Ally P.H. Prebtani

A systematic review of the literature examining the diagnostic efficacy of measurement of fractionated plasma free metanephrines in the biochemical diagnosis of pheochromocytoma

BackgroundFractionated plasma metanephrine measurements are commonly used in biochemical testing in search of pheochromocytoma.MethodsWe aimed to critically appraise the diagnostic efficacy of fractionated plasma free metanephrine measurements in detecting pheochromocytoma. Nine electronic databases, meeting abstracts, and the Science Citation Index were searched and supplemented with previously unpublished data. Methodologic and reporting quality was independently assessed by two endocrinologists using a checklist developed by the Standards for Reporting of Diagnostic Studies Accuracy Group and data were independently abstracted.ResultsLimitations in methodologic quality were noted in all studies. In all subjects (including those with genetic predisposition): the sensitivities for detection of pheochromocytoma were 96%–100% (95% CI ranged from 82% to 100%), whereas the specificities were 85%–100% (95% CI ranged from 78% to 100%). Statistical heterogeneity was noted upon pooling positive likelihood ratios when those with predisposition to disease were included (p < 0.001). However, upon pooling the positive or negative likelihood ratios for patients with sporadic pheochromocytoma (n = 191) or those at risk for sporadic pheochromocytoma (n = 718), no statistical heterogeneity was noted (p = 0.4). For sporadic subjects, the pooled positive likelihood ratio was 5.77 (95% CI = 4.90, 6.81) and the pooled negative likelihood ratio was 0.02 (95% CI = 0.01, 0.07).ConclusionNegative plasma fractionated free metanephrine measurements are effective in ruling out pheochromocytoma. However, a positive test result only moderately increases suspicion of disease, particularly when screening for sporadic pheochromocytoma.

Pantoprazole-induced acute interstitial nephritis

A 73-year-old man presented to the emergency department feeling tired and nauseous, and unable to eat. His medical history included congestive heart failure, stable rheumatoid arthritis and benign prostatic hypertrophy. He had not recently had any fever, rash or joint pain, nor did he have symptoms

Primary aldosteronism: a common cause of resistant hypertension

Resistant or difficult-to-control hypertension is a problem that may affect as many as 13% of all persons with hypertension.[1][1] It is estimated that more than 6 million (22.6%) of adults in Canada have hypertension, but less than two-thirds have it adequately controlled despite conventional

Tools for Enhancement and Quality Improvement of Peer Assessment and Clinical Care in Endocrinology and Metabolism

Members of the College of Physicians and Surgeons of Ontario Endocrinology and Metabolism Peer Review Network have been involved in a quality improvement project to help standardize the peer assessment of physicians practicing in endocrinology and metabolism. This has included developing state-of-the-art summaries of common endocrine problems by Canadian experts in endocrinology and metabolism. These tools have been developed in response to the educational needs, as identified by peer reviewers, of practicing endocrinologists in Ontario. These pedagogical tools aim not only to standardize the documentation of the clinical performance of endocrinologists but also to make the process more transparent and to improve the quality of patient care in Ontario. This article summarizes the project and also provides the tools developed for the endocrinology and metabolism section of the College of Physicians and Surgeons of Ontario.

The Potential Role of Primary Care in Case Detection/Screening of Primary Aldosteronism

Endocrine hypertension, particularly primary aldosteronism (PA), was previously considered to account for less than 1% of all hypertension and was suspected only when patients presented with spontaneous hypokalemia. However, the last 20 years of PA research has now clearly shown that PA is not a rarity, but rather, may account for up to 13% of unselected hypertensive individuals and between 10% and 20% of those with resistant hypertension. Most of these patients do not have spontaneous hypokalemia. The population prevalence of PA likely far exceeds actual detection rates in routine clinical care. As PA represents one of the most common, potentially reversible causes of hypertension, and is associated with significant cardiovascular complications over the long term, it is clear that a pragmatic strategy for targeted case detection in primary care is needed.

An Unusual Cause of Severe Immunosuppression

Ectopic adrenocorticotropic hormone secretion (EAS) is a rare cause of endogenous Cushing’s syndrome and is associated with immunosuppression and opportunistic infections. We report the case of a person who presented with rapid onset of hypertension, diabetes mellitus, and severe hypokalemia in the context of significantly elevated adrenocorticotropic hormone (ACTH) levels and marked hypercortisolism. Subsequent investigations led to a diagnosis of EAS without an identifiable source. Her clinical status continued to deteriorate despite medical management of her hypercortisolemia, thus an urgent bilateral adrenalectomy was performed. This patient’s course was complicated by multiple opportunistic infections with cytomegalovirus, Pneumocystis jirovecii (PJP), Mycobacterium tuberculosis and possibly BK virus. To the best of our knowledge, this is the first description of this specific constellation of opportunistic infections in the setting of EAS. Our case highlights the need to consider multiple and rare opportunistic infections while managing EAS and supports early bilateral adrenalectomy in critically ill patients with EAS of unknown origin.