Federico Hawkins Carranza

Recalcitrant hypocalcaemia in a patient with post-thyroidectomy hypoparathyroidism and Roux-en-Y gastric bypass.

INTRODUCTION Roux-en-Y gastric bypass (RYGB) places patients at an increased risk of hypocalcaemia due to the reduction in calcium absorption (because the procedure bypasses the duodenum and jejunum) and vitamin D deficiency. Subsequent thyroid surgery increases the risk of severe hypocalcaemia due to potential post-operative hypoparathyroidism. Only a few cases have been published before of this type of treatment-challenging hypocalcaemia. CLINICAL PRESENTATION We report the case of a 31-year-old woman with a previous RYGB, who suffered severe and symptomatic chronic hypocalcaemia after total thyroidectomy. She required aggressive therapy with oral calcium and calcitriol and frequent calcium infusions, but there was no improvement in serum calcium level. Due to the lack of response to standard therapy, teriparatide treatment was started (first with subcutaneous injections and thereafter with a multipulse subcutaneous infusor) but the results were disappointing. As there was no response to different medical treatments, reversal of RYGB was performed with no complications and a subsequent sustained increase in serum calcium level. CONCLUSIONS This case shows that patients with postoperative hypoparathyroidism and RYGB have increased risk of severe recalcitrant symptomatic hypocalcaemia. In our case teriparatide was ineffective but, as this is the first patient reported, more results are needed to evaluate properly the effect of teriparatide in this multifactorial hypocalcaemia. Reversal of RYGB should be considered when medical therapy has failed, because surgery restores an adequate absorption of calcium and vitamin D from previously bypassed duodenum and proximal jejunum.

Etiopatogenia y tratamiento de la osteoporosis y fracturas del varón adulto

Los varones han sido menos estudiados para el diagnóstico de osteoporosis. Basta con hacer una búsqueda en PubMed para comprobar que en la última década hay 26.556 trabajos publicados para la osteoporosis posmenopáusica frente a 8.523 en los varones. Se ha podido confirmar que un 30% de las mujeres y menos del 10% de los varones con osteoporosis reciben antirresortivos. Se revisan el impacto de la osteoporosis del varón en la práctica clı́nica, los factores que contribuyen a su etiopatogenia, el diagnóstico actual de la pérdida ósea en el varón, ası́ como las últimas aproximaciones terapéuticas.

Hiperparatiroidismo primario normocalcémico: un problema en aumento

Normocalcemic primary hyperparathyroidism is at present one of the most common reasons for consultation in bone metabolism units. It is characterized by increased levels of intact parathyroid hormone in the presence of normal serum calcium (total and ionized) in generally asymptomatic individuals. The differential diagnosis should be considered in all situations that occur with secondary hyperparathyroidism. Its natural history is not well known, and it does not always progress to hypercalcemia. As a recently recognized entity, there are still no specific recommendations for its management. In this review we discuss some aspects of this entity, emphasizing the importance of a proper laboratory diagnosis, assessing possible signs or symptoms associated such as kidney stones or osteoporosis, which can help the clinician to take a conservative or interventionist attitude.

Low trabecular bone score in postmenopausal women with differentiated thyroid carcinoma after long-term TSH suppressive therapy

The effect of thyroid suppression therapy (TST) on trabecular bone scores (TBS) and bone mineral density (BMD) in thyroidectomized women with differentiated thyroid carcinoma (DTC) on long-term follow-up is presently not conclusive. Patients and Methods. We carried out a study in 61 premenopausal and 84 postmenopausal Caucasian women with DTC. Serum biochemistry, bone markers, TBS, BMD, and bone fractures were evaluated 1–3 months post surgery and after a median follow-up of 10 years. Results. In the final study, patients belonged to Group I Premenopausal (n = 14) who remained in this status; Group II Premenopausal who became postmenopausal (n = 47); Group III patients who were and continued as postmenopausal (n = 84). Baseline premenopausal patients had a normal TBS mean value of 1.39 ± 0.14 significantly higher than that found in postmenopausal 1.31 ± 0.12 (p = 001). In the final study, premenopausal patients continued to have a normal TBS of 1.46 ± 0.08 compared to the significantly lower value of postmenopausal patients 1.25 ± 0.11 (p = 0.0009). Lumbar BMD (L-BMD) loss after the long-term study was significant in Group II (0.99 g/cm2 ± 0.13 vs. 0.91 ± 0.12 g/cm2, p < 0.0001) and there was a slight, but not significant, bone loss in Group I (1.00 ± 0.12 vs. 0.98 ± 0.11, p = 0.1936) and in Group III (0.86 ± 0.12 vs. 0.84 ± 0.15, p = 0.1924) compared with baseline values. Conclusion: Longer-term suppression therapy in female patients with DTC did not increase significantly the risk of bone loss, although we found in postmenopausal patients deterioration of bone microarchitecture. TBS study should be considered in the evaluation of postmenopausal DTC patients on long-term DTC for the evaluation of the risk of fractures.

Analysis of 176 cases of adrenal incidentaloma investigated in a single clinical center, what are we doing?

CONCLUSIONS:  The incidental adrenal masses studied in our centre are predominantly small, bening, nonfunctioning, stable in time in terms of growth, hormonal production and malignancy.  Most of them are well characterized with the first radiologic test.  We found a high prevalence of bilateral lesions and of Subclinical Cushing síndrome when compared with other series.  In non-oncologic patients is rare to find malignant lesions.  Adrenal carcinoma is rarely presented as asymptomatic adrenal incidentaloma.  The low incidence of malignant transformation of bening lesions should make us reconsider our clinical practice to avoid prolonged follow up and duplicity of radiologic and laboratory tests. RESULTS: 176 patients (111 women and 65 men) met inclusion criteria. The medium age was 59,68±12,54 years (31-84).