Prevalencia y factores asociados a complicaciones macrovasculares en pacientes con diabetes en mellitus 2 de inicio temprano.

Introducción Se define diabetes mellitus tipo 2 (DM2) de inicio temprano en aquella población en la que se detecta DM2 entre los 20 y 45 años de edad. La evidencia reciente sugiere que este grupo poblacional, en comparación a la población con diagnóstico más tardío de la diabetes, se asocia a un fenotipo más agresivo de diabetes, mayor riesgo cardiovascular y complicaciones crónicas propias de la diabetes, mayor disfunción de la célula beta y peor control glucémico. Material y métodos Se realizó un estudio, transversal, analítico de casos y controles en Departamento de Endocrinología, Hospital Universitario “Dr. José Eleuterio González”. Se incluyeron todos los pacientes con diagnóstico de Diabetes Mellitus tipo 2 (DM2) que acuden a la consulta de Endocrinología o que son valorados en las salas de internamiento para pacientes no críticos, con DM2 de al menos 1 año de evolución y edad ≥20 años. Se realizó historia clínica, exploración física y revisión de expediente clínico la cual incluyó todo lo relacionado al diagnóstico y la evolución de la diabetes, comorbilidades y complicaciones asociadas. Se clasificaron a los pacientes de acuerdo a la edad de diagnóstico en DM2 temprana si se realizó antes de los 45 años o tardía si fue ≥45 años. Se evaluaron diferencias en las características de la diabetes, antecedentes, factores de riesgo cardiovascular, complicaciones microvasculares, adherencia a tratamiento y depresión. Objetivos El objetivo principal consiste en establecer si existen diferencias en la prevalencia de enfermedad macrovascular (infarto agudo de miocardio, evento vascular cerebral, enfermedad vascular periférica y amputaciones) en población con DM2 de inicio temprano en comparación a sujetos con DM2 de inicio tardío. Como objetivos secundarios se incluyeron determinar la prevalencia de enfermedad microvascular, síndrome metabólico y depresión además de evaluar si existen diferencias en control glucémico y adherencia al tratamiento entre ambos grupos. Resultados Se incluyeron 180 pacientes, de los cuales 99 correspondieron al grupo de diabetes de inicio temprano y 81 al grupo de diabetes de inicio tardío. Al realizar el apareamiento por género y tiempo de evolución de la diabetes se completaron 67 pacientes en cada grupo. No se encontraron diferencias en la prevalencia del desenlace compuesto de alguna complicación macrovascular (infarto agudo de miocardio, angina inestable, evento vascular cerebral, amputación y enfermedad vascular periférica) o de cada uno de los desenlaces en forma individual. Se encontró la misma prevalencia de complicaciones microvasculares entre ambos grupos. Respecto a prevención de riesgo cardiovascular, solo un tercio de los pacientes con DM2 tardía utiliza aspirina, sin embargo la proporción es significativamente mayor en esta población en comparación a los pacientes con DM2 temprana. La prevalencia de depresión fue de 20% en los pacientes con DM2 temprana en comparación a 31% en aquellos con DM2 de inicio tardío. Conclusiones La población con DM2 de inicio temprano tiene la misma prevalencia de presentar alguna complicación macrovascular o microvascular asociada a la diabetes, sin embargo no se le ofrecen las mismas opciones de tratamiento en lo que respecta a prevención de riesgo cardiovascular con indicación adecuada de estatinas y ácido acetil-salicílico. De igual forma, el perfil de riesgo cardiovascular es similar en ambos grupo

1,25-dihydroxyvitamin D and PTHrP mediated malignant hypercalcemia in a seminoma

Background: Seminomas have been rarely associated with malignant hypercalcemia. The responsible mechanism of hypercalcemia in this setting has been described to be secondary to 1,25-dihydroxyvitamin D secretion. The relationship with PTHrP has not been determined or studied. The aim of this study is to describe and discuss the case and the pathophysiological mechanisms involved in a malignant hypercalcemia mediated by 1,25-dihydroxyvitamin D and PTHrP cosecretion in a patient with seminoma. Case presentation: A 35-year-old man was consulted for assessment and management of severe hypercalcemia related to an abdominal mass. Nausea, polyuria, polydipsia, lethargy and confusion led him to the emergency department. An abdominal and pelvic enhanced CT confirmed a calcified pelvic mass, along with multiple retroperitoneal lymphadenopathy. Chest x-ray revealed “cannon ball” pulmonary metastases. The histopathology result was consistent with a seminoma. Serum calcium was 14.7 mg/dl, PTH was undetectable, 25-dihydroxyvitamin D was within normal values and PTHrP and 1,25 dihydroxyvitamin were elevated (35.0 pg/ml, and 212 pg/ml, respectively). After the first cycle of chemotherapy with bleomycin, etoposide and cisplatin, normocalcemia was restored. Both PTHrP and 1,25-dihydroxyvitamin D, dropped dramatically to 9.0 pg/ml and 8.0 pg/ml, respectively. Conclusion: The association of seminoma and malignant hypercalcemia is extremely rare. We describe a case of a patient with a seminoma and malignant hypercalcemia related to paraneoplastic cosecretion of 1,25-dihydroxyvitamin D and PTHrP. After successful chemotherapy, calcium, PTHrP and 1,25-Dihydroxyvitamin D returned to normal values

Glucose disturbances in non-diabetic patients receiving acute treatment with methylprednisolone pulses

Objective: Methylprednisolone pulses are used in a variety of disease conditions, both for acute and chronic therapy. Although well tolerated, they increase glucose levels in both non-diabetic and diabetic patients. They may also be considered a significant risk for acute metabolic alterations. The purpose of this report is to determine the metabolic changes in blood glucose levels in non-diabetic patients receiving methylprednisolone pulses and identify the presence of predictive factors for its development. Methods: Observational, prospective study in 50 non-diabetic patients receiving 1 g intravenous methylprednisolone pulses for three consecutive days as an indication for diverse autoimmune disorders. Demographic, anthropometric, and metabolic variables were analyzed, and glucose, insulin and C-peptide levels after each steroid pulse were identified. Different variables and the magnitude of hyperglycemia were analyzed using Pearson’s correlation. Results: 50 patients were included, predominantly women (66%, n = 33). The average age was 41 ± 14 years with a BMI of 26 ± 3 kg/m2 . Baseline glucose was 83 ± 10 mg/dL. After each steroid pulse, glucose increased to 140 ± 28, 160 ± 38 and 183 ± 44, respectively (p <0.001). C-peptide and insulin concentrations increased significantly (p <0.001). The prevalence of fasting hyperglycemia after each pulse was 68%, 94% and 98%, respectively. We found no correlation between the magnitude of hyperglycemia and the studied variables. Conclusion: Methylprednisolone pulses produced significant increases in fasting glucose in most patients without diabetes. Further studies are needed to define its role in long-term consequences

Secondary plasma cell leukemia in a patient with light chain multiple myeloma in post-chemotherapy remission phase

Plasma cell leukemia (PCL) is a rare presentation of multiple myeloma characterized by the presence of >20% plasma cells in peripheral blood, and an absolute plasma cell count >2 × 109 K/L. It is classified as primary and secondary with the latter representing a terminal event in 12% of patients. A case of a 78-year-old man who presented a secondary form of PCL during post-chemotherapy remission phase is discussed accompanied with a brief review

Acute Pancreatitis and Diabetic Ketoacidosis following L-Asparaginase/Prednisone Therapy in Acute Lymphoblastic Leukemia

Acute pancreatitis and diabetic ketoacidosis are unusual adverse events following chemotherapy based on L-asparaginase and prednisone as support treatment for acute lymphoblastic leukemia. We present the case of a 16-year-old Hispanic male patient, in remission induction therapy for acute lymphoblastic leukemia on treatment with mitoxantrone, vincristine, prednisone, and L-asparaginase. He was hospitalized complaining of abdominal pain, nausea, and vomiting. Hyperglycemia, acidosis, ketonuria, low bicarbonate levels, hyperamylasemia, and hyperlipasemia were documented, and the diagnosis of diabetic ketoacidosis was made. Because of uncertainty of the additional diagnosis of acute pancreatitis as the cause of abdominal pain, a contrast-enhanced computed tomography was performed resulting in a Balthazar C pancreatitis classification