Antibody-Mediated Extreme Insulin Resistance: The Importance of Pre-Treatment Screening

We report the case of a 56 year-old Hispanic male with a 10-year history of type 2 diabetes who presented with abrupt onset of hyperglycemia resistant to escalating doses of intravenous insulin infusion (>2500 units daily). He was diagnosed with antibody-mediated insulin resistance given the presence of hyperglycemia despite receiving >200 units insulin/day, a lack of identifiable precipitants for diabetic ketoacidosis or hyperosmolar hyperglycemic state, and elevated insulin antibodies. He underwent pre-immunomodulatory therapy screening for infections, rheumatologic disorders, and malignancy, which uncovered a new diagnosis of latent tuberculosis. While concurrently being treated for latent tuberculosis, he successfully responded to immunomodulatory therapy with rituximab, dexamethasone, and cyclophosphamide. Insulin was discontinued completely, and he maintained appropriate glycemic control on oral diabetic agents (metformin and pioglitazone). This case supports the use of immunomodulatory therapy for the treatment of antibody-mediated insulin resistance and highlights the importance of pre-immunomodulatory therapy screening to uncover occult infection or identify underlying neoplastic/rheumatologic disease prior to immunosuppression

Spindle cell oncocytoma of adenohypophysis: Cytogenetics and β-catenin findings with pathology differential diagnosis and review of the literature

Spindle cell oncocytoma (SCO) is an extremely rare neoplasm arising in the anterior pituitary. We report comprehensive pathological description of a case of SCO in a 60 year-old male who presented with nausea, vomiting and severe hyponatremia, and pan hypopituitarism. Magnetic resonance imaging (MRI) showed a 3.1 × 2.3 × 2.0 cm homogeneously enhancing bilobed mass within the sella turcica and suprasellar cistern. Intraoperative frozen section and touch imprint cytology showed cohesive spindle cells with abundant oncocytic cytoplasm. Histologic sections revealed the tumor was composed of interlacing fascicles of compact spindled cells with abundant dense oncocytic cytoplasm. There was no mitosis or necrosis present. Ki-67 index varied in areas, with an average of 3%. By immunohistochemistry (IHC), the tumor cells were negative for Cam5.2, AE1/3, neurofilament (NF), NeuN, glial fibrillary acidic protein (GFAP) and synaptophysin, and strongly positive for vimentin, TTF-1 and EMA. S-100 showed focal weakly positivity. By electron microscopy (EM), the cytoplasm of the spindle cells contained numerous abundant, back-to-back, uniform, round, normal-sized mitochondria with long and lamellar cristae. Beta-catenin showed diffuse membranous and partial cytoplasmic positivity. Cytogenetic analysis showed extra copies of chromosome 1 (74%, up to 8 copies), and loss of chromosome 2 (35%). The histogenesis, classification and differential diagnosis are discussed. Keywords: Spindle cell oncocytoma, Adenohypophysis, Immunohistochemistry, Differential diagnosis, Pathogenesis, Chromosomal abnormalit

Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19.

SARS-CoV-2 infection is associated with significant lung and cardiac morbidity but there is a limited understanding of the endocrine manifestations of coronavirus disease 2019 (COVID-19). Although thyrotoxicosis due to subacute thyroiditis has been reported in COVID-19, it is unknown whether SARS-CoV-2 infection can also lead to decompensated hypothyroidism. We present the first case of myxedema coma (MC) in COVID-19 and we discuss how SARS-CoV-2 may have precipitated multiorgan damage and sudden cardiac arrest in our patient. A 69-year-old woman with a history of small cell lung cancer presented with hypothermia, hypotension, decreased respiratory rate, and a Glasgow Coma Scale score of 5. The patient was intubated and administered vasopressors. Laboratory investigation showed elevated thyrotropin, very low free thyroxine, elevated thyroid peroxidase antibody, and markedly elevated inflammatory markers. SARS-CoV-2 test was positive. Computed tomography showed pulmonary embolism and peripheral ground-glass opacities in the lungs. The patient was diagnosed with myxedema coma with concomitant COVID-19. While treatment with intravenous hydrocortisone and levothyroxine were begun the patient developed a junctional escape rhythm. Eight minutes later, the patient became pulseless and was eventually resuscitated. Echocardiogram following the arrest showed evidence of right heart dysfunction. She died 2 days later of multiorgan failure. This is the first report of SARS-CoV-2 infection with MC. Sudden cardiac arrest likely resulted from the presence of viral pneumonia, cardiac arrhythmia, pulmonary emboli, and MC-all of which were associated with the patient's SARS-CoV-2 infection

Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19.

SARS-CoV-2 infection is associated with significant lung and cardiac morbidity but there is a limited understanding of the endocrine manifestations of coronavirus disease 2019 (COVID-19). Although thyrotoxicosis due to subacute thyroiditis has been reported in COVID-19, it is unknown whether SARS-CoV-2 infection can also lead to decompensated hypothyroidism. We present the first case of myxedema coma (MC) in COVID-19 and we discuss how SARS-CoV-2 may have precipitated multiorgan damage and sudden cardiac arrest in our patient. A 69-year-old woman with a history of small cell lung cancer presented with hypothermia, hypotension, decreased respiratory rate, and a Glasgow Coma Scale score of 5. The patient was intubated and administered vasopressors. Laboratory investigation showed elevated thyrotropin, very low free thyroxine, elevated thyroid peroxidase antibody, and markedly elevated inflammatory markers. SARS-CoV-2 test was positive. Computed tomography showed pulmonary embolism and peripheral ground-glass opacities in the lungs. The patient was diagnosed with myxedema coma with concomitant COVID-19. While treatment with intravenous hydrocortisone and levothyroxine were begun the patient developed a junctional escape rhythm. Eight minutes later, the patient became pulseless and was eventually resuscitated. Echocardiogram following the arrest showed evidence of right heart dysfunction. She died 2 days later of multiorgan failure. This is the first report of SARS-CoV-2 infection with MC. Sudden cardiac arrest likely resulted from the presence of viral pneumonia, cardiac arrhythmia, pulmonary emboli, and MC-all of which were associated with the patient's SARS-CoV-2 infection

Polyphenols and phytic acid contribute to the low iron bioavailability from common beans in young women

10.3945/jn.110.125369Journal of Nutrition140111977-1982JONU