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Yu Arai Department of Family & General Medicine, Tokyo-Kita Medical Center, Japan

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Satoru Okada Department of Family & General Medicine, Tokyo-Kita Medical Center, Japan

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Taiju Miyagami Department of General Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan

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Narumi Sue Department of Family & General Medicine, Tokyo-Kita Medical Center, Japan

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Chisato Kainaga Department of Family & General Medicine, Tokyo-Kita Medical Center, Japan

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Summary

Myxoedema coma is a severe form of hypothyroidism with multiple organ dysfunction, characterised by an altered state of consciousness and hypothermia. Intravenous thyroid hormone replacement therapy is the preferred treatment for myxoedema. The mortality rate associated with this disease is high, and early detection and intervention are essential. Supraglottal myxoedema is a rare form of periglottic oedema and can be fatal. A previously healthy 66-year-old man presented with impaired consciousness, hypothermia, and nonpitting oedema. Blood tests revealed the presence of hypothyroidism and respiratory acidosis. He was intubated for type 2 respiratory failure; however, severe laryngeal oedema made the procedure difficult to perform. Oral thyroid hormone therapy was initiated under the diagnosis of myxoedema coma. Tracheostomy was performed because of prolonged type 2 respiratory failure and laryngeal oedema. Three weeks after admission, the patient was weaned off the ventilator. Approximately a week later, laryngeal oedema improved, and the tracheostomy tube was removed. The patient was discharged and remained stable for 3 months. This case report describes a patient with comatose myxoedema and supraglottic oedema who was successfully treated with oral medication alone. This case shows that supraglottic oedema should be considered even in the absence of wheezing or other signs of upper airway obstruction.

Learning points

  • Myxoedema coma is a differential diagnosis of respiratory acidosis.

  • In myxoedematous coma, the possibility of difficult intubation due to supraglottic oedema should be considered.

  • Tracheostomy should be considered for supraglottic myxoedema, which often results in prolonged ventilator use.

  • Supraglottic myxoedema can be treated with oral medications.

Open access
Motohiro Kubori Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan

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Megumi Fujimoto Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan

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Yukiyoshi Okauchi Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan

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Kanae Matsuno Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan

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Eri Yamabayashi Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan

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Ryuki Sakamoto Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan

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Shinya Inada Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan

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Hiromi Iwahashi Diabetes Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan

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Summary

IgG4-related disease is a multiorgan disorder in which nodules and hypertrophic lesions are observed simultaneously, or separately, in areas including the pancreas, liver, lungs, salivary glands, thyroid glands, and pituitary glands. IgG4-related hypophysis is one of several IgG4-related diseases and is characterized by pituitary gland and pituitary stalk thickening, various degrees of hypopituitarism, and increased serum IgG4 levels. Steroid therapy is effective for patients with IgG4-related hypophysis, but the reported effectiveness of steroid therapy for restoring pituitary function differs between studies. Following an episode of autoimmune pancreatitis 10 years prior, enlargement of the pituitary gland and stalk along with panhypopituitarism and polyuria developed in a 73-year-old male. A high serum IgG4 level and biopsy of the submandibular gland showing infiltration of IgG4-positive plasma cells led to a clinical diagnosis of IgG4-related hypophysitis. Prednisolone treatment reduced the swelling of the pituitary gland and stalk and improved anterior pituitary function. Although arginine vasopressin secretion remained insufficient, polyuria was relieved and kept in remission even after prednisolone treatment was completed. This is the first reported case in which prednisolone was able to maintain both normal anterior pituitary function and remission of polyuria caused by IgG4-related hypophysitis. IgG4-related hypophysitis has previously been associated with a relapse of symptoms during treatment. However, the patient reported in this case study remained in remission for over 3 months after completion of steroid treatment and should be monitored closely for changes in pituitary function.

Learning points

  • Steroid therapy is the first-line therapy for pituitary dysfunction and pituitary stalk swelling in IgG4-related hypophysitis.

  • In this case, although posterior pituitary function remained insufficient, polyuria was relieved and kept in remission for over 3 months even after prednisolone treatment was completed.

  • IgG4-related hypophysitis has been associated with the relapse of symptoms during steroid tapering, and changes in pituitary function and symptoms should be monitored closely.

  • When we encounter cases of adrenal insufficiency and polyuria during observation of autoimmune pancreatitis or other IgG4-related disease, we should consider the possibility of IgG4-related hypophysitis in mind.

Open access
Hiroaki Iwasaki Division of Endocrinology and Metabolism, Department of Internal Medicine, Toshiba Rinkan Hospital, Sagamihara, Kanagawa, Japan
Division of Endocrinology and Metabolism, Department of Internal Medicine, Minamiyamato Hospital, Yamato, Kanagawa, Japan

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Summary

A 73-year-old woman with type 2 diabetes mellitus was referred to our department for glycaemic control. Physical examination revealed two subcutaneous hard masses around the left shoulder and the right hip joint. The patient could not fully extend her fingers because of skin sclerosis in both hands. Laboratory studies showed hyperphosphataemia and a high ratio of renal tubular maximum reabsorption of phosphate to glomerular filtration rate. There were no abnormalities in serum calcium, creatinine, alkaline phosphatase, and intact parathyroid hormone levels, whereas serum fibroblast growth factor 23 was low. Hyperphosphataemic familial tumoural calcinosis/hyperostosis-hyperphosphataemia syndrome (HFTC/HHS) was diagnosed using whole genome sequencing that revealed a novel frameshift beyond the 584th threonine located in the lectin domain of UDP-N-acetyl-alpha-D-galactosamine:polypeptide N-acetylgalactosaminyltransferase 3 associated with a duplication of the 1748th thymine in the coding region of the corresponding gene. Furthermore, anti-nuclear, anti-centromere, and anti-cardiolipin antibodies were positive, implying that comorbid limited type scleroderma might play a role in tumoural calcinosis (TC) development. A low phosphate diet was prescribed with phosphate-lowering medications, including aluminium hydroxide, acetazolamide, and sevelamer hydrochloride. The patient displayed a decrease in serum phosphate levels from 6.5 to 5.5 mg/dL 10 months after the initiation of treatment, but her TC had not improved during treatment for more than 1 year. This case was interesting because the patient with HFTC/HHS exhibited TC despite being over her 60s, and subsequent scleroderma might contribute to the specific clinical course. When HFTC/HHS presents with elderly-onset TC, the involvement of comorbidities in exacerbating TC should be considered.

Learning points

  • HFTC/HHS occurs on an autosomal recessive basis, but its clinical course and manifestations differ significantly throughout the cases.

  • HFTC/HHS may be undiagnosed until later in life because of its rarity, unfamiliarity, and phenotype diversity; therefore, HFTC/HHS should be included in the differential diagnosis of elderly patients with unexplained hyperphosphataemia or ectopic calcinosis.

  • Comorbidities, including rheumatologic disorders, may contribute to developing HFTC/HHS-associated calcinosis.

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Yuko Kiyohara Department of Medicine, Yokohama Rosai Hospital, Yokohama, Japan

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Rei Hirose Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan

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Hiroshi Kawamata Department of Interventional Radiology, Yokohama Rosai Hospital, Yokohama, Japan

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Kazuki Nakai Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan

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Akane Hirataka Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan

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Jun Saito Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan

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Yuya Tsurutani Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan

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Summary

Fibromuscular dysplasia can cause renovascular hypertension. Since fibromuscular dysplasia may be underdiagnosed, precise diagnosis and management are crucial, especially for young women. A 20-year-old woman with hypertension and hypokalemia was referred to our hospital for further evaluation of secondary hypertension. At the previous hospital, her blood pressure was 160/110 mmHg and the serum potassium level was 2.9 mEq/L. The equilibrium phase on contrast-enhanced computed tomography revealed a low-density area in the upper median portion of the right kidney. On admission to our hospital, her blood pressure was 141/96 mmHg under 5 mg of amlodipine. Laboratory tests revealed plasma renin activity of 11.3 ng/mL/h and plasma aldosterone concentration of 117.1 pg/mL. Renal venous sampling of active renin concentration showed a right-to-left renin ratio of 3.13, confirming a significant increase in renin secretion from the right kidney. Selective reno-angiography detected focal stenosis with adjacent aneurysmal dilation and tortuosity in the proximal branch of the right renal artery. She was diagnosed with branch artery fibromuscular dysplasia and successfully treated with percutaneous transluminal angioplasty. After the treatment, she was free from hypertension and hypokalemia without any medications. Since branch artery fibromuscular dysplasia is sometimes difficult to diagnose, contrast-enhanced computed tomography can be a promising diagnostic tool as shown in this case. Concerning treatment, our patient was treated with percutaneous transluminal angioplasty, which should be considered for women of reproductive age because recommended antihypertensive medications can be teratogenic even in the first trimester of pregnancy.

Learning points

  • Although branch artery fibromuscular dysplasia (FMD) is sometimes difficult to diagnose, it should be considered in patients with high-renin, high-aldosterone hypertension.

  • Branch artery FMD can present with a low-density area of the kidney on contrast-enhanced computed tomography, as shown in this case.

  • Percutaneous transluminal angioplasty (PTA) can be an appropriate treatment for branch artery FMD, especially in young female patients.

  • PTA may immediately improve hypertension and hypokalemia without the need for medications.

Open access
Muneo Kawasumi Department of Endocrinology and Diabetes, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan

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Mitsunobu Kubota Department of Endocrinology and Diabetes, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan

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Yoko Yoshii Department of Endocrinology and Diabetes, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan

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Tadahiro Tokunaga Department of Rheumatology and Clinical Immunology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan

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Summary

This is a report on antithyroid arthritis syndrome (AAS) which is a rare adverse effect of antithyroid agents. AAS presents with severe symptoms including myalgia, arthralgia, arthritis, fever, and skin eruption due to the use of antithyroid agents. We encountered a 55-year-old woman with severe pain in the hand and forearm and arthralgia in multiple joints, including the knee, ankle, hand, and wrist on day 23 after initiation of methimazole (MMI) for Graves’ disease. Blood tests revealed elevated inflammation markers such as C-reactive protein and interleukin-6, and magnetic resonance imaging of the hands confirmed inflammation findings. After withdrawing MMI on day 25, symptoms showed a tendency toward improvement. Afterwards, inflammation markers also dropped to an almost normal range. In addition to the above findings, the absence of anti-neutrophil cytoplasmic antibodies and most vasculitis symptoms such as nephritis, skin, or pulmonary lesions led to the diagnosis of AAS. A resolution of symptoms, except for mild arthralgia in the second to fourth fingers of the right hand, was observed 61 days after discontinuation of MMI. Although the pathogenesis is unclear, the positive drug lymphocyte stimulation test for MMI and the several weeks before the onset of AAS suggested involvement of a type IV allergic reaction. Based on a discussion of definitive treatment for Graves’ disease, radioactive iodine ablation with 131I, which was selected by the patient, was performed and improved her thyroid function. Our case demonstrates the importance of awareness regarding AAS, which is a rare and under-recognized, but life-threatening adverse effect of antithyroid agents.

Learning points

  • Clinicians should be aware of the possibility of developing antithyroid arthritis syndrome (AAS) in patients treated with antithyroid medications, which can lead to severe migratory polyarthritis.

  • Prompt cessation of the antithyroid agent is essential for the resolution of AAS.

  • Anti-neutrophil cytoplasmic antibody (ANCA) negativity is needed to differentiate from antithyroid agent-induced ANCA-associated vasculitis, which shows arthritis similar to AAS.

Open access
Rikako Nakajima Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Hiroto Idesawa Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Daisuke Sato Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Jun Ito Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Kei Ito Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Masanao Fujii Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Takamichi Suzuki Department of Gastrointestinal Surgery, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Tomoaki Furuta Department of Gastrointestinal Surgery, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Hitomi Kawai Department of Pathology, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Norio Takayashiki Department of Pathology, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Masanao Kurata Department of Gastrointestinal Surgery, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Hiroaki Yagyu Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan

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Summary

Unawareness of postprandial hypoglycemia for 5 years was identified in a 66-year-old man at a local clinic. The patient was referred to our hospital because of this first awareness of hypoglycemia (i.e. lightheadedness and impaired consciousness) developing after lunch. In a 75 g oral glucose tolerance test, the plasma glucose concentration was decreased to 32 mg/dL (1.8 mmol/L) at 150 min with relatively high concentrations of insulin (8.1 μU/mL), proinsulin (70.3 pmol/L), and C-peptide (4.63 ng/mL). In a prolonged fasting test, the plasma glucose concentration was decreased to 43 mg/dL (2.4 mmol/L) at 66 h with an insulin concentration of 1.4 μU/mL and a C-peptide concentration of 0.49 ng/mL. Computed tomography showed an 18 mm hyperenhancing tumor in the uncinate process of the pancreas. A selective arterial calcium stimulation test showed an elevated serum insulin concentration in the superior mesenteric artery. The patient was then diagnosed with insulinoma and received pancreaticoduodenectomy. Continuous glucose monitoring (CGM) using the Dexcom G6 system showed unawareness of hypoglycemia mainly during the daytime before surgery. When the sensor glucose value was reduced to 55 mg/dL (3.1 mmol/L), the Dexcom G6 system emitted an urgent low glucose alarm to the patient four times for 10 days. Two months after surgery, an overall increase in daily blood glucose concentrations and resolution of hypoglycemia were shown by CGM. We report a case of insulinoma with unawareness of postprandial hypoglycemia in the patient. The Dexcom G6 system was helpful for assessing preoperative hypoglycemia and for evaluating outcomes of treatment by surgery.

Learning points

  • Insulinoma occasionally leads to postprandial hypoglycemia.

  • The CGM system is useful for revealing the presence of unnoticed hypoglycemia and for evaluating treatment outcomes after surgical resection.

  • The Dexcom G6 system has an urgent low glucose alarm, making it particularly suitable for patients who are unaware of hypoglycemia.

Open access
Rei Hirose Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan

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Hiromitsu Tannai Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan

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Kazuki Nakai Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan

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Kohzoh Makita Department of Radiology, Nerima Hikarigaoka Hospital, Tokyo, Japan

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Seishi Matsui Department of Interventional Radiology, Yokohama Rosai Hospital, Yokohama, Japan

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Jun Saito Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan

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Summary

A 42-year-old female patient was referred to our hospital with hypertension and hypokalemia and was diagnosed with primary aldosteronism. Dynamic contrast-enhanced computed tomography images revealed a 13-mm nodule on the lateral segment of the left adrenal gland and a fine venous connection between the nodule and the prominent renal capsular vein running nearby. The venograms in the left lateral tributary with a microcatheter confirmed alternative drainage to the left renal capsular vein during adrenal venous sampling, and the left renal capsular vein sampling was added. The patient was diagnosed with a left aldosterone-producing adenoma (APA) using the lateralization index (48.3) and a higher plasma aldosterone concentration (PAC) of the left lateral tributary (66 700 pg/mL) than other tributary samples after adrenocorticotropic hormone stimulation. Furthermore, markedly higher PAC (224 000 pg/mL) was observed in the left renal capsular vein blood than in the left adrenal central vein (45 000 pg/mL) and tributaries, confirming the diagnosis. Laparoscopic left partial adrenalectomy and following histopathological analysis revealed a CYP11B2-positive adrenocortical adenoma. Complete clinical and biochemical success for primary aldosteronism was achieved after 6 months. Direct evidence of APA blood venous drainage into the renal capsular vein has been demonstrated. Sampling from an alternative drainage pathway could be beneficial for APA diagnosis if such APA blood drainage is assumed.

Learning points

  • Aldosterone-producing adenomas may drain blood into an alternative pathway but for the adrenal vein.

  • The presence of alternative venous drainage could be assumed by contrast-enhanced computed tomography or venogram during adrenal venous sampling.

  • Sampling in the alternative drainage veins and demonstrating elevated aldosterone levels could help in diagnosing aldosterone-producing adenoma.

Open access
Takuya Kumagai Postgraduate Clinical Training Center, Akita Red Cross Hospital, Akita, Japan

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Syohei Koyama Department of Metabolism, Akita Red Cross Hospital, Akita, Japan

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Haruka Yorozu Department of Gastroenterology, Akita Red Cross Hospital, Akita, Japan

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Ayaka Kokita Department of Metabolism, Akita Red Cross Hospital, Akita, Japan

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Naoko Shimizu Department of Metabolism, Akita Red Cross Hospital, Akita, Japan

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Yumi Suganuma Department of Metabolism, Akita Red Cross Hospital, Akita, Japan

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Takashi Goto Department of Metabolism, Akita Red Cross Hospital, Akita, Japan

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Summary

There are very few reports of syndrome of inappropriate antidiuresis hormone secretion (SIADH) after receiving severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccine. Herein, we present the case of an 84-year-old woman who developed severe hyponatremia following the second administration of the SARS-CoV-2 mRNA vaccine. The patient presented with nausea, vomiting, and headache. Laboratory tests showed a plasma sodium level of 119 mmol/L. After receiving 500 mL of intravenous saline over a 2-h period, her plasma sodium level raised to 121 mmol/L, but her symptoms persisted. Considering that rapid plasma sodium correction was necessary, we started 3% saline solution overnight. Her plasma sodium level raised to 132 mmol/L and her symptoms completely resolved. Clinical and laboratory findings were consistent with a diagnosis of SIADH. In the absence of any other triggering factors, we concluded that the condition was likely associated with the vaccination. Clinicians should be aware of the potential for hyponatremia, particularly SIADH, associated with SARS-CoV-2 mRNA vaccination.

Learning points

  • Reports of syndrome of inappropriate antidiuresis hormone secretion after receiving severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination are limited.

  • If nausea, headache, and confusion are observed immediately after SARS-CoV-2 vaccination, clinicians should consider the presence of hyponatremia.

  • As similar case reports to date have presented with severe hyponatremia, prompt treatment may be required.

Open access
Seigo Konishi Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan

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Mitsuhiro Kometani Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan

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Ko Aiga Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan

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Daisuke Aono Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan

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Takahiro Nohara Integrative Cancer Therapy and Urology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan

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Hiroko Ikeda Department of Diagnostic Pathology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan

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Shigehiro Karashima Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan

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Yoshiyu Takeda Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
Endocrine and Diabetes Center, Asanogawa General Hospital, Kanazawa, Japan

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Takashi Yoneda Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan

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Summary

The COVID-19 pandemic has led to the emergence of telemedicine on a global scale. In endocrinology, telemedicine has mainly been used in relation to chronic diseases, including diabetes. Herein, we report the case of an 18-year-old woman with a hypertensive emergency due to a pheochromocytoma who was quickly diagnosed and treated using telemedicine. The patient was referred to a cardiovascular hospital because of fatigue and sweating that did not improve with carvedilol. She had fluctuating blood pressure and tachycardia. Subsequently, since her thyroid function was normal, endocrine hypertension not due to thyroid dysfunction was suspected; a case consultation was made by phone to our clinic. Plain computed tomography (CT) was recommended owing to the high possibility of a pheochromocytoma; the CT scan showed an adrenal tumor with a 30 mm diameter. To assess her condition, endocrinologists, together with the attending doctor, interviewed her and her family directly using an online tool to obtain detailed information. We thus determined that she was at risk of a pheochromocytoma crisis. She was transferred to our hospital immediately for treatment, was diagnosed with pheochromocytoma, and underwent surgery. Telemedicine, especially involving doctor-to-patient with doctor consultations, can be effective in treating rare and emergent medical conditions such as pheochromocytoma crisis.

Learning points

  • Telemedicine can be used for chronic diseases and emergency conditions.

  • Online doctor-to-patient with doctor (D-to-P with D) consultations are useful when the expert opinion of a highly specialized physician present in a different geographical location is required.

  • Telemedicine, especially D-to-P with D online consultations, can be effectively used for the diagnosis of rare and emergent medical conditions, such as pheochromocytoma crisis.

Open access
Tatsuro Aikawa Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan

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Eiryu Sai Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan

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Ayako Kudo Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan

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Yuko O Kawaguchi Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan

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Kazuhisa Takamura Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan
Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital, Tomioka, Urayasu-shi, Chiba, Japan

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Makoto Hiki Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan

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Takayuki Yokoyama Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan

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Tetsuro Miyazaki Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan
Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital, Tomioka, Urayasu-shi, Chiba, Japan

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Shinichiro Fujimoto Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan

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Kazunori Shimada Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan
Sportology Center, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan

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Ken-ichi Hirano Laboratory of Cardiovascular Disease, Novel, Non-invasive, and Nutritional Therapeutics and Triglyceride Research Center (TGRC), Department of Triglyceride Science, Graduate School of Medicine, Osaka University, Furuedai, Suita, Osaka, Japan

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Hiroyuki Daida Faculty of Health Science, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan

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Tohru Minamino Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan
Japan Agency for Medical Research and Development-Core Research for Evolutionary Medical Science and Technology (AMED-CREST), Japan Agency for Medical Research and Development, Otemachi, Chiyoda-ku, Tokyo, Japan