Browse

You are looking at 1 - 10 of 52 items

Tomomi Nakao First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

Search for other papers by Tomomi Nakao in
Google Scholar
PubMed
Close
,
Ken Takeshima First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

Search for other papers by Ken Takeshima in
Google Scholar
PubMed
Close
,
Hiroyuki Ariyasu First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

Search for other papers by Hiroyuki Ariyasu in
Google Scholar
PubMed
Close
,
Chiaki Kurimoto First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

Search for other papers by Chiaki Kurimoto in
Google Scholar
PubMed
Close
,
Shinsuke Uraki First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

Search for other papers by Shinsuke Uraki in
Google Scholar
PubMed
Close
,
Shuhei Morita First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

Search for other papers by Shuhei Morita in
Google Scholar
PubMed
Close
,
Yasushi Furukawa First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

Search for other papers by Yasushi Furukawa in
Google Scholar
PubMed
Close
,
Hiroshi Iwakura First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

Search for other papers by Hiroshi Iwakura in
Google Scholar
PubMed
Close
, and
Takashi Akamizu First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

Search for other papers by Takashi Akamizu in
Google Scholar
PubMed
Close

Summary

Thyroid storm (TS) is a life-threatening condition that may suffer thyrotoxic patients. Therapeutic plasma exchange (TPE) is a rescue approach for TS with acute hepatic failure, but it should be initiated with careful considerations. We present a 55-year-old male patient with untreated Graves’ disease who developed TS. Severe hyperthyroidism and refractory atrial fibrillation with congestive heart failure aggregated to multiple organ failure. The patient was recovered by intensive multimodal therapy, but we had difficulty in introducing TPE treatment considering the risk of exacerbation of congestive heart failure due to plasma volume overload. In addition, serum total bilirubin level was not elevated in the early phase to the level of indication for TPE. The clinical course of this patient instructed delayed elevation of bilirubin until the level of indication for TPE in some patients and also demonstrated the risk of exacerbation of congestive heart failure by TPE.

Learning points:

  • Our patient with thyroid storm could be diagnosed and treated promptly using Japan Thyroid Association guidelines for thyroid storm.

  • Delayed elevation of serum bilirubin levels could make the decision of introducing therapeutic plasma exchange difficult in cases of thyroid storm with acute hepatic failure.

  • The risk of worsening congestive heart failure should be considered carefully when performing therapeutic plasma exchange.

Open access
Tzy Harn Chua Department of Endocrinology, Changi General Hospital, Singapore

Search for other papers by Tzy Harn Chua in
Google Scholar
PubMed
Close
and
Wann Jia Loh Department of Endocrinology, Changi General Hospital, Singapore

Search for other papers by Wann Jia Loh in
Google Scholar
PubMed
Close

Summary

Severe hyponatremia and osmotic demyelination syndrome (ODS) are opposite ends of a spectrum of emergency disorders related to sodium concentrations. Management of severe hyponatremia is challenging because of the difficulty in balancing the risk of overcorrection leading to ODS as well as under-correction causing cerebral oedema, particularly in a patient with chronic hypocortisolism and hypothyroidism. We report a case of a patient with Noonan syndrome and untreated anterior hypopituitarism who presented with symptomatic hyponatremia and developed transient ODS.

Learning points:

  • Patients with severe anterior hypopituitarism with severe hyponatremia are susceptible to the rapid rise of sodium level with a small amount of fluid and hydrocortisone.

  • These patients with chronic anterior hypopituitarism are at high risk of developing ODS and therefore, care should be taken to avoid a rise of more than 4–6 mmol/L per day.

  • Early recognition and rescue desmopressin and i.v. dextrose 5% fluids to reduce serum sodium concentration may be helpful in treating acute ODS.

Open access
Anna Luiza Galeazzi Rech Kantonsspital Sankt Gallen, Klinik für Allgemeine Innere Medizin/Hausarztmedizin, Sankt Gallen, Switzerland

Search for other papers by Anna Luiza Galeazzi Rech in
Google Scholar
PubMed
Close
,
Yvon Stüve Kantonsspital Sankt Gallen, Klinik für Allgemeine Innere Medizin/Hausarztmedizin, Sankt Gallen, Switzerland

Search for other papers by Yvon Stüve in
Google Scholar
PubMed
Close
,
Andreas Toepfer Kantonsspital Sankt Gallen, Klinik für Orthopädische Chirurgie und Traumatologie des Bewegungsapparts, Sankt Gallen, Switzerland

Search for other papers by Andreas Toepfer in
Google Scholar
PubMed
Close
, and
Katrin E Schimke Kantonsspital Sankt Gallen, Klinik für Allgemeine Innere Medizin/Hausarztmedizin, Sankt Gallen, Switzerland

Search for other papers by Katrin E Schimke in
Google Scholar
PubMed
Close

Summary

Acute Charcot neuropathic osteoarthropathy (CN) is a clinical entity which can easily go unrecognized in its acute early stages due to lack of awareness and unspecific presentation. However, missing early diagnosis can lead to severe complications. We present the case of a 72-year-old male patient who went through the natural course of the disease unnoticed before the very eyes of his physicians leading to a tragic end. We aim to raise awareness for this rare diabetic complication, emphasizing the necessity of early diagnosis and adequate, interdisciplinary treatment.

Learning points:

  • Clinical signs and symptoms of acute Charcot neuropathic osteoarthropathy (CN).

  • Red flags.

  • Importance of early diagnosis and correct treatment.

  • Diagnostic challenges of acute CN.

  • Awareness of high morbidity and mortality.

Open access
Daniela Gallo Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy

Search for other papers by Daniela Gallo in
Google Scholar
PubMed
Close
,
Sara Rosetti Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy

Search for other papers by Sara Rosetti in
Google Scholar
PubMed
Close
,
Ilaria Marcon Department of Oncology, ASST dei Sette Laghi, Varese, Italy

Search for other papers by Ilaria Marcon in
Google Scholar
PubMed
Close
,
Elisabetta Armiraglio Pathology Unit, ASST Gaetano Pini, Centro Specialistico Ortopedico Traumatologico, Gaetano Pini-CTO, Milano, Italy

Search for other papers by Elisabetta Armiraglio in
Google Scholar
PubMed
Close
,
Antonina Parafioriti Pathology Unit, ASST Gaetano Pini, Centro Specialistico Ortopedico Traumatologico, Gaetano Pini-CTO, Milano, Italy

Search for other papers by Antonina Parafioriti in
Google Scholar
PubMed
Close
,
Graziella Pinotti Department of Oncology, ASST dei Sette Laghi, Varese, Italy

Search for other papers by Graziella Pinotti in
Google Scholar
PubMed
Close
,
Giuseppe Perrucchini I.R.C.C.S Istituto Ortopedico Galeazzi, Milano, Italy

Search for other papers by Giuseppe Perrucchini in
Google Scholar
PubMed
Close
,
Bohdan Patera Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy

Search for other papers by Bohdan Patera in
Google Scholar
PubMed
Close
,
Linda Gentile Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy

Search for other papers by Linda Gentile in
Google Scholar
PubMed
Close
,
Maria Laura Tanda Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy

Search for other papers by Maria Laura Tanda in
Google Scholar
PubMed
Close
,
Luigi Bartalena Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy

Search for other papers by Luigi Bartalena in
Google Scholar
PubMed
Close
, and
Eliana Piantanida Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy

Search for other papers by Eliana Piantanida in
Google Scholar
PubMed
Close

Summary

Brown tumors are osteoclastic, benign lesions characterized by fibrotic stroma, intense vascularization and multinucleated giant cells. They are the terminal expression of the bone remodelling process occurring in advanced hyperparathyroidism. Nowadays, due to earlier diagnosis, primary hyperparathyroidism keeps few of the classical manifestations and brown tumors are definitely unexpected. Thus, it may happen that they are misdiagnosed as primary or metastatic bone cancer. Besides bone imaging, endocrine evaluation including measurement of serum parathyroid hormone and calcium (Ca) levels supports the pathologist to address the diagnosis. Herein, a case of multiple large brown tumors misdiagnosed as a non-treatable osteosarcoma is described, with special regards to diagnostic work-up. After selective parathyroidectomy, treatment with denosumab was initiated and a regular follow-up was established. The central role of multidisciplinary approach involving pathologist, endocrinologist and oncologist in the diagnostic and therapeutic work-up is reported. In our opinion, the discussion of this case would be functional especially for clinicians and pathologists not used to the differential diagnosis in uncommon bone disorders.

Learning points:

  • Brown tumors develop during the remodelling process of bone in advanced and long-lasting primary or secondary hyperparathyroidism.

  • Although rare, they should be considered during the challenging diagnostic work-up of giant cell lesions.

  • Coexistence of high parathyroid hormone levels and hypercalcemia in primary hyperparathyroidism is crucial for the diagnosis.

  • A detailed imaging study includes bone X-ray, bone scintiscan and total body CT; to rule out bone malignancy, evaluation of bone lesion biopsy should include immunostaining for neoplastic markers as H3G34W and Ki67 index.

  • If primary hyperparathyroidism is confirmed, selective parathyroidectomy is the first-line treatment.

  • In advanced bone disease, treatment with denosumab should be considered, ensuring a strict control of Ca levels.

Open access
S Hamidi Division of Endocrinology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Montréal, Canada

Search for other papers by S Hamidi in
Google Scholar
PubMed
Close
,
S Mottard Division of Orthopedic Surgery, Department of Surgery, Hôpital Maisonneuve-Rosemont, Montréal, Canada

Search for other papers by S Mottard in
Google Scholar
PubMed
Close
,
M J Berthiaume Department of Radiology, Hôpital Maisonneuve-Rosemont, Montréal, Canada

Search for other papers by M J Berthiaume in
Google Scholar
PubMed
Close
,
J Doyon Department of Pathology, Hôpital Maisonneuve-Rosemont, Montréal, Canada

Search for other papers by J Doyon in
Google Scholar
PubMed
Close
,
M J Bégin Division of Endocrinology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Montréal, Canada

Search for other papers by M J Bégin in
Google Scholar
PubMed
Close
, and
L Bondaz Division of Endocrinology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Montréal, Canada

Search for other papers by L Bondaz in
Google Scholar
PubMed
Close

Summary

Brown tumors (BTs) are expansile osteolytic lesions complicating severe primary hyperparathyroidism (PHPT). Clinical, radiological and histological features of BTs share many similarities with other giant cell-containing lesions of the bone, which can make their diagnosis challenging. We report the case of a 32-year-old man in whom an aggressive osteolytic lesion of the iliac crest was initially diagnosed as a giant cell tumor by biopsy. The patient was scheduled for surgical curettage, with a course of neoadjuvant denosumab. Routine biochemical workup prior to denosumab administration incidentally revealed high serum calcium levels. The patient was diagnosed with PHPT and a parathyroid adenoma was identified. In light of these findings, histological slices of the iliac lesion were reviewed and diagnosis of a BT was confirmed. Follow-up CT-scans performed 2 and 7 months after parathyroidectomy showed regression and re-ossification of the bone lesion. The aim of this case report is to underline the importance of distinguishing BTs from other giant cell-containing lesions of the bone and to highlight the relevance of measuring serum calcium as part of the initial evaluation of osteolytic bone lesions. This can have a major impact on patients’ management and can prevent unnecessary invasive surgical interventions.

Learning points:

  • Although rare, brown tumors should always be considered in the differential diagnosis of osteolytic giant cell-containing bone lesions.

  • Among giant cell-containing lesions of the bone, the main differential diagnoses of brown tumors are giant cell tumors and aneurysmal bone cysts.

  • Clinical, radiological and histological characteristics can be non-discriminating between brown tumors and giant cell tumors. One of the best ways to distinguish these two diagnoses appears to be through biochemical workup.

  • Differentiating brown tumors from giant cell tumors and aneurysmal bone cysts is crucial in order to ensure better patient care and prevent unnecessary morbid surgical interventions.

Open access
J K Witczak Section of Endocrinology, Department of Medicine, Prince Phillip Hospital
Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Heath Park, Cardiff, UK

Search for other papers by J K Witczak in
Google Scholar
PubMed
Close
,
N Ubaysekara Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Heath Park, Cardiff, UK

Search for other papers by N Ubaysekara in
Google Scholar
PubMed
Close
,
R Ravindran Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Heath Park, Cardiff, UK

Search for other papers by R Ravindran in
Google Scholar
PubMed
Close
,
S Rice Section of Endocrinology, Department of Medicine, Prince Phillip Hospital

Search for other papers by S Rice in
Google Scholar
PubMed
Close
,
Z Yousef Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff, UK

Search for other papers by Z Yousef in
Google Scholar
PubMed
Close
, and
L D Premawardhana Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Heath Park, Cardiff, UK

Search for other papers by L D Premawardhana in
Google Scholar
PubMed
Close

Summary

Graves’ disease is associated with tachydysrythmia, cardiac ischaemia and cardiomyopathy – all uncommon in young adults without previous cardiac disease. We present three young individuals who developed cardiac complications after periods of uncontrolled Graves’ disease. Subject 1: A 34-year-old female had severe thyrotoxic symptoms for weeks. Investigations showed fT4: 98.4 (11–25 pmol/L), fT3: 46.9 (3.1–6.8 pmol/L), TSH <0.01 (0.27–4.2 mU/L) and thyrotrophin receptor antibody (TRAb): 34.8 (<0.9 U//l). She had appropriate treatment but several weeks later she became breathless despite improving thyroid function. Echocardiography showed a pericardial effusion of 2.9 cm. She responded well to steroids and NSAIDs but developed active severe Graves’ orbitopathy after early total thyroidectomy. Subject 2: A 28-year-old male developed thyrotoxic symptoms (fT4: 38 pmol/L, fT3: 13.9 pmol/L, TSH <0.01 (for over 6 months) and TRAb: 9.3 U/L). One month after starting carbimazole, he developed acute heart failure (HF) due to severe dilated cardiomyopathy – EF 10–15%. He partially recovered after treatment – EF 28% and had early radioiodine treatment. Subject 3: A 42-year-old woman who had been thyrotoxic for several months (fT4: 54.3; fT3 >46.1; TSH <0.01; TRAb: 4.5) developed atrial fibrillation (AF) and heart failure. Echocardiography showed cardiomegaly – EF 29%. She maintains sinus rhythm following early total thyroidectomy (EF 50%). Significant cardiac complications may occur in previously fit young adults, who have had uncontrolled Graves’ disease for weeks to months. Cardiac function recovers in the majority, but early definitive treatment should be discussed to avoid Graves’ disease relapse and further cardiac decompensation.

Learning points:

  • Cardiac complications of Graves’ disease are uncommon in young adults without previous cardiac disease.

  • These complications may however occur if Graves’ disease had been poorly controlled for several weeks or months prior to presentation.

  • Persistent symptoms after adequate control should alert clinicians to the possibility of cardiac disease.

  • Specific treatment of Graves’ disease and appropriate cardiac intervention results in complete recovery in the majority and carries a good prognosis.

  • Early definitive treatment should be offered to them to prevent cardiac decompensation at times of further relapse.

Open access