Case Reports in Endocrinology https://www.hindawi.com The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Hypocalciuric Hypercalcemia due to Impaired Renal Tubular Calcium Excretion in a Type 2 Diabetic Patient Tue, 11 Apr 2017 00:00:00 +0000 http://www.hindawi.com/journals/crie/2017/3694868/ The case we presented here was a 73-year-old gentleman, who was admitted to endocrinology department due to recurrent fatigue for 1 year. He had medical histories of type 2 diabetes for 18 years and developed CKD 4 years ago. He also suffered from dilated cardiomyopathy, and coronary heart disease, moderate sleep apnea syndrome, primary hypothyroidism, and gout. His treatment regimen was complicated which included Caltrate D and compound α-keto acid (1200 mg calcium/d). Laboratory examination revealed that his serum calcium level elevated, 24-hour urine calcium output decreased, PTH level was suppressed, and 25-hydroxyvitamin D was in normal low range. No other specific abnormalities were found in serum bone turnover markers, ultrasonography, computed tomography, and bone scintigraphy. The diagnosis was suggested to be hypocalciuric hypercalcemia but was different from familial or acquired hypocalciuric hypercalcemia which were featured by elevated PTH level. The patient was asked to restrict calcium intake and to take diuretics; then his serum calcium level gradually lowered. In brief, patients with CKD could present with hypocalciuric hypercalcemia due to impaired renal calcium excretion. In this case, calcium restriction should be applied for treatment. Sihao Yang, Yan Ren, Xi Li, Haoming Tian, Zhenmei An, and Tao Chen Copyright © 2017 Sihao Yang et al. All rights reserved. Anaplastic Spindle Cell Squamous Carcinoma Arising from Tall Cell Variant Papillary Carcinoma of the Thyroid Gland: A Case Report and Review of the Literature Thu, 06 Apr 2017 00:00:00 +0000 http://www.hindawi.com/journals/crie/2017/4581626/ Tall cell variant (TCV) of papillary thyroid carcinoma (PTC), an aggressive form of thyroid cancer, is characterised by 50% of cells with height that is three times greater than the width. Very rarely, some of these cancers can progress to spindle cell squamous carcinoma (SCSC) resulting in cancers with elements of both SCSC and TCV PTC. Here we report a case of SCSC arising from TCV PTC. In addition to this case, we have performed a literature review and compiled all published reports of SCSC arising from TCV PTC, including the nature of treatment and the prognosis for each of the 20 patients recorded. This is intended for use as a guide for clinicians in what the most appropriate treatment options may be for a newly diagnosed patient. Due to the rarity coupled with diagnosis occurring at a very advanced stage of disease progression, performing clinical trials is difficult and therefore drawing conclusions on optimal treatment methods remains a challenge. Darren K. Patten, Alia Ahmed, Owain Greaves, Roberto Dina, Rashpal Flora, and Neil Tolley Copyright © 2017 Darren K. Patten et al. All rights reserved. A Normotensive Patient with Primary Aldosteronism Sun, 02 Apr 2017 09:12:45 +0000 http://www.hindawi.com/journals/crie/2017/5159382/ This study was to report a case of normotensive patient with primary aldosteronism who was admitted to our department recently. The patient was a 33-year-old male with right adrenal incidentaloma, but without any symptom. He has no history of hypertension, and blood pressure was normal when measured at multiple time points during hospitalization stay. The 24-hour ambulatory blood pressure prompted a normal blood pressure with the existence of circadian rhythm. The patient was diagnosed with primary aldosteronism by screening and confirmatory test. Due to the absence of symptom, surgery was not preferred. Blood pressure was found to be normal with the 2-month follow-up from discharge until now. Xiao Lin, Xiaoyu Miao, Pengli Zhu, and Fan Lin Copyright © 2017 Xiao Lin et al. All rights reserved. A Rare Complication following Thyroid Percutaneous Ethanol Injection: Plummer Adenoma Wed, 29 Mar 2017 00:00:00 +0000 http://www.hindawi.com/journals/crie/2017/1026139/ Percutaneous ethanol injection (PEI) is a technique used only for benign thyroid nodules, cystic or mixed cystic-solid with a large fluid component. It is a quite low-cost, safe, and outpatient method of treatment. Rare and severe complications have been described after PEI: jugular vein thrombosis and severe ethanol toxic necrosis of the larynx combined with necrotic dermatitis. Moreover, only four thyrotoxicosis cases due to Graves’ disease have been reported. We report a case of 58-year-old female with a voluminous thyroid cystic nodule, occupying almost the entire left thyroid lobe. Our patient had already performed surgical visit and intervention of thyroidectomy had been proposed to her, which she refused. At baseline, our patient has a normal thyroid function with negative autoantibodies. According to the nodular structure, intervention of PEI has been performed with a significant improvement of compressive symptoms and cosmetic disorders. About 30 days after treatment, there was a significant volume reduction, but patient developed an acclaimed symptomatic thyrotoxicosis. After ruling out several causes of hyperthyroidism and according to the thyroid scintigraphy findings, we made the diagnosis of Plummer adenoma. To our knowledge, our patient is the first case of Plummer adenoma following PEI treatment of nontoxic thyroid nodule. Roberto Cesareo, Anda Mihaela Naciu, Valerio Pasqualini, Giuseppe Pelle, Silvia Manfrini, Gaia Tabacco, Angelo Lauria Pantano, Alessandro Casini, Roberto Cianni, and Andrea Palermo Copyright © 2017 Roberto Cesareo et al. All rights reserved. Normalization of Bilateral Adrenal Gland Enlargement after Treatment for Cryptococcosis Sun, 26 Mar 2017 08:30:41 +0000 http://www.hindawi.com/journals/crie/2017/1543149/ Cryptococcosis usually occurs in immunocompromised patients and can cause enlargement of the adrenal glands, although the morphologic changes after treatment have not been reported in detail. We report the case of 24-year-old man with fevers, headaches, and impaired consciousness who had been treated with glucocorticoids for a protein-losing gastroenteropathy. The cerebrospinal fluid analysis revealed cryptococcal meningitis. Computed tomography showed bilateral adrenal enlargement. A retrospective analysis revealed that the enlargement had been detected 5 months before admission and gradually increased. The enlargement was improved with antifungal therapy and normalized 6 months later. This is the first report describing morphological changes in the adrenal glands associated with cryptococcal meningitis. Adrenal enlargement by cryptococcosis can be improved without any abnormal findings, including calcifications, which may be a unique characteristic from other diseases, including tuberculosis. Yuka Muraoka, Shintaro Iwama, and Hiroshi Arima Copyright © 2017 Yuka Muraoka et al. All rights reserved. Usefulness of Stereotactic Radiotherapy Using CyberKnife for Recurrent Lymph Node Metastasis of Differentiated Thyroid Cancer Wed, 15 Mar 2017 07:59:50 +0000 http://www.hindawi.com/journals/crie/2017/7956726/ A woman in her 60s presented with a recurrent lymph node metastasis from a papillary thyroid carcinoma in the right parapharyngeal space. She had already undergone total thyroidectomy, five resections for cervical lymph node metastases, and right carotid rebuilding. Surgical resection of the current metastasis was impossible. 131I-radioiodine therapy (RIT) with 3.7 GBq 131I was not effective; therefore, stereotactic radiation therapy (SRT) using a CyberKnife radiotherapy system was scheduled. The prescription dose was 21 Gy, and a dose covering 95% of the planning target volume (PTV) in three fractions was administered. The PTV was 4,790 mm3. Follow-up magnetic resonance imaging conducted 3 and 12 months after the SRT demonstrated a remarkable and gradual reduction of the recurrent lymph node metastasis in the right parapharyngeal space and no evidence of recurrence. For multidisciplinary therapy of unresectable and/or RIT unresponsive locoregional lymph node metastases and recurrences of DTC, SRT using the CyberKnife system should be considered. Joji Kawabe, Shigeaki Higashiyama, Mitsuharu Sougawa, Atsushi Yoshida, Kohei Kotani, and Susumu Shiomi Copyright © 2017 Joji Kawabe et al. All rights reserved. Psychological Aspects of Androgen Insensitivity Syndrome: Two Cases Illustrating Therapeutical Challenges Sun, 12 Mar 2017 09:12:08 +0000 http://www.hindawi.com/journals/crie/2017/8313162/ Androgen Insensitivity Syndrome (AIS) and its heterogeneous phenotypes comprise the pieces of a challenging clinical problem. The lack of standardized guidelines results in controversies regarding the proper diagnostic and therapeutic approach, including the time and type of intervention. Due to its variable phenotype, AIS is not diagnosed at the proper age that would allow optimal psychological and medical support to the patient. Therapeutic approaches are not established, mainly due to the rarity of the disease. In addition, various social and ethical consequences may emerge. The aim of this double case report is to outline the difficulties that may rise during diagnostic, therapeutic, and psychological approach of AIS, especially concerning the handling of the relatives’ reaction. Filippa Pritsini, Georgios A. Kanakis, Ioannis Kyrgios, Eleni P. Kotanidou, Eleni Litou, Konstantina Mouzaki, Aggeliki Kleisarchaki, Dimitrios G. Goulis, and Assimina Galli-Tsinopoulou Copyright © 2017 Filippa Pritsini et al. All rights reserved. A Rapid Biochemical and Radiological Response to the Concomitant Therapy with Temozolomide and Radiotherapy in an Aggressive ACTH Pituitary Adenoma Sun, 05 Mar 2017 00:00:00 +0000 http://www.hindawi.com/journals/crie/2017/2419590/ Background and Importance. In the last eight years temozolomide (TMZ) has been used as the last-line treatment modality for aggressive pituitary tumors to be applied after the failure of surgery, medical therapy, and radiotherapy. The objective was to achieve a rapid control of tumor growth and hormone normalization with concurrent chemoradiotherapy in a patient with very aggressive ACTH pituitary adenoma. Clinical Presentation. We describe a patient with an aggressive ACTH-producing adenoma treated with concurrent temozolomide and radiotherapy. The patient suffered from an aggressive ACTH adenoma resistant to surgical and medical treatment. After two months of concurrent temozolomide and radiotherapy, cortisol normalization and significant tumor shrinkage were observed. After 22 months of follow-up, there is still no evidence of tumor recurrence. Conclusion. Concurrent treatment with temozolomide and irradiation appears to be highly effective in the achievement of the tumor volume control as well as in the control of ACTH secretion in aggressive ACTH adenoma. Ana Misir Krpan, Tina Dusek, Zoran Rakusic, Mirsala Solak, Ivana Kraljevic, Vesna Bisof, David Ozretic, and Darko Kastelan Copyright © 2017 Ana Misir Krpan et al. All rights reserved. Addison’s Disease and Possible Cannabis Withdrawal Syndrome Presenting as an Eating Disorder in a Thirty-Year-Old Female Wed, 01 Mar 2017 09:43:47 +0000 http://www.hindawi.com/journals/crie/2017/4096021/ A 30-year-old female with a history of anxiety, cannabis use, and Avoidant/Restrictive Food Intake Disorder presented for residential treatment of a Cannabis Use Disorder. Upon arrival, she had not eaten for two days and was found to be hypotensive with electrolyte disturbances. She was admitted to a nearby hospital, where the Internist diagnosed her with Addison’s disease. She was treated with corticosteroid therapy, with rapid normalization of her electrolytes, eating, and anxiety. This is the first published case of undiagnosed Addison’s disease presenting as an eating disorder, with cannabis use likely contributing to symptoms. This case elucidates the importance of ruling out other biologic and psychologic causes of clinical presentations before an eating disorder diagnosis can be made. Kimberly Lazare Copyright © 2017 Kimberly Lazare. All rights reserved. Atypical Complications of Graves’ Disease: A Case Report and Literature Review Tue, 28 Feb 2017 07:32:59 +0000 http://www.hindawi.com/journals/crie/2017/6087135/ Graves’ disease (GD) may display uncommon manifestations. We report a patient with rare complications of GD and present a comprehensive literature review. A 35-year-old woman presented with a two-week history of dyspnea, palpitations, and edema. She had a raised jugular venous pressure, goiter, and exophthalmos. Laboratory tests showed pancytopenia, a raised alkaline phosphatase level, hyperbilirubinemia (mainly direct bilirubin), and hyperthyroidism [TSH: <0.01 mIU/L (reference values: 0.45–4.5), fT4: 54.69 pmol/L (reference values: 9.0–20.0), and fT3: >46.08 pmol/L (reference values: 2.6–5.7)]. Her thyroid uptake scan indicated GD. Echocardiography showed a high right ventricular systolic pressure: 60.16 mmHg. Lugol’s iodine, propranolol, cholestyramine, and dexamethasone were initiated. Hematologic investigations uncovered no reason for the pancytopenia; therefore, carbimazole was started. Workup for hepatic impairment and pulmonary hypertension (PH) was negative. The patient became euthyroid after 3 months. Leukocyte and platelet counts and bilirubin levels normalized, and her hemoglobin and alkaline phosphatase levels and right ventricular systolic pressure (52.64 mmHg) improved. This is the first reported single case of GD with the following three rare manifestations: pancytopenia, cholestatic liver injury, and PH with right-sided heart failure. With antithyroid drugs treatment, pancytopenia should resolve with euthyroidism, but PH and liver injury may take several months to resolve. Khaled Ahmed Baagar, Mashhood Ahmed Siddique, Shaimaa Ahmed Arroub, Ahmed Hamdi Ebrahim, and Amin Ahmed Jayyousi Copyright © 2017 Khaled Ahmed Baagar et al. All rights reserved. Pituitary Adenoma and Hyperprolactinemia Accompanied by Idiopathic Granulomatous Mastitis Wed, 22 Feb 2017 00:00:00 +0000 http://www.hindawi.com/journals/crie/2017/3974291/ Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory disease of the breast, and its etiology remains not fully elucidated. IGM is observed more often in patients with autoimmune disease. Hyperprolactinemia is observed during pregnancy, lactation, and a history of oral contraceptive use. A 39-year-old patient with no history of oral contraceptive use presented with complaints such as redness, pain, and swelling in her left breast. Ultrasound and magnetic resonance imaging (MRI) revealed a suspicious inflamed mass lesion. Core biopsy was performed to exclude breast cancer and to further diagnose. The breast abscess was drained and steroids were given for treatment. In order to monitor any progression during the three months of treatment, hormone levels were routinely examined. Prolactin level was above the reference range, and pituitary MRI revealed a pituitary prolactinoma. After treatment with prolactin inhibitors, IGM also improved with hyperprolactinemia. This report emphasizes attention to hyperprolactinemia in cases of IGM diagnosis and treatment. Sebahattin Destek, Vahit Onur Gul, Serkan Ahioglu, and Kursat Rahmi Serin Copyright © 2017 Sebahattin Destek et al. All rights reserved. Simultaneous Papillary Carcinoma in Thyroglossal Duct Cyst and Thyroid Wed, 08 Feb 2017 00:00:00 +0000 http://www.hindawi.com/journals/crie/2017/8541078/ Thyroglossal duct cyst (TDC) is a cystic expansion of a remnant of the thyroglossal duct tract. Carcinomas in the TDC are extremely rare and are usually an incidental finding after the Sistrunk procedure. In this report, an unusual case of a 36-year-old woman with concurrent papillary thyroid carcinoma arising in the TDC and on the thyroid gland is presented, followed by a discussion of the controversies surrounding the possible origins of a papillary carcinoma in the TDC, as well as the current management options. Gustavo Cancela e Penna, Henrique Gomes Mendes, Adele O. Kraft, Cynthia Koeppel Berenstein, Bernardo Fonseca, Wagner José Martorina, Andreise Laurian N. R. de Souza, Gustavo Meyer de Moraes, Kamilla Maria Araújo Brandão Rajão, and Bárbara Érika Caldeira Araújo Sousa Copyright © 2017 Gustavo Cancela e Penna et al. All rights reserved. False Positive Findings on I-131 WBS and SPECT/CT in Patients with History of Thyroid Cancer: Case Series Thu, 26 Jan 2017 00:00:00 +0000 http://www.hindawi.com/journals/crie/2017/8568347/ Introduction. Although whole body scan (WBS) with I-131 is a highly sensitive tool for detecting normal thyroid tissue and metastasis of differentiated thyroid cancer (DTC), it is not specific. Additional information, provided by single photon emission computed tomography combined with X-ray computed tomography (SPECT/CT) and by the serum thyroglobulin level, is extremely useful for the interpretation of findings. Case Presentation. We report four cases of false positive WBS in patients with DTC: ovarian uptake corresponding to an endometrioma, scrotal uptake due to a spermatocele, rib-cage uptake due to an old fracture, and hepatic and renal uptake secondary to a granuloma and simple cyst, respectively. Conclusions. Trapping, organification, and storage of iodine are more prominent in thyroid tissue but not specific. Physiologic sodium-iodine symporter expression in other tissues explains some, but not all, of the WBS false positive cases. Other proposed etiologies are accumulation of radioiodine in inflamed organs, metabolism of radiodinated thyroid hormone, presence of radioiodine in body fluids, and contamination. In our cases nonthyroidal pathologies were suspected since the imaging findings were not corroborated by an elevated thyroglobulin level, which is considered a reliable tumor marker for most well-differentiated thyroid cancers. Clinicians should be aware of the potential pitfalls of WBS in DTC to avoid incorrect management. Zeina C. Hannoush, Juan D. Palacios, Russ A. Kuker, and Sabina Casula Copyright © 2017 Zeina C. Hannoush et al. All rights reserved. Hypercalcemia of Malignancy in Thymic Carcinoma: Evolving Mechanisms of Hypercalcemia and Targeted Therapies Thu, 12 Jan 2017 00:00:00 +0000 http://www.hindawi.com/journals/crie/2017/2608392/ Here we describe, to our knowledge, the first case where an evolution of mechanisms responsible for hypercalcemia occurred in undifferentiated thymic carcinoma and discuss specific management strategies for hypercalcemia of malignancy (HCM). Case Description. We report a 26-year-old male with newly diagnosed undifferentiated thymic carcinoma associated with HCM. Osteolytic metastasis-related hypercalcemia was presumed to be the etiology of hypercalcemia that responded to intravenous hydration and bisphosphonate therapy. Subsequently, refractory hypercalcemia persisted despite the administration of bisphosphonates and denosumab indicative of refractory hypercalcemia. Elevated 1,25-dihydroxyvitamin D was noted from the second admission with hypercalcemia responding to glucocorticoid administration. A subsequent PTHrP was also elevated, further supporting multiple mechanistic evolution of HCM. The different mechanisms of HCM are summarized with the role of tailoring therapies based on the particular mechanism underlying hypercalcemia discussed. Conclusion. Our case illustrates the importance of a comprehensive initial evaluation and reevaluation of all identifiable mechanisms of HCM, especially in the setting of recurrent and refractory hypercalcemia. Knowledge of the known and possible evolution of the underlying mechanisms for HCM is important for application of specific therapies that target those mechanisms. Specific targeting therapies to the underlying mechanisms for HCM could positively affect patient outcomes. Cheng Cheng, Jose Kuzhively, and Sanford Baim Copyright © 2017 Cheng Cheng et al. All rights reserved. Asymptomatic Congenital Hyperinsulinism due to a Glucokinase-Activating Mutation, Treated as Adrenal Insufficiency for Twelve Years Mon, 09 Jan 2017 14:47:38 +0000 http://www.hindawi.com/journals/crie/2017/4709262/ Congenital hyperinsulinism (CHI) caused by a glucokinase- (GCK-) activating mutation shows autosomal dominant inheritance, and its severity ranges from mild to severe. A 43-year-old female with asymptomatic hypoglycemia (47 mg/dL) was diagnosed as partial adrenal insufficiency and the administration of hydrocortisone (10 mg/day) was initiated. Twelve years later, her 8-month-old grandchild was diagnosed with CHI. Heterozygosity of exon 6 c.590T>C (p.M197T) was identified in a gene analysis of GCK, which was also detected in her son and herself. The identification of GCK-activating mutations in hyperinsulinemic hypoglycemia patients may be useful for a deeper understanding of the pathophysiology involved and preventing unnecessary glucocorticoid therapy. Kae Morishita, Chika Kyo, Takako Yonemoto, Rieko Kosugi, Tatsuo Ogawa, and Tatsuhide Inoue Copyright © 2017 Kae Morishita et al. All rights reserved. Isolated Liver Metastasis in Hürthle Cell Thyroid Cancer Treated with Microwave Ablation Mon, 09 Jan 2017 12:37:47 +0000 http://www.hindawi.com/journals/crie/2017/2790741/ Hürthle cell thyroid cancer (HCTC) is a less common form of differentiated thyroid cancer. It rarely metastasizes to the liver, and when it does, the metastasis is almost never isolated. Here we report a 62-year-old male with widely invasive Hürthle cell thyroid cancer, who underwent total thyroidectomy and received adjuvant treatment with I-131 with posttreatment scan showing no evidence of metastatic disease. His thyroglobulin however continued to rise after that and eventually an isolated liver metastasis was identified. He underwent laparoscopic microwave ablation of the liver metastasis, with dramatic decline in thyroglobulin and no structural disease identified to date. This case highlights the rare occurrence of isolated liver metastasis from HCTC and also illustrates the utility of thermoablation as an alternative to surgical resection in the treatment of small isolated liver metastases from HCTC. Konstantinos Segkos, Carl Schmidt, and Fadi Nabhan Copyright © 2017 Konstantinos Segkos et al. All rights reserved. Horner Syndrome Secondary to Thyroid Surgery Wed, 04 Jan 2017 09:54:14 +0000 http://www.hindawi.com/journals/crie/2017/1689039/ Horner syndrome (HS), caused by an interruption in the oculosympathetic pathway, is characterised by myosis, ipsilateral blepharoptosis, enophthalmos, facial anhydrosis, and vascular dilation of the lateral part of the face. HS is a rare complication of thyroidectomy. A 15-year-old female patient presented with solitary solid and large nodule in the right thyroid lobe. Ultrasound-guided fine-needle aspiration was performed and the cytological examination results were undefined. The patient underwent a total thyroidectomy. On postoperative day 2, she developed right-sided myosis and upper eyelid ptosis. HS was diagnosed. Interestingly, the patient exhibited an incomplete clinical syndrome with the absence of vasomotor symptoms. We herein report a case of HS in a 15-year-old female patient after total thyroidectomy. The possible causes of HS were ischaemia-induced nerve damage and stretching of the cervical sympathetic chain by the retractor during thyroidectomy. Clinicians should be aware of the possibility of this rare but important surgical complication. Meliha Demiral, Ciğdem Binay, Enver Simsek, and Hüseyin Ilhan Copyright © 2017 Meliha Demiral et al. All rights reserved. Vasopressin Bolus Protocol Compared to Desmopressin (DDAVP) for Managing Acute, Postoperative Central Diabetes Insipidus and Hypovolemic Shock Tue, 03 Jan 2017 10:40:41 +0000 http://www.hindawi.com/journals/crie/2017/3052102/ Introduction. Management of postoperative central diabetes insipidus (DI) can be challenging from changes in volume status and serum sodium levels. We report a case successfully using a dilute vasopressin bolus protocol in managing hypovolemic shock in acute, postoperative, central DI. Case Report. Patient presented after bifrontal decompressive craniotomy for severe traumatic brain injury. He developed increased urine output resulting in hypovolemia and hypernatremia. He was resuscitated with intravenous fluids including a dilute vasopressin bolus protocol. This protocol consisted of 1 unit of vasopressin in 1 liter of 0.45% normal saline. This protocol was given in boluses based on the formula: urine output minus one hundred. Initial serum sodium was 148 mmol/L, and one-hour urine output was 1 liter. After 48 hours, he transitioned to 1-desamino-8-D-arginine vasopressin (DDAVP). Pre-DDAVP serum sodium was 149 mmol/L and one-hour urine output 320 cc. Comparing the bolus protocol to the DDAVP protocol, the average sodium was 143.8 ± 3.2 and 149.6 ± 3.2 mmol/L (), average urine output was 433.2 ± 354.4 and 422.3 ± 276.0 cc/hr (), and average specific gravity was 1.019 ± 0.009 and 1.016 ± 0.01 (), respectively. Conclusion. A protocol using dilute vasopressin bolus can be an alternative for managing acute, central DI postoperatively, particularly in setting of hypovolemic shock resulting in a consistent control of serum sodium. Anukrati Shukla, Syeda Alqadri, Ashley Ausmus, Robert Bell, Premkumar Nattanmai, and Christopher R. Newey Copyright © 2017 Anukrati Shukla et al. All rights reserved. Artifactual Hypoglycaemia in Systemic Sclerosis and Raynaud’s Phenomenon: A Clinical Case Report and Short Review Wed, 28 Dec 2016 13:19:21 +0000 http://www.hindawi.com/journals/crie/2016/7390927/ Background. Artifactual hypoglycaemia, defined as a discrepancy between glucometer (capillary) and plasma glucose levels, may lead to overtreatment and costly investigations. It is not infrequently observed in patients with Raynaud’s phenomenon due to vascular capillary distortion, yet this is clinically underappreciated. Case Report. We report a 76-year-old woman with systemic sclerosis and Raynaud’s phenomenon, who presented with upper gastrointestinal bleeding and found to have concomitant persistent hypoglycaemia (1.0–2.7mmol/L) on a point-of-care glucometer in the absence hypoglycaemic symptoms. She underwent a 2-week hospital admission, repeated glucose monitoring, hydrocortisone replacement and dextrose infusions, with consequent hyperglycaemia on plasma measurements. Clinically, she did not satisfy Whipple’s triad and radiological investigations failed to identify pituitary or pancreatic pathology. A 72-hour fast was negative for hyperinsulinaemia or exogenous insulin use and her sulphonylurea metabolite urinary screen was negative. Discussion. Treatment of low capillary blood glucose is usually met with clinical impetus to treat, even when hypoglycaemic symptoms are lacking. The correct diagnosis may have been achieved had there been an observation of her cold hands, scleroderma facies, and consideration of the likely distorted peripheral microvasculature. Early identification of this presumably rare clinical scenario may have prevented overtreatment, altered methods of monitoring, and avoided unnecessary investigations. RH Bishay and A. Suryawanshi Copyright © 2016 RH Bishay and A. Suryawanshi. All rights reserved. A 33-Year-Old Man with Gynaecomastia and Galactorrhea as the First Symptoms of Graves Hyperthyroidism Thu, 01 Dec 2016 13:44:40 +0000 http://www.hindawi.com/journals/crie/2016/1946824/ Graves’ hyperthyroidism has a various number of well-recognized manifestations. Galactorrhea is a rare manifestation in this disease. We describe a 33-year-old man who presented with the symptoms of hyperthyroidism, gynaecomastia, and galactorrhea for 2 months. Physical examination revealed goitre, gynaecomastia, and galactorrhea, bilaterally. Laboratory investigations demonstrated high free thyroxine with suppressed thyroid-stimulating hormone level together with elevated anti-TSH receptor; therefore, the diagnosis of Graves’ disease was confirmed. Other investigations to elucidate the etiology of galactorrhea were normal, so the galactorrhea was hypothesized to be caused by Graves’ disease. The gynaecomastia and galactorrhea resolved with the successful treatment of hyperthyroidism. Although the galactorrhea is extremely rare in thyrotoxicosis male patients, to the best of our knowledge, this is the third case which reported gynaecomastia and galactorrhea in male patient who presented with thyrotoxicosis. Somdul Khoohaphatthanakul and Apiradee Sriwijitkamol Copyright © 2016 Somdul Khoohaphatthanakul and Apiradee Sriwijitkamol. All rights reserved. Unusual Cushing’s Syndrome and Hypercalcitoninaemia due to a Small Cell Prostate Carcinoma Thu, 01 Dec 2016 12:09:29 +0000 http://www.hindawi.com/journals/crie/2016/6308058/ A 75-year-old man was hospitalized because of severe hypokalaemia due to ACTH dependent Cushing’s syndrome. Total body computed tomography (TBCT) and 68 Gallium DOTATATE PET/CT localized a voluminous prostate tumour. A subsequent transurethral prostate biopsy documented a small cell carcinoma positive for ACTH and calcitonin and negative for prostatic specific antigen (PSA) at immunocytochemical study; serum prostatic specific antigen (PSA) was normal. Despite medical treatments, Cushing’s syndrome was not controlled and the patient’s clinical condition progressively worsened. Surgical resection was excluded; the patient underwent a cycle of chemotherapy followed by febrile neutropenia and fatal intestinal perforation. This case report describes a rare case of Cushing’s syndrome and hypercalcitoninaemia due to a small cell carcinoma of the prostate, a rare tumour with very few therapeutic options and negative prognosis. Antonio Balestrieri, Elena Magnani, and Fiorella Nuzzo Copyright © 2016 Antonio Balestrieri et al. All rights reserved. Nodular Lymphocyte Predominant Hodgkin Lymphoma of the Thyroid Thu, 01 Dec 2016 08:09:02 +0000 http://www.hindawi.com/journals/crie/2016/8756723/ Thyroid lymphomas are rare clinical entities that may result from either the primary intrathyroid de novo or secondary thyroid gland involvement of a lymphoma. Among these, the Hodgkin’s subtype is quite uncommon, accounting for 0.6–5% of all thyroid malignancies. The authors report on a 76-year-old female presenting with a thyroid nodule that, upon surgical excision, was found to be a nodular lymphocyte predominant Hodgkin lymphoma of the thyroid. So far, thyroid involvement by this variant has never been reported. Upon reporting on this clinical case, the authors emphasize the difficulties usually found in establishing the diagnosis and in defining the best management strategy. A thorough review of the available literature is done. Carlos Tavares Bello, João Cassis, Helder Simões, and João Sequeira Duarte Copyright © 2016 Carlos Tavares Bello et al. All rights reserved. Patients with Acromegaly Presenting with Colon Cancer: A Case Series Tue, 29 Nov 2016 14:05:21 +0000 http://www.hindawi.com/journals/crie/2016/5156295/ Introduction. Frequent colonoscopy screenings are critical for early diagnosis of colon cancer in patients with acromegaly. Case Presentations. We performed a retrospective analysis of the incidental diagnoses of colon cancer from the ACCESS trial (ClinicalTrials.gov identifier: NCT01995734). Colon cancer was identified in 2 patients (4.5%). Case  1 patient was a 36-year-old male with acromegaly who underwent transsphenoidal surgery to remove the pituitary adenoma. After surgery, the patient underwent routine colonoscopy screening, which revealed a 40 mm tubular adenoma in the descending colon. A T1N1a carcinoma was surgically removed, and 1 of 22 lymph nodes was positive for metastatic disease, leading to a diagnosis of stage 3 colon cancer. Case  2 patient was a 50-year-old male with acromegaly who underwent transsphenoidal surgery to remove a 2 cm pituitary adenoma. The patient reported severe cramping and lower abdominal pain, and an invasive 8.1 cm3 grade 2 adenocarcinoma with signet rings was identified in the ascending colon and removed. Of the 37 lymph nodes, 34 were positive for the presence of tumor cells, and stage 3c colon cancer was confirmed. Conclusion. Current guidelines for colonoscopy screening at the time of diagnosis of acromegaly and at appropriate follow-up intervals should be followed. Murray B. Gordon, Samer Nakhle, and William H. Ludlam Copyright © 2016 Murray B. Gordon et al. All rights reserved. A Large Isolated Hydatid Cyst of the Adrenal Gland: A Case Report and Review of the Literature Mon, 28 Nov 2016 12:17:56 +0000 http://www.hindawi.com/journals/crie/2016/9237903/ A 44-year-old patient presented with two-year history of (R) lumbar pain. There was a strong history of childhood animals’ contact, including dogs. A brother had multiple hydatid cysts requiring surgery. Initial ultrasound showed a large (R) adrenal mass measuring  cm. Subsequent CT scan confirmed a heavily calcified cyst in the (R) adrenal gland. Hormonal studies were normal. He had an uneventful course following a total adrenalectomy. Isolated adrenal hydatid is extremely rare with an incidence of less than 0.5%; however, the diagnosis should always be suspected in all patients from an endemic area presenting with an adrenal cystic mass. Fatehi Elnour Elzein, Abdullah Aljaberi, Abdullah AlFiaar, and Abdullah Alghamdi Copyright © 2016 Fatehi Elnour Elzein et al. All rights reserved. Short-Term PTH(1-34) Therapy in Children to Correct Severe Hypocalcemia and Hyperphosphatemia due to Hypoparathyroidism: Two Case Studies Sun, 13 Nov 2016 09:39:28 +0000 http://www.hindawi.com/journals/crie/2016/6838626/ The standard treatment of hypoparathyroidism is to control hypocalcemia using calcitriol and calcium supplementation. However, in severe cases this approach is insufficient, and the risks of intravenous (i.v.) calcium administration and prolonged hospitalization must be considered. While the use of recombinant human parathyroid hormone 1-34 [rhPTH(1-34)] for long-term control of hypocalcemia has been established, the benefits of short-term rhPTH(1-34) treatment in children have not been explored. We report two patients with hypoparathyroidism treated with rhPTH(1-34). Patient 1 is a 10-year-old female with polyglandular autoimmune syndrome type 1. Patient 2 is a 12-year-old female with hypoparathyroidism after total thyroidectomy. Both patients showed poor response to i.v. and oral calcium and calcitriol, and patient 1 did not respond to phosphate binders. Patient 1 had rapid increase in serum calcium with a decrease in serum phosphate after a 3-day course of subcutaneous rhPTH(1-34). Patient 2 had normalization of calcium and phosphate levels after a 7-day course of rhPTH(1-34). These cases support a role for rhPTH(1-34) in the acute management of hypoparathyroidism in hospitalized patients to more rapidly correct hypocalcemia and hyperphosphatemia, shorten hospitalization, and reduce the need for frequent i.v. calcium boluses. Pooja E. Mishra, Betsy L. Schwartz, Kyriakie Sarafoglou, Kristen Hook, Youngki Kim, and Anna Petryk Copyright © 2016 Pooja E. Mishra et al. All rights reserved. Nonislet Cell Tumor Hypoglycemia in a Patient with Adrenal Cortical Carcinoma Thu, 10 Nov 2016 08:20:39 +0000 http://www.hindawi.com/journals/crie/2016/5731417/ Nonislet cell tumor hypoglycemia (NICTH) is a rare but serious paraneoplastic syndrome in which a tumor secretes incompletely processed precursors of insulin-like growth factor-II (IGF-II), causing hypoglycemia. Here, we report an exceptional case of NICTH caused by nonfunctioning adrenocortical carcinoma in a 39-year-old male with recurrent hypoglycemia. The patient’s serum IGF-II/IGF-I ratio had increased to 27.8. The serum level of the IGF-II/IGF-I ratio was normalized after removal of the tumor, and the hypoglycemic attacks no longer occurred after the operation. Se Won Kim, Seung-Eun Lee, Young Lyun Oh, Seokhwi Kim, Sun Hee Park, and Jae Hyeon Kim Copyright © 2016 Se Won Kim et al. All rights reserved. The Biochemical Profile of Familial Hypocalciuric Hypercalcemia and Primary Hyperparathyroidism during Pregnancy and Lactation: Two Case Reports and Review of the Literature Wed, 09 Nov 2016 07:43:16 +0000 http://www.hindawi.com/journals/crie/2016/2725486/ Background. Primary hyperparathyroidism (PHPT) and Familial Hypocalciuric Hypercalcemia (FHH) result in different maternal and fetal complications in pregnancy. Calcium to creatinine clearance ratio (CCCR) is commonly used to help distinguish these two conditions. Physiological changes in calcium handling during pregnancy and lactation can alter CCCR, making it a less useful tool to distinguish PHPT from FHH. Cases. A 25-year-old female presented with hypercalcemia and an inappropriately normal PTH. Her CCCR was 0.79% before pregnancy and rose to 1.99% in her second trimester. The proband’s mother and neonate had asymptomatic hypercalcemia. Genetic analysis revealed a CaSR mutation consistent with FHH. A 19-year-old female presented with a history of nephrolithiasis who underwent emergent caesarean section at 29 weeks of gestation for severe preeclampsia. At delivery, she was diagnosed with hypercalcemia with an inappropriately normal PTH and a CCCR of 2.67%, which fell to 0.88% during lactation. Parathyroidectomy cured her hypercalcemia. Pathology confirmed a parathyroid adenoma. Conclusion. These cases illustrate the influence of pregnancy and lactation on renal calcium indices, such as the CCCR. To avoid diagnostic error of women with hypercalcemia during pregnancy and lactation, calcium biochemistry of first-degree relatives and genetic testing of select patients are recommended. S. A. Ghaznavi, N. M. A. Saad, and L. E. Donovan Copyright © 2016 S. A. Ghaznavi et al. All rights reserved. Surgical Management of Life-Threatening Thyroid Haematoma following Occult Blunt Neck Trauma Tue, 25 Oct 2016 12:45:10 +0000 http://www.hindawi.com/journals/crie/2016/4307695/ A 42-year-old man arrived at the emergency department in severe respiratory distress, requiring immediate intubation and ventilation. An emergency computed tomography (CT) neck scan identified a substantial haematoma within a multinodular goitre, necessitating an emergency total thyroidectomy. It was later discovered that the patient had been the victim of an assault involving blunt trauma to the anterior neck. Five days postoperatively the patient was extubated and was well enough to self-discharge the following day. Pathology revealed the lesion to be a ruptured follicular adenoma within his multinodular goitre. Signs of this rare but life-threatening condition may be subtle on initial presentation, particularly if the patient is obtunded. Patients with suspected blunt neck trauma should be observed for signs of respiratory distress. If this develops, the patient should be intubated to facilitate CT scan, and if thyroid haematoma is confirmed, emergency thyroidectomy is the definitive treatment. Ronak Ved, Neil Patel, and Michael Stechman Copyright © 2016 Ronak Ved et al. All rights reserved. Anterior Pituitary Aplasia in an Infant with Ring Chromosome 18p Deletion Mon, 24 Oct 2016 07:41:40 +0000 http://www.hindawi.com/journals/crie/2016/2853178/ We present the first reported case of an infant with 18p deletion syndrome with anterior pituitary aplasia secondary to a ring chromosome. Endocrine workup soon after birth was reassuring; however, repeat testing months later confirmed central hypopituitarism. While MRI reading initially indicated no midline defects, subsequent review of the images confirmed anterior pituitary aplasia with ectopic posterior pituitary. This case demonstrates how deletion of genetic material, even if resulting in a chromosomal ring, still results in a severe syndromic phenotype. Furthermore, it demonstrates the necessity of close follow-up in the first year of life for children with 18p deletion syndrome and emphasizes the need to verify radiology impressions if there is any doubt as to the radiologic findings. Edward J. Bellfield, Jacqueline Chan, Sarah Durrin, Valerie Lindgren, Zohra Shad, and Claudia Boucher-Berry Copyright © 2016 Edward J. Bellfield et al. All rights reserved. Moyamoya Disease with Coexistent Hypertriglyceridemia in Pediatric Patient Mon, 24 Oct 2016 07:41:05 +0000 http://www.hindawi.com/journals/crie/2016/7974182/ Moyamoya disease is a rare chronic and progressive cerebrovascular disease of the arteries of the circle of Willis that can affect children and adults. It has been associated with multiple diseases, including immunologic, like Graves’ disease, diabetes mellitus, and SLE. Hyperlipidemia has been recognized in patients with Moyamoya disease with an incidence of 27–37%. However, no case in pediatric patients has been reported of the coexistence of Moyamoya disease and hyperlipidemia. Here we present a case of a 9-year-old female diagnosed with Moyamoya disease after a stroke with incidental finding of familial hypercholesterolemia. This finding will make our patient a very unique case, since there has not been any reporting of Moyamoya disease and hypercholesterolemia association. Jacqueline Chan, Fabiola D’Ambrosio Rodriguez, Deepank Sahni, and Claudia Boucher-Berry Copyright © 2016 Jacqueline Chan et al. All rights reserved.