Aditi Pandit

Assessment of thyroid and gonadal function in liver diseases

Introduction: Liver is involved with the synthesis of carrier proteins and metabolism of various hormones and liver diseases may, therefore, be associated with various endocrine disturbances. This study was conducted to assess thyroid and gonadal function in subjects with acute hepatitis (AH), chronic liver disease (CLD), and those who had undergone liver transplantation (LT). Materials and Methods: Patients with AH, CLD with Child-Pugh stage A (CLD-1) and Child-Pugh stage B or C (CLD-2), and LT seen at our tertiary level hospital were assessed clinically, biochemically, and for thyroid and gonadal functions besides 25 healthy controls. Results: Thyroid dysfunction and hypogonadism were present in 14 (16%) and 24 (28%) patients with liver diseases respectively. Among thyroid dysfunction, the commonest was sick euthyroid syndrome six (7%), followed by subclinical hypothyroidism in three patients (3.5%), subclinical hyperthyroidism and thyrotoxicosis in two patients each (2.3%) and overt hypothyroidism in one patient. Among patients with LT and AH groups, the only abnormality was significantly lower total T3 compared with healthy controls. The CLD2 group had significantly lower levels of all thyroid hormones compared with controls and CLD1 group. Hypogonadism was commonest in patients with CLD-2 (14; 50%) followed by LT (3; 33%), CLD-1 (4; 20%), and AH (3; 14%). Hypogonadism was predicted by older age, lower levels of serum albumin, total cholesterol, and triglycerides and higher levels of plasma glucose, serum bilirubin, aspartate transaminases, and international normalized ratio. Gonadal functions showed recovery following LT. Conclusions: Thyroid dysfunction and hypogonadism form an important part of the spectrum of acute and CLD, and patients with LT. Deterioration of synthetic functions of liver disease predicts presence of hypogonadism.

Clinical spectrum of hypopituitarism in India: A single center experience

Objectives: There is paucity of information regarding clinical profile of hypopituitarism from India. We report the clinical profile of hypopituitarism from a tertiary center in North India. Materials and Methods: This study was carried out in patients attending our endocrine center between January 2010 and December 2011. All new patients were studied prospectively and those registered before January 2010 retrospectively. Relevant clinical, hormonal, and imaging data were collected. Dynamic testing for pituitary functions was carried out as necessary. Hormonal deficiencies were defined as per prevailing recommendations. Results: This study included 113 subjects. The mean age was 38.6 ± 17.8 years (range, 4 – 76 years). There were 78 (69%) males and 35 females (31%). There were 22 subjects aged ≤18 years (childhood and adolescence) and 91 adults (>18 years). Visual disturbances were the most common presenting complaint (33%), though headache was the most common symptom (81%). Fifteen percent presented with pituitary apoplexy. Tumors comprised of 84% of cases. Hypogonadism (97%) was the most common abnormality seen followed by hypothyroidism (83.2%), hypoadrenalism (79.6%), growth hormone deficiency (88.1% of the 42 patients tested), and diabetes insipidus (13.3%). Panhypopituitarism was seen in 104 (92%) patients. There were no cases of hypopituitarism secondary to traumatic brain injury, subarachnoid hemorrhage, central nervous system infections, or cranial irradiation to extrasellar tumors. Conclusion: The most common cause of hypopituitarism at tertiary care center is pituitary tumors and the commonest presenting complaint is visual symptoms. Panhypopituitarism is present in 92% cases.

Assessment of adrenal function in liver diseases

Background: In recent times, there are reports of adrenal dysfunction in whole spectrum of liver disease. Adrenal insufficiency (AI) has been shown to correlate with progression of liver disease. Hence this study was conducted to assess adrenal function in subjects with acute liver disease (ALD), chronic liver disease (CLD) and post liver transplantation (LT). Material and Methods: This study included 25 healthy controls, 25 patients of ALD, 20 subjects of CLD with Child-Pugh stage A (CLD-1) and 30 with Child-Pugh stage B or C (CLD-2), and 10 subjects with LT. All subjects were assessed clinically, biochemically and for adrenal functions. Results: AI was present in 9 (34.6%) patients with ALD, 20 (40%) patients with CLD and 4 (40%) in subjects with LT. AI was more common in CLD-2 (18 patients – 60%) than CLD-1 (2 patients – 10%). All patients with chronic liver disease had significantly lower basal cortisol (8.8±4.8, P=0.01), stimulated cortisol (18.2±6.3, P <0.00001) and incremental cortisol (9.4±4.6, P <0.00001) as compared to controls. There was increase in percentage of subjects with adrenal dysfunction with progression of liver disease as assessed by Child-Pugh staging. AI was predicted by lower levels of serum protein, serum albumin, total cholesterol and HDL cholesterol and higher levels of serum bilirubin and INR. Adrenal functions showed recovery following liver transplantation. Conclusions: AI forms important part of spectrum of acute and chronic liver disease. Deterioration of synthetic functions of liver disease predicts presence of AI, and these patients should be evaluated for adrenal dysfunction periodically.

Variability of capillary blood glucose monitoring measured on home glucose monitoring devices

Self monitoring of blood glucose helps achieve glycemic goals. Glucometers must be accurate. Many variables affect blood glucose levels. Factors are analytical variables (intrinsic to glucometer and glucose strips) and pre analytical related to patients. Analytical variables depend on factors like shelf life, amount of blood and enzymatic reactions. Preanalytical variables include pH of blood, hypoxia, hypotension, hematocrit etc. CGMS has the potential to revolutionise diabetes care but accuracy needs to be proven beyond doubt before replacing current glucometer devices.

Spinal polyostotic fibrous dysplasia in two adults: Does only biopsy unravel the mystery?

Polyostotic fibrous dysplasia is a rare non-inheritable genetic disease due to mutation in GNAS gene. Here we present two adults who were accidentally detected lytic lesions in spine and after extensive evaluation for malignancies; was diagnosed on biopsy. Current concept of the disease and management is discussed.

Changes in bone mineral density and bone turnover markers in patients undergoing hematopoietic stem cell transplant

Introduction: Hematopoietic stem cell transplant (HSCT) is frequently complicated by endocrine abnormalities and loss of bone mass. This prospective study was conducted to evaluate the bone loss post-HSCT. Materials and Methods: A total of 50 patients was evaluated pretransplantation, and 25 had HSCT (17 males, 8 females; 19 allogenic, 6 autologous). Bone mineral density (BMD) and bone markers were measured at baseline, 3–6 months and 12 months. Results: The mean age and body mass index were 25.1 ± 16.3 years and 19.4 ± 4.5 kg/m2, respectively. There were 15 adults (60%), and 10 adolescents (40%). There was a significant decline in BMD from the baseline at total femur (−8.7%; P < 0.0001), femoral neck (−5.0%; P = 0.003), femoral trochanter (−6.0%; P = 0.001), and Wards triangle (−9.9%; P < 0.0001) at 6 months posttransplantation. From the 6 months to 12 months, there was a significant improvement in BMD at above sites except at Wards triangle. The decline in BMD was nonsignificant at the whole body (−0.3%, P = 0.748) and the lumbar spine (−2.7%, P = 0.130) at 6 months posttransplant. Younger patients with allogenic graft and steroid use are more likely to have significant loss of BMD at hip posttransplant. Serum osteocalcin decreased, and N-telopeptide increased at 3–6 months, which return to baseline at 1-year posttransplant. Conclusions: A significant bone loss is observed at 6 months in patients with post-HSCT. The bone loss occurs predominantly at cortical bone. There is recovery of bone mass at 12 months posttransplant except at Wards triangle. Bone loss after HSCT is multifactorial.

Non invasive and percutaneous ablation of nontoxic solid nodules

Thyroid nodules (TNs) are commonly seen in the general population with a prevalence of about 4% by palpation and about 10-41% by ultrasound. Most of the TNs are benign. Surgery and radioiodine therapy have been the mainstay of therapy in compressive TNs. Surgery has its own complications and hence, the quest for a non-invasive modality of treatment remains. Radiofrequency ablation, ethanol ablation and laser ablation are the non-invasive methods of treating a benign TN. Also, microwave ablation and high intensity focused ultrasound have recently been tried in the treatment of TNs. In this review, we will be discussing the above newer and emerging modalities in the non-invasive ablation of non-toxic nodules.

Sarcomatous transformation (Leiomyosarcoma) in polyostotic fibrous dysplagia.

Malignant changes in polyostotic fibrous dysplasia are very rare. Most common malignancies reported are osteosarcoma and fibrosarcoma, chondrosarcoma and malignant fibrous histiocytoma. Here, we report a previously diagnosed case of fibrous dysplasia who has developed leiomyosarcoma; diagnosis of which was delayed for about one year despite repeated fine needle aspiration and open biopsy.

Hidden diagnosis of multiple endocrine neoplasia-1 unraveled during workup of virilization caused by adrenocortical carcinoma

Multiple endocrine neoplasia-1 (MEN1) is an autosomal dominant syndrome with classic triad of parathyroid hyperplasia, pancreatic neuroendocrine tumors, and pituitary adenomas. Other recognized manifestations include carcinoid, cutaneous or adrenocortical tumors. It is commonly presented with clinical features related to parathyroid, pancreas or pituitary lesions. Here, we have presented a case that had virilization and biochemical Cushings syndrome due to adrenocortical carcinoma as presenting feature of MEN1. Cushings syndrome in MEN1 is an extremely rare and usually late manifestation and most cases are due to corticotropin-producing pituitary adenomas. Although Cushings syndrome generally develops years after the more typical manifestations of MEN1 appear, it may be the primary manifestation of MEN1 syndrome particularly when related to adrenal adenoma or carcinoma.

Raised CA19.9 and hepatic space occupying lesion after teriparatide therapy in a case of polyostotic fibrous dysplasia.

Indian Journal of Endocrinology and Metabolism / Sep-Oct 2013 / Vol 17 | Issue 5 947 Besides hypertensive crisis, management of hypotensive crisis during phaeochromocytoma resection is almost equally challenging. Sudden cessation of influx of catecholamines from the tumor as a result of vascular ligation can lead to sudden hypotension.[6] A larger size of the functional tumor, higher amount of pre-operative catecholamine secretion, and presence of co-morbidities are the predominant factors that cause a greater fall of blood pressure during intra-operative and post-operative period, which is sometimes refractory even to aggressive management.[6]