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Diagnosis and Treatment > Medication

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Takuya Higashitani Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan

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Shigehiro Karashima Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan

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Daisuke Aono Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan

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Seigoh Konishi Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
Department of Internal Medicine, Keiju Medical Center, Nanao, Ishikawa, Japan

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Mitsuhiro Kometani Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan

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Rie Oka Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan

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Masashi Demura Department of Hygiene, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan

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Kenji Furukawa Health Care Center, Japan Advanced Institute of Science and Technology, Nomi, Ishikawa, Japan

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Yuto Yamazaki Department of Pathology, Tohoku University Hospital, Sendai, Miyagi, Japan

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Hironobu Sasano Department of Pathology, Tohoku University Hospital, Sendai, Miyagi, Japan

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Takashi Yoneda Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan

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Yoshiyu Takeda Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan

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Summary

Renovascular hypertension (RVHT) is an important and potentially treatable form of resistant hypertension. Hypercortisolemia could also cause hypertension and diabetes mellitus. We experienced a case wherein adrenalectomy markedly improved blood pressure and plasma glucose levels in a patient with RVHT and low-level autonomous cortisol secretion. A 62-year-old Japanese man had been treated for hypertension and diabetes mellitus for 10 years. He was hospitalized because of a disturbance in consciousness. His blood pressure (BP) was 236/118 mmHg, pulse rate was 132 beats/min, and plasma glucose level was 712 mg/dL. Abdominal CT scanning revealed the presence of bilateral adrenal masses and left atrophic kidney. Abdominal magnetic resonance angiography demonstrated marked stenosis of the left main renal artery. The patient was subsequently diagnosed with atherosclerotic RVHT with left renal artery stenosis. His left adrenal lobular mass was over 40 mm and it was clinically suspected the potential for cortisol overproduction. Therefore, laparoscopic left nephrectomy and adrenalectomy were simultaneously performed, resulting in improved BP and glucose levels. Pathological studies revealed the presence of multiple cortisol-producing adrenal nodules and aldosterone-producing cell clusters in the adjacent left adrenal cortex. In the present case, the activated renin-angiotensin-aldosterone system and cortisol overproduction resulted in severe hypertension, which was managed with simultaneous unilateral nephrectomy and adrenalectomy.

Learning points:

  • Concomitant activation of the renin-angiotensin-aldosterone system and cortisol overproduction may contribute to the development of severe hypertension and lead to lethal cardiovascular complications.

  • Treatment with simultaneous unilateral nephrectomy and adrenalectomy markedly improves BP and blood glucose levels.

  • CYP11B2 immunohistochemistry staining revealed the existence of aldosterone-producing cell clusters (APCCs) in the adjacent non-nodular adrenal gland, suggesting that APCCs may contribute to aldosterone overproduction in patients with RVHT.

Taxonomy:
Clinical Overview, Gland/Organ, Adrenal, Topic, Adrenal, Hormone, Aldosterone, Cortisol, Renin, Condition/ Syndrome, Diabetes mellitus type 2, Hyperaldosteronism, Hyperosmolar hyperglycaemic state, Hypertension, Macronodular Adrenal Hyperplasia, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, Asian - Japanese, Country of Treatment, Japan, Diagnosis and Treatment, Signs and Symptoms, Arteriosclerosis, Collapse, Dyslipidaemia, Hypercortisolaemia, Hypertension, Renal failure, Investigation, ACTH stimulation, Adrenal scintigraphy, Adrenal venous sampling, Aldosterone (blood), Angiography, Blood pressure, Cortisol, Creatinine, Creatinine (serum), CT scan, Dexamethasone suppression, Estimated glomerular filtration rate, Glucose (blood), Glucose (blood, fasting), Haematoxylin and eosin staining, Histopathology, HOMA, Immunohistochemistry, Insulin tolerance, MRI, PET scan, Renin plasma activity, Total cholesterol, Triglycerides, Urinalysis, Intervention, Adrenalectomy, Laparoscopic adrenalectomy, Medication, Alpha-blockers, Atorvastatin, Doxazosin, DPP4 inhibitors, Insulin, Insulin Aspart, Linagliptin, Meglitinides, Nifedipine, Repaglinide, Related Disciplines, Urology, Publication Details, Case Report Type, Novel treatment
DOI:
https://doi.org/10.1530/EDM-19-0163
Volume/Issue:
Volume 2020: Issue 1
Open access
Frank Gao Department of Endocrinology and Diabetes, The Alfred Hospital, Melbourne, Australia

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Stephen Hall Department of Medicine, Monash University and Cabrini Health, Melbourne, Australia

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Leon A Bach Department of Endocrinology and Diabetes, The Alfred Hospital, Melbourne, Australia
Department of Medicine (Alfred), Monash University, Melbourne, Australia

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Summary

Sodium/glucose co-transporter 2 (SGLT2) inhibitors are novel oral hypoglycaemic agents that are increasingly used in the management of type 2 diabetes mellitus (T2DM). They are now recommended as second-line pharmacotherapy (in conjunction with metformin) in patients with type 2 diabetes and established atherosclerotic heart disease, heart failure or chronic kidney disease due to their favourable effects on cardiovascular and renal outcomes. We report a case of a 69-year-old man who developed muscle pain, weakness and wasting after commencing the SGLT2 inhibitor empagliflozin. This persisted for 1 year before he underwent resistance testing, which confirmed muscle weakness. His symptoms resolved within weeks of ceasing empagliflozin, with improvement in muscle strength on clinical assessment and resistance testing and reversal of MRI changes. No other cause of myopathy was identified clinically, on biochemical assessment or imaging, suggesting that empagliflozin was the cause of his myopathy.

Learning points:

  • Empagliflozin, a commonly used SGLT2 inhibitor, was associated with myopathy.

  • A high degree of suspicion is required to diagnose drug-induced myopathy, with a temporal relationship between starting the medication and symptom onset being the main indicator.

  • Recognition of drug-induced myopathy is essential, as discontinuation of the offending drug typically improves symptoms.

Taxonomy:
Clinical Overview, Gland/Organ, Pancreas, Topic, Diabetes, Hormone, Insulin, Condition/ Syndrome, Diabetes mellitus type 2, Iatrogenic disorder, Myositis, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, White, Country of Treatment, Australia, Diagnosis and Treatment, Signs and Symptoms, Diabetes mellitus type 2, Fatigue, Muscle atrophy, Myalgia, Myasthaenia, Myopathy, Oedema, Polyuria, Weight loss, Investigation, Exercise tolerance, MRI, Medication, Atorvastatin, Empagliflozin, Insulin, Insulin Aspart, SGLT2 inhibitors, Publication Details, Case Report Type, Unusual effects of medical treatment
DOI:
https://doi.org/10.1530/EDM-20-0017
Volume/Issue:
Volume 2020: 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