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Diagnosis and Treatment > Medication

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Diana Catarino Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal

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Cristina Ribeiro Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal

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Leonor Gomes Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal

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Isabel Paiva Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal

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Summary

Pituitary infections, particularly with fungus, are rare disorders that usually occur in immunocompromised patients. Cushing’s syndrome predisposes patients to infectious diseases due to their immunosuppression status. We report the case of a 55-year-old woman, working as a poultry farmer, who developed intense headache, palpebral ptosis, anisocoria, prostration and psychomotor agitation 9 months after initial diabetes mellitus diagnosis. Cranioencephalic CT scan showed a pituitary lesion with bleeding, suggesting pituitary apoplexy. Patient underwent transsphenoidal surgery and the neuropathologic study indicated a corticotroph adenoma with apoplexy and fungal infection. Patient had no preoperative Cushing’s syndrome diagnosis. She was evaluated by a multidisciplinary team who decided not to administer anti-fungal treatment. The reported case shows a rare association between a corticotroph adenoma and a pituitary fungal infection. The possible contributing factors were hypercortisolism, uncontrolled diabetes and professional activity. Transsphenoidal surgery is advocated in these infections; however, anti-fungal therapy is still controversial.

Learning points:

  • Pituitary infections are rare disorders caused by bacterial, viral, fungal and parasitic infections.

  • Pituitary fungal infections usually occur in immunocompromised patients.

  • Cushing’s syndrome, as immunosuppression factor, predisposes patients to infectious diseases, including fungal infections.

  • Diagnosis of pituitary fungal infection is often achieved during histopathological investigation.

  • Treatment with systemic anti-fungal drugs is controversial.

  • Endocrine evaluation is recommended at the time of initial presentation of pituitary manifestations.

Taxonomy:
Clinical Overview, Gland/Organ, Pituitary, Topic, Pituitary, Hormone, ACTH, Cortisol, FSH, GH, IGF1, LH, Oestradiol (E2), Prolactin, Thyroxine (T4), TSH, Condition/ Syndrome, Corticotrophic adenoma, Cushing's syndrome, Diabetes mellitus type 2, Hypopituitarism, Pituitary adenoma, Pituitary apoplexy, Patient Demographics, Age, Adult, Gender, Female, Ethnicity, White, Country of Treatment, Portugal, Diagnosis and Treatment, Signs and Symptoms, Agitation, Anisocoria, Diabetes mellitus type 2, Fatigue, Headache, Hypercortisolaemia, Hypertension, Hypopituitarism, Ptosis, Investigation, ACTH, Blood pressure, Cortisol (serum), CT scan, FSH, FT4, GH, Haematoxylin and eosin staining, Haemoglobin A1c, Histopathology, IGF1, Immunohistochemistry, LH, MRI, Oestradiol (E2), Prolactin, TSH, Intervention, Resection of tumour, Transsphenoidal surgery, Medication, DPP4 inhibitors, Gliclazide, Glucocorticoids, Hydrocortisone, Insulin glargine, Metformin, Sitagliptin, Spironolactone, Thyroxine (T4), Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-20-0010
Volume/Issue:
Volume 2020: Issue 1
Open access
Senhong Lee of Endocrinology, Monash Health, Clayton, Victoria, Australia

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Aparna Morgan of Endocrinology, Monash Health, Clayton, Victoria, Australia

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Sonali Shah of Endocrinology, Monash Health, Clayton, Victoria, Australia

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Peter R Ebeling of Endocrinology, Monash Health, Clayton, Victoria, Australia
Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia

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Summary

We report a case of a 67-year-old man with type 2 diabetes presented with diabetic ketoacidosis, two weeks after his first dose of nivolumab therapy for non–small-cell lung carcinoma. He was started on empagliflozin two days prior in the setting of hyperglycaemia after the initiation of nivolumab therapy. Laboratory evaluation revealed an undetectable C-peptide and a positive anti-glutamic acid decarboxylase (GAD) antibody. He was treated with intravenous fluids and insulin infusion and was subsequently transitioned to subcutaneous insulin and discharged home. He subsequently has developed likely autoimmune thyroiditis and autoimmune encephalitis.

Learning points:

  • Glycemic surveillance in patients receiving immune checkpoint inhibitors is recommended.

  • Early glycemic surveillance after commencement of anti-programmed cell death-1 (PD-1) inhibitors may be indicated in selected populations, including patients with underlying type 2 diabetes mellitus and positive anti-glutamic acid decarboxylase (GAD) antibody.

  • Sodium-glucose co transporter-2 (SGLT2) inhibitors should be used with caution in patients on immunotherapy.

Taxonomy:
Clinical Overview, Gland/Organ, Pancreas, Topic, Diabetes, Hormone, Insulin, Thyroxine (T4), TSH, Condition/ Syndrome, Autoimmune disorders, Diabetes mellitus type 2, Diabetic ketoacidosis, Hyperglycaemia, Hyperthyroidism, Iatrogenic disorder, Thyroiditis, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, White, Country of Treatment, Australia, Diagnosis and Treatment, Signs and Symptoms, Coughing, Diabetes mellitus type 2, Diabetic ketoacidosis, Fatigue, Hyperglycaemia, Hyperthyroidism, Metabolic acidosis, Polydipsia, Polyuria, Seizures, Investigation, Anion gap, Bicarbonate, Biopsy, C-peptide (blood), CT scan, FT4, GADA, Glucose (blood), Haemoglobin A1c, Ketones (plasma), TSH, Intervention, Chemotherapy, Fluid repletion, Medication, Carboplatin, DPP4 inhibitors, Empagliflozin, Insulin, Metformin, Nivolumab, Paclitaxel, SGLT2 inhibitors, Sitagliptin, Related Disciplines, Oncology, Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-18-0021
Volume/Issue:
Volume 2018: Issue 1
Open access
Ken Takeshima First Department of Internal Medicine, Wakayama Medical University, Wakayama,, Japan

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Hiroyuki Ariyasu First Department of Internal Medicine, Wakayama Medical University, Wakayama,, Japan

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Tatsuya Ishibashi First Department of Internal Medicine, Wakayama Medical University, Wakayama,, Japan

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Shintaro Kawai First Department of Internal Medicine, Wakayama Medical University, Wakayama,, Japan

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Shinsuke Uraki First Department of Internal Medicine, Wakayama Medical University, Wakayama,, Japan

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Jinsoo Koh Department of Neurology, Wakayama Medical University, Wakayama,, Japan

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Hidefumi Ito Department of Neurology, Wakayama Medical University, Wakayama,, Japan

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Takashi Akamizu First Department of Internal Medicine, Wakayama Medical University, Wakayama,, Japan

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Summary

Myotonic dystrophy type 1 (DM1) is an autosomal dominant multisystem disease affecting muscles, the eyes and the endocrine organs. Diabetes mellitus and primary hypogonadism are endocrine manifestations typically seen in patients with DM1. Abnormalities of hypothalamic–pituitary–adrenal (HPA) axis have also been reported in some DM1 patients. We present a case of DM1 with a rare combination of multiple endocrinopathies; diabetes mellitus, a combined form of primary and secondary hypogonadism, and dysfunction of the HPA axis. In the present case, diabetes mellitus was characterized by severe insulin resistance with hyperinsulinemia. Glycemic control improved after modification of insulin sensitizers, such as metformin and pioglitazone. Hypogonadism was treated with testosterone replacement therapy. Notably, body composition analysis revealed increase in muscle mass and decrease in fat mass in our patient. This implies that manifestations of hypogonadism could be hidden by symptoms of myotonic dystrophy. Our patient had no symptoms associated with adrenal deficiency, so adrenal dysfunction was carefully followed up without hydrocortisone replacement therapy. In this report, we highlight the necessity for evaluation and treatment of multiple endocrinopathies in patients with DM1.

Learning points:

  • DM1 patients could be affected by a variety of multiple endocrinopathies.

  • Our patients with DM1 presented rare combinations of multiple endocrinopathies; diabetes mellitus, combined form of primary and secondary hypogonadism and dysfunction of HPA axis.

  • Testosterone treatment of hypogonadism in patients with DM1 could improve body composition.

  • The patients with DM1 should be assessed endocrine functions and treated depending on the degree of each endocrine dysfunction.

Taxonomy:
Clinical Overview, Gland/Organ, Adrenal, Topic, Adrenal, Hormone, ACTH, Aldosterone, Cortisol, FSH, IGF1, Insulin, LH, Prolactin, Testosterone, Condition/ Syndrome, Adrenal insufficiency, Autoimmune hypophysitis, Hypergonadotropic hypogonadism, Hyperkalaemia, Hypernatraemia, Hypogonadism, Insulin resistance, Myotonic dystrophy type 1, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, Asian - Japanese, Country of Treatment, Japan, Diagnosis and Treatment, Signs and Symptoms, Diabetes mellitus type 2, Erectile dysfunction, Facies - abnormal, Hyperkalaemia, Hypernatraemia, Hypogonadism, Insulin resistance, Libido reduction/loss, Muscle atrophy, Myasthaenia, Myopathy, Obesity, T-reflex (depressed), Investigation, ACTH, Adrenal function, Aldosterone (24-hour urine), Aldosterone (blood), BMI, Body fat mass, Corticotropin-releasing hormone stimulation test, Cortisol, free (24-hour urine), C-peptide (24-hour urine), C-peptide (blood), CT scan, Electromyography, FSH, Glucose (blood, fasting), Haemoglobin A1c, IGF1, LH, Molecular genetic analysis, Potassium, Prolactin, Respiratory status, Skeletal muscle mass, Sodium, Testosterone, Triglycerides, Waist circumference, White blood cell count, Intervention, Diet, Medication, Alpha-glucosidase inhibitors, DPP4 inhibitors, Insulin, Insulin glargine, Metformin, Pioglitazone, Sitagliptin, Testosterone, Testosterone enanthate esters, Thiazolidinediones, Voglibose, Related Disciplines, Neurology, Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-17-0143
Volume/Issue:
Volume 2018: Issue 1
Open access
Murray B Gordon Allegheny Neuroendocrinology Center, Departments of Medicine and Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA

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Kellie L Spiller Allegheny Neuroendocrinology Center, Departments of Medicine and Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA

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Summary

Long-acting pasireotide is an effective treatment option for acromegaly, but it is associated with hyperglycemia, which could impact its use in patients with diabetes. We present a case of a 53-year-old man with acromegaly and type 2 diabetes mellitus (glycated hemoglobin (HbA1c): 7.5%), who refused surgery to remove a pituitary macroadenoma and enrolled in a Phase 3 clinical trial comparing long-acting pasireotide and long-acting octreotide in acromegalic patients. The patient initially received octreotide, but insulin-like growth factor 1 (IGF-1) levels remained elevated after 12 months (383.9 ng/mL; 193.0 ng/mL; reference range: 86.5–223.8 ng/mL), indicating uncontrolled acromegaly. He switched to pasireotide 40 mg and subsequently increased to 60 mg. Within 6 months, IGF-1 levels normalized (193.0 ng/mL), and they were mostly normal for the next 62 months of treatment with pasireotide (median IGF-1: 190.7 ng/mL). Additionally, HbA1c levels remained similar to or lower than baseline levels (range, 6.7% to 7.8%) during treatment with pasireotide despite major changes to the patient’s antidiabetic regimen, which included insulin and metformin. Uncontrolled acromegaly can result in hyperglycemia due to an increase in insulin resistance. Despite having insulin-requiring type 2 diabetes, the patient presented here did not experience a long-term increase in HbA1c levels upon initiating pasireotide, likely because long-term control of acromegaly resulted in increased insulin sensitivity. This case highlights the utility of long-acting pasireotide to treat acromegaly in patients whose levels were uncontrolled after long-acting octreotide and who manage diabetes with insulin.

Learning points

  • Long-acting pasireotide provided adequate, long-term biochemical control of acromegaly in a patient with insulin-requiring type 2 diabetes mellitus who was unresponsive to long-acting octreotide.

  • Glycemic levels initially increased after starting treatment with pasireotide but quickly stabilized as acromegaly became controlled.

  • Long-acting pasireotide, along with an appropriate antidiabetic regimen, may be a suitable therapy for patients with acromegaly who also have insulin-requiring type 2 diabetes mellitus.

Taxonomy:
Clinical Overview, Gland/Organ, Pituitary, Topic, Pituitary, Hormone, IGF1, Insulin, Condition/ Syndrome, Acromegaly, Diabetes mellitus type 2, Hyperlipidaemia, Pituitary adenoma, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, White, Country of Treatment, United States, Diagnosis and Treatment, Signs and Symptoms, Arthralgia, Carpal tunnel syndrome, Hypertension, Insulin resistance, Obesity, Obstructive sleep apnoea, Vertigo, Investigation, GH, Haemoglobin A1c, IGF1, MRI, Medication, DPP4 inhibitors, Glipizide, GLP1 agonists, Insulin, Liraglutide, Metformin, Octreotide, Pasireotide, Pioglitazone, Sitagliptin, Sulphonylureas, Thiazolidinediones, Publication Details, Case Report Type, Novel treatment
DOI:
https://doi.org/10.1530/EDM-17-0003
Volume/Issue:
Volume 2017: Issue 1
Open access
E Rapti Diabetes Center of 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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S Karras Diabetes Center of 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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M Grammatiki Diabetes Center of 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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A Mousiolis Diabetes Center of 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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X Tsekmekidou Diabetes Center of 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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E Potolidis Diabetes Center of 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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P Zebekakis Diabetes Center of 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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M Daniilidis 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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K Kotsa Diabetes Center of 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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Summary

Latent autoimmune diabetes in adults (LADA) is a relatively new type of diabetes with a clinical phenotype of type 2 diabetes (T2D) and an immunological milieu characterized by high titers of islet autoantibodies, resembling the immunological profile of type 1 diabetes (T1D). Herein, we report a case of a young male, diagnosed with LADA based on both clinical presentation and positive anti-glutamic acid decarboxylase antibodies (GAD-abs), which were normalized after combined treatment with a dipeptidyl peptidase-4 inhibitor (DPP-4) (sitagliptin) and cholecalciferol.

Learning points

  • Anti-glutamic acid decarboxylase antibodies (GAD-abs) titers in young patients being previously diagnosed as type 2 diabetes (T2D) may help establish the diagnosis of latent autoimmune diabetes in adults (LADA).

  • Sitagliptin administration in patients with LADA might prolong the insulin-free period.

  • Vitamin D administration in patients with LADA might have a protective effect on the progression of the disease.

Taxonomy:
Clinical Overview, Gland/Organ, Pancreas, Topic, Diabetes, Vitamin D, Hormone, Insulin, Condition/ Syndrome, Latent Autoimmune Diabetes of Adults (LADA), Patient Demographics, Age, Adult, Gender, Male, Ethnicity, White, Country of Treatment, Greece, Diagnosis and Treatment, Signs and Symptoms, Hypovitaminosis D, Nausea, Polydipsia, Polyuria, Vision - blurred, Vomiting, Weight loss, Investigation, GADA, Glucose (blood), Haemoglobin A1c, HLA genotyping, Urinalysis, Medication, DPP4 inhibitors, Gliclazide, Metformin, Sitagliptin, Sulphonylureas, Vitamin D, Publication Details, Case Report Type, Insight into disease pathogenesis or mechanism of therapy
DOI:
https://doi.org/10.1530/EDM-15-0136
Volume/Issue:
Volume 2016: Issue 1
Open access
Jiman Kim
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Eulsun Moon Seoul 365 Medical Clinic, Seoul, Korea

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Seungwon Kwon Department of Cardiovascular and Neurologic Diseases, College of Korean Medicine, KyungHee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea

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Summary

Diabetic nephropathy, a microvascular complication of diabetes, is a progressive kidney disease caused by angiopathy of the capillaries in the kidney glomeruli. Herein, we report a case of a 62-year-old patient with a 30 year history of diabetes, who showed a substantial improvement in diabetic nephropathy on administration of 30 g of Astragalus membranaceus extract per day. After 1 month, estimated glomerular filtration rate increased from 47 to 72 ml/min per 1.73 m2 and was subsequently maintained at the 1-month follow-up. Urinary protein levels also decreased following treatment. Herein, we present and discuss the evidence and mechanism of A. membranaceus on diabetic nephropathy in this patient.

Learning points

  • Diabetic nephropathy is a progressive kidney disease.

  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are currently used to prevent and delay the progression of diabetic nephropathy. However, their effects are not sufficient to prevent a decline in kidney function.

  • Furthermore, combination therapy with an ACE inhibitor and an ARB can produce adverse effects without additional benefits.

  • In the early phase of diabetic nephropathy, administration of Astragalus membranaceus can be a therapeutic option.

Taxonomy:
Clinical Overview, Gland/Organ, Pancreas, Topic, Diabetes, Hormone, Insulin, Condition/ Syndrome, Diabetes mellitus type 2, Diabetic nephropathy, Hypertension, Patient Demographics, Age, Geriatric, Gender, Male, Ethnicity, Asian - Korean, Country of Treatment, Korea, Republic of, Diagnosis and Treatment, Signs and Symptoms, Diabetic foot ulceration, Hypertension, Proteinuria, Retinopathy, Investigation, Creatinine (serum), Estimated glomerular filtration rate, Medication, Astragalus membranaceus, Atorvastatin, Calcium dobesilate, Clopidogrel, Diltiazem, DPP4 inhibitors, Ginkgo biloba, Insulin, Metformin, Perindopril, Sitagliptin, Related Disciplines, Nephrology, Publication Details, Case Report Type, Novel treatment
DOI:
https://doi.org/10.1530/EDM-14-0063
Volume/Issue:
Volume 2014: Issue 1
Open access