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Endocrinological Investigation 2024 47 101 – 113 . ( https://doi.org/10.1007/s40618-023-02128-x ) 4 Erickson AW Parker J Khat DZ Li M Gaebe K Li A Mehra V Tan CC Chan J Lu J and Ramendra R . Toronto Notes 2023 : Comprehensive Medical
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-related paraneoplastic thyroid storm . JCEM Case Reports 2024 2 luae019 . ( https://doi.org/10.1210/jcemcr/luae019 ) 2 Chiha M Samarasinghe S & Kabaker AS . Thyroid storm . Journal of Intensive Care Medicine 2015 30 131 – 140 . ( https://doi.org/10
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the detection of macro TSH in different immunoassay systems . European Journal of Endocrinology 2016 174 9 – 15 . ( https://doi.org/10.1530/EJE-15-0883 ) 10 Thyroid stimulating hormone (TSH) [Internet]. Italy; 2016 [16 Jan 2024]. Available at
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. Available at: https://www.mayocliniclabs.com/test-catalog/overview/607788#Clinical-and-Interpretive . Accessed on 28 January 2024. 12 Rathbun KM Nguyen M & Singhal M . Addisonian crisis - statpearls - NCBI bookshelf . N I H 2023 . Available at
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Nova Medical School, Clinical Medicine, New University of Lisbon, Lisbon, Portugal
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) i68 – i85 . ( https://doi.org/10.1093/bja/aes393 ) 5 Gosi SKY Nguyen M & Garla VV . Riedel thyroiditis . In StatPearls . Treasure Island (FL) : StatPearls Publishing LLC , 2024 . 6 Lopes-Pinto M López-Presa D & Lacerda
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11071164 ) 5 Lucchesi D Randazzo E Del Prato S & Bianchi C . An Italian MODY family with proband and son carrying variants in GCK and HFN1A: is it a true case of digenic MODY? Acta Diabetologica 2024 61 131 – 134 . ( https://doi.org/10.1007/s
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Summary
Gonadotroph adenomas are the most common type of nonfunctional pituitary adenomas. However, functioning gonadotroph adenomas causing clinical manifestations are rare. We present the case of a 42-year-old man with an incidental finding of a pituitary gland mass. A pituitary MRI revealed a 3 cm macroadenoma, and laboratory investigations revealed elevated follicle-stimulating hormone (FSH) and total testosterone levels. A diagnosis of functioning FSH-secreting pituitary adenoma was considered, with possible concomitant luteinizing hormone secretion, given the elevated testosterone, prompting further evaluation. Testicular ultrasound showed bilaterally enlarged testicles, and visual field testing revealed a monocular superior temporal defect. Transsphenoidal resection of pituitary adenoma was the treatment of choice. Histopathology assessment confirmed the diagnosis of gonadotroph-secreting adenoma, with positive staining for FSH. Within the 12-week postoperative period, FSH and testosterone levels normalized, and the patient experienced significant improvement in vision, along with the resolution of macroorchidism. While functional gonadotroph adenomas are rare, patients can present with a wide range of symptoms that are often unnoticeable due to their slow development. Careful evaluation can help guide multidisciplinary management to achieve full remission.
Learning points
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Endocrine evaluation is indicated in all cases of pituitary incidentalomas to determine functional status.
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Clinically functioning gonadotroph adenomas, while rare, pose a diagnostic challenge and require careful clinical evaluation.
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Transsphenoidal surgery is the mainstay of treatment of functioning gonadotroph adenomas, with the involvement of a multidisciplinary team to achieve desirable outcomes.
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Summary
Diabetes foot ulcer (DFU) is a common long-term complication of diabetes. Intractable chronic wounds to standard care of diabetic foot raise the question of whether other factors intervene in disease development. We report a case of a 54-year-old male patient who came to Sardjito General Hospital with leg pain and previous history of multiple debridement and amputation for DFU referred from a remote hospital yet no improvement was evident in the surrounding lesion following treatment. Consequently, a histopathological examination was carried out proving the presence of other aetiologic factors, vasculitis and panniculitis existing in the lesion. In this case, we report a rare type of causative factor of foot ulcers among diabetic patients. Vasculitis suspected for polyarteritis nodosa accompanied by panniculitis is considered in this patient. The treatment of choice is corticosteroids or immunosuppressants based on the clinical condition, contrary to usual wound care in DFU. Based on the evidence, clinicians need to consider other causes than only macrovascular complications in a diabetic patient with DFU that is intractable to standard wound care. In this patient, vasculitis may be considered in forming diabetic foot ulcers alongside macrovascular complications.
Learning points
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A thorough examination is essential to rule out other processes in intractable DFU patients.
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Prompt management based on proper diagnosis is crucial to prevent peripheral arterial disease complications.
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Vasculitis and macrovascular complication are inseparable processes forming DFU in this patient.
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Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung, Taiwan
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Division of Endocrinology and Metabolism, Department of Internal Medicine, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan
Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung, Taiwan
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Summary
A 69-year-old woman presented with weight loss, fever, dizziness, exertional dyspnea, and drenching night sweats. Imaging showed a thyroid goiter at the left lobe that measured 5.6 × 3.4 × 3.5 cm in size. On computed tomography, she was found to have large adrenal masses. Core needle biopsy of the left thyroid mass revealed the presence of a mucosa-associated lymphoid tissue extranodal marginal zone B cell lymphoma. Non-Hodgkin’s lymphomas (NHL) typically develop in lymph nodes or other lymphatic tissues. There have been cases where the thyroid has been affected, and the secondary involvement of the adrenal gland is common. In reported cases, 7–59% of patients with NHL exhibited symptoms of thyroid dysfunction. Our patient presented no symptoms of thyroid dysfunction or Hashimoto’s thyroiditis. The patient had bilateral adrenal lymphomas that led to adrenal insufficiency. Immunochemotherapy provided a good response in this case, as seen by the rapid improvement in thyroid and adrenal mass on follow-up PET/CT.
Learning points
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Thyroid lymphoma requires a high index of suspicion for diagnosis in patients with a rapidly growing thyroid tumor, even in the absence of chronic inflammatory thyroid disease.
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Depending on the extent of involvement, adrenal lymphoma may rapidly cause adrenal insufficiency.
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In the setting of acute illness, appropriate levels of plasma cortisol are often unclear, necessitating early initiation of glucocorticoid therapy based on clinical suspicion, especially when features like bilateral adrenal masses and elevated ACTH levels are present.
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Treatment modalities include chemotherapy and radiation therapy for localized lesions, together with hormone replacement for organ dysfunction.
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The origin of the tumor influences the clinical outcome of patients with lymphoma simultaneously involving the thyroid and adrenal glands.
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Summary
Myxoedema coma is a severe form of hypothyroidism with multiple organ dysfunction, characterised by an altered state of consciousness and hypothermia. Intravenous thyroid hormone replacement therapy is the preferred treatment for myxoedema. The mortality rate associated with this disease is high, and early detection and intervention are essential. Supraglottal myxoedema is a rare form of periglottic oedema and can be fatal. A previously healthy 66-year-old man presented with impaired consciousness, hypothermia, and nonpitting oedema. Blood tests revealed the presence of hypothyroidism and respiratory acidosis. He was intubated for type 2 respiratory failure; however, severe laryngeal oedema made the procedure difficult to perform. Oral thyroid hormone therapy was initiated under the diagnosis of myxoedema coma. Tracheostomy was performed because of prolonged type 2 respiratory failure and laryngeal oedema. Three weeks after admission, the patient was weaned off the ventilator. Approximately a week later, laryngeal oedema improved, and the tracheostomy tube was removed. The patient was discharged and remained stable for 3 months. This case report describes a patient with comatose myxoedema and supraglottic oedema who was successfully treated with oral medication alone. This case shows that supraglottic oedema should be considered even in the absence of wheezing or other signs of upper airway obstruction.
Learning points
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Myxoedema coma is a differential diagnosis of respiratory acidosis.
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In myxoedematous coma, the possibility of difficult intubation due to supraglottic oedema should be considered.
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Tracheostomy should be considered for supraglottic myxoedema, which often results in prolonged ventilator use.
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Supraglottic myxoedema can be treated with oral medications.
