From acute hypercalcaemia to post-parathyroidectomy hungry bone syndrome in a patient with primary hyperparathyroidism-associated brown tumours

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Parathyroids: Pandemic update

Parathyroid glands-related issues (also involving calcium-phosphorus metabolism) amid pandemic are represented by: complicated recovery after COVID-19 infection in cases with severe vitamin D (VD) deficiency or uncorrected hypocalcemia (hCa); the cases with primary hyperparathyroidism-related hypercalcemia who are postponed for parathyroid adenoma removal might be complicated with arrhythmia if the patient becomes COVID-19 positive; lockdown restrictions limited the physical activity, a situation which might aggravate sarcopenia and bone mineral density loss; subjects with renal hyperparathyroidism who do not have controlled values of serum calcium are at higher risk of severe COVID-19 infection due to a wide area of chronic renal failure-associated complications, including Ca, VD and PTH disturbances. This is an update concerning parathyroid glands in relationship to two-year pandemic experience. The mini-review of literature is based on PubMed navigation using a combination of key words like “parathyroid glands”, “parathyroid”, “parathormone”, “vitamin D”, “calcium” and “COVID-19” or “coronavirus” or “pandemic”. During the first months of COVID-19 pandemic there was a massive reduction of parathyroidectomies volume which was elective for severe forms associating life threatening values of serum calcium. The number of parathyroidectomies increased during the second year of pandemic Hypocalcemia remains a poor prognostic factor in severe COVID-19 infections while underling mechanisms are complex and might not be exclusively related to vitamin D deficiency which is a topic still on trends. Direct hypoparathyroidism is a new entity amid coronavirus-induced puzzle. E-health is mandatory to follow calcium correcting medication and associated life style intervention in cases with anomalies of calcium/PTH/VD levels

Adrenal surgery amid COVID-19 pandemic

COVID-19 pandemic affected every aspect of medical life, including the field of adrenal glands (AG). Our purpose is to overview the literature concerning AG domain, especially adrenal surgery amid COVID-19 pandemic. The approach of adrenal tumors (AT) is reflected by two aspects: what happens to a patient known with an adrenal mass if COVID-19 infection is positive and the other is related to restrictions amid pandemic daily practice that involve AT surgery. Patients with AT underling active hormonal over-production are at higher risk of COVID-19 infection or at increased risk of developing a more severe form of coronavirus infection, for instance, via diabetes mellitus, high blood pressure, and obesity. During the first year of pandemic, especially if considering the periods with severe restrictions and lockdown, there was a massive reduction of adrenalectomies, when compare to the same months of the previous year. Several systems of deciding the timing of intervention were used; they is still an insufficient statistical validation of these scores until now. The reduction of surgery volume was less expressive during the second year of pandemic. The rate of peri-operatory infections is relatively low, but it depends on center. Post-operative adrenal insufficiency exposes the patient to a higher risk of infections, including coronavirus infection. Peri-operative management can be handle via telemedicine in most of cases

DIFFERENT INDICATIONS, ONE PROCEDURE: THYROIDECTOMY (AS SIMPLE AS THAT)

Introduction. Thyroidectomy is currently a rather simple procedure with various indications, regardless total or subtotal/near total, based on conventional approach or modern like robotic (trans-axillary and axillobreast robotic). We aim to introduce a few scenarios in daily endocrine practice based on a pictorial essay. This is a cases series. Case 1 is a 59-year old female with recent subclinical thyrotoxicosis with an extremely large multinodular goitre who was confirmed benign by the pathological report was provided after. Case 2 is a 70-year old female who self detected through palpation a large left thyroid macronodule with suspected ultrasound features. However, she still delays thyroidectomy. Case 3 is a 51-year old female also with compressive symptoms due multinodular goitre and a dominant left lobe nodule who was referred to surgery. Case 4 is a 59-year female treated with thiamazole for 12 years presents a large multinodular goitre which was referred to surgery. Conclusion. Different scenarios are ending with the idea of thyroidectomy from compressive local symptoms, to curative option for a potential malignancy etc

Follow-up of second adrenal tumor after remission of Cushing syndrome

Bilateral adrenal tumors (BAT) represent a vast domain of endocrinology and connected medical and surgical fields. Our purpose is to introduce several key points in relationship with long time management on a 56-year old female case who is currently admitted for reassessment of a left adrenal tumor with potential autonomous cortisol secretion. She is also known with pituitary incidentaloma since 2014, cerebral meningioma which was partially removed in 2015, uncontrolled diabetes mellitus under metformin and insulin therapy since 2017, and high blood pressure since 2021. Her medical history includes right adrenalectomy for Cushing syndrome in 2014. At that moment, she was first admitted for BAT, a tumor of 2 centimeters (cm) on the left gland according to computed tomography, respective of 3.5 cm maximum diameter on the right adrenal. The hormonal panel confirmed adrenal Cushing syndrome. After 6 months of non-interventional follow-up, the right tumor increased to 4 cm, also associating small areas of necrosis, thus a decision of unilateral laparoscopic adrenalectomy was done with good clinical post-operatory outcome. She did not develop adrenal insufficiency at any point in time, moreover, a low-normal ACTH (Adrenocorticotrop Hormone) with intermittent elevation of morning plasma cortisol levels after Dexamethasone suppression test showed a possible autonomous cortisol secretion of the left adrenal tumor during a 7-year follow-up. In 2014, the female patient received the confirmation of an adrenocortical adenoma which was consistent with cortisol over-secretion. Particular gene contributions are attributed to protein kinase A (PKA) defects (or B) that usually induce bilateral adrenocortical hyperplasia; however, they are not routinely tested in daily endocrine practice, neither had we performed it. Interestingly, the patient was detected with a cerebral meningioma after years of intermittent, mild headache. The diagnostic was established during initial endocrine evaluations. The headache was not associated with uncontrolled high blood pressure, as first expected due to excessive cortisol amount. Recently, it was identified that mutations of ARMC5 (armadillo repeat containing 5) gene are responsible for macronodular adrenal hyperplasia, but also meningioma. They may be also responsible for severe diabetes mellitus as seen here. The key points of following a patient with bilateral adrenal tumors include the timing of uni/bilateral adrenalectomy, the multidisciplinary management of associated complications, as well as the need of understanding the genetic rational behind it

Gamma Knife radiosurgery: effect on corticotropin-secreting pituitary adenoma

Introduction: Cushing's disease (CD) is a complex endocrine disorder characterized by an increased risk of recurrence and persistence of hypercortisolism after initial transsphenoidal adenomectomy, a situation requiring alternative therapeutic measures. Case presentation: A 21-year-old female patient was admitted for weight gain with centripetal fat distribution, transient headache, hair thinning and psycho-emotional lability. Clinical examination revealed round facies, acne, purple-red striae, hirsutism with a Ferriman-Gallwey score of 20. The hormonal profile revealed high serum cortisol (of 283.1 ng/mL, normal:70-225 ng/mL) and high ACTH (Adrenocorticotropic Hormone) levels (of 260.6 pg/mL, normal: 7.2-63.3 pg/mL). The pituitary MRI (Magnetic Resonance Imaging) examination found a 4.3/4.4/6.2mm left paramedian microadenoma. The persistence of hypercortisolism after adenomectomy required GKRS (Gamma Knife radiosurgery). Four months after radiosurgery, complete remission of the disease was achieved and it was maintained at the last evaluation. At present, the patient is 20 weeks pregnant. Conclusions: Gamma Knife radiosurgery offers a high control rate of pituitary adenomas and a reasonable rate of remission of residual hypercortisolism after neurosurgical treatment. After surgery or GKRS, periodic monitoring is necessary for patients with CD due to the risk of pituitary insufficiency or relapse

Rehabilitation management of postmenopausal osteoporosis associated with degenerative neurological conditions

Background: The evolving association of neurological disorders such as Parkinson's disease (PD) and stroke may aggravate postmenopausal osteoporosis. In this situation, inactivity and lack of movement are the main factors that contribute contribute to exacerbate osteoporosis and the occurrence of osteoporotic fractures. Material and Methods: We present the case of a 62-year-old female patient diagnosed with diffuse postmenopausal osteoporosis, Parkinson's disease, and left frontal ischemic lacuna. 6 months before admission to our rehabilitation clinic, she suffered a trauma by falling that resulted in an L3 vertebral fracture and a right forearm fracture. L2-L4 posterior segmental spinal fusion and right forearm osteosynthesis were per-formed. Postoperatively, a motor deficit was found in the lower limbs. She was diagnosed clin-ically and following neurophysiological investigations with bilateral external popliteal sciatic nerve paresis. In these circumstances, the patient suffered a new trauma, resulting in an open fracture at the same level of the right forearm which also required surgical treatment. Results and discussion: Following the rehabilitation program, the evolution was favorable with im-proved functioning and partial restoration of walking. Conclusion: The association of degener-ative neurological and bone metabolic diseases in this case led to significant disability, making the rehabilitation process more challenging

PITUITARY NON-FUNCTIONING MACROADENOMAS: IF AND WHEN TO RECOMMEND SURGERY

Pituitary non-functioning adenomas may be detected based on pituitary insufficiency, eye field complications or headache, etc, so called pituitary mass syndrome. We introduce a series of three cases of non-functioning pituitary macroadenoma with a different management based on local anatomy of the tumour and complications, as well as the tumour speed of growth. Non-functioning macroadenoma, even rare, require lifetime follow-up and a rigorous multidisciplinary decision of intervention

The Entity of Connshing Syndrome: Primary Aldosteronism with Autonomous Cortisol Secretion

Connshing syndrome (CoSh) (adrenal-related synchronous aldosterone (A) and cortisol (C) excess) represents a distinct entity among PA (primary hyperaldosteronisms) named by W. Arlt et al. in 2017, but the condition has been studied for more than 4 decades. Within the last few years, this is one of the most dynamic topics in hormonally active adrenal lesions due to massive advances in steroids metabolomics, molecular genetics from CYP11B1/B2 immunostaining to genes constellations, as well as newly designated pathological categories according to the 2022 WHO classification. In gross, PA causes 4–10% of all high blood pressure (HBP) cases, and 20% of resistant HBP; subclinical Cushing syndrome (SCS) is identified in one-third of adrenal incidentalomas (AI), while CoSh accounts for 20–30% to 77% of PA subjects, depending on the tests used to confirm autonomous C secretion (ACS). The clinical picture overlaps with PA, hypercortisolemia being mild. ACS is suspected in PA if a more severe glucose and cardiovascular profile is identified, or there are larger tumours, ACS being an independent factor risk for kidney damage, and probably also for depression/anxiety and osteoporotic fractures. It seems that one-third of the PA-ACS group harbours mutations of C-related lines like PRKACA and GNAS. A novel approach means we should perform CYP11B2/CYP11B1 immunostaining; sometimes negative aldosteronoma for CYP11B1 is surrounded by micronodules or cell clusters with positive CYP11B1 to sustain the C excess. Pitfalls of hormonal assessments in CoSh include the index of suspicion (check for ACS in PA patients) and the interpretation of A/C ratio during adrenal venous sample. Laparoscopic adrenalectomy is the treatment of choice. Post-operative clinical remission rate is lower in CoSh than PA. The risk of clinically manifested adrenal insufficiency is low, but a synthetic ACTH stimulating testing might help to avoid unnecessary exposure to glucocorticoids therapy. Finally, postponing the choice of surgery may impair the outcome, having noted that long-term therapy with mineralocorticoids receptors antagonists might not act against excessive amounts of C. Awareness of CoSh improves management and overall prognosis

The neuroendocrine markers assay and the glycemia profile in patients with neuroendocrine tumors under octreotide therapy: a 2 years study / Determinarea markerilor neuroendocrini şi a profilului glicemic la pacienţii cu tumori neuroendocrine în tratament cu octreotid

Tumorile neuroendocrine (NET) sunt mult mai frecvente în ultimele decade. Unul din intrumentele majore de evaluare în această patologie este reprezentat de dozarea markerilor neuroendocrini precum cromogranina A, serotonina, acidul 5-hidroxi indolacetic urinar şi enolaza neuronal specifică. Aceştia se schimbă cu progresia tumorală, indiferent de terapie. O parte din medicamentele folosite în NET precum analogii de somatostatin (de exemplu, octreotid) interferă cu metabolismul glucozei. Obiectiv. Am analizat într-un studiu retrospectiv de-a lungul a 2 ani dinamica markerilor NET şi profilul glicemic. Material si metode.Toţi pacienţii au avut cel puţin o evaluare pe an. Rezultate. 9 pacienţi au fost incluşi (5 femei şi 4 bărbaţi), cu o vârstă medie de 57,33 de ani. Perioada de tratament anterior cu octreotid a fost de 18 +/- 14,69 de luni. Doza de octreotid a variat de la 20 la 50 mg lunar. Glicemia s-a modificat nesemnificativ de la bază după 2 ani. Nu s-a înregistrat nici un caz nou de diabet. O pacientă a necesitat insulină pentru diabetul preexistent (dar între timp s-a adaugat şi terapie cu interferon) Cromogranina A a avut valori mari sustinute pentru toate cele 9 cazuri, sugerând progresia bolii. Enolaza neuronal specifică a crescut semnificativ iar serotonina serică şi 5HIIA au crescut considerabil în 2 cazuri cu simptome severe de sindrom carcinoid. Concluzie. Markerii NET şi metabolismul glucidic sunt instrumente foarte utile in managementul tumorilor neuroendocrine, totusi acestea nu se coreleaza