A rare cause of hypercalcemia presenting with high parathormone levels: Familial hypocalciuric hypercalcemia

Familial Hypocalciuric Hypercalcemia is a generally benign disorder caused by heterozygous inactivating mutations in the Calcium-Sensing-Receptor gene resulting in altered calcium metabolism. It should be considered in differential diagnosis of primary hyperparathyroidism. Our case whom was diagnosed as toxic nodular goitre and primary hyperparathyroidism and suggested surgical treatment in another clinical center was evaluated in our out-patient clinic. Furosemid treatment which may affect calcium metabolism was stopped and medical therapy for hyperthyroidism was given. During follow-up the patient was considered as familial hypocalciuric hypercalcemia because of mild hypercalcemia, borderline elevated parathormone levels and significantly decreased daily urinary calcium excretion. The diagnosis was confirmed with the determination of similar laboratory findings for calcium metabolism in her children. In conclusion, evaluating the calcium metabolism after correcting the other factors and keeping familial hypocalciuric hypercalcemia in mind while diagnostic approach to hypercalcemia and differentially diagnosis of primary hyperparathyroidism may prevent unnecessary surgery. [Cukurova Med J 2013; 38(4.000): 765-769

A Rare Cause of Hypothyroidism: TSH’oma

TSH (tyrotiropin) secreting pituitary adenomas account for <1% of all hypophyseal adenomas with a prevelance of 1/1.000.000 and is a very rare reason of hyperthyroidism (TSH&#146;oma). In these casess free t4 and free t3 levels are elevated whereas TSH levels are normal or elevated. A 26 year old women referred to our outpatient clinic with complaints of palpitation, tremors, weight loss and dispnea for three months. Laboratory analysis showed that plasm free T3 levels (8,2 mIU/ml-normal 3,2-5,4 ) and TSH levels were high(5,7 mIU/ml, normal 0,3-4,9 mIU/ml), and free T4 level was on the upper limit (14,7 mIU/ml- normal 9-15 mIU/ml). Considering TSH depended hyperthyrodism the patient went under a magnetic resonance imaging scan (MRI) which confirmed an 11 mm lesion on hypophysis which was compatible with adenoma.The patient was diagnosed with TSH&#146;oma and went under transnasal, transsphenoidal hypophysis surgery. Although TSH secreting pituitary adenomas are rare causes of hyperthyrodism, advanced laboratory methods allow them to be diagnosed early and avoid unnecessary tests and time loss. [Cukurova Med J 2013; 38(3.000): 499-502

Assessment of prenatal and perinatal characteristics of pregnants with gestationel diabetes mellitus who have postnatal glucose abnormalities

Purpose: To examine the difference in terms of prenatal and perinatal characteristics between gestational diabetic (GDM) cases diagnosed with impaired fasting glucose (IFG)and impaired glucose tolerance (IGT) during early postpartum period. Material and Methods: Cases who had no history of any glucose metabolism disorder and diagnosed as GDM due to American Diabetes Association (ADA) criteria were included. Subjects were inquired for pregestational characteristics(glucose abnormality in previous pregnancies, birth of macrosomic baby and history of diabetes in a first-degree relative), prenatal characteristics (age, body mass index BMI), features at diagnosis (BMI,weight-gain ,blood pressure and HbA1C), and perinatal characteristics (birth week and baby birth weight) were recorded. Oral glucose tolerance test (OGTT) was reperformed in the 6th postpartum week. Effects of pregestational, prenatal and perinatal features on postpartum glucose abnormalities were analysed. Results: Out of 80 cases who completed the study 58.7%(n=47) had normal glucose metabolism, 13.7%( n=11) had IFG and 27.5%(n=22) had IGT. No difference was found between pregestational, prenatal , perinatal characteristics, features at the time of diagnosis and postpartum OGTT results. Incidence of IFG in postpartum OGTT for those who had diabetes in a first degree relative was elevated when compared with other cases(p=0,042). The difference was preserved after adjustment for other characteristic features with multivariate analysis (p=0,037). Conclusion: Presence of diabetes in a first degree relative may be a risk factor for postnatal early IFG. In our study other pregestational, prenatal, perinatal factors and features at diagnosis didn&#146;t affect early postpartum glucose metabolism. [Cukurova Med J 2013; 38(4.000): 617-626

Association between Serum Osteopontin Levels and Cardiovascular Risk in Hypothyrodism

Purpose: Cardiovascular effects of hypothyroidism are well known. Osteopontin (OPN) is a new inflammatory marker which was first isolated from the bone. Flow-mediated dilatation (FMD), a noninvasive technique to measure this endothelium-dependent function, has been used in several clinical studies to show cardiovascular risks. The aim of our study was to assess FMD value in hypothyroidism patients and to investigate whether plasma OPN level is a parameter which can predict cardiovascular risks in this group of patients. Material and Method: This study included 39 patients who had high levels of thyroid-stimulating hormone (TSH) and 11 healthy euthyroid controls. Plasma TSH, free thyroxine, fibrinogen, high-sensitive C-reactive protein (hsCRP), fasting plasma glucose, total cholesterol (T-chol), low density lipoprotein (LDL), triglyceride and OPN levels were measured at the time hypothyroidism was first detected and after euthyroid state was achieved with levothyroxine treatment. In parallel with these assessments, brachial FMD measurements were also performed. Results: In hypothyroid patients cardiovascular risk factors such as T-chol, LDL and triglyceride levels were higher than in control group but fibrinogen and hsCRP levels were not different between the groups. OPN levels were similar in patient and control groups, but basal FMD levels were lower in patients with hypothyroidism. After euthyroidism was achieved, OPN levels significantly decreased and FMD levels significantly increased, but a correlation was not detected between these two parameters. Discussion: Our study did not show a significant correlation between OPN and cardiovascular risk parameters. Further studies are needed to use OPN as a cardiovascular risk marker in hypothyroid patients

Mean platelet volume in Graves' disease: A sign of hypermetabolism rather than autoimmunity?

Objective: To evaluate the impact of mean platelet volume (MPV) on predicting disease course among patients with Graves' disease (GD). Methods: This retrospective study was performed between 2013-2016 at the Outpatient Endocrinology Clinic of Baskent University Faculty of Medicine, Adana hospital on 65 patients with GD. Among participants, 30 cases experienced thyrotoxicosis again during the first six months after discontinuing anti-thyroid drug (ATD) sessions that had been carried out for at least 12 months prior to stopping (Relapse group). We also observed 35 patients who exhibited normal thyroid functions within six months following ATD withdrawal (Remission group). MPV levels and thyroid function tests were recorded and total duration of ATD therapy was calculated for all participants. Results: The mean MPV level that was measured at the time of drug withdrawal did not differ between groups, being 8.0 +/- 1.2 fL in the Relapse group vs. 8.0 +/- 1.0 fL in the Remission group (p=0.81). However, we found that the relapse MPV was higher than the withdrawal MPV in the Relapse group (9.2 +/- 1.3 fL) than it was in the Remission group (8.0 +/- 1.2 fL, p=0.00). Conclusions: Higher relapse MPV in Relapse group but similar MPV levels in both groups at ATD withdrawal may be attributed to hypermetabolism or hyperthyroidism rather than autoimmunity of GD

Low Prevalence of Periodontitis in Acromegaly: Growth Hormone May Exert a Protective Effect

Purpose: To evaluate bone mineral density (BMD) measurements and the presence of periodontitis in patients with acromegaly, as well as to inquire the impact of interfering factors. Material and Method: Forty-seven acromegalic patients with any accompanying condition known to affect calcium-bone metabolism and 60 age-matched healthy controls were included. Age, gender, duration and activity of acromegaly, past-present therapy options, pituitary hormone profiles, replacement therapies, and the results of periodontal analysis were recorded. Results: Eighteen patients were male (38.3%), 29 were female (61.7%). The mean age of the patients was 46.6 +/- 11.5 years, twenty-five (53.1%) had active, 22 (46.8%) had inactive acromegaly. The latter were older and had longer disease duration (p=0.04, p=0.003, respectively). Serum calcium and phosphorus levels, 24-hour urinary calcium excretion and BMD at the lumbar spine and femur neck insignificantly associated with disease activity (p>0.05). Osteoporosis was detected in 6 patients (12.76%). Periodontitis and advanced periodontitis were more common in control group (66.7% vs. 44.7%), (43.3% vs. 12.8%) (p=0.022, p=0.0001, respectively). There was no difference in chronic periodontitis and severity between active and inactive groups (48% vs. 40.9%; p=0.279). No difference was noted in other study parameters, as well. Repeated measures analysis of variance demonstrated statistically insignificant distribution between GH change in time and periodontitis subgroups. Discussion: We demonstrated that acromegaly exerted no clear negative impact on vertebral BMD in the absence of overt hypogonadism. Regardless of disease activity, acromegaly cases exhibited lower rates of periodontitis with less severity which remained unchanged in the presence of accompanying metabolic disorders known to have negative impact on periodontal tissue. Chronic exposure to excess GH may have a protective role against periodontitis

Insulin Resistance in Non-Obese Polycystic Ovary Syndrome Subjects and Relation with Family History of Diabetes Mellitus

Purpose: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women in reproductive age. Conflicting results are reported in the studies examining insulin resistance in lean PCOS subjects. We aimed to observe the controversial presence of insulin resistance in lean PCOS subjects with the gold standard method and assess the impacts of family history of type 2 diabetes mellitus (T2DM) on insulin resistance in these patients. Material and Method: Nineteen patients with PCOS and nine age-BMI matched control subjects were recruited into the study. Patients with PCOS were divided into two groups according to their FH of T2DM among their first degree relatives (FHneg vs FHpos). Insulin resistance was evaluated with homeostasis model assessment of insulin resistance (HOMA-IR) and hyperinsulinemic euglycemic clamp technique for all participants. Results: Mean M values were significantly higher in the control group when compared with PCOS patients (p=0.003). There was no statistically significant difference for HOMA-IR and M values when FHneg and FHpos patients were compared. Although HOMA-IR values were similar between all groups, M values were lower in FHneg and FHpos groups compared to the controls (p=0.02 and 0.004 respectively). Discussion: Lean PCOS patients have evident insulin resistance when compared to healthy subjects, and FH of T2DM seems to not affect insulin resistance. Even non-obese PCOS patients should be encouraged for healthy eating style and exercise to prevent the potential risks associated with insulin resistance. Furthermore these patients can see benefits from medical therapies which improve insulin sensitivity

A Case of Inoperable Malignant Insulinoma with Resistant Hypoglycemia Who Experienced the Most Significant Clinical Improvement with Everolimus

Metastatic insulinomas may sometimes present with recurrent life-threatening hypoglycemia episodes. Such patients usually fail to respond to various therapeutic agents which causes constant dextrose infusion requirement. Herein, we present a resistant case of inoperable malignant insulinoma who was treated with many therapeutic agents and interventions including somatostatin analogues, Yttrium-90 radioembolization, everolimus, radiotherapy, and chemoembolization. Close blood sugar monitorization during these therapies showed the most favourable response with everolimus. Everolimus treatment resulted in rapid improvement of hypoglycemia episodes, letting us discontinue dextrose infusion and discharge the patient. However, experience with everolimus in such patients is still limited, and more precise data can be obtained with the increasing use of this agent for neuroendocrine tumours