ncc14 | Highlighted Cases | SFENCC2021

Multiple electrolyte disturbances as the presenting feature of MEN-1

Li Adrian , Sathyanarayan Sheela , Arshad Sobia , Aylwin Simon , Dimitriadis Georgios

Case history: A 49-year-old teacher presented to his GP with lethargy and lower limb weakness. He had noticed polydipsia and polyuria, and had experienced weight loss albeit with an increase in central abdominal fat mass. He had previously undergone cholecystectomy and colonic polypectomy. He took no regular medications. Investigations: He had hypercalcaemia 3.34 mmol/l with PTH of 356 ng/l and hypokalaemia 2.7 mmol/l and was admitted for intravenous flu...

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ea0074ncc15 | Highlighted Cases | SFENCC2021

A case report on rare metastic Paraganglioma with SDHB mutation

Dhakshinamoorthy Barkavi , Nag Sath , Ahmad Waquar

Paragangliomas are rare neuroendocrine tumours that originate from neural crest cells and can arise from any autonomic ganglion of the body. This is a challenging entity given the limited therapeutic options. Here, we present a rare case of metastatic Paraganglioma in a patient with a germline pathogenic succinate dehydrogenase subunit B (SDHB) mutation. A 54 year old lady was initially diagnosed with functioning bladder paraganglioma with raised metanephrine and norm...

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ea0074ncc16 | Highlighted Cases | SFENCC2021

AIP-mutated Acromegaly responding well to a first generation somatostatin analogue

Elamin Aisha , Debono Miguel

Introduction: Aryl hydrocarbon receptor interacting protein (AIP) mutated Acromegaly is a complex rare disease. AIP mutations are associated with an aggressive, inheritable form of acromegaly that responds poorly to SST2-specific somatostatin analogues (SSAs). Literature reports demonstrate that second generation SSA, Pasireotide LAR, is superior to first generation SSAs in treating acromegaly with AIP mutation. Treating acromegaly with AIP mutation could be quite challenging....

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ea0074ncc17 | Highlighted Cases | SFENCC2021

Hyperthyroidism as an under-recognised reversible cause of microcytosis

Eyzaguirre Valencia Mario , Kyaw Ye , Chinnasamy Eswari

Introduction: Hypothyroidism is a well-recognised cause of macrocytosis, but microcytosis is not widely recognised to be associated with hyperthyroidism. Thyroid abnormalities are often associated with various haematological changes and Graves disease has been reported to be mimicking beta thalassaemia trait in the literature. We discuss two cases of microcytosis related to hyperthyroidism that fully resolved once euthyroidism was achieved.Case 1: ...

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ea0074ncc18 | Highlighted Cases | SFENCC2021

A case of iatrogenic Cushing’s disease and secondary adrenal insufficiency following a drug interaction between intra-articular triamcinolone injection and ritonavir

Khan Shaila , Walsh John , Cox Jeremy , Agha-Jaffar Rochan , Gable David

Section 1: Case history: A 50-year-old woman presented to the HIV clinic after suspecting adverse effects following two intra-articular triamcinolone injections to her left hip, administered three and seven months prior. She complained of ongoing leg pain, generalised weakness and lethargy. Her past medical history included HIV infection, mild asthma for which she took inhalers only and had never required oral steroids. Her antiretroviral medications included dolutegravir, dar...

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ea0074ncc19 | Highlighted Cases | SFENCC2021

Conservative management of incidentally detected isolated ectopic papillary thyroid carcinoma: A case report vs possibility of future management protocols?

Sharma Bhavna , Sahu Radhamadhab , Sharma Indu , Aggarwal Sunil

Section 1:: 25 year old lady presented in 2014 with subacute submental midline neck swelling. Ultrasound neck: thyroid glands noted to be normal in size, shape and echotexture. No foci/nodules/mass lesion noted with normal vascularity. Isthmus of thyroid also noted to be normal in size, shape and echotexture. Neck vessels seen normally. Few hypoechoic lesions noted in submental region with echogenic area within it, on application of color doppler flow showing blood flow in ech...

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ea0074ncc20 | Highlighted Cases | SFENCC2021

What next when parathyroid surgery fails?

Tanveer Quratulain , Tremble Jennifer , Charles Debbie-Ann

Case History: Mr AT, a 54 year old male was referred by his GP in 2019 with a two year history of raised calcium. He initially sought medical attention for pain radiating from the left buttock to the knee. He had a background of hypertension and pre-diabetes and was on Nifedipine LA 3 mg OD and Furosemide 20 mg OD. He denied headaches, insomnia, concentrating problems, constipation, polyuria and polydipsia. He had no history of fractures nor renal stones. He was a non-smoker a...

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ea0074ncc21 | Highlighted Cases | SFENCC2021

Steroid responsive encephalopathy associated with autoimmune graves thyroid disease, a rare presentation

Uchambally Manjima , Nahar Meheroon , Macinerney Ruth

Case History: We describe a case of a 30-year-old female who presented at 8 weeks postpartum with history of altered behaviour, clouding of consciousness and status epilepticus. She had been diagnosed with autoimmune graves thyroid disease and was commenced on carbimazole prior to this episode. She was treated as meningoencephalitis. Also, consideration was given for possibility of thyroid storm and post-partum eclampsia. She was intubated and ventilated, treated with IV acycl...

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ea0074ncc22 | Highlighted Cases | SFENCC2021

Familial hypocalciuric hypercalcemia. Not so benign

Tanveer Quratulain , Tremble Jennifer , Charles Debbie-Ann , Khanum Amina

Section 1: Case history: At the age of 18 our patient presented with renal stones and was diagnosed with Primary Hyperparathyroidism (PHPT). At 20 she underwent a right sided nephrectomy for a calculus associated non-functioning kidney. Over the years she has had numerous renal calculi, ureteric obstructions with stents, requiring urology input. Of note she had osteoporosis, hypertension, pancreatitis, gastritis, intracranial hypertension (with shunt in situ) and resistant Vit...

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ea0074ncc23 | Highlighted Cases | SFENCC2021

An interesting case of POEMS syndrome with adrenal insufficiency

Sillars Anne , Tough Jillian , Cleland Steve

POEMS syndrome is rare multi-system disorder characterised by a paraneoplastic plasma cell disorder. The acronym POEMS stands for Polyneuropathy, Organomegaly, Endocrinopathy, M protein, and Skin changes. The underlying mechanisms are poorly understood, but chronic overproduction of pro-inflammatory cytokines have an integral role in the disorder. Diagnosis of POEMS is difficult owing to the variety of clinical manifestations. Mandatory diagnostic criteria are (a) one major cr...

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ea0074ncc24 | Highlighted Cases | SFENCC2021

Severe postmenopausal hyperandrogenism with diagnostic dilemma. The source of androgen being unmasked by the adrenal ovarian venous sampling

Ali Mudassir , Madathil Asgar , Mamoojee Yaasir , Boot Christopher , Ramzan Muhammed , Okpokam Atuora , Johnson Sarah , Truran Peter , R Jason , Quinton Richard

Section 1: Case history: A 60 year-old lady presented with a 4-year history of progressively increasing virilisation on the background of right salpingo-oophorectomy for ectopic pregnancy in 1984 (no histology available).Section 2: Investigations: Testosterone 23.6 nmol/l (NR < 1.7), LH 16 IU/l (7.758.5), FSH 33 IU/l (25.8134.8), androstenedione 3.2 nmol/l (NR 1.414.3), DHEAs 1.2 umol/l (0.55.6), 17-OHP 2.7 nmol/l (14.5)...

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ea0074ncc25 | Highlighted Cases | SFENCC2021

An adrenocortical carcinoma with distinct features of 21-hydroxylase deficiency

Ly Elisa , Howell Simon , Kaushal Kalpana , Zelhof Bachar , Wahie Twesha , Ghatore Lea , Laing Ian

Adrenal carcinomas are rare with a poor prognosis, highlighting the importance of prompt investigation of adrenal incidentalomas. We report a challenging case of an adrenocortical carcinoma secreting steroids in a pattern characteristic of 21-hydroxylase deficiency, which also proved to be a histopathological enigma. A 36-year-old woman underwent investigation for right-sided loin pain. A CT showed an avidly heterogeneously enhancing circumscribed left adrenal mass measuring 6...

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ea0074ncc26 | Highlighted Cases | SFENCC2021

Rapidly progressing Cushing’s syndrome secondary to ACTH producing Parotid Carcinoma

Rafique Shemitha , Barnes Dennis

61 year male presented with productive cough and was noted to have persistent hypokalaemia. On examination he had an elevated blood pressure; previously not known to be hypertensive and significant proximal myopathy in his lower limbs. He also had central obesity. In October 2018 he had a left parotid swelling. He had left parotidectomy and left neck dissection. The histology was an adenocarcinoma. In the following year he had cough, and shortness of breath, which on investiga...

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ea0074ncc27 | Highlighted Cases | SFENCC2021

Hyperandrogenism and breast cancer in a postmenopausal woman – treatment challenges

Lider Burciulescu Sofia Maria , Dumitrascu Anda , Vladoiu Suzana , Caragheorgheopol Anda , Gheorghiu Monica Livia

Introduction: New-onset hyperandrogenism is rare in postmenopausal women and is usually associated with causes such as ovarian hyperthecosis, androgen-secreting tumor or medication. Patients with hyperandrogenism and breast cancer need a special attention when choosing the treatment.Case history: A 46-year old woman diagnosed with hormone receptor-positive breast cancer at 37 years old, for which she underwent surgery, chemotherapy, radiotherapy and horm...

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ea0074ncc28 | Highlighted Cases | SFENCC2021

Cushing’s syndrome and the diagnostic challenge

Wordsworth Georgina , Talbot Fleur , Parfitt Vernon , Chau Fong

Section 1: Case history: This 41 year old lady was seen in the Endocrine clinic with an 8 year history of worsening hypertension, obesity and Type 2 diabetes. She had no conditions known to cause physiological hypercortisolism, no exogenous steroid use and had clear physical features of Cushings syndrome.Section 2: Investigations: Investigations confirmed Cushings syndrome with two elevated urinary free cortisol assessments (UFC) (934 and 906...

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ea0074ncc29 | Highlighted Cases | SFENCC2021

A triumvirate of macroprolactinoma, apoplexy and aneurysm: what is the optimal management strategy?

Mathara Diddhenipothage Shani Apsara Dilrukshi , Anguelova Lia , Amarouche Meriem , May Christine , Jafar-Mohammadi Bahram , Joseph Robin , Cudlip Simon , Pal Aparna

Case history: A 57-year-old male with well controlled primary hypertension presented with acute onset severe headache while exercising, associated with nausea and vomiting. He had no visual or other neurological symptoms. The pain settled with analgesics in ED. He reported four transient similar episodes during the preceding 18 months. There were no symptoms suggestive of pituitary or other endocrine dysfunction, including hyperprolactinaemia. Clinical examination was unremark...

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ea0074ncc30 | Highlighted Cases | SFENCC2021

The management of ectopic ACTH syndrome secondary to a lung neuro-endocrine tumour with metyrapone: Illustration from a clinical case

Kapoor Ashutosh , Latchford Charles , Chatzimavridou Victoria , Mansoor Wasat , Adam Safwaan

Case history: We report the case of a previously healthy 69-year-old female who was referred to our centre after she presented with rapidly progressive weight-gain, hyperglycaemia, hypokalaemia and hypertension. She had no symptoms suggestive of carcinoid syndrome. On assessment, she had pathognomonic features of Cushings syndrome: central weight gain (peripheral wasting) proximal myopathy, leg oedema, skin thinning, bruising and facial puffiness; this appearance being m...

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ea0074ncc31 | Highlighted Cases | SFENCC2021

Resistance to thyroid hormone receptor-beta: diagnostic pitfalls

Khan Ahtisham Ali , Westal Sam , Bujawansa Sumudu , Sullivan Heather , Khan Abidullah , Narayanan Prakash , McNulty Sid

Section 1: A 77 year female was referred by her GP in May 2019 for abnormal thyroid function tests (TFT) which were requested due to new diagnosis of atrial fibrillation. The patient was otherwise asymptomatic and clinically euthyroid. Family History was negative for thyroid abnormalities. On enquiry, the patient revealed that she had abnormal thyroid function tests associated with a large goitre in 1970s and subsequently underwent partial thyroidectomy followed by radioactive...

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ea0074ncc32 | Highlighted Cases | SFENCC2021

The perils of post prandial paralysis and palpitations

Lam George , Crown Anna

Section 1: Case history: A 53 year old male of Chinese ethnicity presented to hospital with a fall and a long lie. He had a heavy meal for dinner, and he fell later in the evening after standing from the sofa. He lacked strength in his limbs and could not stand up again. He was on the floor for 7 hours before he could shuffle his way to the phone and call for help. On examination he had MRC grade. power in the proximal arms and MRC grade. hip. flexion. Sensation was normal. He...

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ea0074ncc33 | Highlighted Cases | SFENCC2021

Pituitary apoplexy in the setting of recent COVID-19 infection

Seese Rachel , Shames Abdul , Liew Su-Yi

Section 1: Case history: We present a case of a 75-year-old male with hypopituitarism on the background of recent COVID-19 infection. The patient was COVID-19 swab positive six weeks prior and suffered mild hypoxia, however declined hospital admission at that time. He presented one month later with sudden onset severe headache associated with fever; drowsiness and abdominal pain. He was discharged with antibiotics for suspected diverticulitis. His GP subsequently performed a p...

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ea0074ncc34 | Highlighted Cases | SFENCC2021

DDAVP: diagnosis, dentition and arginine vasopressin

Busby Jordan , Mirza Showkat , Sinha Saurabh , Connolly Daniel , Newell-Price John

Case History: A 47-year-old man presented to his GP in November 2019 with sudden onset polydipsia, polyuria and large volume nocturia, passing approximately 5L of urine daily. He was drinking to thirst, had no past medical or family history, and was not taking any medication. He had normal serum calcium, sodium and HbA1c. His GP referred to the local endocrinologist. Five months later, he was referred to our tertiary centre for a water deprivation test, as it had not been poss...

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ea0074ncc35 | Highlighted Cases | SFENCC2021

Challenges in managing toxic multinodular goitre and propylthiouracil-induced anti-neutrophil cytoplasmic antibody associated vasculitis

Koysombat Kanyada , Rehman Zahra , Aung Htet Htet , Elmustafa Sarra , Lin Nyan , Zac-Varghese Sagen , Solomon Andrew

Case history: A 53-year-old woman presented with vasculitic rash affecting her limbs. She has a 3-year history of thyrotoxicosis. Having developed intolerance to carbimazole she was maintained on propylthiouracil (PTU) for the last two years. Imaging results were consistent with multinodular goitre. Thyroid stimulating immunoglobulin was negative. A few months prior to this presentation she developed dysphagia. Repeat imaging showed an 8 cm right thyroid nodule that grew signi...

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ea0074ncc36 | Highlighted Cases | SFENCC2021

Asymptomatic primary hyperparathyroidism-acute deterioration with intercurrent illness-hypercalcaemic crisis

Akhter Rabia , Dar Shujah

Case history: 80 year old male was referred to endocrine clinic for incidental hypercalcemia picked up on six monthly blood tests for follow up of treated carcinoma of prostate in remission. Patient himself complained only of mild mechanical backache and no other symptoms of hypercalcemia. There was no family history of thyroid or parathyroid related disorders. Drug history did not include thiazides or lithium. Investigations: serum calcium 2.75 mmol/l, ...

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ea0074ncc37 | Highlighted Cases | SFENCC2021

Management of unresectable insulinoma using cloud-based continuous glucose monitoring: a case report

Gardner Gemma , Sherriff David , Flanagan Daniel

Section 1: Case history: A 62 year old man presented with a three month history of abdominal bloating and discomfort, loose stools and weight loss. This progressed to hypoglycaemic symptoms that occurred initially after exercise. Symptoms included confusion and light-headedness, fatigue, cold sweats and shakiness. The patient had to eat regularly to prevent hypoglycaemia which resulted in weight gain. Hypoglycaemic episodes increased in frequency to the point where the patient...

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ea0074ncc38 | Highlighted Cases | SFENCC2021

Perinatal headaches and the postpartum diagnosis

Trainer Harris , Modi Manish , Caterson Jessica , Agha-Jaffar Rochan

Case history: A 42-year old female was urgently referred to the endocrinology clinic. Symptomatology included worsening lethargy, polydipsia, poor appetite, postural dizziness and hypogalactia. Relevant background included the delivery of a healthy baby at term four weeks prior (Emergency caesarean section, 1000 ml blood loss documented). She had undergone an MRI at 39 weeks gestation following a 10-day history of persistent headaches with associated photophobia and dizziness ...

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ea0074ncc39 | Highlighted Cases | SFENCC2021

A rare case of Carbimazole induced peripheral neuropathy

Rich Laura

Section 1: Case history: A 55 year woman presented with a one month history of fatigue, anxiety, tremor and diarrhoea. She was diagnosed with Grave’s thyrotoxicosis and commenced on Carbimazole 30 mg daily. Thyroid hormones normalised, but after three weeks of therapy she developed rapidly progressive ascending numbness and weakness predominantly affecting her legs. Examination revealed distal symmetrical lower motor neurone weakness and widespread loss of light touch sensatio...

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ea0074ncc40 | Highlighted Cases | SFENCC2021

A Lady with thyrotoxicosis and rapidly growing goiter

Samarasinghe Gayani Pramuditha , Antonipillai Charles

Case history: A 62 years old lady presented with a history of weight loss, sweating, and tremor for 3 months. The diagnosis of thyrotoxicosis was made following biochemical confirmation and she was started on carbimazole 20 mg twice a day. Several weeks later she got admitted with progressive shortness of breath, hoarseness of voice, and a painful neck lump. Examination revealed a firm to hard fixed multinodular goiter with a dominant hard nodule at the left upper pole. There ...

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ea0074ncc41 | Highlighted Cases | SFENCC2021

A Rare case of abnormal thyroid functions

Pillai Sanesh , Rao Preethi , Merza Zayd

52 year old lady was referred to the endocrine clinic with h/o lethargy and tiredness. She also had mild tremors. She denied weight loss, palpitations or diarrhoea. Past medical history includes bipolar disorder. She was on Venlafaxine, Carbamazepine, Pregabalin and HRT. GP has done thyroid functions because of the symptoms and results are as below. TSH: 7.15 mIU/l(0.38–5.50), FT4:24.3pmol/l (10.0–18.7) on 05.02.2020 TPO:<10 IU/Ml This was rechecked in a different laborator...

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ea0074ncc42 | Highlighted Cases | SFENCC2021

Lithium-induced polyendocrinopathy in a single patient

Shah Preet , Hammond Peter

Case history: A 50-year-old lady, on Lithium for 30 years, presented with a history of progressively increasing thirst since 12 months; associated with polyuria and nocturia. She had been having some joint aches and was finding it more difficult to get up and down stairs. She was found to be hypothyroid few months back and prior to that had been falling asleep easily. There had been an improvement in her energy levels after starting Levothyroxine. She gave no history of renal ...

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ea0074ncc43 | Highlighted Cases | SFENCC2021

Severe and resistant hypercalcaemia: a diagnostic and management challenge

Aung Ei Thuzar , Amer Lida , Wilmington Rebekah , Srinivas-Shankar Upendram

Case history: An 81 years old lady with treated follicular lymphoma, hypertension and osteoporosis was admitted to hospital with a fall and was found to have hypercalcaemia with adjusted calcium of 4.9 mmol/l (nr 2.2–2.6 mmol/l). There was history of constipation but no history of excessive thirst or polyuria. The patient was on atorvastatin, amlodipine, bendroflumethiazide, ramipril, calcium and vitamin D. On examination our patient was dehydrated and mildly confused. There w...

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ea0074ncc44 | Highlighted Cases | SFENCC2021

Dose-dependent Carbimazole-induced eosinophilic dermatitis: a rare reminder of potentially serious side effects

Edwards Amy , Vathenen Ramu , Gunganah Kirun

Case History: A 23-year-old Bengali woman with a 2-year history of Graves’ disease presented to the endocrine day unit with a widespread, pruritic, vasculitic-looking rash. She was treated with Carbimazole since diagnosis but was poorly compliant. One month prior to presentation, her Carbimazole dose was increased from 20 mg daily to 60 mg daily, as she remained biochemically thyrotoxic (Free T4 79.9 pmol/l, T3 34.8 pmol/l and TSH < 0.01 mU/l). The rash started on her lower...

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ea0074ncc45 | Highlighted Cases | SFENCC2021

Opiod induced hypoadrenalism: a increasingly frequent condition, but easily forgotten

Amjad Wajiha

A 57 year-old female patient was admitted for the supervision of supplementary parenteral feeding, due to excessive weight loss and difficulty with gastric motility since having Roux-en-Y gastric bypass surgery a decade ago. During her stay she was noted to have regular episodes of significant resting hypotension, postural hypotension, and tachycardia, which did not respond to fluid replacement or nutritional support. Endocrinology specialist advice were requested by her gastroe...

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ea0074ncc46 | Highlighted Cases | SFENCC2021

Recurrence of cushing’s disease after several years of remission

Ganawa Shawg , Kearney Tara

68 Y M Has Background of Hypertension and Asthma. Presented with progressive visual deterioration for 12 months in 2012. VF testing confirmed Bitemporal Hemianopia. He has symptoms suggestive of cortisol excess. Therefore, MRI pituitary and pituitary hormone profile was done. MRI showed pituitary macroadenoma A Pituitary Hormone profile in 2012 showed cortisol excess at value of 755 nmol/l and ACTH 156 ng/l(0–46). IGF-1 17.2 nmol/l which is normal. LDDST was done and cortisol ...

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ea0074ncc47 | Highlighted Cases | SFENCC2021

Postpartum isolated cranial diabetes insipidus

Cairns Ross , Azharuddin Mohammed

Cranial Diabetes Insipidus is a rare diagnosis and rarer still postpartum. We present the case of 24-year-old woman who developed CDI following pregnancy. The patient had developed polydipsia and polyuria 5 months following pregnancy. The pregnancy had been complicated by Gestational Diabetes Mellitus and a large Postpartum Haemorrhage. The patient reported feeling fatigued, lightheaded and she stated a need to drink water frequently: ~ 8 litres throughout the day and 4 litres...

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ea0074ncc48 | Highlighted Cases | SFENCC2021

The pragmatic use of corticosteroids in the diagnosis and treatment of non-PTH driven hypercalcaemia

Yousif Yasear Zainab Akram , Ijaz Nadia , Gittoes Neil , Sanders Anna , Pang Terence

A 65-year-old gentleman was referred by his GP because of acute kidney injury and hypercalcaemia, which was associated with low levels of parathyroid hormone. He had been fit and well and was on no regular medications. Whilst his hypercalcaemia was partly correctible with saline rehydration, cautious use of bisphosphonates and cinacalcet were not effective in preventing rebound, and his nephropathy persisted. Curiously, he had longstanding low plasma alkaline phosphatase, but had normal denti...

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ea0074ncc49 | Highlighted Cases | SFENCC2021

Diagnostic and management challenges in a case of aggressive PTH-dependent hypercalcaemia associated with malignancy

Aung Nwe , Stokes Victoria , Ballav Chitrabhanu

A 76 years old previously healthy gentleman presented with severe hypercalcaemia (5.19 mmol/l;, 2.1–2.55) and raised Parathyroid Hormone (PTH, 37 pmol/l, 1.6–7.2) after a three weeks history of confusion, diarrhoea, and weight loss. There were no other focal symptoms and family history was not significant. Other significant findings included mild recent hyponatraemia (132 mmol/l;, 136–145), acute kidney injury (urea 16.1 mmol/l, 3.2–7.4, creatinine 177 umol/l, 63–111), low vit...

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Incidental finding of lipaemia retinalis on diabetes retinal screening

Melson Eka , Kempegowda Punith , Chen Wentin , Leong Annabelle , Amrelia Prashant , Amrelia Ateeq Syed

Section 1: Case history: A 37-year-old South Asian woman was referred to our diabetes clinic from the Diabetes Eye Screening Programme. Her retinal blood vessels appeared white, in contrast to the normal pink-red colour. The patient was diagnosed with diabetes secondary to chronic pancreatitis a year prior to this presentation, for which she was on metformin and long-acting insulin but had suboptimal control and multiple hospitalisations with chronic pancreatitis. She was prev...

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“The eyes have it”: a case of treatment-induced neuropathy of diabetes

Nicholson Martha , Morrison Emily , Hammond Christopher , Page Oliver , Lim Jonathan , Wilding John , Cuthbertson Daniel , Ooi Cheong , Malik Rayaz , Alam Uazman

Case History: A male in his 40’s diagnosed with type 2 diabetes in 2011 (BMI:20.7 kg/m2) was admitted with DKA (Dec 2018) after a period of poor glycaemic control on oral hypoglycaemic agents (Feb 2017: HbA1c-105 mmol/mol, Nov 2018: HbA1c-115 mmol/mol). There was dramatic improvement in glycaemic control after commencing him on subcutaneous insulin (April 2019: HbA1c-56 mmol/mol). GAD65 antibodies were positive (24 u/ml; normal<5 u/ml) and a diagnosis of latent a...

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Unmasking of hyperthyroidism by Takotsubo cardiomyopathy

Shah Preet , Hammond Peter

Case History: A 74-year-lady with a background of COPD presented to the emergency department with precordial chest pain radiating to the left arm. The pain had been ongoing since a few hours, and was associated with diaphoresis. She was hemodynamically stable, with no tachycardia Investigations: ECG showed significant ST-segment elevations, predominantly in the chest leads, with elevated troponins. Assuming it to be STEMI, she was transferred to the tert...

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A case of heterophile antibody interference causing a falsely positive thyroglobulin in a patient with non-relapsing thyroid carcinoma

Dewdney Charlotte , McDonald Lindsay , Isa Aidah , Smith Karen , Muir Kenneth

Case History: We report the case of a 59-year-old lady with a persistently elevated serum thyroglobulin following a total thyroidectomy for multifocal papillary thyroid carcinoma. She subsequently underwent radioiodine therapy following which her serum thyroglobulin remained elevated. However, it was later found to be almost undetectable at 0.3 μg/l after a change in laboratory method. This discrepancy prompted further investigation, and repeat analysis using the original assa...

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Surgical dilemma in management of hyperparathyroidism in multiple endocrine neoplasia type 1

Smout Vera , Lakshmipathy Kavitha , Emmanuel Julian , Nayyar Vidhu , Field Ben , Clark James , Bano Gul , Zachariah Sunil

Case History: 29 year old lady presented with profuse diarrhoea, lethargy and hypokalaemia in 2010. CT scan confirmed mass lesion in tail of pancreas. Chromogranin A and 24 hour urinary 5HIAA were normal. Fasting Gut hormone level showed elevated level of Vasoactive Intestinal Peptide (VIP), suggesting diagnosis of VIPoma. Further investigations confirmed hyperparathyroidism and microprolactinoma. Investigations: Adjusted calcium 2.98 mmol/l (<2.55), ...

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A case of adrenocortical carcinoma in a female with rapid virilisation and mild Cushing’s Syndrome

Lam George , Ahmed Fahad

Section 1: Case history An 86 year old female presented to hospital after being found on the floor and had profound lower limb oedema. She was treated for a urinary tract infection and possible heart failure. On examination she had significant hirsutism and bruised skin. She had a past medical history of BCC removal and primary hyperparathyroidism. Her ECOG performance status was 1–2. There was a family history of pancreatic cancer (father) and pancreatic neuroendocrine tumour...

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Thyroidectomy for recurrent sub-acute thyroiditis

Yousif Yasear Zainab Akram , Lubina-Solomon Alexandra

A 21-year-old woman presented in 2015 with palpitations, weight and hair loss, mood swings and diarrhoea. She was diagnosed with thyrotoxicosis (Table). On examination, thyroid was normal and no evidence of opthalmopathy. Treatment with Propranolol and Carbimazole was commenced. Ultrasound neck revealed moderate diffuse enlargement of the thyroid with uniformly abnormal echotexture, consistent with thyroiditis. A month later, she developed profound hypothyroidism, therefore Carbimazole was ...

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“BED IS BAD” – Finding the unusual cause of hypercalcaemia

Zafar Sadia , Latif Muhammad Mubashir , Khan Hafsa , Awais Muhammad , Rahman Mohammad M

Section 1: Case history: A 78 years old lady presented to Emergency Department with two weeks history of lethargy and confusion. She had background of advanced destructive Rheumatoid Arthritis diagnosed 30 years ago, multiple joint fractures, osteoporosis, long-term urinary catheter, recurrent UTI and renal calculi. She was recently discharged from hospital for urosepsis. She was bed-bound for the last 15 years after crushing vertebrae C2 C3 pressing on spinal cord. Her regula...

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Challenging management of type II amiodarone induced thyrotoxicosis AIT

Arfan Rabia , May Christine

Case history: 20 year old man with a complex cardiac history of Shone’s syndrome, out of hospital cardiac arrest 2015 (CRT-D implant) and multiple previous episodes of fast atrial fibrillation was admitted to hospital (28/11/2019) with 3 weeks history of intermittent palpitations and shortness of breath. His regular medications included amiodarone and bisoprolol. Examination revealed a fine tremor of outstretched hands, no obvious goitre or thyroid eye disease. Thyroid functio...

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Fresh pair of eyes for peri-menopausal lady

Yin Yin , Langworthy JND , Mcgettigan Christopher

A 50-year-old peri-menopausal lady has had a background history of hypertension on single-agent antihypertensive medication (ACEI), chronic headache, recurrent collapses, and panic attacks for the past 14 years. She has been visited by her GP frequently and performed countless blood tests including FSH, LH, and TSH which confirmed that her symptoms were neither related to menopause nor hyperthyroidism. She also presented to the Emergency Department a dozen times and called par...

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Learning to weather the storm: a case highlighting the challenges of managing a thyrotoxic crisis in a ventilated, co-morbid patient

Virk Jasmine , Talbot Fleur , Tatovic Danijela

Section 1: Case history: A 60-year-old woman was transferred to the receiving hospital after thrombolysis for a left-sided total anterior circulation stroke. Her past medical history was significant for alcohol dependence (70 units/week), atrial fibrillation (not anticoagulated but rate controlled with propranolol), seizures and severe mitral regurgitation. This lady underwent a successful thrombectomy, but subsequently developed haemorrhagic transformation and hydrocephalus. ...

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An unusual cause of hypercortisolism: Adrenal carcinoma

Tulsi Dooshyant , Lim Chong

Case History: A 76 year old woman presented to the Accident & Emergency Department with persistent hypokalaemia, hypertension and metabolic alkalosis. She complained of ongoing muscle fatigue and tiredness and denied any headaches or vision problems. On examination, she had evidence of centripetal obesity, proximal myopathy, pink striae and bruises on her abdomen. No visual field deficit on confrontation and neurological examination was normal. She had a past medical histo...

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A case of pseudohyperkalaemia in a patient with myeloproliferative disorder and acute kidney injury

Eyzaguirre Valencia Mario , Tuddenham Emma , Theofanoyiannis Panayiotis , Muralidhara Koteshwara , Chinnasamy Eswari

Introduction: Pseudohyperkalaemia is one of the most common testing errors that occur in clinical practice. It’s commonly due to pre-analytical factors many of which are clinically well recognised. These include incorrect sampling, delay in sample processing and haemolysis to name a few. However non-recognition of some rarer causes like thrombocytosis often results in initial inappropriate, potentially dangerous treatment. Here we present one such case of pseudohyperkalaemia i...

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Diagnostic conundrums: Severe hypoglycaemia in a non-diabetic individual

Westall Samuel , Sullivan Heather , Khan Abidullah , AliKhan Ahtisham , McNulty Sid , Furlong Niall , Narayanan Ram Prakash , Balafshan Tala , Bujawansa Sumudu

Case history: A 26-year-old female with a past medical history of migraines was admitted to the Emergency Department (ED) with severe hypoglycaemia after drowsiness was noted by her partner in the early hours of the morning. On initial paramedic assessment, the patient had a reduced Glasgow Coma Scale (13/15), hypoglycaemia (capillary blood glucose of 0.9 mmol/l [16.2 mg/dl]), hypothermia (34.3 degrees Celsius [°C]) and bradycardia (heart rate 41 beats per minute). The patient...

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A case of sight threatening pituitary macro-adenoma in pregnancy

Krishna Prasad Savi Prabha , Vachhani Shyamsunder , Das Gautam

Introduction: Pituitary adenomas account for 10% of intracranial tumours and are almost always benign. In some individuals, who may have a pre-existing adenoma, the pituitary gland undergoes remarkable hyperplasia especially during pregnancy, due to increase in oestrogen levels leading to increase in the tumour volume causing mass effects. This case report reviews a pregnancy with incidental finding of pituitary macro adenoma causing visual field defect, its management and fur...

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Multi-disciplinary management of the diabetic foot: putting patient choice at the forefront of clinical decision making

Wynn Nyunt Sandhi , Kiritkumar Amin Amit , Parsapour Shadeh , Bertok Szabolcs , Todd Gaytree , May Kong Wing

Case History: A 54 year old man with type 2 diabetes mellitus was referred in 2014 to our multi-disciplinary foot care service for the management of ulcers. One year previously he had undergone a left hallux amputation due to underlying osteomyelitis. Over the period 2015 through 2021, he required multiple admissions for management of limb threatening foot sepsis with exposed necrotic mid and hind foot bone. In 2016 he suffered a cerebrovascular infarct and in 2019 an episode ...

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Diagnostic dilemma of cushing disease

Kejem Helmine , Chattington Paula , Mahmud Ahmad

57 year old female physiotherapist, diagnosed with osteoporosis following a fibula fracture from a low impact stretch and a wedge vertebral fracture at age 51 with a metatarsal fracture age 54. With associated history of easy bruising, increase abdominal girth although her weight remained stable at 48.5 kg with BMI 19.9 and proximal myopathy. Blood pressure was constantly normal. Investigations: Early morning random Cortisol 564 and ACTH 6.6 (2–11), cort...

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A challenging case of lithium induced thyrotoxicosis and thyroid storm

Saad Ali Shah Syed , Bawa Fareha

Case History: A 69-year-old woman with bipolar schizoaffective disorder of 11 year’s duration and recent diagnosis of atrial fibrilation was admitted with acute onset of delirium, lethargy, shakiness and confusion. On admission, the patient was restless and non-compliant. Her skin was warm and sweaty, clinically dehydrated. Her heart rate ranging between 75 and 100 /min. The rhythm was irregular, consistent with atrial fibrillation on ECG and was afebrile. She was oriented to ...

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An interesting case of pan-hypopituitarism associated with empty sella syndrome

Singh Rajiv , Ogunko Arthur , Mohandas Cynthia , Abedo Itopa

Background: Empty Sella syndrome (ESS) is caused by the herniation of the subarachnoid space into the sella turcica, causing compression of the pituitary gland. Patients may be asymptomatic or exhibit different degrees of pituitary hormone deficiency. Pan-hypopituitarism can occur if there is decreased or absent secretion of all of the anterior pituitary hormones. Case: We report the case of a 68 year old female of Pakistani background who was visiting t...

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How novel is Dapagliflozin?

Vachhani Shyamsunder , Das Gautam

Case history: This 55 years old gentleman has past medical history of obesity, type 2 diabetes (since age of 27 yrs.), hypercholesterolemia, hypertension and osteoarthritis. He recently suffered from myocardial infarction discharged 2 days back and presented to emergency department with central chest pain radiating to both arms in the morning. Investigations: ECG reported as normal and venous blood gas showed pH- 7.10, pCo2- 3.84, pO2- 5.54, glucose- 10,...

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Omeprazole induced hypomagnesemia leading to hypocalcemia

Thacker Jeet , Das Gautam

Case History: A 58 year old female was referred by the GP to hospital for symptoms of tingling and numbness in fingers and toes, muscle cramps in arms and legs and swollen legs. The patient had a history of gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), hypertension, fibromyalgia, iron deficiency anaemia, knee osteoarthritis, and heart failure. Investigations: On admission, a corrected calcium level was 1.9 mmol/l and serum magne...

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Polycystic ovarian syndrome-atypical presentation with severe hyperandrogenism

Akhter Rabia , Dar Shujah

Case History: 27 year old female was referred to endocrine clinic with complaints of excess hirsutism over face, chin and neck accompanied with oligomenorrhea and acne for three years. The hirsutism was worsening gradually and she had to shave or wax her facial hair on daily basis. She was born at full term and had menarche at 12 to 13 years of age with regular periods. She had no symptoms of galactorrhea, headache, visual problems or recent weight gain. There was no family hi...

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Society for Endocrinology National Clinical Cases 2021

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