Vitamin D Deficiency in ambulatory patients

OBJECTIVE: To determine the frequency of subclinical vitamin D deficiency in an ambulatory care setting. METHODS: This was an observational study which measured 25 vitamin D levels in medical clinic patients. Patients with chronic renal failure, known osteomalacia and rickets were excluded. A total of 119 patients were evaluated. They were divided in three diagnostic categories based on their serum 25 vitamin D levels. Those with levels below 8 ng/ml were categorized to have severe deficiency, levels between 8 - 20 ng/ml as moderate deficiency and levels of 21-35 mg/ml as mild deficiency. RESULTS: Of 119 patients, 92% had vitamin D deficiency. Their mean age was 44.3 +/- 18.3 years, with female to male ratio of 5:1. Sixty two percent (62%) had severe, 24% moderate and 8% had mild deficiency. Nearly half of all these patients (including those with severe deficiency) were asymptomatic. Whereas a low serum calcium, elevated phosphate and elevated alkaline phosphatase were reflective of severe deficiency. It was only an elevated iPTH that correlated with mild to moderate deficiency. CONCLUSION: Subclinical vitamin D deficiency is extensive in the adult ambulatory care patients. Serum calcium, phosphate and alkaline phosphatase are poor markers of moderate to mild deficiency. A serum 25 vitamin D level and an iPTH are better biofunctional markers of this deficiency

Remission of Grave\u27s disease after oral anti-thyroid drug treatment

OBJECTIVE: To evaluate remission rate of anti-thyroid drug treatment in patients with Grave\u27s disease, and to study the factors associated with remission. STUDY DESIGN: A cross sectional study. ,p\u3ePLACE AND DURATION OF STUDY: The Endocrine Department of the Aga Khan University Hospital, Karachi from 1999 to 2000. METHODOLOGY: Seventy four patients of Grave\u27s disease were recruited who were prescribed medical treatment. Grave\u27s disease was diagnosed in the presence of clinical and biochemical hyperthyroidism along with anti-microsomal (AMA) and anti-thyroglobulin antibodies (ATA) and thyroid scan. These patients were prescribed oral anti-thyroid drugs using titration regime and followed at 3, 6, 12 and 18 months. Patients were categorized into two groups: remission group and treatment failure group and results were compared using a chi-square test, t-test and logistic regression model with significance at p \u3c 0.05. RESULTS: A majority of the patients were females (62.6%, n=46). During the follow-up period of 18 months, 41.9% patients went into remission. Univariate analysis showed that the initial free T4 level was significantly different (p \u3c 0.05) in patients in remission and treatment failure groups. Multivariate analysis showed only initial free T4 level was a significant predictor of outcome. Positive AMA patients (n=27) had higher treatment failure (odds ratio: 2.55: 95%, CI 0.69 - 9:31), although the difference was not statistically significant (p = 0.13). CONCLUSION: Remission rates with oral anti-thyroid agents is markedly high. Patients should be offered alternate treatment options to those who do not enter remission during a period of 12-18 months of treatment, those who develop relapse, and those who have aggressive disease on initial presentation

Rare among the rarities--recurrent insulinoma

A patient with recurrent insulinoma without co-existing multiple endocrine neoplasia syndrome is described. In a 32-year-old man with recurrent episodes of symptomatic hypoglycemia, the supervised fast showed high insulin (24.5 IU/ml) and C-peptide level (3.06 ng/ml) with low blood sugar (27 mg/dl). A 1 x 1.5 cm nodule from the lower part of pancreatic body was removed on exploratory laparotomy. Histopathology confirmed the diagnosis of islet cell tumor. After 11 years, he started experiencing symptomatic hypoglycemic episodes with inappropriately elevated serum insulin and C-peptide levels (2.2 ng/ml). On pancreatic angiography, a 16 x 11 mm size tumor blush was noted. Due to fibrosis from previous surgery, distal pancreatectomy along with splenectomy was done. Histopathology confirmed the diagnosis of insulinoma. On both occasions, workup for multiple endocrine neoplasia turned out to be negative. He was given small amounts of intermediate acting insulin in early postoperative period, which was discontinued shortly thereafter

Cushing\u27s disease and pregnancy: case report and literature review

Objective: To describe a patient with untreated Cushing\u27s disease who had 2 spontaneous pregnancies that resulted in healthy babies on both occasions. Methods: We present a case report with clinical, laboratory, and imaging data and discuss the literature pertaining to pregnancy in patients with Cushing\u27s syndrome. Results: A 28-year-old woman came to our endocrinology clinic with a 1-year history of symptoms and signs of Cushing\u27s syndrome. An elevated 24-hour urinary cortisol excretion and an unsuppressed 1-mg overnight dexamethasone test confirmed the diagnosis. On her next visit, she reported a confirmed pregnancy, which ultimately resulted in the birth of a normal child. Further work-up subsequently showed 2 elevated 24-hour urinary cortisol values, loss of diurnal variation, and an elevated corticotropin level. There was lack of suppression on low-dose and high-dose overnight dexamethasone suppression tests. Magnetic resonance imaging of the pituitary showed normal findings. Inferior petrosal sinus sampling was recommended, but she declined the procedure. The patient returned 3 years later for reevaluation, at which time she reported the birth of another healthy child by cesarean delivery 10 months previously. There were no reported maternal or fetal complications. Examination at this visit revealed buccal pigmentation and proximal myopathy. Investigations showed increased 24-hour urinary cortisol excretion and serum corticotropin levels. Repeated magnetic resonance imaging disclosed a microadenoma on the right side of the pituitary. Unstimulated inferior petrosal sinus sampling showed a gradient to the right; thus, the presence of pituitary-dependent Cushing\u27s disease was confirmed. Conclusion: Our case demonstrates that patients with pituitary-dependent Cushing\u27s disease are more likely to have spontaneous pregnancies with favorable outcomes than are patients with Cushing\u27s syndrome due to other causes. Our patient, despite having Cushing\u27s disease for more than 7 years, had 2 uneventful pregnancies that produced normal healthy children, without exacerbation of her disease during pregnancy

Laparoscopic adrenalectomy for Conn\u27s syndrome

Laparoscopic adrenalectomy is now used worldwide to resect adrenal adenomas and other adrenal tumors recently introduced in Pakistan. Two cases of endocrine hypertension, due to Conn s syndrome, undergoing laparoscopic adrenalectomy for the first time here, are reported

A case reported with 46, XX testicular disorders of sexual development and its possible association with dysembryoplastic neuroepithelial tumour

The main factor determining differentiation of bipotential gonads into testes or ovaries is the presence or absence of SRY (sex-determining region on Y chromosome) gene. De la Chapelle syndrome is a chromosomal anomaly with chromosomal makeup of a female (46, XX) and phenotypic presentation of a male. Previously known as XX sex reversal, it is now called 46, XX testicular disorders of sexual development (DSD). Although rare, it presents as a major chromosomal anomaly, with SRY gene crossover proposed as an underlying aetiology in most patients. We report the case of a 25-year-old male who presented with infertility and was diagnosed with De 46, XX testicular DSD. He has a previous history of resected dysembryoplastic neuroepithelial tumour (DNT). The differential diagnosis of 46, XX DSD and possible association/coincidental finding of DNT have been discussed. ---Continu