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Caroline Schulmeister Pediatric Endocrinology, University of California at San Francisco, San Francisco, California, USA
Pediatric Endocrinology, University of California at Davis, Sacramento, California, USA

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Jason Lee Pediatric Nephrology, University of California at San Francisco, San Francisco, California, USA
Pediatric Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA

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Farzana Perwad Pediatric Nephrology, University of California at San Francisco, San Francisco, California, USA

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Roger Long Pediatric Endocrinology, University of California at San Francisco, San Francisco, California, USA

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Shylaja Srinivasan Pediatric Endocrinology, University of California at San Francisco, San Francisco, California, USA

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Summary

Skeletal abnormalities with delayed bone age and decreased linear bone growth are commonly found in children with prolonged juvenile hypothyroidism. However, rachitic bone abnormalities have not been previously reported in children with acquired hypothyroidism. Here, we present a case of newly found rickets in an 8-year-old female with untreated acquired hypothyroidism secondary to Hashimoto’s thyroiditis. Laboratory finding for abnormalities in calcium/phosphorus homeostasis and hormones that regulate skeletal health was normal. Her radiographic anomalies resolved with levothyroxine treatment alone, suggesting that hypothyroidism was the etiology of the rickets. To our knowledge, this is the first case report of rickets associated with long-standing severe acquired hypothyroidism that resolved exclusively with thyroid repletion.

Learning points

  • Thyroid hormone plays an important role in bone mineralization.

  • Prolonged hypothyroidism can result in rachitic bone abnormalities noted on radiographs.

  • Hypothyroidism should be considered in the evaluation of a child with rickets.

Open access
Maheswaran Dhanasekaran Department of Endocrinology, Diabetes, Nutrition, Mayo Clinic, Rochester, Minnesota, USA

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Siddharth Narayanan Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio, USA

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Ioannis Mastoris Albert Einstein College of Medicine, Bronx, New York City, New York, USA

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Suchita Mehta Northwell Health, Long Island Jewish Medical Center, New Hyde Park, New York, USA

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Summary

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) induce osmotic diuresis by inhibiting the proximal renal tubular reabsorption of the filtered glucose load, which in turn can occasionally lead to severe dehydration and hypotension amidst other adverse effects. We present a case of a 49-year-old man with type 2 diabetes mellitus (T2D) on canagliflozin, a SGLT2i. The patient was brought to the emergency room following a motor vehicle accident. He was confused and had an altered mental status. His blood alcohol and urine toxicology screens were negative. Initial investigations revealed that he had severe hyponatremia with euglycemic ketoacidosis. The adverse condition was reversed with close monitoring and timely management, and the patient was eventually discharged. This is the first report to suggest hyponatremia as a potentially serious adverse effect following SGLT2i therapy. Its impact on the renal tubule handling of sodium and water is not yet well characterized. While further studies are warranted to understand better the pathophysiological mechanisms associated with SGLT2i-induced adverse effects, timely dose reduction or perhaps even its temporary discontinuation may be recommended to prevent complications.

Learning points

  • Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are usually well-tolerated, but some serious adverse effects have been documented.

  • Our case report suggests hyponatremia as a potential, rare side effect of SGLT2i and makes physicians aware of the occurrence of such life-threatening but preventable complications.

  • Timely and close monitoring of the patient, with temporary discontinuation of this drug, may be recommended towards effective management.

  • Studies demonstrating a comprehensive understanding of SGLT2i-related electrolyte derangements are warranted.

Open access
N Ayub Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands

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A J A T Braat Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands

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H J L M Timmers Departments of Endocrinology and Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands

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M G E H Lam Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands

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R S van Leeuwaarde Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands

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Summary

Von Hippel–Lindau’s disease (VHL) is a hereditary tumor syndrome characterized by its prototype lesions, hemangioblastomas, and renal cell carcinomas. Treatment for renal cell carcinomas can ultimately result in long-term dialysis. Pancreatic neuroendocrine tumors (pNET) can also occur in the course of the disease. Currently, peptide receptor radionuclide therapy (PRRT) is the standard treatment for progressive neuroendocrine tumors. However, little is known about treatment with PRRT in patients on dialysis, an infrequent presentation in patients with VHL. We present a 72-year-old man with VHL on hemodialysis and a progressive pNET. He received four cycles of PRRT with a reduced dose. Only mild thrombopenia was seen during treatments. The patient died 9 months after the last PRRT because of acute bleeding in a hemangioblastoma. Hemodialysis is not a limiting factor for PRRT treatment and it should be considered as it seems a safe short-term treatment option for this specific group.

Learning points

  • Von Hippel–Lindau disease (VHL) is a complex disease in which former interventions can limit optimal treatment for following VHL-related tumors later in life.

  • Metastasized pancreatic neuroendocrine tumors occur as part of VHL disease.

  • Peptide receptor radionuclide therapy seems a safe short-term treatment option in patients on hemodialysis.

Open access
Nikitas S Skarakis Unit of Endocrinology and Diabetes Center, ‘G. Gennimatas’ General Hospital, Athens, Greece

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Irene Papadimitriou Unit of Endocrinology and Diabetes Center, ‘G. Gennimatas’ General Hospital, Athens, Greece

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Labrini Papanastasiou Unit of Endocrinology and Diabetes Center, ‘G. Gennimatas’ General Hospital, Athens, Greece

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Sofia Pappa Department of Pathology, ‘G. Gennimatas’ General Hospital, Athens, Greece

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Anastasia Dimitriadi Department of Pathology, ‘G. Gennimatas’ General Hospital, Athens, Greece

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Ioannis Glykas Department of Urology, General Hospital of Athens ‘G Gennimatas’, Athens, Greece

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Konstantinos Ntoumas Department of Urology, General Hospital of Athens ‘G Gennimatas’, Athens, Greece

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Penelope Lampropoulou Department of Radiology, General Hospital of Athens ‘G Gennimatas’, Athens, Greece

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Theodora Kounadi Unit of Endocrinology and Diabetes Center, ‘G. Gennimatas’ General Hospital, Athens, Greece

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Summary

Juxtaglomerular cell tumour (JGCT) is an unusually encountered clinical entity. A 33-year-old man with severe long-standing hypertension and hypokalaemia is described. The patient also suffered from polyuria, polydipsia, nocturia and severe headaches. On admission, laboratory investigation revealed hypokalaemia, kaliuresis, high aldosterone and renin levels, and the abdomen CT identified a mass of 4 cm at the right kidney. Kidney function was normal. Following nephrectomy, the histological investigation revealed the presence of a JGCT. Immunostaining was positive for CD34 as well as for smooth muscle actin and vimentin. Following surgery, a marked control of his hypertension with calcium channel blockers and normalization of the serum potassium, renin or aldosterone levels were reached. According to our findings, JGCT could be included in the differential diagnosis of secondary hypertension as it consists of a curable cause. The association of JGCT with hypertension and hypokalaemia focusing on the clinical presentation, diagnostic evaluation and management is herein discussed and a brief review of the existing literature is provided.

Learning points

  • Juxtaglomerular cell tumours (JGCT), despite their rarity, should be included in the differential diagnosis of secondary hypertension as they consist of a curable cause of hypertension.

  • JGCT could be presented with resistant hypertension along with hypokalaemia, kaliuresis and metabolic alkalosis. Early recognition and management can help to prevent cardiovascular complications.

  • Imaging (enhanced CT scans) may be considered as the primary diagnostic tool for the detection of renal or JGCT.

  • For the confirmation of the diagnosis, a histopathologic examination is needed.

Open access
Clare E Bonnar Centre for Diabetes, Endocrinology & Metabolism

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John F Brazil Centre for Diabetes, Endocrinology & Metabolism

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Julie O Okiro Department of Nephrology, Endocrinology & Metabolism

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Louise Giblin Department of Nephrology, Endocrinology & Metabolism

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Yvonne Smyth Department of Cardiology, Galway, Ireland

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Paula M O’Shea Department of Clinical Biochemistry, Galway University Hospitals, Saolta University Healthcare Group, Galway, Ireland

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Francis M Finucane Centre for Diabetes, Endocrinology & Metabolism

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Summary

A 32-year-old Caucasian male presented to the emergency department with a one-day history of acute severe bilateral lower limb weakness, three days after competing in a bodybuilding competition. He consumed large quantities of carbohydrate-rich foods following the competition. His past medical history was significant for anxiety, and family history was non-contributory. Examination was normal except for reduced power and hyporeflexia in both legs, despite his muscular physique. He was noted to have severe hypokalaemia (K+= 1.9 mmol/L). His thyroid function tests were consistent with thyrotoxicosis. He reported taking thyroxine and several other agents to facilitate muscle mass generation before the bodybuilding competition. His presentation was reminiscent of thyrotoxic periodic paralysis, albeit uncommon with Caucasian ethnicity. He also had transient hyperglycaemia at presentation with concomitant hyperinsulinaemia, which could be attributed to the carbohydrate load and may have exacerbated his hypokalaemia through a transcellular shift. Urine toxicology screen subsequently ruled out the use of diuretics but confirmed the presence of a long-acting beta agonist (clenbuterol) which, along with other substances, may have aggravated the hypokalaemia further. After 12 h of i.v. replacement, the potassium level normalised and leg weakness resolved. The patient agreed to stop taking thyroxine and beta agonists and was well during the clinic visit at one month follow-up. This case highlights the potential for thyrotoxicosis factitia to exacerbate hypokalaemia and muscle weakness from other causes in bodybuilders presenting with acute severe weakness, irrespective of ethnicity.

Learning points

  • In patients presenting with muscle weakness and hypokalaemia, early consideration of thyrotoxicosis is essential, even in the absence of a past history of thyroid disease or specific symptoms of thyrotoxicosis, in order to allow prompt initiation of appropriate treatment and to prevent recurrence.

  • Bodybuilders may constitute a uniquely ‘at-risk’ group for thyrotoxic periodic paralysis secondary to thyrotoxicosis factitia, especially where there is concomitant use of beta-adrenergic agonists, even in the absence of diuretic use.

  • Although rare and usually described in patients of Asian or Polynesian ethnicity, this case highlights that thyrotoxic periodic paralysis secondary to thyrotoxicosis factitia can also occur in patients with Caucasian ethnicity.

  • We speculate that consuming large quantities of carbohydrates may induce hyperinsulinaemia, which could theoretically contribute to worse hypokalaemia, though mechanistic studies would be needed to explore this further.

Open access
Lachlan M Angus Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia

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Jun Yang Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
Department of Medicine, Monash University, Victoria, Australia

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Ada S Cheung Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia

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Summary

Primary aldosteronism is one of the most common (affecting up to 10%) yet treatable causes of hypertension in our community, notable due to an associated elevated risk of atrial fibrillation, stroke and myocardial infarction compared to essential hypertension. Guidelines have focussed on improving case detection due to significant underdiagnosis in the community. While our case experienced significant delay in diagnosis, we highlight a state of protracted, persistent post-operative hypoaldosteronism which manifested with severe hyponatraemia and hyperkalaemia, necessitating long-term mineralocorticoid replacement. We discuss whether pre-operative mineralocorticoid receptor antagonists to stimulate aldosterone secretion from the contralateral gland may have prevented this complication.

Learning points

  • Hypoaldosteronism is an uncommon complication of adrenalectomy for primary aldosteronism, typically manifesting with hyperkalaemia and hyponatraemia. While most cases are transient, it may be persistent, necessitating ongoing mineralocorticoid replacement.

  • Routine electrolyte monitoring is recommended post-adrenalectomy.

  • Risk factors for hypoaldosteronism include age >50 years, duration of hypertension >10 years, pre-existing renal impairment and adrenal adenoma size >2 cm.

  • Mineralocorticoid receptor antagonists may assist in the management of hypokalaemia and hypertension pre-operatively. However, it is unclear whether this reduces the risk of post-operative hypoaldosteronism.

Open access
Darija Tudor Department of Pediatrics, University Hospital of Split, Split, Croatia

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Iva Kolombo Department of Pediatrics, Šibenik General Hospital, Šibenik, Croatia

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Ana Tot Department of Pediatrics, University Hospital of Split, Split, Croatia

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Drasko Cikojevic Department of Otorhinolaryngology, University Hospital of Split, Split, Croatia

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Marko Simunovic Department of Pediatrics, University Hospital of Split, Split, Croatia
Department of Pediatrics, University of Split School of Medicine, Split, Croatia

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Veselin Skrabic Department of Pediatrics, University Hospital of Split, Split, Croatia
Department of Pediatrics, University of Split School of Medicine, Split, Croatia

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Summary

This is a case report of a child with chronic hyponatremia due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a paraneoplastic manifestation of olfactory neuroblastoma (OFN). We hereby report a clinical presentation as well as a pragmatic approach to one of the most common electrolytic disorders in the pediatric population and have emphasized the necessity of involving the sinonasal area in the diagnostic procedure while evaluating possible causes of SIADH. This report indicates that the chronicity of the process along with the gradual onset of hyponatremia occurrence is responsible for the lack of neurological symptoms at the moment of disease presentation.

Learning points

  • Hyponatremia is not infrequently attributed to SIADH.

  • Paraneoplastic syndromes are uncommon but they should be considered in the differential diagnosis of pediatric SIADH.

  • Chronic insidious hyponatremia may not be associated with clear neurological symptoms despite its severity.

Open access
Ryizan Nizar Department of Diabetes and Endocrinology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK

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Nathan W P Cantley Department of Clinical Biochemistry, Southmead Hospital, North Bristol NHS Trust, Bristol, UK

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Jonathan C Y Tang Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK

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Summary

A 33-year-old gentleman of Egyptian heritage presented with a 21 years history of unexplained and recurrent hypercalcaemia, nephrolithiasis, nephrocalcinosis, and myocarditis. A similar history was also found in two first-degree relatives. Further investigation into the vitamin D metabolism pathway identified the biochemical hallmarks of infantile hypercalcaemia type 1 (IIH). A homozygous, likely pathogenic, variant in CYP24A1 was found on molecular genetic analysis confirming the diagnosis. Management now focuses on removing excess vitamin D from the metabolic pathway as well as reducing calcium intake to achieve serum-adjusted calcium to the middle of the reference range. If undiagnosed, IIH can cause serious renal complications and metabolic bone disease.

Learning points

  • Infantile hypercalcaemia type 1 (IIH) is an autosomal recessive disorder characterised by homozygous mutations in the CYP24A1 gene that encodes the 24-hydroxylase enzyme used to convert active vitamin D metabolites such as 1,25-(OH)2-vitamin D into their inactive form.

  • IIH should be questioned in individuals presenting with a history of unexplained hypercalcaemia, especially if presenting from childhood and/or where there is an accompanying family history of the same in first and/or second degree relatives, causing complications such as nephrocalcinosis, pericarditis, and calcium-based nephrolithiasis.

  • Associated biochemistry of IIH is persistent mild to moderate hypercalcaemia, normal or raised 25-(OH)-vitamin D and elevated 1,25-(OH)2-vitamin D. An elevated ratio of 25-(OH)-vitamin D to 24,25-(OH)2-vitamin D can be a useful marker of defects in the 24-hydroxylase enzyme, whose measurement can be facilitated through the supra-regional assay service.

  • Management should focus on limiting the amount of vitamin D introduced into the body either via sunlight exposure or supplementation in addition to calcium dietary restriction to try and maintain appropriate calcium homeostasis

Open access
Rishi Raj Pikeville Medical Center, Pikeville, Kentucky, USA

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Samaneh Hasanzadeh Bushehr University of Medical Sciences, Bushehr, Iran

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Mitra Dashtizadeh Bushehr University of Medical Sciences, Bushehr, Iran

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Mohammadreza Kalantarhormozi Bushehr University of Medical Sciences, Bushehr, Iran

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Katayoun Vahdat Bushehr University of Medical Sciences, Bushehr, Iran

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Mohammad Hossein Dabbaghmanesh Shiraz University of Medical Sciences, Shiraz, Iran

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Iraj Nabipour Bushehr University of Medical Sciences, Bushehr, Iran

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Mohammdreza Ravanbod Shiraz University of Medical Sciences, Shiraz, Iran

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Majid Assadi Bushehr University of Medical Sciences, Bushehr, Iran

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Basir Hashemi Shiraz University of Medical Sciences, Shiraz, Iran

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Kamyar Asadipooya University of Kentucky, Lexington, Kentucky, USA

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Summary

Oncogenic osteomalacia secondary to glomus tumor is extremely rare. Localization of causative tumors is critical as surgical resection can lead to a complete biochemical and clinical cure. We present a case of oncogenic osteomalacia treated with resection of glomus tumor. A 39-year-old woman with a history of chronic sinusitis presented with chronic body ache and muscle weakness. Biochemical evaluation revealed elevated alkaline phosphatase hypophosphatemia, increased urinary phosphate excretion, low calcitriol, and FGF23 was unsuppressed suggestive of oncogenic osteomalacia. Diagnostic studies showed increase uptake in multiple bones. Localization with MRI of paranasal sinuses revealed a sinonasal mass with concurrent uptake in the same area on the octreotide scan. Surgical resection of the sinonasal mass was consistent with the glomus tumor. The patient improved both clinically and biochemically postoperatively. Along with the case of oncogenic osteomalacia secondary to a glomus tumor, we have also discussed in detail the recent development in the diagnosis and management of oncogenic osteomalacia.

Learning points

  • Tumor-induced osteomalacia is a rare cause of osteomalacia caused by the secretion of FGF23 from mesenchymal tumors.

  • Mesenchymal tumors causing TIO are often difficult to localize and treat.

  • Resection of the tumor can result in complete resolution of biochemical and clinical manifestations in a very short span of time.

  • Glomus tumor can lead to tumor induced osteomalacia and should be surgically treated.

Open access
Ayesha Ghayur Department of Medicine, McMaster University, Hamilton, Ontario, Canada

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Qurrat Elahi Department of Family Medicine, Pikeville Medicine Center, Pikeville, Kentucky, USA

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Chinmay Patel Department of Nephrology, Southern Kidney Associates, Shreveport, LA, USA

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