Diagnosis and Treatment > Signs and Symptoms > Depression
You are looking at 1 - 10 of 13 items
Research Institute in Biomedical and Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
Search for other papers by Mauro Boronat in
Google Scholar
PubMed
Summary
Isolated, adult-onset central hypothyroidism is very rare, and its diagnosis can be challenging. A 42-year-old patient was referred for evaluation of a 2.8 cm thyroid nodule. She referred symptoms that could be attributed to hypothyroidism and thyroid tests showed low TSH and normal-low levels of free T4. However, evaluation of the remaining pituitary hormones and pituitary MRI were normal, yet a radionuclide scanning revealed that the thyroid nodule was ‘hot’ and the tracer uptake in the remaining thyroid tissue was suppressed. Interpretation of these studies led to a misdiagnosis of subclinical hyperthyroidism and the patient was treated with radioiodine. Soon after treatment, she developed a frank hypothyroidism without appropriate elevation of TSH and the diagnosis of central hypothyroidism was made a posteriori. Long term follow-up revealed a progressive pituitary failure, with subsequent deficiency of ACTH and GH. This case should alert to the possibility of overlooking central hypothyroidism in patients simultaneously bearing primary thyroid diseases able to cause subclinical hyperthyroidism.
Learning points:
-
Although rarely, acquired central hypothyroidism can occur in the absence of other pituitary hormone deficiencies.
-
In these cases, diagnosis is challenging, as symptoms are unspecific and usually mild, and laboratory findings are variable, including low, normal or even slightly elevated TSH levels, along with low or low-normal concentrations of free T4.
-
In cases with low TSH levels, the coexistence of otherwise common disorders able to cause primary thyroid hyperfunction, such as autonomous nodular disease, may lead to a misdiagnosis of subclinical hyperthyroidism.
Search for other papers by Bidhya Timilsina in
Google Scholar
PubMed
Search for other papers by Niranjan Tachamo in
Google Scholar
PubMed
Search for other papers by Prem Raj Parajuli in
Google Scholar
PubMed
Search for other papers by Ilan Gabriely in
Google Scholar
PubMed
Summary
A 74-year-old woman presented with progressive lethargy, confusion, poor appetite and abdominal pain. She was found to have non-PTH-mediated severe hypercalcemia with renal failure and metabolic alkalosis. Extensive workup for hypercalcemia to rule out alternate etiology was unrevealing. Upon further questioning, she was taking excess calcium carbonate (Tums) for her worsening heartburn. She was diagnosed with milk-alkali syndrome (MAS). Her hypercalcemia and alkalosis recovered completely with aggressive hydration along with improvement in her renal function. High index of suspicion should be maintained and history of drug and supplements, especially calcium ingestion, should be routinely asked in patients presenting with hypercalcemia to timely diagnose MAS and prevent unnecessary tests and treatments.
Learning points:
-
Suspect milk-alkali syndrome in patients with hypercalcemia, metabolic alkalosis and renal failure, especially in context of ingestion of excess calcium-containing supplements.
-
Careful history of over-the-counter medications, supplements and diet is crucial to diagnose milk-alkali syndrome.
-
Milk-alkali syndrome may cause severe hypercalcemia in up to 25–30% of cases.
Search for other papers by Benedetta Zampetti in
Google Scholar
PubMed
Search for other papers by Roberto Attanasio in
Google Scholar
PubMed
Search for other papers by Renato Cozzi in
Google Scholar
PubMed
Summary
A 69-year-old male was admitted for severe hyponatremia disclosed after an accidental fall. He was anticoagulated from 2 months after the implantation of a biologic aortic valve prosthesis. The work-up disclosed adrenal failure and MRI showed bilateral adrenal hemorrhage. Clinical picture and lab parameters normalized quickly after the appropriate replacement treatment. Anticoagulation excess should be added to the list of drugs potentially causing hyponatremia.
Learning points:
-
Hyponatremia requires a complete and timely workup in order to start an appropriate treatment for the improvement of clinical conditions.
-
History is crucial: a detailed list of drugs potentially causing hyponatremia should be collected. Anticoagulants should be added to the list, mostly in the event of excessive anticoagulation.
-
Intra-adrenal hemorrhage is a rare cause of hyponatremia and adrenal failure.
-
The ACTH test is still the gold standard for the diagnosis of hypoadrenalism.
Search for other papers by Catherine Alguire in
Google Scholar
PubMed
Search for other papers by Jessica Chbat in
Google Scholar
PubMed
Search for other papers by Isabelle Forest in
Google Scholar
PubMed
Search for other papers by Ariane Godbout in
Google Scholar
PubMed
Search for other papers by Isabelle Bourdeau in
Google Scholar
PubMed
Summary
Pheochromocytoma is a rare tumor of the adrenal gland. It often presents with the classic triad of headache, palpitations and generalized sweating. Although not described as a typical symptom of pheochromocytoma, anxiety is the fourth most common symptom reported by patients suffering of pheochromocytoma. We report the case of a 64 year old man who had severe anxiety and panic disorder as presenting symptoms of pheochromocytoma. After 13 years of psychiatric follow-up, the patient was diagnosed with malignant pheochromocytoma. After surgical resection of his pheochromocytoma and his hepatic metastases, the major panic attacks completely disappeared, the anxiety symptoms improved significantly and the psychiatric medications were stopped except for a very low maintenance dose of venlafaxine. We found in our cohort of 160 patients with pheochromocytoma 2 others cases of apparently benign tumors with severe anxiety that resolved after pheochromocytoma resection. These cases highlight that pheochromocytoma should be included in the differential diagnosis of refractory anxiety disorder.
Learning points:
-
Anxiety and panic disorder may be the main presenting symptoms of pheochromocytoma.
-
The diagnosis of pheochromocytoma should be excluded in cases of long-term panic disorder refractory to medications since the anxiety may be secondary to a catecholamine-secreting tumor.
-
Surgical treatment of pheochromocytoma leads to significant improvement of anxiety disorders.
Search for other papers by Jennifer Hague in
Google Scholar
PubMed
Department of Medical Genetics, University of Cambridge and NIHR Cambridge Biomedical Research Centre and Cancer Research UK Cambridge Centre, Cambridge, UK
Search for other papers by Ruth Casey in
Google Scholar
PubMed
Search for other papers by Jonathan Bruty in
Google Scholar
PubMed
Search for other papers by Tom Legerton in
Google Scholar
PubMed
Search for other papers by Stephen Abbs in
Google Scholar
PubMed
Search for other papers by Susan Oddy in
Google Scholar
PubMed
Search for other papers by Andrew S Powlson in
Google Scholar
PubMed
Search for other papers by Mohamed Majeed in
Google Scholar
PubMed
Search for other papers by Mark Gurnell in
Google Scholar
PubMed
Search for other papers by Soo-Mi Park in
Google Scholar
PubMed
Search for other papers by Helen Simpson in
Google Scholar
PubMed
Summary
Activating mutations in AVPR2 are associated with nephrogenic syndrome of inappropriate antidiuresis (NSIAD). NSIAD causes hyponatremia, decreased serum osmolality and clinical symptoms, which may present from birth or in infancy and include hypotonia, irritability, vomiting and/or seizures. Symptoms in later life are often less specific and include malaise, dizziness, confusion, tiredness and headache. NSIAD is a rare X-linked condition, which is associated with a variable phenotype in males, of whom some present in infancy but others do not become symptomatic until adulthood, or occasionally, never. Female carriers may present with episodes of hyponatremia, usually found incidentally. Literature in this field is limited; namely, two clinical reports describing a female proband, both diagnosed in infancy. We describe, for the first time, the case of an adult female proband with NSIAD, who had longstanding associated symptoms of tiredness, headache, temporary memory loss and mood changes as well as hyponatremia and decreased serum osmolality. A water load test demonstrated an inability to dilute urine and gene sequencing confirmed a recurrent activating mutation in AVPR2. The variant was inherited from the proband’s mother who had had longstanding episodes of transient asymptomatic hyponatremia. This is the third report of a female proband with NSIAD and is the first female reported who sought medical treatment for chronic symptoms from adulthood. This case acts as a reminder of the importance of considering NSIAD as a diagnosis in females of all ages with unexplained hyponatremia.
Learning points:
-
Activating mutations in the AVPR2 gene are associated with the rare X-linked condition nephrogenic syndrome of inappropriate antidiuresis.
-
NSIAD is associated with hyponatremia, decreased serum osmolality and inappropriately increased urinary osmolality. Early clinical symptoms in infancy include hypotonia, irritability, vomiting and/or seizures. Symptoms in later life include malaise, dizziness, confusion, tiredness and headache.
-
NSIAD should be considered in female, as well as male, patients who present with unexplained hyponatremia and decreased serum osmolality. Family history may reveal relevant symptoms or biochemical features in other family members. However, family history may not always be informative due to the variable nature of the condition or if the proband has a de novo pathogenic variant.
-
A water load test with measurement of AVP may be informative in distinguishing NSIAD from SIADH. Measurement of co-peptin levels may be considered, in substitution for direct measurement of AVP.
-
Patients with NSIAD should be counseled about appropriate daily fluid volume intake. Potential episodes of fluid overload should be avoided.
Search for other papers by Naoya Toriu in
Google Scholar
PubMed
Search for other papers by Masayuki Yamanouchi in
Google Scholar
PubMed
Search for other papers by Rikako Hiramatsu in
Google Scholar
PubMed
Search for other papers by Noriko Hayami in
Google Scholar
PubMed
Search for other papers by Junichi Hoshino in
Google Scholar
PubMed
Search for other papers by Akinari Sekine in
Google Scholar
PubMed
Search for other papers by Masahiro Kawada in
Google Scholar
PubMed
Search for other papers by Eiko Hasegawa in
Google Scholar
PubMed
Search for other papers by Tatsuya Suwabe in
Google Scholar
PubMed
Search for other papers by Keiichi Sumida in
Google Scholar
PubMed
Search for other papers by Toshiharu Ueno in
Google Scholar
PubMed
Search for other papers by Naoki Sawa in
Google Scholar
PubMed
Department of Pathology, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
Search for other papers by Kenichi Ohashi in
Google Scholar
PubMed
Search for other papers by Takeshi Fujii in
Google Scholar
PubMed
Okinaka Memorial Institute for Medical Research, Tokyo, Japan
Search for other papers by Kenmei Takaichi in
Google Scholar
PubMed
Search for other papers by Motoko Yanagita in
Google Scholar
PubMed
Search for other papers by Tetsuro Kobayasi in
Google Scholar
PubMed
Okinaka Memorial Institute for Medical Research, Tokyo, Japan
Search for other papers by Yoshifumi Ubara in
Google Scholar
PubMed
Summary
We report the case of a 67-year-old Japanese woman with type 1 diabetes mellitus. At 47 years of age, her hemoglobin A1c (HbA1c) was 10.0%, and she had overt nephropathy. The first renal biopsy yielded a diagnosis of diabetic nephropathy. Intensive glycemic control was initiated and her HbA1c improved to 6.0%. Renal dysfunction showed no progression for 15 years. At 62 years of age, a second renal biopsy was performed. Glomerular lesions did not show progression but tubulointerstitial fibrosis and vascular lesions showed progression compared with the first biopsy. Intensive glycemic control can prevent the progression of glomerular lesions, but might not be effective for interstitial and vascular lesions.
Learning points:
-
Intensive control of blood glucose can prevent the progression of glomerular lesions.
-
Intensive control of blood glucose may not be able to prevent progression of interstitial and vascular lesions.
-
CSII reduces HbA1c without increasing the risk of hypoglycemia.
Search for other papers by Tessa Glyn in
Google Scholar
PubMed
Search for other papers by Beverley Harris in
Google Scholar
PubMed
Search for other papers by Kate Allen in
Google Scholar
PubMed
Summary
We present the case of a 57-year-old lady who had a delayed diagnosis of central hypothyroidism on a background of Grave’s thyrotoxicosis and a partial thyroidectomy. During the twenty years following her partial thyroidectomy, the patient developed a constellation of symptoms and new diagnoses, which were investigated by numerous specialists from various fields, namely rheumatology, renal and respiratory. She developed significantly impaired renal function and raised creatine kinase (CK). She was also referred to a tertiary neurology service for investigation of myositis, which resulted in inconclusive muscle biopsies. Recurrently normal TSH results reassured clinicians that this did not relate to previous thyroid dysfunction. In 2015, she developed increased shortness of breath and was found to have a significant pericardial effusion. The clinical biochemist reviewed this lady’s blood results and elected to add on a free T4 (fT4) and free T3 (fT3), which were found to be <0.4 pmol/L (normal range (NR): 12–22 pmol/L) and 0.3 pmol/L (NR: 3.1–6.8 pmol/L), respectively. She was referred urgently to the endocrine services and commenced on Levothyroxine replacement for profound central hypothyroidism. Her other pituitary hormones and MRI were normal. In the following year, her eGFR and CK normalised, and her myositis symptoms, breathlessness and pericardial effusion resolved. One year following initiation of Levothyroxine, her fT4 and fT3 were in the normal range for the first time. This case highlights the pitfalls of relying purely on TSH for excluding hypothyroidism and the devastating effect the delay in diagnosis had upon this patient.
Learning points:
-
Isolated central hypothyroidism is very rare, but should be considered irrespective of previous thyroid disorders.
-
If clinicians have a strong suspicion that a patient may have hypothyroidism despite normal TSH, they should ensure they measure fT3 and fT4.
-
Laboratories that do not perform fT3 and fT4 routinely should review advice sent to requesting clinicians to include a statement explaining that a normal TSH excludes primary but not secondary hypothyroidism.
-
Thyroid function tests should be performed routinely in patients presenting with renal impairment or a raised CK.
Search for other papers by Kingsley Okolie in
Google Scholar
PubMed
Australian National University Medical School, Canberra, ACT, Australia
Search for other papers by Sumathy Perampalam in
Google Scholar
PubMed
Search for other papers by Anthony Barker in
Google Scholar
PubMed
Australian National University Medical School, Canberra, ACT, Australia
Search for other papers by Christopher J Nolan in
Google Scholar
PubMed
Klinefelter syndrome (KS) is a chromosomal disorder affecting males, with the typical karyotype of 47,XXY due to a supernumerary X chromosome, which causes progressive testicular failure resulting in androgen deficiency and infertility. Despite it being the most common sex chromosomal disorder, its diagnosis is easily missed. In addition to its classical clinical features of tall stature, gynaecomastia, small testes, and symptoms and signs of hypogonadism including infertility, KS is also often associated with neurocognitive, behavioural and psychiatric disorders.
We present a 44-year-old man with KS who, despite having erectile dysfunction, paradoxically had increased libido. He used sildenafil to overcome his erectile dysfunction. Hypersexuality was manifested by very frequent masturbation, multiple sexual partners most of whom were casual, and a sexual offence conviction at the age of 17 years.
Discussion focuses on the frequent failure of clinicians to diagnose KS, the neurocognitive, behavioural and psychiatric aspects of KS, this unusual presentation of hypersexuality in a man with KS, and the challenges of medical management of hypogonadism in a man with a history of a sexual offence.
Learning points:
-
Klinefelter syndrome (KS) is common in men (about 1 in 600 males), but the diagnosis is very often missed.
-
In addition to classic features of hypogonadism, patients with KS can often have associated neurocognitive, behavioural and/or psychiatric disorders.
-
More awareness of the association between KS and difficulties related to verbal skills in boys could improve rates of early diagnosis and prevent longer-term psychosocial disability.
-
Hypersexuality in the context of hypogonadism raises the possibility of sex steroid independent mechanistic pathways for libido.
-
Testosterone replacement therapy in KS with hypersexuality should be undertaken with caution using a multidisciplinary team approach.
Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
Search for other papers by B Cangiano in
Google Scholar
PubMed
Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
Search for other papers by C Cacciatore in
Google Scholar
PubMed
Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
Search for other papers by L Persani in
Google Scholar
PubMed
Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
Search for other papers by M Bonomi in
Google Scholar
PubMed
We describe a case of severe erythrocytosis caused by testosterone replacement therapy in a 66-year-old man affected with hypogonadotropic hypogonadism (HH) determining osteoporosis, resolved by switching to restoration therapy with clomiphene citrate. The patient complained fatigue, loss of libido and defective erections and a spontaneous vertebral fracture despite bisphosphonate therapy and vitamin D supplementation. The examinations proved isolated HH and he was therefore treated with testosterone gel with regression of specific manifestations but elevated hemoglobin and hematocrit values. Therefore, it was decided to switch to a restoration therapy with clomiphene citrate 25 mg/die, which resulted in the resolution of symptoms without evident side effects. In a couple of months, the patient showed normalization of testosterone levels and increment of testicular volume. Since secondary hypogonadism is the consequence of an insufficient stimulation of the gonads by hypothalamic–pituitary axis, therapeutic approaches aimed to restore endogenous testosterone production should be considered in alternative to testosterone replacement, particularly if side effects intervene. Among these strategies, clomiphene citrate seems to have a high efficacy and safety profile also in the elderly with isolated HH and no evident pituitary lesion.
Learning points:
-
Hypogonadism should always be assessed in patients with severe loss in BMD and undergo appropriate medical treatment.
-
In hypogonadotropic hypogonadism, more approaches are available other than testosterone replacement therapy alone.
-
In patients with severe late-onset central hypogonadism presenting with erythrocytosis even at low doses of replacement therapy, restoration therapy with clomiphene could prove to be an effective solution, particularly in patients with a reversible disruption of GNRH/gonadotropin functions.
-
Clomiphene citrate increases gonadotropin levels and testicular volume and should therefore be considered in hypogonadal men who wish to remain fertile.
Search for other papers by Ilse C A Bakker in
Google Scholar
PubMed
Search for other papers by Chris D Schubart in
Google Scholar
PubMed
Search for other papers by Pierre M J Zelissen in
Google Scholar
PubMed
Summary
In this report, we describe a female patient with both prolactinoma and psychotic disorder who was successfully treated with aripiprazole, a partial dopamine 2 receptor agonist. During the follow-up of more than 10 years, her psychotic symptoms improved considerably, prolactin levels normalised and the size of the prolactinoma decreased. This observation may be of clinical relevance in similar patients who often are difficult to treat with the regular dopaminergic drugs.
Learning points
-
Prolactinoma coinciding with psychosis can represent a therapeutic challenge.
-
In contrast to many other antipsychotic drugs, aripiprazole is associated with a decrease in prolactin levels.
-
Aripiprazole can be a valuable pharmaceutical tool to treat both prolactinoma and psychosis.
