ACTA ENDOCRINOLOGICA (BUC)

Context. Red cell distribution width (RDW) has been associated with type 2 diabetes (T2DM), however data in relation to diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar non-ketotic acidosis (HONK) remains unclear. Objective. The aim of this study was to evaluate the association between RDW, MCV, and RDW/MVC values and acute complications in T2DM. Patients and Methods. RDW was measured in 90 T2DM patients (30 DKA, 30 HONK and 30 T2DM without acute complications). Clinical variables were analyzed by One –Way ANOVA, Kruskal-Wallis and Pearson analysis with SPSS software. Diagnostic screening tests and ROC curve analysis determined the cut-off point of MCV,RDW and RDW/MCV values. Results. DKA patients had higher levels of plasma glucose (524.20±201.43mg/dL, p<0.001), HbA1c (10.73±2.29%, p<0.001), osmotic pressure (310.32 mosm/L, p<0.001), RDW (14.61±1.75g/L, p<0.01), and the RDW/MCV ratio (0.17±0.04%, p<0.01), compared to HONK patients. RDW/MCV cut-off value was 0.15 with 90% sensitivity 50% specifity these values for only MCV were 76.67%-70%, for only RDW were 76.67%- 63.33% respectively. The area under curve values for the ability to reflect DKA for RDW and the RDW/MCV ratio were 0.708 and 0.766, respectively (p<0.001). Conclusions. RDW and RDW/MCV ratio were found associated with DKA and valuable in predicting DKA. However these parameters were not valuable in predicting HONK.

Background. Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced cancers. Antibodies directed against programmed cell death receptor 1 (PD-1) interrupt the ability of the cancerous cell to depress the immune system. Methods and results. We report three patients who developed different endocrine abnormalities after treatment with nivolumab, a monoclonal antibody directed against PD-1. First, we report a 76-year-old male presenting with generalized fat loss after treatment with nivolumab which predominantly affected his face and trunk. Second, we described the development of thyroiditis that presented with thyrotoxicosis and the expression of thyroid-stimulating hormone receptor antibodies (TRAb). Finally, we observed the emergence of adrenal insufficiency due to hypophysitis in another case. Conclusion. Although immune checkpoint inhibitors are an effective anticancer treatment modality, adverse effects are evident that can affect the endocrine system. These adverse events may relate to different endocrine systems that include the thyroid and pituitary glands. Also, acquired generalized lipodystrophy should be suspected in patients developing unusual fat loss after treatment with ICIs.

Intrasellar plasmacytoma is a rare pituitary tumor, which originates from monoclonal plasma cells in a single lesion. Knowledge of its features comes from case reports only. Here, we present an interesting case of a 77-year-old woman with a presumptive diagnosis of nonfunctioning pituitary adenoma, as based on both clinical and radiological examinations. Following endoscopic endonasal transsphenoidal surgery, the definitive diagnosis of intrasellar plasmacytoma was made by immunohistochemical analysis of the sellar mass. Intrasellar plasmacytoma is rare, but it should be evaluated in the differential diagnosis of a pituitary mass due to its different therapeutic approach and prognosis, since it can frequently progress to multiple myeloma.

Diabetes Mellitus is a huge syndrome which can be detected from the first day of life until the last year of life of a centenarian. In the current classification of diabetes among the so-called “idiopathic phenotypes”, apart Type 1 Diabetes (T1D) and Type 2 Diabetes (T2D) has been included provisionally term “Latent Autoimmune Diabetes in Adults” (LADA). This has unclear characterization regarding the age at onset, the presence of anti-β-cell antibodies and the level of insulin secretory function, in conformity with C-peptide levels. According to several recent publications, there are no specific biochemical or genetic markers for Latent Autoimmune Diabetes in Adults (LADA), but only a gradual transition from T1D to T2D. In addition, the word “latent” in the construction of “LADA” term is inaccurate because in this phenotype nothing is latent: both the autoimmunity and diabetes are present and are even parts of the diagnosis. So that, the best term should be what in reality this subphenotype is: an Intermediary Diabetes Mellitus (IDM). Some recent genetic data strongly support this designation.

Context. Mealtime insulin bolus is traditionally administered before meals in children with type 1 diabetes (T1D). Controlled studies on the use of pre-and postprandial insulin bolus have shown variable results. There are no realworld studies on postprandial bolusing of insulin in young children with T1D. Methods. Children with T1D aged <7 years were grouped into preprandial (Group 1) or postprandial (Group 2) groups according to the practice of prandial insulin use. Their retrospective data on mean glycosylated hemoglobin (HbA1c), hypoglycemic events, and diabetic ketoacidosis (DKA) episodes were compared. Results. Forty-four children (mean age 4.1±1.3 years, range 2-7 years) with mean diabetes duration of 2.0±0.7 years (range, 1-4 years) were identified; 23 (52.3%) belonged to Group 1 and 21 (47.7%) to Group 2. There were no differences in the mean HbA1c levels, mean hypoglycemic events, and DKA episodes between the two groups during a mean follow-up duration of two years. Conclusion. Young children with T1D administered insulin bolus during or immediately after meals showed similar long-term glycemic control and diabetesrelated adverse event profile compared to the premeal timing of insulin bolus. Larger real-world studies are needed on flexible insulin bolus timing in young children with T1D.

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Introduction. Subacute thyroiditis (SAT) is a self-limiting thyroid disease associated with a triphasic clinical direction of hyperthyroidism, hypothyroidism and back to normal thyroid function. Precise etiology of this clinical condition is unknown. Generally diagnosis is based on clinical-laboratory parameters. Considerable cases of SAT develop after several types of viral infections. We herein describe two cases that developed SAT after dental extraction. Cases. Two-female patients in the forties ages experienced fever and neck pain after dental extraction. The patients presented elevated sedimentation rates and SAT symptoms. After clinical diagnosis and therapy administration, symptoms resolved after one week. Conclusion. We have presented two cases experiencing SAT after dental extraction. The management and possible association with current literature were discussed.

Background. Drug induced thrombocytopenia is mostly related with nonsteroidal\r\nanti-inflammatory drugs (NSAID), anticonvulsants, sulfonamides, diuretics, cinchona\r\nalkaloid derivatives, penicillamine and gold salts. Oral sulfonylureas such as glibenclamide,\r\nchlorpropamide and glimepiride are known to induce thrombocytopenia.\r\nCase report. We report a 42 year old female admitted to emergency department with\r\na complaint of hematochesia. She has been using oral gliclazide for three years. Laboratory\r\nresults revealed bicytopenia: haemoglobin=8.9 g/dL (N=12.3-15.3), white blood count\r\n(WBC)=12100/&#956;L (N=4400-11300), platelet count=4000/&#956;L (N=150000-450000). All\r\nexaminations to etiology of thrombocytopenia were negative including autoimmune,\r\ninfectious (viral-bacterial) and haematological diseases. Colonoscopic examination showed\r\n50% construction of the lumen in the first 15 cm segment of the colon by an ulcerovegetant\r\nmass. Pathological examination was reported as adenocarcinoma. Thrombocyte levels\r\nincreased on the 4th day after stopping gliclazid treatment.\r\nConclusions. It is the first case of gliclazid induced thrombocytopenia in literature. So\r\nwe recommended that platelet count should be regularly checked in all patients receiving\r\nsulfonylurea drugs including gliclazid.

Background. Phosphaturic mesenchymal tumor (PMT) is a recently described concept\r\nunifying the mesenchymal tumor associated with oncogenic osteomalacia. Most of the cases of\r\nPMT occur in the extremities and appendicular skeleton. PMT occurring in the paranasal\r\nsinuses is extremely rare with only a few cases reported in the available literature.\r\nCase. A 51-year-old man presented with a long history of bone pains. Biochemical\r\nand radiologic investigations, including skeletal survey showed features of osteomalacia.\r\nPositron emission tomography (PET) scan showed a small tumor in the left nasal cavity,\r\nethmoid and sphenoid sinuses. Histopathological examination of the excised tumor showed\r\nfeatures of a phosphaturic mesenchymal tumor- mixed connective tissue variant. Excision\r\nof the tumor was associated with marked improvement in the biochemical parameters and\r\nremarkable clinical relief.\r\nConclusion. Phosphaturic mesenchymal tumor is a rare cause of osteomalacia and is\r\nusually associated with small tumors, which escape detection for long periods. Its occurrence in\r\nthe paranasal sinuses needs to be kept in mind and evaluated to allow for timely detection of the\r\ntumor with subsequent surgical excision and clinico-biochemical relief.

We describe clinical features of women with extremely low bone density, and investigate secondary causes of osteoporosis. Our hypothesis was that this population would be enriched in identifiable causes of osteoporosis. We performed a retrospective review of medical records of all women seen at our university over 4 years with T-score on bone densitometry at/below -4 at any site. Historical and fracture details were abstracted. We considered a thorough work up to include Vitamin D, PTH, CBC, chemistry panel, cortisol, transglutaminase, myeloma screen, tryptase and 24-hour urine calcium. Results. 137 women were identified with T-score at/below -4. Percent identified as Asian was 26% (higher than local prevalence of 8%). Average BMI was 21.6 kg/ m2. Clearly identifiable causes of osteoporosis were noted in 57% (inflammatory disorder, glucocorticoid or antacid exposure, prolonged immobilization and alcoholism were most prevalent). Of the remainder, full work up was performed only in 8%. Endocrine consultation and white race predicted thoroughness of secondary work-up. Conclusion. Fragility fractures, leanness and Asian race were common in women with very low T-score. However, few new causes were identified. Underlying etiology was either immediately evident or inadequately studied, especially in minorities.