Browse

You are looking at 1 - 10 of 59 items

Jai Madhok Department of Anesthesiology, Perioperative and Pain Medicine

Search for other papers by Jai Madhok in
Google Scholar
PubMed
Close
,
Amy Kloosterboer Department of Anesthesiology, Perioperative and Pain Medicine

Search for other papers by Amy Kloosterboer in
Google Scholar
PubMed
Close
,
Chitra Venkatasubramanian Department of Neurology & Neurological Sciences, Stanford University Medical Center, Stanford, California, USA

Search for other papers by Chitra Venkatasubramanian in
Google Scholar
PubMed
Close
, and
Frederick G Mihm Department of Anesthesiology, Perioperative and Pain Medicine

Search for other papers by Frederick G Mihm in
Google Scholar
PubMed
Close

Summary

We report the case of a 76-year-old male with a remote history of papillary thyroid cancer who developed severe paroxysmal headaches in the setting of episodic hypertension. Brain imaging revealed multiple lesions, initially of inconclusive etiology, but suspicious for metastatic foci. A search for the primary malignancy revealed an adrenal tumor, and biochemical testing confirmed the diagnosis of a norepinephrine-secreting pheochromocytoma. Serial imaging demonstrated multiple cerebral infarctions of varying ages, evidence of vessel narrowing and irregularities in the anterior and posterior circulations, and hypoperfusion in watershed areas. An exhaustive work-up for other etiologies of stroke including thromboembolic causes or vasculitis was unremarkable. There was resolution of symptoms, absence of new infarctions, and improvement in vessel caliber after adequate alpha-adrenergic receptor blockade for the management of pheochromocytoma. This clinicoradiologic constellation of findings suggested that the etiology of the multiple infarctions was reversible cerebral vasoconstriction syndrome (RCVS). Pheochromocytoma remains a poorly recognized cause of RCVS. Unexplained multifocal cerebral infarctions in the setting of severe hypertension should prompt the consideration of a vasoactive tumor as the driver of cerebrovascular dysfunction. A missed or delayed diagnosis has the potential for serious neurologic morbidity for an otherwise treatable condition.

Learning points:

  • The constellation of multifocal watershed cerebral infarctions of uncertain etiology in a patient with malignant hypertension should trigger the consideration of undiagnosed catecholamine secreting tumors, such as pheochromocytomas and paragangliomas.

  • Reversible cerebral vasoconstriction syndrome is a serious but reversible cerebrovascular manifestation of pheochromocytomas that may lead to strokes (ischemic and hemorrhagic), seizures, and cerebral edema.

  • Alpha-adrenergic receptor blockade can reverse cerebral vasoconstriction and prevent further cerebral ischemia and infarctions.

  • Early diagnosis of catecholamine secreting tumors has the potential for reducing neurologic morbidity and mortality in patients presenting with cerebrovascular complications.

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
Dured Dardari Diabetology Department, Centre Hopitalier Sud Francilien, Corbeil-Essonnes, France
Sorbonne Université, Paris, France

Search for other papers by Dured Dardari in
Google Scholar
PubMed
Close
,
Alfred Penfornis Diabetology Department, Centre Hopitalier Sud Francilien, Corbeil-Essonnes, France
Paris-Sud Medical School, Paris-Saclay University, Orsay, France

Search for other papers by Alfred Penfornis in
Google Scholar
PubMed
Close
, and
Agnes Hartemann Diabetology Department, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
Sorbonne Université, Paris, France

Search for other papers by Agnes Hartemann in
Google Scholar
PubMed
Close

Summary

We report the onset of acute Charcot neuroarthropathy during pregnancy in two patients with type 1 diabetes using retrospective review of case notes. We describe for the first time the onset of acute Charcot neuroarthropathy during pregnancy in two patients with type 1 diabetes. Pregnancy may promote the onset and worsening of a number of diabetic complications. A link between pregnancy and the onset of acute Charcot neuroarthropathy is demonstrated for the first time in this report.

Learning points:

  • Patients with already diagnosed sensitive neuropathy can develop an active phase of Charcot neuroarthropathy during pregnancy.

  • The rapid correction of hyperglycaemia may induce an active phase of Charcot neuroarthropathy during pregnancy.

Open access
Mariana Barbosa Department of Endocrinology, Hospital de Braga, Braga, Portugal

Search for other papers by Mariana Barbosa in
Google Scholar
PubMed
Close
,
Sílvia Paredes Department of Endocrinology, Hospital de Braga, Braga, Portugal

Search for other papers by Sílvia Paredes in
Google Scholar
PubMed
Close
,
Maria João Machado Department of Neurosurgery, Hospital de Braga, Braga, Portugal

Search for other papers by Maria João Machado in
Google Scholar
PubMed
Close
,
Rui Almeida Department of Neurosurgery, Hospital de Braga, Braga, Portugal
Pituitary Consult, Hospital de Braga, Braga, Portugal

Search for other papers by Rui Almeida in
Google Scholar
PubMed
Close
, and
Olinda Marques Department of Endocrinology, Hospital de Braga, Braga, Portugal
Pituitary Consult, Hospital de Braga, Braga, Portugal

Search for other papers by Olinda Marques in
Google Scholar
PubMed
Close

Summary

Gonadotropin-releasing hormone (GnRH) agonists, currently used in the treatment of advanced prostate cancer, have been described as a rare cause of pituitary apoplexy, a potentially life-threatening clinical condition. We report the case of a 69-year-old man with a known pituitary macroadenoma who was diagnosed with prostate cancer and started treatment with GnRH agonist leuprorelin (other hormones were not tested before treatment). Few minutes after drug administration, the patient presented with acute-onset severe headache, followed by left eye ptosis, diplopia and vomiting. Pituitary MRI revealed tumor enlargement and T1-hyperintense signal, compatible with recent bleeding sellar content. Laboratory endocrine workup was significant for low total testosterone. The patient was managed conservatively with high-dose steroids, and symptoms significantly improved. This case describes a rare phenomenon, pituitary apoplexy induced by GnRH agonist. We review the literature regarding this condition: the pathophysiological mechanism involved is not clearly established and several hypotheses have been proposed. Although uncommon, healthcare professionals and patients should be aware of this complication and recognize the signs, preventing a delay in diagnosis and treatment.

Learning points:

  • Pituitary apoplexy (PA) is a potentially life-threatening complication that can be caused by gonadotropin-releasing hormone agonist (GnRHa) administration for the treatment of advanced prostate cancer.

  • This complication is rare but should be taken into account when using GnRHa, particularly in the setting of a known pre-existing pituitary adenoma.

  • PA presents with classic clinical signs and symptoms that should be promptly recognized.

  • Patients should be instructed to seek medical care if suspicious symptoms occur.

  • Healthcare professionals should be aware of this complication, enabling its early recognition, adequate treatment and favorable outcome.

Open access
Carmina Teresa Fuss Division of Endocrinology and Diabetology, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany

Search for other papers by Carmina Teresa Fuss in
Google Scholar
PubMed
Close
,
Stephanie Burger-Stritt Division of Endocrinology and Diabetology, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany

Search for other papers by Stephanie Burger-Stritt in
Google Scholar
PubMed
Close
,
Silke Horn Division of Endocrinology and Diabetology, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany

Search for other papers by Silke Horn in
Google Scholar
PubMed
Close
,
Ann-Cathrin Koschker Division of Endocrinology and Diabetology, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany

Search for other papers by Ann-Cathrin Koschker in
Google Scholar
PubMed
Close
,
Kathrin Frey Division of Endocrinology and Diabetology, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany

Search for other papers by Kathrin Frey in
Google Scholar
PubMed
Close
,
Almuth Meyer Division of Endocrinology and Diabetology, Department of Internal Medicine, Helios Klinikum Erfurt, Erfurt, Germany

Search for other papers by Almuth Meyer in
Google Scholar
PubMed
Close
, and
Stefanie Hahner Division of Endocrinology and Diabetology, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany

Search for other papers by Stefanie Hahner in
Google Scholar
PubMed
Close

Summary

Standard treatment of hypoparathyroidism consists of supplementation of calcium and vitamin D analogues, which does not fully restore calcium homeostasis. In some patients, hypoparathyroidism is refractory to standard treatment with persistent low serum calcium levels and associated clinical complications. Here, we report on three patients (58-year-old male, 52-year-old female, and 48-year-old female) suffering from severe treatment-refractory postsurgical hypoparathyroidism. Two patients had persistent hypocalcemia despite oral treatment with up to 4 µg calcitriol and up to 4 g calcium per day necessitating additional i.v. administration of calcium gluconate 2–3 times per week, whereas the third patient presented with high frequencies of hypocalcemic and treatment-associated hypercalcemic episodes. S.c. administration of rhPTH (1–34) twice daily (40 µg/day) or rhPTH (1–84) (100 µg/day) only temporarily increased serum calcium levels but did not lead to long-term stabilization. In all three cases, treatment with rhPTH (1–34) as continuous s.c. infusion via insulin pump was initiated. Normalization of serum calcium and serum phosphate levels was observed within 1 week at daily 1–34 parathyroid hormone doses of 15 µg to 29.4 µg. Oral vitamin D and calcium treatment could be stopped or reduced and regular i.v. calcium administration was no more necessary. Ongoing efficacy of this treatment has been documented for up to 7 years so far. Therefore, we conclude that hypoparathyroidism that is refractory to both conventional treatment and s.c. parathyroid hormone (single or twice daily) may be successfully treated with continuous parathyroid hormone administration via insulin pump.

Learning points:

  • Standard treatment of hypoparathyroidism still consists of administration of calcium and active vitamin D.

  • Very few patients with hypoparathyroidism also do not respond sufficiently to standard treatment or administration of s.c. parathyroid hormone once or twice daily.

  • In those cases, continuous s.c. administration of parathyroid hormone via insulin pump may represent a successful treatment alternative.

Open access