Arun S Menon

Utility of Gallium-68 DOTANOC PET/CT in the localization of Tumour-induced osteomalacia.

Tumour‐induced osteomalacia (TIO) is a rare disorder characterized by hypophosphataemic osteomalacia caused by small mesenchymal tumours secreting fibroblast growth factor 23 (FGF 23). The most difficult part in the management of these patients is the localization of tumours causing TIO.

Technetium uptake predicts remission and relapse in Grave's disease patients on antithyroid drugs for at least 1 year in South Indian subjects.

Context: Most of the information on remission related factors in Graves disease are derived from Western literature. It is likely that there may be additional prognostic factors and differences in the postdrug treatment course of Graves disease in India. Aim: To study factors which predict remission/relapse in Graves disease patients from South India. Also to establish if technetium (Tc) uptake has a role in predicting remission. Subjects and Methods: Records of 174 patients with clinical, biochemical, and scintigraphic criteria consistent with Graves disease, seen in our Institution between January 2006 and 2014 were analyzed. Patient factors, drug-related factors, Tc-99m uptake and other clinical factors were compared between the remission and nonremission groups. Statistical Analysis Used: Mann–Whitney U-test and Chi-square tests were used when appropriate to compare the groups. Results: Fifty-seven (32.7%) patients attained remission after at least 1 year of thionamide therapy. Of these, 11 (19.2%) patients relapsed within 1 year. Age, gender, goiter, and presence of extrathyroidal manifestations were not associated with remission. Higher values of Tc uptake were positively associated with remission (P- 0.02). Time to achievement of normal thyroid function and composite dose: Time scores were significantly associated with remission (P - 0.05 and P - 0.01, respectively). Patients with lower FT4 at presentation had a higher chance of remission (P - 0.01). The relapse rates were lower than previously reported in the literature. A higher Tc uptake was found to be significantly associated with relapse also (P - 0.009). Conclusion: The prognostic factors associated with remission in Gravess disease in this South Indian study are not the same as that reported in Western literature. Tc scintigraphy may have an additional role in identifying people who are likely to undergo remission and thus predict the outcome of Graves disease.

Treatment outcomes in pediatric differentiated thyroid carcinoma.

Abstract Background Until the American Thyroid Association (ATA) guidelines on management of pediatric differentiated thyroid carcinoma (DTC) became available in 2015, all children with DTC were treated like adults. This study aims to investigate the outcome of pediatric DTC and factors predicting the response to therapy in pediatric DTC managed according to adult guidelines. Methods Clinical records of 41 children less than 18 years of age diagnosed with DTC followed from 2007 in a single center were reviewed. According to the new ATA classification for pediatric DTC, five had low-risk, 28 had intermediate-risk and eight had high-risk disease at presentation. Results There was no mortality or recurrence in this cohort of pediatric DTC patients and the cure rate was 46% during a mean follow-up of 44 months when they were managed according to adult guidelines. Neither the new ATA risk classification nor any clinicopathological character was identified which could predict the response to therapy. The new ATA guidelines would have avoided 27% of the radioiodine therapies given. Conclusions This study showed that DTC in children managed according to adult guidelines had a good cure rate. The new ATA guidelines on pediatric DTC might have drastically reduced the number of radioiodine therapies in the affected children. Long term prospective studies are needed to validate the benefits and risks of both these approaches.

Prevalence of thyroid disorders is not different in type 2 diabetes mellitus compared to nondiabetics in South India

Studies on thyroid disorders in type 2 diabetes mellitus (DM) are fewer than those in type 1 diabetes, but data from different parts of the world have shown conflicting results. To look at the prevalence of thyroid disorders in type 2 DM and nondiabetic controls separately in a community cohort and a hospital cohort from the same locality in South India. Thyroid function tests and thyroid autoantibodies were done in 986 people in the community (258 diabetics and 634 nondiabetics). In the hospital cohort of 194 people (147 diabetics and 47 nondiabetics), an ultrasonography of the neck was done in addition. Thyroid dysfunction was more common in the community compared to the hospital cohort 15.9 vs 9.6% but there was no difference in the proportion of people with thyroid dysfunction in diabetics and nondiabetics in both the community and the hospital cohorts. (15.6 vs 16.2% in the community and 9.6 vs 6.3% in the hospital in diabetics and nondiabetics respectively). Clinical goiter and sonographically detected goiter were also similar in diabetics and nondiabetics in the community and the hospital cohorts respectively. Females had more prevalence of goiter irrespective of the presence of diabetes. Commonest thyroid dysfunction was hypothyroidism and subclinical hypothyroidism in both cohorts. This unique study conducted in a community and hospital cohort from the same locality showed that the prevalence of thyroid disorders is similar in type 2 diabetic and nondiabetic subjects in our population.

Radiofrequency Ablation Followed by Percutaneous Ethanol Ablation Leading to Long-Term Remission of Hyperparathyroidism

A 30-year-old male with cerebral palsy and motor impairment presented with right femur fracture. He had gradually worsening mobility and contractures of all extremities for the preceding 5 years. Evaluation showed multiple vertebral and femoral fractures, severe osteoporosis, a large parathyroid adenoma, and parathormone (PTH) exceeding 2500 pg/mL. Because of poor general health and high anesthetic risk, parathyroidectomy was deemed impractical. Ultrasound-guided radiofrequency ablation (RFA) helped achieve 50% size reduction and PTH levels with better control of hypercalcemia. Later, as calcium and PTH remained elevated, percutaneous ethanol ablation was performed with resultant normalization of PTH and substantial symptomatic improvement. Two years later, he still remains normocalcaemic with normal PTH levels. We propose that RFA and percutaneous ethanol ablation be considered as effective short-term options for surgically difficult cases, which could even help achieve long-term remission. Although not previously reported, our case illustrates that both RFA and percutaneous ethanol ablation could be safely performed successively achieving long-term remission.

Unilateral adrenal mass as the sole initial manifestation of differentiated thyroid cancer.

Unilateral adrenal metastases without disseminated disease has rarely been reported in differentiated thyroid carcinoma (DTC). A 72-year-old female presented with vague abdominal discomfort and loss of appetite of 2 months duration. She had undergone left hemithyroidectomy for a benign thyroid nodule 18 years ago. A contrast CT of the abdomen showed a large left adrenal mass measuring 11×9 cm, suspicious of adrenocortical carcinoma. Hormonal evaluation was in keeping with a non-functional tumour. The patient underwent left adrenalectomy, histopathology of which revealed metastatic well-differentiated thyroid carcinoma. Ultrasound of thyroid done postoperatively showed a subcentimetric hypoechoic lesion with increased vascularity and microcalcifications in the right thyroid bed. Histopathology from a completion thyroidectomy specimen was consistent with follicular variant of papillary thyroid carcinoma. She was treated with high-dose radioiodine ablation therapy and has remained disease-free on follow-up for more than a year.

Autoantibodies to Insulin and Dysglycemia in People With and Without Diabetes: An Underdiagnosed Association

The potential effects of inhibitory immunoglobulins to insulin were first described in insulin-treated patients many decades ago (1). This antibody response is thought to occur in at least 40% of patients on insulin therapy (2). Subsequent case reports documented glycemic excursions in the form of markedly increased insulin requirements and unpredictable hypoglycemic episodes, both of which were attributable to insulin autoantibodies (3). Autoantibodies to insulin also can occur occasionally in patients who have not been previously exposed to insulin. Autoimmune hypoglycemia resulting from high titers of insulin autoantibodies have been reported, mostly from Japan, as a rare cause of hyperinsulinemic hypoglycemia (4). There has only been one confirmed case of autoimmune hypoglycemia reported from India (5). The estimation of insulin autoantibodies is an integral part of the diagnosis in such cases. Apart from insulin, other inciting agents implicated include sulfahydryl group–containing drugs and alpha-lipoic acid (ALA). Autoimmune hypoglycemia also has been reported to be associated with autoimmune disorders and plasma cell dyscrasias (6). Spontaneous resolution has been reported in a few cases of autoimmune hypoglycemia, and a dramatic response to steroids was seen in some other cases that manifested both hypoglycemia and hyperglycemia. In this article, we describe our experience with patients who presented with glycemic excursions resulting from insulin autoantibodies from a single university referral teaching center in South India. ### Case Presentation At the Department of Endocrinology of Amrita Institute of Medical Sciences in Kochi, Kerala, India, a large tertiary care center, between 2008 and 2014, we diagnosed eight cases in which insulin autoantibodies could be implicated as the etiological factor responsible for spontaneous hyperinsulinemic hypoglycemia. One patient presented exclusively with postprandial hypoglycemia–related symptoms, whereas the others presented with a combination of fasting and postprandial symptoms. During the same time period, there were only seven cases of histopathologically proven insulinomas …

Epidemiology of diabetic foot complications in a podiatry clinic of a tertiary hospital in South India

Introduction: The prevalence of diabetes is increasing worldwide resulting in foot complications, which leads to poor quality of life and increased cost of living. Aim: The main aim of this study was to find out the foot complications in diabetic patients and to analyze the underlying etiology. Methodology: A retrospective study was carried out in the podiatry Department of Amrita Institute of Medical Sciences, Kerala among 277 diabetic patients with recent and recurrent foot complications. Results: Systemic hypertension (76.89%) has been found to be one of the major risk factor coexisting in the study population. 49.45% patients had preexisting peripheral neuropathy and non-healing ulcers were seen in 41.51%. Other complications include charcot arthropathy (10.46%), gangrene (9.38%), cellulitis (7.94%), fungal infections (6.89%), callus (3.61%), osteomyelitis (3.97%), and necrotizing fasciitis (2.52%). Culture report on foot ulcer patients revealed that Gram-positive Staphylococcus species (18.8%) and the Gram-negative Pseudomonas species (18.2%) were the predominant organisms. Other organisms isolated were Klebsiella species, Escherichia coli, Acenetobacter, Proteus, Enterococcus species, and streptococci. Fluoroquinolones were the most commonly prescribed antibiotics (33.5%), followed by penicillin (8.3%), clindamycin (6.1%), carbapenems (5.05%), cephalosporins (2.8%), cotrimoxazole (2.5%), and chloramphenicol (0.7%). Conclusion: The study highlights the importance of foot care, relevance of early detection of diabetes and subsequent monitoring of diabetic complications.