Awakening from Sleep and Hypoglycemia in Type 1 Diabetes Mellitus

The authors discuss a new study showing that patients with type 1 DM are susceptible to nocturnal hypoglycemia and that there is a relationship between awakening and activation of the counterregulatory response to hypoglycemia

Primary Hyperparathyroidism in Pregnancy: Successful Parathyroidectomy during First Trimester.

Primary hyperparathyroidism in pregnancy can result in significant maternal and fetal complications. When indicated, prompt parathyroidectomy in the early second trimester is considered the treatment of choice. Pregnant patients with primary hyperparathyroidism who have an indication for parathyroidectomy during the first trimester represent a therapeutic challenge. We present the case of a 32-year-old primigravida who presented with symptomatic hypercalcemia from her primary hyperparathyroidism. She remained symptomatic despite aggressive conservative management and underwent parathyroidectomy in her first trimester with excellent outcomes

Esophageal Tear with Pneumomediastinum Secondary to Esophageal Candidiasis in a Patient with Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy (APECED)

Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy (APECED) is a rare condition that diffusely affects many organ systems. Chronic mucocutaneous candidiasis is one of the features of APECED, which needs to be treated and monitored to prevent severe complications. This case demonstrates esophageal structuring and resultant esophageal perforation, in the setting of chronic mucocutaneous candidiasis. Learning Points • Chronic mucocutaneous candidiasis (CMC) can be present without overt esophageal thrush • CMC can result in esophageal lesions causing significant morbidity. • APECED patients with dysphagia should be assessed for chronic candida esophagitis and treated accordingly. • Patients with recurrent candida esophagitis should be considered for intermittent topical and systemic antifungal prophylactic therapy. • Esophageal perforation due to candidiasis is most often seen in the setting of immunocompromised states. Background Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive disease caused by mutations of the AIRE(autoimmuneregulator)genes[1,2,6,7].Itischaracterizedbytheclinicaltrialofchronicmucocutaneouscandidiasis(CMC),hypoparathyroidism, and adrenal insufficiency [7]. APECED has been reported worldwide, but is more prevalent in some historically- isolated homogeneous populations in Finland (1/25000), Sardinia, and Iranian Jews (1/9000) [7]. APECED is also seen at a lower incidence in Norway, Sweden, Slovenia, Great Britain, Italy, Ireland, and North America [7]. Most patients have CMC from early childhood [2, 3]. Rarely, untreated esophageal candidiasis may lead to complications such as esophageal stricture, rupture and or fistula formation [4, 5]

Acute milk-alkali syndrome

A 74-year-old woman presented with progressive lethargy, confusion, poor appetite and abdominal pain. She was found to have non-PTH-mediated severe hypercalcemia with renal failure and metabolic alkalosis. Extensive workup for hypercalcemia to rule out alternate etiology was unrevealing. Upon further questioning, she was taking excess calcium carbonate (Tums) for her worsening heartburn. She was diagnosed with milk-alkali syndrome (MAS). Her hypercalcemia and alkalosis recovered completely with aggressive hydration along with improvement in her renal function. High index of suspicion should be maintained and history of drug and supplements, especially calcium ingestion, should be routinely asked in patients presenting with hypercalcemia to timely diagnose MAS and prevent unnecessary tests and treatments

Strangulation Thyrotoxicosis

We present a case of thyrotoxicosis provoked by mechanical trauma to the neck in the setting of previously undiagnosed subclinical Graves’ disease.33-year-old female smoker with history of postpartum weight loss, tremors, and goiter one year prior presented with dyspnea, progressive neck pain and swelling 2 days after being strangled by her boyfriend

Extreme Longevity Is Associated with Increased Serum Thyrotropin

Context: The distribution of serum TSH shifts progressively to higher concentrations with age