Case Reports in Endocrinology http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. SDHB-Associated Paraganglioma in a Pediatric Patient and Literature Review on Hereditary Pheochromocytoma-Paraganglioma Syndromes Mon, 15 Sep 2014 00:00:00 +0000 http://www.hindawi.com/journals/crie/2014/502734/ Pheochromocytoma and paraganglioma are rare in the pediatric population occurring in approximately 1 in 50,000 children. While some cases are sporadic, they have commonly been associated with syndromes such as von Hippel-Lindau, multiple endocrine neoplasia types IIa and IIb, neurofibromatosis type 1, and hereditary pheochromocytoma-paraganglioma syndromes. In children less than 18 years of age approximately 60% of pheochromocytomas and paragangliomas are associated with a germline mutation. We present an 11-year-old child with an abdominal paraganglioma related to a succinate dehydrogenase subunit B gene mutation whose father had a previously resected abdominal paraganglioma and was found to carry the same mutation. In addition, we review the etiology, genetics, diagnostic approach, and challenges of preoperative management of secretory pheochromocytomas and paragangliomas in children. Heather Choat, Kerri Derrevere, Lisa Knight, Whitney Brown, and Elizabeth H. Mack Copyright © 2014 Heather Choat et al. All rights reserved. Sphenoid Brown Tumor Associated with a Parathyroid Carcinoma Mon, 08 Sep 2014 09:14:47 +0000 http://www.hindawi.com/journals/crie/2014/837204/ Brown tumors are osteolytic bone lesions that occur as a result of persistent hyperparathyroidism. They usually appear late in the natural history of the disease and are currently very rare due to an earlier diagnosis of primary hyperparathyroidism. We present the case of a 53-year-old female with a 2-month history of bitemporal hemianopsia and diplopia. A computed tomography showed an osteolytic bone lesion that involved the sphenoid corpus and clivus. A biopsy was made and the histopathology result was consistent with a brown tumor. The aforementioned location is very infrequent to such tumors, and therefore represented a diagnostic challenge. However, in this case, its association to primary hyperparathyroidism was the clue for the diagnosis. The association of a brown tumor secondary to a parathyroid carcinoma has been seldom reported. This case represents, to our knowledge, one of the few brown tumors described in such location and the first secondary to a parathyroid carcinoma. Abelardo Loya-Solís, Alejandra Mendoza-García, Luis Ceceñas-Falcón, and René Rodríguez-Gutiérrez Copyright © 2014 Abelardo Loya-Solís et al. All rights reserved. A Case of Adenomatous Goiter Involving Diffuse, Acute, and Painful Thyroid Enlargement after Fine-Needle Aspiration Cytology Wed, 03 Sep 2014 12:03:17 +0000 http://www.hindawi.com/journals/crie/2014/284912/ The patient was a 44-year-old woman who exhibited a diffuse goiter during health screening. Her medical history did not include any significant medication-based treatment. An echographic examination detected a solid cystic tumor, which measured 21 × 14 × 10 mm, in her right thyroid lobe; however, she displayed normal thyroid function. After fine-needle aspiration cytology had been performed with a 22 G injection needle, the patient immediately complained of compression and pain extending from the front of her neck to her lower chin, which was not accompanied by dyspnea. A second echographic examination revealed diffuse and edematous enlargement and increased internal blood flow in the bilateral thyroid lobes as well as a thyroid nodule. We immediately iced the patient’s neck and administered 125 mg methylprednisolone via an intravenous infusion. Within one hour, her symptoms had markedly improved, but acute pain remained. Thus, we continued the steroid (prednisone) treatment, but the dose was gradually reduced from 10 mg/day to 5 mg/day at 1 week after the patient’s symptoms disappeared. The mechanism responsible for the patient’s condition remains unclear. Toshiro Shimo, Katsuhiro Tanaka, Ryohei Ogata, Wataru Saito, Yusuke Ohta, Yoshikazu Koike, Tetsumasa Yamashita, Yutaka Yamamoto, and Junichi Kurebayashi Copyright © 2014 Toshiro Shimo et al. All rights reserved. Tumor-Induced Osteomalacia: Increased Level of FGF-23 in a Patient with a Phosphaturic Mesenchymal Tumor at the Tibia Expressing Periostin Sun, 24 Aug 2014 07:58:40 +0000 http://www.hindawi.com/journals/crie/2014/729387/ In our case, a 45-year-old male patient had multiple fractures accompanied by hypophosphatemia. FGF-23 levels were significantly increased, and total body magnetic resonance imaging (MRI) revealed a tumor mass located at the distal tibia leading to the diagnosis of tumor-induced osteomalacia (TIO). After resection of the tumor, hypophosphatemia and the increased levels of FGF-23 normalized within a few days. Subsequent microscopic examination and immunohistochemical analysis revealed a phosphaturic mesenchymal tumor mixed connective tissue variant (PMTMCT) showing a positive expression of somatostatin receptor 2A (SSTR2A), CD68, and Periostin. Electron microscopy demonstrated a poorly differentiated mesenchymal tumor with a multifocal giant cell component and evidence of neurosecretory-granules. However, the resected margins showed no tumor-free tissue, and therefore a subsequent postoperative radiotherapy was performed. The patient is still in complete remission after 34 months. Tumor resection of PMTMCTs is the therapy of choice. Subsequent radiotherapy in case of incompletely resected tumors can be an important option to avoid recurrence or metastasis even though this occurs rarely. The prognostic value of expression of Periostin has to be evaluated more precisely in a larger series of patients with TIO. Anke H. Hautmann, Josef Schroeder, Peter Wild, Matthias G. Hautmann, Elisabeth Huber, Patrick Hoffstetter, Martin Fleck, and Christiane Girlich Copyright © 2014 Anke H. Hautmann et al. All rights reserved. Chronic Heroin Dependence Leading to Adrenal Insufficiency Wed, 20 Aug 2014 08:28:11 +0000 http://www.hindawi.com/journals/crie/2014/461816/ Opioids have been the mainstay for pain relief and palliation over a long period of time. They are commonly abused by drug addicts and such dependence usually imparts severe physiologic effects on multiple organ systems. The negative impact of opioids on the endocrine system is poorly understood and often underestimated. We describe a patient who developed severe suppression of the hypothalamic-pituitary adrenal (HPA) axis leading to secondary adrenal insufficiency due to long standing abuse of opioids. Gautam Das Copyright © 2014 Gautam Das. All rights reserved. Teriparatide Induced Delayed Persistent Hypercalcemia Mon, 18 Aug 2014 06:58:52 +0000 http://www.hindawi.com/journals/crie/2014/802473/ Teriparatide, a recombinant PTH, is an anabolic treatment for osteoporosis that increases bone density. Transient hypercalcemia is a reported side effect of teriparatide that is seen few hours following administration of teriparatide and resolves usually within 16 hours of drug administration. Persistent hypercalcemia, although not observed in clinical trials, is rarely reported. The current case describes a rare complication of teriparatide induced delayed persistent hypercalcemia. Nirosshan Thiruchelvam, Jaskirat Randhawa, Happy Sadiek, and Gaurav Kistangari Copyright © 2014 Nirosshan Thiruchelvam et al. All rights reserved. Fine-Needle Aspiration Cytology of Parathyroid Carcinoma Mimic Hürthle Cell Thyroid Neoplasm Sun, 10 Aug 2014 13:24:26 +0000 http://www.hindawi.com/journals/crie/2014/680876/ Background. Fine-needle aspiration (FNA) can cause misdiagnosis of cytomorphological findings between parathyroid and thyroid lesions. Case Presentation. A 31-year-old man presented with a palpable neck mass on the right thyroid lobe. FNA cytology was reported as intrathyroidal lymphoid hyperplasia. After 5 years, repeated FNA was done on the enlarged nodule with result of Hürthle cell lesion. Prior to right lobectomy, laboratories revealed elevated serum calcium and parathyroid hormone (PTH). Careful history taking revealed chronic knee pain and ossifying fibroma at the maxilla. Ultrasonography showed a 2.8 cm mass inferior to right thyroid lobe. Pathology from en bloc resection was parathyroid carcinoma and immunohistochemical study revealed positivity for PTH. Genetic analysis found somatic mutation of CDC73 gene in exon1 (c.70delG) which caused premature stop codon in amino acid 26 (). The final diagnosis was hyperparathyroidism-jaw tumor syndrome. Conclusions. FNA cytology of parathyroid can mimic thyroid lesion. It is important to consider and correlate the entire information from clinical history, laboratory, imaging, and FNA. Chutintorn Sriphrapradang, Pattana Sornmayura, Niramol Chanplakorn, Objoon Trachoo, Pattarana Sae-Chew, and Rangsima Aroonroch Copyright © 2014 Chutintorn Sriphrapradang et al. All rights reserved. A Case of Marine-Lenhart Syndrome with a Negative TSH Receptor Antibody Titer Successfully Treated with a Fixed, Low Dose of I131 Sun, 03 Aug 2014 11:35:30 +0000 http://www.hindawi.com/journals/crie/2014/423563/ We herein describe a case of Marine-Lenhart syndrome with a negative TSH receptor antibody titer. A 75-year-old female presented to our hospital with malaise, palpitations, and mild fine tremors. She did not have any signs suggestive of Graves’ ophthalmopathy, including conjunctival injection, periorbital edema, or proptosis. Her laboratory data were negative for thyroid autoantibodies, including anti-thyroid peroxidase antibodies, anti-thyroglobulin antibodies, and anti-TSH receptor antibodies (TRAb). Ultrasonography of the thyroid gland revealed a tumor in the right lobe. The remaining thyroid gland had an inhomogeneous and rough texture with a high color Doppler flow. I123 scintigraphy disclosed a hot nodule in the right thyroid gland corresponding to the tumor detected on ultrasonography, suggesting Plummer disease. Furthermore, there was an increased uptake of radionuclide in the rest of the thyroid gland, despite the suppressed level of TSH and negative titer of TRAb, suggesting underlying Graves’ disease. The present findings suggested a diagnosis of Marine-Lenhart syndrome with a negative TRAb titer. Treatment with 10 mCi of radioiodine was highly effective in treating hyperthyroidism in this case. A negative TSH receptor antibody titer does not necessarily rule out the existence of Graves’ disease in patients with Plummer disease. Masahiro Takei, Hiroaki Ishii, Yoshihiko Sato, and Mitsuhisa Komatsu Copyright © 2014 Masahiro Takei et al. All rights reserved. Long-Term Follow-Up of a Child with Autoimmune Thyroiditis and Recurrent Hyperthyroidism in the Absence of TSH Receptor Antibodies Wed, 09 Jul 2014 11:59:24 +0000 http://www.hindawi.com/journals/crie/2014/749576/ Hashitoxicosis is an initial, transient, hyperthyroid phase that rarely affects patients with Hashimoto thyroiditis. We present here an unusual case of a child with Hashimoto thyroiditis and recurrent hyperthyroidism. A 4 yr 6/12 old male was diagnosed by us with autoimmune subclinical hypothyroidism (normal free T4, slightly elevated TSH, and elevated TG antibody titer). Two years and 6/12 later he experienced increased appetite and poor weight gain; a laboratory evaluation revealed suppressed TSH, elevated free T4, and normal TSI titer. In addition, an I123 thyroid uptake was borderline-low. A month later, the free T4 had normalized. After remaining asymptomatic for 3 years, the patient presented again with increased appetite, and he was found with low TSH and high free T4. Within the following 3 months, his free T4 and TSH normalized. At his most recent evaluation, his TSH was normal and the free T4 was borderline-high; the TG antibody titer was still elevated and the TSI titer was negative. To our knowledge, this is the first patient reported with Hashimoto thyroiditis and recurrent hyperthyroidism. This case exemplifies the variability of the manifestations and natural history of Hashimoto thyroiditis and supports the need for a long-term evaluation of patients with autoimmune thyroid disease. Christopher Dunne and Francesco De Luca Copyright © 2014 Christopher Dunne and Francesco De Luca. All rights reserved. Ovarian Leydig Cell Hyperplasia: An Unusual Case of Virilization in a Postmenopausal Woman Thu, 19 Jun 2014 08:31:05 +0000 http://www.hindawi.com/journals/crie/2014/762745/ Objective. To report an unusual case of ovarian Leydig cell hyperplasia resulting in virilization in a postmenopausal woman. Methods. Patient’s medical history and pertinent literature were reviewed. Results. A 64-year-old woman presented with virilization with worsening hirsutism, deepening of her voice, male musculature, and male pattern alopecia. Her pertinent past medical history included type 1 diabetes, hyperlipidemia, and hypertension. Her pertinent past surgical history included hysterectomy due to fibroids. On further work-up, her serum total testosterone was 506 ng/dL (nl range: 2–45) and free testosterone was 40 pg/mL (nl range: 0.1–6.4). After ruling out adrenal causes, the patient underwent an empiric bilateral oophorectomy that showed Leydig cell hyperplasia on pathology. Six weeks postoperatively, serum testosterone was undetectable with significant clinical improvement. Conclusion. Postmenopausal hyperandrogenism can be the result of numerous etiologies ranging from normal physiologic changes to ovarian or rarely adrenal tumors. Our patient was found to have Leydig cell hyperplasia of her ovaries, a rarely reported cause of virilization. Jaya M. Mehta, Jeffrey L. Miller, Anthony J. Cannon, Stacey K. Mardekian, Lawrence C. Kenyon, and Serge A. Jabbour Copyright © 2014 Jaya M. Mehta et al. All rights reserved. A 23-Year-Old Female with a Mixed Germ Cell Tumor of the Pituitary Infundibulum: The Challenge of Differentiating Neoplasm from Lymphocytic Infundibuloneurohypophysitis—A Case Report and Literature Review Wed, 18 Jun 2014 09:16:28 +0000 http://www.hindawi.com/journals/crie/2014/129471/ The pathologic spectrum of diseases that infiltrate the pituitary infundibulum includes a broad variety of clinical entities. There are significant differences in the prevalence of these etiologies depending on the age of presentation. Lymphocytic infundibuloneurohypophysitis (LINH) predominates over other causes of infundibular disease in adults over age 21. Differentiating LINH from other causes of infundibular disease can be difficult because the various etiologies often have similar clinical presentations and radiologic imaging characteristics. We report the first case in an adult of a mixed germ cell tumor comprised of germinoma and embryonal cell carcinoma infiltrating the pituitary infundibulum. In our case, a 23-year-old female was initially misdiagnosed as having LINH. She presented with panhypopituitarism and diabetes insipidus, which is the most common initial presentation in both entities. The two diagnoses are difficult to distinguish based on MRI imaging, CSF findings, and histopathological examination. Our case demonstrates the need for close follow-up of patients with isolated lesions of the pituitary infundibulum and reinforces the need for biopsy of an infundibular lesion when progression of disease is demonstrated. In our case, biopsy with comprehensive immunohistochemical staining was the sole means of making a definitive diagnosis. Sann Yu Mon, Hussain Mahmud, Munira Abbasi, Geoff Murdoch, Juan C. Fernandez-Miranda, Paul A. Gardner, and Sue M. Challinor Copyright © 2014 Sann Yu Mon et al. All rights reserved. Recurrent Silent Thyroiditis as a Sequela of Postpartum Thyroiditis Tue, 27 May 2014 05:55:27 +0000 http://www.hindawi.com/journals/crie/2014/286373/ Thyroiditis encompasses a group of disorders characterized by thyroid inflammation. Though clinically indistinguishable from silent thyroiditis, postpartum thyroiditis occurs in women within 12 months after delivery. Recurrent postpartum thyroiditis in subsequent pregnancies is common, but recurrent silent thyroiditis is rare. We reported a case of patient with recurrent episodes of thyroiditis, unrelated to pregnancy, after an episode of postpartum thyroiditis. It is of interest that postpartum thyroiditis and silent thyroiditis could occur closely to each other; however, the link between these disorders is not well established. This report is to remind physicians of the possibility of recurrent silent thyroiditis in women with a history of postpartum thyroiditis. Preaw Hanseree, Vincent Bryan Salvador, Issac Sachmechi, and Paul Kim Copyright © 2014 Preaw Hanseree et al. All rights reserved. From Childhood Migraine Headache to Pheochromocytoma Sun, 25 May 2014 08:50:08 +0000 http://www.hindawi.com/journals/crie/2014/746723/ Pheochromocytoma may have multiple clinical manifestations including paroxysmal hypertension, tachycardia, sweating, nausea, and headache (Phillips et al., 2002). Migraine has some of the manifestations seen with pheochromocytoma. We describe a patient who had a history of migraine headaches since childhood and was found to have pheochromocytoma. Resection of her tumor significantly improved her headache. The diagnoses of pheochromocytoma subsequently lead to diagnosing her with medullary thyroid cancer (MTC) and multiple endocrine neoplasia type 2A (MEN-2A). Y. M. Hazimeh, M. Luidens, M. E. Ehlers, and V. Sharma Copyright © 2014 Y. M. Hazimeh et al. All rights reserved. Metastases to the Thyroid Presenting as a Metabolically Inactive Incidental Thyroid Nodule with Stable Size in 15 Months Thu, 10 Apr 2014 13:38:31 +0000 http://www.hindawi.com/journals/crie/2014/643986/ Though the thyroid gland has a rich vascular supply, incidence of metastatic disease from distant organs is rare. Here we present an unusual case of metastases to the thyroid with several interesting features. A 63-year-old male with history of adenocarcinoma of the right lobe lung (5 years prior to presentation), treated with surgery and chemotherapy, followed by new adenosquamous lung cancer in the left lobe of the lung (one year prior to presentation), treated surgically followed by adjuvant chemotherapy, was referred to Endocrinology section for evaluation of an incidental thyroid nodule on CT chest. Ultrasound (US) of the thyroid revealed a complex, predominantly hypoechoic lesion measuring 1.8 cm within the lower pole of the right thyroid lobe and a subcentimeter lesion in the left lobe of the thyroid. Review of prior CT chests showed that the lesion in the right lobe was stable for 15 months, with no evidence of a hypermetabolic lesion on PET scan. The subcentimeter lesion was not seen on prior CT scans. US guided fine needle aspiration (FNA) and pathology of the lobectomy of the thyroid confirmed adenosquamous carcinoma. Interesting features in this case are that the thyroid metastases occurred without any evidence of synchronous lesions elsewhere, the size was stable over 15 months, and the lesions were metabolically inactive. Subhashini Yaturu and Raina A. Patel Copyright © 2014 Subhashini Yaturu and Raina A. Patel. All rights reserved. A Case of Acute Psychosis in an Adolescent Male Sun, 30 Mar 2014 12:49:16 +0000 http://www.hindawi.com/journals/crie/2014/937631/ Primary hyperparathyroidism (PHPT) is a disorder of calcium homeostasis. We report the case of a 17-year-old adolescent male, who presented with an acute psychosis coinciding with severe hypercalcemia and markedly elevated intact parathyroid hormone (iPTH) level and low vitamin D level. A Sestamibi scan showed a positive signal inferior to the left lobe of the thyroid gland. He had only a partial response to the initial medical and psychiatric management. The enlarged parathyroid gland was resected surgically and postoperatively serum calcium and iPTH levels normalized. The histopathology was compatible with a benign adenoma. Patient’s acute psychotic symptoms resolved gradually after surgery; however he remained under psychiatric care for the behavioral issues for about 6 months after surgery. While psychosis is a rare clinical manifestation of hypercalcemia secondary to PHPT in pediatric population, it should be considered as a clinical clue in an otherwise asymptomatic pediatric patient. Ghufran Babar and Ramin Alemzadeh Copyright © 2014 Ghufran Babar and Ramin Alemzadeh. All rights reserved. Testosterone- and Cortisol-Secreting Adrenocortical Oncocytoma: An Unusual Cause of Hirsutism Tue, 11 Mar 2014 09:54:01 +0000 http://www.hindawi.com/journals/crie/2014/206890/ Objective. Oncocytomas of the adrenal cortex are usually benign and nonfunctional. They are rarely seen as the cause of hirsutism. Therefore, we aimed to report a case of adrenocortical oncocytoma presenting with hirsutism. Methods. We report a testosterone- and cortisol-secreting adrenal oncocytoma in a 23-year-old female patient presenting with hirsutism. Results. The patient had the complaint of hirsutism for the last year. Laboratory tests revealed total testosterone level of 4.2 ng/mL, free testosterone of >100 pg/mL, and DHEAS level of 574 µg/dL. There was no suppression in cortisol levels with 2 mg dexamethasone suppression test (5.4 µg/dL). Adrenal MRI revealed a  mm isointense solid mass lesion in the left adrenal gland and the patient underwent laparoscopic left adrenalectomy. Pathological examination confirmed the diagnosis of benign adrenocortical oncoyctoma. Conclusion. This well-characterized case describes a testosterone- and cortisol-secreting adrenocortical oncocytoma as a possible cause of hirsutism. To our knowledge, this is the second report in the literature. Adrenal oncocytomas should always be considered in the differential diagnosis of hirsutism. Serap Baydur Sahin, Ahmet Fikret Yucel, Recep Bedir, Sabri Ogullar, Teslime Ayaz, and Ekrem Algun Copyright © 2014 Serap Baydur Sahin et al. All rights reserved. Diabetic Myonecrosis: Uncommon Complications in Common Diseases Mon, 10 Mar 2014 07:04:53 +0000 http://www.hindawi.com/journals/crie/2014/175029/ We report a case of sudden thigh pain from spontaneous quadriceps necrosis, also known as diabetic myonecrosis, in a 28-year-old patient with poorly controlled diabetes mellitus. Diabetic muscle infarction is a rare end-organ complication seen in patients with poor glycemic control and advanced chronic microvascular complications. Proposed mechanisms involve atherosclerotic microvascular occlusion, ischemia-reperfusion related injury, vasculitis with microthrombi formation, and an acquired antiphospholipid syndrome. Diabetic myonecrosis most commonly presents as sudden thigh pain with swelling and should be considered in any patient who has poorly controlled diabetes mellitus. Sisira Sran, Manpreet Sran, Nicole Ferguson, and Prachi Anand Copyright © 2014 Sisira Sran et al. All rights reserved. Evaluation of Teriparatide for Treatment of Osteoporosis in Four Patients with Cystic Fibrosis: A Case Series Thu, 06 Mar 2014 12:57:37 +0000 http://www.hindawi.com/journals/crie/2014/893589/ Introduction. Bone disease is a common complication of cystic fibrosis (CF). To date, there have been no reports on the effectiveness of teriparatide, recombinant human parathyroid hormone, to treat CF-related bone disease. Case Presentation. We report on four patients with CF-related bone disease who were treated with teriparatide. Three patients completed two years of therapy with teriparatide, and all had significant improvements in their bone mineral density (BMD). One patient was unable to tolerate teriparatide and discontinued treatment 1 week into therapy. Conclusion. Teriparatide may be a potential treatment option for CF-related bone disease. This report highlights the need for further investigation into the use of teripartide in the CF population. Oranan Siwamogsatham, Kelly Stephens, and Vin Tangpricha Copyright © 2014 Oranan Siwamogsatham et al. All rights reserved. Multifactorial Hypercalcemia and Literature Review on Primary Hyperparathyroidism Associated with Lymphoma Wed, 05 Mar 2014 06:54:06 +0000 http://www.hindawi.com/journals/crie/2014/893134/ The most common cause of hypercalcemia in hospitalized patients is malignancy. Primary hyperparathyroidism most commonly causes hypercalcemia in the outpatient setting. These two account for over 90% of all cases of hypercalcemia. Hypercalcemia can be divided into PTH-mediated and PTH-independent variants. Primary hyperparathyroidism, familial hypocalciuric hypercalcemia, familial hyperparathyroidism, and secondary hyperparathyroidism are PTH mediated. The most common PTH-independent type of hypercalcemia is malignancy related. Several mechanisms lead to hypercalcemia in malignancy-direct osteolysis by metastatic disease or, more commonly, production of humoral factors by the primary tumor also known as humoral hypercalcemia of malignancy that accounts for about 80% of malignancy-related hypercalcemia. The majority of HHM is caused by tumor-produced parathyroid hormone-related protein and less frequently production of 1,25-dihydroxyvitamin D or parathyroid hormone by the tumor. We report the rare case of a patient with hypercalcemia and diagnosed primary hyperparathyroidism. The patient had persistent hypercalcemia after surgical removal of parathyroid adenoma with recorded significant decrease in PTH level. After continued investigation it was found that the patient also had elevated 1,25-dihydroxyvitamin D and further studies confirmed a large spleen mass that was later confirmed to be a lymphoma. This is a rare example of two concomitant causes of hypercalcemia requiring therapy. Jelena Maletkovic, Jennifer P. Isorena, Miguel Fernando Palma Diaz, Stanley G. Korenman, and Michael W. Yeh Copyright © 2014 Jelena Maletkovic et al. All rights reserved. F-18 FDG-PET-CT in the Diagnostic of a Late Medullary Thyroid Carcinoma Recurrence in a Patient with Follicular-Papillary Thyroid Cancer Thu, 20 Feb 2014 12:58:43 +0000 http://www.hindawi.com/journals/crie/2014/741262/ Mixed medullary and follicular or papillary carcinoma of thyroid is an extremely rare tumor, characterized by coexistence of morphological and immunohistochemical features of both medullary carcinoma and follicular (or papillary) carcinoma. This case report describes for the first time in the indexed database a late recurrence of a medullary thyroid carcinoma initially diagnosed as follicular-papillary form, treated and monitored accordingly. After 14 years, a superior mediastinum tumor was discovered incidentally at a thorax computer tomography. The whole-body I-131 scan was negative and F-18 FDG-PET-CT showed glucose avidity of the tumor. The patient was operated on and the histology revealed medullary thyroid carcinoma. If there are no possibilities to have routinely extensive immunohistologic profiles, it is recommended to check the serum calcitonin, at least in any patient with confirmed thyroid carcinoma. Doina Piciu and Andra Piciu Copyright © 2014 Doina Piciu and Andra Piciu. All rights reserved. Rhabdomyolysis Induced by Nonstrenuous Exercise in a Patient with Graves’ Disease Tue, 11 Feb 2014 12:21:38 +0000 http://www.hindawi.com/journals/crie/2014/286450/ Hyperthyroidism can result in several musculoskeletal conditions such as thyrotoxic periodic paralysis, thyrotoxic myopathy, and thyroid ophthalmopathy. Rhabdomyolysis has been rarely reported to be associated with hyperthyroidism. We describe a 33-year-old man who presented with bilateral thigh pain and dark brown urine after regular squatting. He had a past medical history of hyperthyroidism but stopped taking it 2 months prior to admission. He was found to have rhabdomyolysis, myoglobinuria, and thyrotoxicosis. Presence of thyroid-stimulating immunoglobulins (TSI) and high radioiodine uptake confirmed a diagnosis of Graves' disease. He received aggressive fluid resuscitation and sodium bicarbonate intravenously along with monitoring fluid and electrolyte. Methimazole was also resumed. The patient responded to treatment and rhabdomyolysis gradually resolved. Therefore, nonstrenuous exercise can potentially induce rhabdomyolysis in patients with hyperthyroidism. Although hyperthyroidism is not widely recognized as a cause of rhabdomyolysis, it should be considered in the differential diagnosis of rhabdomyolysis. Sarawut Summachiwakij and Issac Sachmechi Copyright © 2014 Sarawut Summachiwakij and Issac Sachmechi. All rights reserved. A Case Report of Post-Operative Jöd-Basedow Phenomennon Following Oral and IV Iodine Contrast Administration Tue, 11 Feb 2014 09:11:50 +0000 http://www.hindawi.com/journals/crie/2014/980283/ This is a case of thyrotoxicosis, due to the Jöd-Basedow phenomenon following administration of oral and IV iodinated contrast in a patient with history of gastrointestinal stromal tumor (GIST) and small bowel obstruction. The patient developed atrial fibrillation and had an extended stay in the intensive care unit. Given the aging population with possible subclinical hyperthyroidism, multinodular goiter, and the rise in contrast administration for routine diagnostic studies, this case serves to raise awareness of the risks of “routine” tests administered to our aging patient population. Maureen Higgs, Erroll Hull, and Eugenio Lujan Copyright © 2014 Maureen Higgs et al. All rights reserved. Life-Threatening Hypokalemic Paralysis in a Young Bodybuilder Tue, 11 Feb 2014 00:00:00 +0000 http://www.hindawi.com/journals/crie/2014/483835/ We report a case of life-threatening hypokalemia in a 28-year-old bodybuilder who presented with sudden onset bilateral lower limbs paralysis few days after his bodybuilding competition. His electrocardiogram (ECG) showed typical u-waves due to severe hypokalemia (serum potassium 1.6 mmol/L, reference range (RR) 3.5–5.0 mmol/L). He was admitted to the intensive care unit (ICU) and was treated with potassium replacement. The patient later admitted that he had exposed himself to weight loss agents of unknown nature, purchased online, and large carbohydrate loads in preparation for the competition. He made a full recovery after a few days and discharged himself from the hospital against medical advice. The severe hypokalemia was thought to be caused by several mechanisms to be discussed in this report. With the ever rising number of new fitness centers recently, the ease of online purchasing of almost any drug, and the increasing numbers of youngsters getting into the bodybuilding arena, clinicians should be able to recognize the possible causes of sudden severe hypokalemia in these patients in order to revert the pathophysiology. Kitty K. T. Cheung, Wing-Yee So, Alice P. S. Kong, Ronald C. W. Ma, and Francis C. C. Chow Copyright © 2014 Kitty K. T. Cheung et al. All rights reserved. Three-Year Successful Cinacalcet Treatment of Secondary Hyperparathyroidism in a Patient with X-Linked Dominant Hypophosphatemic Rickets: A Case Report Mon, 10 Feb 2014 13:39:49 +0000 http://www.hindawi.com/journals/crie/2014/479641/ Hypophosphatemic rickets (HR) is a rare inherited disorder characterized by a classic rickets phenotype with low plasma phosphate levels and resistance to treatment with vitamin D. Development of secondary hyperparathyroidism (SHPT) as a direct consequence of treatment is a frequent complication and a major clinical challenge, as this may increase risk of further comorbidity. Cinacalcet, a calcimimetic agent that reduces the secretion of PTH from the parathyroid glands, has been suggested as adjuvant treatment to SHPT in patients with HR. However, only two papers have previously been published and no data are available on effects of treatment for more than six months. We now report a case of 3-year treatment with cinacalcet in a patient with HR complicated by SHPT. A 53-year-old woman with genetically confirmed X-linked dominant hypophosphatemic rickets developed SHPT after 25 years of conventional treatment with alfacalcidol and phosphate supplements. Cinacalcet was added to her treatment, causing a sustained normalization of PTH. Ionized calcium decreased, requiring reduction of cinacalcet, though asymptomatical. Level of phosphate was unchanged, but alkaline phosphatase increased in response to treatment. Cinacalcet appeared to be efficient, safe, and well tolerated. We recommend close control of plasma calcium to avoid hypocalcemia. Diana Grove-Laugesen and Lars Rejnmark Copyright © 2014 Diana Grove-Laugesen and Lars Rejnmark. All rights reserved. Germinoma with Involvement of Midline and Off-Midline Intracranial Structures Sun, 09 Feb 2014 09:26:32 +0000 http://www.hindawi.com/journals/crie/2014/936937/ Germinomas are malignant intracranial germ tumors, usually found in suprasellar regions. Less than 10% are localized in off-middle structures, and synchronous involvement of both structures has only exceptionally been published. A case of an 18-year-old male patient with progressive right-sided hemiparesis and panhypopituitarism was reviewed. Brain MRI showed a solid mass involving pituitary and hypothalamus with thickening of pituitary stalk, high intensity lesions on T2-weighted imaging in left internal capsule, caudate nucleus, globus pallidus, and mild atrophy of the left internal capsule and cerebral peduncle. Nonadenomatous lesions were considered in the differential diagnosis. Alfa-fetoprotein (AFP) levels were negative in both serum and cerebrospinal fluid (CSF), while β-human chorionic gonadotrophin (β-HCG) levels were slightly increased in CSF. A transsphenoidal biopsy identified a germinoma. Four cycles of chemotherapy with bleomicine, etoposide, and cysplatin were given, followed by radiotherapy, but patients died due to a recidiva. Conclusion. Germinoma must be considered in patients with insipidus diabetes with a sellar mass with thickening of pituitary stalk; and ectopic germinoma must be suspected in patients with slowly progressive hemiparesis with cerebral hemiatrophy. Even with a rare condition, colocalization of midline and off-midline germinoma must be suspected in the presence of these typical signs of both localizations. Monica Graciela Loto, Karina Danilowicz, Santiago González Abbati, Rafael Torino, and Alejandro Misiunas Copyright © 2014 Monica Graciela Loto et al. All rights reserved. FGF23 Producing Mesenchymal Tumor Mon, 03 Feb 2014 14:28:22 +0000 http://www.hindawi.com/journals/crie/2014/492789/ A 40-year-old patient was referred to Clinic of Endocrinology due to hypophosphatemia causing pain, cramps, and weakness of muscles. Moreover, his bone mineral density was very low. The previous treatment with phosphorus and active vitamin D metabolites was ineffective. In lab tests the hypophosphatemia, hyperphosphaturia, and elevated FGF23 levels were found. Somatostatin receptor scintigraphy (SRS) showed increased radiotracer uptake in the right maxillary sinus and CT scans confirmed presence of tumor in this localization. Biopsy and cytological examination created suspicion of mesenchymal tumor—glomangiopericytoma. Waiting for surgery the patient was treated with long acting Somatostatine analogue, and directly before operation short acting Octreotide and intravenous phosphorus were used. Histology confirmed the cytological diagnosis and the phosphatemia return to normal values in 10 days after the tumor removal. Lucyna Papierska, Jarosław B. Ćwikła, Waldemar Misiorowski, Michał Rabijewski, Krzysztof Sikora, and Hubert Wanyura Copyright © 2014 Lucyna Papierska et al. All rights reserved. Testicular “Hyperstimulation” Syndrome: A Case of Functional Gonadotropinoma Tue, 28 Jan 2014 09:37:54 +0000 http://www.hindawi.com/journals/crie/2014/194716/ Gonadotropins secreting pituitary tumors tend to present as sellar mass with hypogonadism. Biologically active LH secretion by these tumors resulting in elevated testosterone is extremely rare. We report a case of a 48-year-old male patient who presented with giant pituitary tumor, elevated testosterone, and elevated levels of gonadotropins. Surgical resection of the tumor resulted in normalization of gonadotropins and fall in serum testosterone to subnormal levels in the postoperative period confirming that the tumor was secreting bioactive luteinizing hormone (LH). Astha Thakkar, Subramanian Kannan, Amir Hamrahian, Richard A. Prayson, Robert J. Weil, and Charles Faiman Copyright © 2014 Astha Thakkar et al. All rights reserved. Unpredictable Nature of Tolvaptan in Treatment of Hypervolemic Hyponatremia: Case Review on Role of Vaptans Wed, 08 Jan 2014 00:00:00 +0000 http://www.hindawi.com/journals/crie/2014/807054/ Hyponatremia is one of the most commonly encountered electrolyte abnormalities occurring in up to 22% of hospitalized patients. Hyponatremia usually reflects excess water retention relative to sodium rather than sodium deficiency. Volume status and serum osmolality are essential to determine etiology. Treatment depends on several factors, including the cause, overall volume status of the patient, severity of hyponatremic symptoms, and duration of hyponatremia at presentation. Vasopressin antagonists like tolvaptan seem promising for the treatment of euvolemic and hypervolemic hyponatremia in heart failure. Low sodium concentrations cause cerebral edema, but the overly rapid sodium correction can also lead to iatrogenic cerebral osmotic demyelination syndrome. Demyelination may occur days after sodium correction or initial neurologic recovery from hyponatremia. The following case report analyzes the role of vasopressin antagonists in the treatment of hyponatremia and the need for daily dosing of tolvaptan and the monitoring of serum sodium levels to avoid rapid overcorrection which can result in osmotic demyelination syndrome (ODS). Ishan Malhotra, Shilpa Gopinath, Kalyana C. Janga, Sheldon Greenberg, Shree K. Sharma, and Regina Tarkovsky Copyright © 2014 Ishan Malhotra et al. All rights reserved. Chemotherapy-Induced Regression of an Adrenocorticotropin-Secreting Pituitary Carcinoma Accompanied by Secondary Adrenal Insufficiency Sun, 22 Dec 2013 18:44:04 +0000 http://www.hindawi.com/journals/crie/2013/675298/ Purpose. Adrenocorticotropin- (ACTH-) secreting pituitary carcinomas are rare and require multimodality treatment. The aim of this study was to report the response to various therapies and discuss the potential development of secondary adrenal insufficiency with cytotoxic chemotherapy. Methods. This report describes a man with a large silent corticotroph adenoma progressing to endogenous hypercortisolism and metastatic ACTH-secreting pituitary carcinoma over a period of 14 years. Results. Seven years after initial presentation, progressive tumor enlargement associated with the development of hypercortisolism mandated multiple pituitary tumor debulking procedures and radiotherapy. Testing of the Ki-67 proliferation index was markedly high and he developed a hepatic metastasis. Combination therapy with cisplatin and etoposide resulted in a substantial reduction in tumor size, near-complete regression of his liver metastasis, and dramatic decrease in ACTH secretion. This unexpectedly resulted in symptomatic secondary adrenal insufficiency. Conclusions. This is the first reported case of secondary adrenal insufficiency after use of cytotoxic chemotherapy for metastatic ACTH-secreting pituitary carcinoma. High proliferative indices may be predictive of dramatic responses to chemotherapy. Given the potential for such responses, the development of secondary adrenal insufficiency may occur and patients should be monitored accordingly. Robert Frank Cornell, Daniel F. Kelly, Gal Bordo, Ty B. Carroll, Huy T. Duong, Julie Kim, Yuki Takasumi, James P. Thomas, Yee Lan Wong, and James W. Findling Copyright © 2013 Robert Frank Cornell et al. All rights reserved. Insulinoma Presenting with Long-Standing Depression, Primary Hypogonadism, and Sertoli Cell Only Syndrome Sun, 22 Dec 2013 11:57:45 +0000 http://www.hindawi.com/journals/crie/2013/926385/ The aim was to report an unusual case of insulinoma presenting with long-standing depression and primary testicular failure. We describe a 34-year-old male with clinical, laboratory, and radiologic data consistent with islet cell tumor and seminiferous tubule failure primary hypogonadism. The literature is reviewed relative to the component of this syndrome, and a possible association is discussed. The subject was investigated for a long-standing history of depression requiring medical attention because of mental confusion and slurred speech and was found to have an insulinoma. He was diagnosed with primary gonadal failure and physical examination showed no evidence of dysmorphic features. Chromosomal analysis revealed normal 46 XY and testicular biopsy showed Sertoli cell only syndrome (SCOS). Biochemistry revealed endogenous hyperinsulinism and histology confirmed an islet cell tumor. He remained euglycemic postoperatively and on followup. From this report, we emphasize drawing clinicians' attention to the possibility of an association between insulinoma and primary testicular failure and suggest consideration of this diagnosis in patients with hypergonadotropic hypogonadism who may present with infertility. Usman H. Malabu, Durgesh Gowda, and Yong Mong Tan Copyright © 2013 Usman H. Malabu et al. All rights reserved.