ACTA ENDOCRINOLOGICA (BUC)

Objective. A partial or complete deficiency of hormone secretion by pituitary gland (hypopituitarism) is commonly seen after a pituitary apoplexy caused by an infarction of a pituitary adenoma or pituitary hyperplasia (as in Sheehan’s syndrome). Hypopituitarism may also follow surgery, when hypovolemia, anticoagulation, fat/ air/bone marrow microemboli can provoke a pituitary infarction/hemorrhage. Other causes of abrupt hypophyseal hypoperfusion, as hypovolemia during a septic shock, could also contribute. In the last mentioned situation, due to the complex endocrine-immune interrelation, sepsis could be masked and improperly managed. Case report. We report a case of a 72 years-old Caucasian woman, previously healthy, who underwent an orthopedic surgery for a femoral fracture. This event apparently triggered a central-origin hypothyroidism, misinterpreted as “post-surgical psychosis”, which, in turn, masked a symptomatology of a subsequent severe sepsis. The patient was admitted in the infectious diseases department with a severe gut-origin sepsis, needing surgery and long course antibiotics. The pituitary insufficiency was reversed. Conclusion. Pituitary apoplexy is an uncommon but potentially life-threatening disease, and could be precipitated by successive events – in our case an orthopedic surgery and a subsequent severe sepsis. It needs recognizing (has intrinsic severity and could mask other serious conditions), treat and monitor (could progress and/or reverse).

Objective. To describe the correlations between serum 25(OH) vitamin D and anthropometric and metabolic parameters in adult outpatients of both sexes with different BMI coming from an urban community. Subjects and Methods. 264 subjects referred for obesity assessment participated – 109 men and 155 women (20-60 years). Body weight and height, waist circumference (WC), blood pressure were recorded. Body composition was assessed by bioelectrical impedance (BIA) on a Tanita BC 420 MA analyzer (Tanita Inc., Japan). Serum 25(OH)D Total, Insulin, High-sensitivity C-reactive protein, blood glucose, total, HDL-cholesterol and triglycerides were measured. The insulin resistance index was calculated (HOMA-IR). Participants with BMI>25.0 kg/m2 underwent standard 75 g OGTT. Statistical analysis was performed on an IBM SPSS Statistics 19.0 for Windows platform (Chicago, IL). Results. Normal weight was found in 27.2 % of the participants, 24.6 % had overweight, 29.2 % -class I obesity, and 18.9 % – class II or III. Vitamin D was weakly and inversely correlated to different variables in the whole group – such as weight, WC, WC/Height, % body fat and HOMA-IR index (r=-0.231, -0.283, -0.307, -0.339, -0.328 respectively, all p<0.001). Building subgroups based on BMI led to loss of significance. Backward analysis revealed Total-C/LDL-C ratio, and LDL-C/HDL-C ratio as strongest predictors of serum vitamin D (p=0.001; R2=0.204). Conclusion. The association of vitamin D with blood pressure, plasma lipids, glucose and insulin is very weak on an individual level. However, several obesity indices (WC, WC/height ratio, % Body fat from BIA) might be used as a screening tool for subjects at risk for vitamin D deficiency.

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Introduction. Ganglioneuromas are rare, benign tumors that arise from the neural crest tissue and are usually asymptomatic and discovered accidentally. GN have good prognosis with surgical removal and the standard treatment for such lesions is laparoscopic adrenalectomy. Case report. We report the case of a 13 year old patient who presented to our hospital with abdominal pain. The ultrasound and the CT scan confirmed the presence of a well-defined mass situated in the right renal space. Taking into account the size of the tumor, its position and the fact that CT scan showed no local signs of invasion, the decision was taken to perform a laparoscopic removal of the right adrenal mass. After dividing the main adrenal vein and while dissecting the adrenal gland, we noticed an intraoperative bleeding due to the fact that one of the clips used to ligate the vein had slipped. Because we were unable to control the intraoperative bleeding we decided to convert to open surgery. The histopathological result showed that the adrenal lesion was a ganglioneuroma. Conclusion. While the role of minimal invasive adrenalectomy in patients with larger lesion is still controversial, advantages such as reduced hospital stay and postoperative morbidity, lower rate of complications, have resulted in the laparoscopic approach for adrenal pathology becoming the choice procedure in the removal of adrenal lesion.

Context. The metabolic effects of primary hyperparathyroidism (PHPT) causing increased cardiovascular morbidity have begun to gain importance in medical science, and the number of studies investigating glucose metabolism disorders in asymptomatic PHPT patients is rare. Objective. To evaluate the relationship between glucose metabolism disorders and calcium, phosphorus and parathyroid hormone concentrations in asymptomatic PHPT patients. Subjects and Methods. Fifty-five asymptomatic PHPT patients were included into the study. Control group consisted of 55 normocalcemic cases. Oral glucose tolerance test (OGTT) of 75 g was performed with patients and controls. Insulin resistance was calculated by HOMA index. Results. No significant difference was present between groups regarding fasting plasma glucose, basal insulin and HOMA levels. Glucose levels measured at minutes 30, 90 and 120 after OGTT were higher in patients than in controls (p=0.041, p=0.025 and p=0.001, respectively). No individuals in both groups were diagnosed with diabetes mellitus. While impaired glucose tolerance was detected in six patients with asymptomatic PHPT, no impaired glucose tolerance was determined in controls. A positive correlation was found between serum calcium levels, and fasting plasma glucose and OGTT glucose levels were measured at minutes 60, 90 and 120. Mean fasting plasma glucose was significantly higher in patients with serum calcium levels ≥ 10.5 mg/dL than those with serum calcium levels <10.5 mg/dL (p=0.008). No significant correlation was detected between serum phosphorus and parathyroid hormone levels, and glucose levels were determined in OGTT and HOMA index. Conclusion. Increased levels of serum calcium affect glucose metabolism, so leading to glucose intolerance.

Context. Recent studies have demonstrated a strong association between cardiorespiratory fitness (CRF) and mortality, but bias due to differences in the distribution of baseline variables has not been adequately considered. We studied a cohort of veterans with and without Type-2 diabetes using a propensity score matching method. Methods. Males with (n=592) and without (n= 6,167) Type-2 diabetes were studied. Propensity scores were used to balance covariate distributions between groups with and without Type-2 diabetes. All-cause mortality was the end point. Results. Predictors of mortality included hypertension, smoking, Type-2 diabetes, BMI and CRF. For each 1 MET increase in CRF in the unmatched group, the adjusted HR was 0.83 in those with diabetes (95% CI 0.77- 0.89; p<0.0001) compared to 0.87 in those without diabetes (95% CI 0.86-0.89; p<0.0001). Similar trends were observed for the matched dataset: the adjusted HRs were 0.83 (95% CI 0.77-0.90; p<0.0001) and 0.88 (95% CI 0.82-0.94; p<0.0001) for those with and without diabetes, respectively. Conclusions. CRF is a strong predictor of mortality in veterans with and without Type-2 diabetes. Although the trend in the association between CRF and all-cause-mortality was similar for matched and unmatched data, the mortality risks were relatively inflated when using unmatched data.

Background. An adrenal collision tumor is a rare entity. We present a rare combination of giant adrenal ganglioneuroma (GN) and myelolipoma. GN is a rare benign tumor of the adrenal medulla that originates from primitive neural crest cells, while myelolipoma is a benign tumor of the adrenal cortex comprising of mature adipose tissue and blood components. Case Report. We present a case of a 52-year-old male who presented with generalized body swelling with episodes of vomiting and diarrhea. There was no history of abdominal pain or any significant history. Routine laboratory investigations and endocrine workup were within normal limits. MRI was performed for unexplained symptoms, and which revealed a solid homogeneous mass measuring 9x7x4.5cm arising from the adrenal gland. A diagnosis of myxoid adrenocortical neoplasm was suggested, and laparoscopic left adrenalectomy was performed based on imaging findings. The final diagnosis of coexisting giant adrenal GN with myelolipoma was made on histopathological examination, which was further confirmed by immunohistochemistry. Conclusion. Ganglioneuroma coexistence with myelolipoma is a rare finding in the adrenal gland. Therefore, histopathology is imperative in such cases for a definitive diagnosis.

Context. Immunoassays are vulnerable to occasional analytical errors despite their sensitivity and specificity. Adrenocorticotropic hormone (ACTH) is among hormones which are vulnerable to assay interference. Objective. In this case report, we aimed to present a case of ACTH interference in a patient with subclinical hypercortisolism. Case report. We present a case of subclinical hypercortisolism with unexpectedly elevated levels of ACTH in whom interference was shown by different biochemical methods. It is important for the clinician to keep in mind the possibility of interference when clinical and laboratory results are discordant. The communication between the clinician and laboratory staff is important while interpreting results. This case report shows that ACTH interference should be considered in patients with subclinical hypercortisolism who have unexpectedly high levels of adrenocorticotropic hormone.

A 5 year 2 months old boy was admitted in our hospital for failure to thrive, muscle weakness, bowing of legs, walking difficulties. At the age of 14 months he had been investigated for failure to thrive. Clinical, biochemical and radiologic signs were suggestive for rickets. Positive celiac serology and histology of the small bowel were consistent with the diagnosis of celiac disease (CD). Treatment included parenteral vitamin D and gluten free diet. The parents did not accept the diet, but the child received a daily vitamin D supplementation of 1000 IU. At the age of 4 years celiac serology was positive and the second duodenal biopsy was normal. \r\nPhysical examination, biochemical data, and rachitic changes on x-ray were compatible with the diagnosis of rickets. Clinically severe rickets, hypocalcemia, elevated level of PTH demonstrating secondary hyperparathyroidism, and low level of calcitriol determined the diagnosis of vitamin D-dependent rickets type I (VDDR I). Although being on a normal diet, tissue antitransglutaminase antibodies were negative, but HLA genotyping showed DQ2 positive. \r\nThe patient associated the diagnosis of VDDR I and latent CD. The VDDR I was masked by CD, rickets being attributed to malabsorption.