Iqbal Malik

Interference in free thyroxine immunoassay

We report two patients who presented with non-specific symptoms of tiredness that prompted their clinician to order a thyroid function test. In both cases, free thyroxine (T4) was reported to be high, with a normal thyroid-stimulating hormone (TSH). Repeated blood tests from the same laboratory using the same assay method yielded similar results. Due to discrepancies between the clinical and laboratory findings, we decided to repeat the blood tests at another laboratory using a different assay method. This revealed normal free T4 and TSH levels, suggesting that heterophile antibodies were interfering with the free T4 assay, leading to clinical confusion.

Fatal Morganella morganii bacteraemia in a diabetic patient with gas gangrene.

We report a case of a 60-year-old lady with a history of a heel ulcer that had not responded to antibiotic therapy. This progressed to involve the right leg, which was swollen and erythematous. Radiological imaging revealed the presence of gas within the fascial planes. Blood cultures on admission yielded Morganella morganii. Due to the extent of the gas gangrene and her co-morbidities the patient was not suitable for surgical intervention and was treated conservatively with antibiotics. She deteriorated and died within 72 h of presentation. Non-clostridial gas gangrene is relatively rare, and diagnosis is frequently delayed and often missed. Early aggressive surgical intervention combined with appropriate antibiotic therapy is essential. Bacterial species other than Clostridium should be considered in all cases of gas gangrene.

Gemella haemolysans Bacteraemia in a Patient with Solitary Liver Abscess

We present a case of a 42-year-old man with a solitary liver abscess and Gemella haemolysans bacteraemia. No other focus of infection was identified. The patient did not have any predisposing factors. He was treated with antibiotics for 6 weeks and the abscess was drained. He made a complete recovery.

A Patient with Thyrotropinoma Cosecreting Growth Hormone and Follicle-Stimulating Hormone with Low α-Glycoprotein: A New Subentity?

BACKGROUND Thyrotropinomas are rare pituitary tumors. In 25 percent of cases there is autonomous secretion of a second pituitary hormone, adding to the clinical complexity. We report a patient with thyrotropin (TSH)-dependant hyperthyroidism along with growth hormone (GH) and follicle-stimulating hormone (FSH) hypersecretion but low alpha-glycoprotein (alpha-subunit) concentrations, a hitherto unique constellation of findings. SUMMARY A 67-year-old Scottish lady presented with longstanding ankle edema, paroxysmal atrial fibrillation, uncontrolled hypertension, fine tremors, warm peripheries, and agitation. Initial findings were a small goiter, elevated serum TSH of 7.37 mU/L (normal range, 0.30-6.0 mU/L), a free-thyroxine concentration of 34.9 pmol/L (normal range, 9.0-24.0 pmol/L), a flat TSH response to TSH-releasing hormone, and serum alpha-subunit of 3.1 IU/L (normal, <3.0 IU/L). There was no evidence of an abnormal thyroid hormone beta receptor by genotyping. Serum FSH was 56.8 U/L, but the luteinizing hormone (LH) was 23.6 U/L (postmenopausal FSH and LH reference ranges both >30 U/L) Basal insulin-like growth factor I was elevated to 487 microg/L with the concomitant serum GH being 14.1 mU/L, and subsequent serum GH values 30 minutes after 75 g oral glucose being 19.1 mU/L and 150 minutes later being 13.7 mU/L. An magnetic resonance imaging pituitary revealed a macroadenoma. Pituitary adenomectomy was performed with the histology confirming a pituitary adenoma, and the immunohistochemistry staining showed positive reactivity for FSH with scattered cells staining for GH and TSH. Staining for other anterior pituitary hormones was negative. After pituitary surgery she became clinically and biochemically euthyroid, the serum IFG-1 became normal, but the pattern of serum FSH and LH did not change. CONCLUSION This case of plurihormonal thyrotropinoma is unique in having hypersecretion of TSH, GH, and FSH with low alpha-subunit. Such a combination may represent a new subentity of TSHomas.

Social Deprivation and Primary Hyperparathyroidism

OBJECTIVE To investigate the potential relationship between social status or deprivation and the prevalence of primary hyperparathyroidism (PHPT). METHODS We retrospectively identified a cohort of patients diagnosed as having PHPT between 1981 and 2007 from the Scottish Morbidity Records database. The Scottish Index of Multiple Deprivation (SIMD) 2006 quintiles were derived for these patients by using the postal codes. The distribution of the SIMD quintiles was examined to determine the possible influence of deprivation on the incidence of PHPT. RESULTS In Scotland between 1981 and 2007, 3,039 patients were diagnosed as having PHPT, in accordance with the International Classification of Diseases code for PHPT. The distribution of the PHPT cohort across the SIMD 2006 quintiles was significantly different from that expected, with a higher representation (27.2%) among the most deprived and a lower representation (14.5%) in the least deprived quintile, in comparison with the 20% expected in each quintile (P<.0001). CONCLUSION The findings in this study suggest that socioeconomic deprivation is associated with an increased risk of developing PHPT.

Retinopathy in prediabetes

It is established that IGT is associated with macrovascular complications. However, only recently has evidence been collated to demonstrate that microvascular complications (including retinopathy) may also occur in patients with prediabetes. Prediabetes refers to the intermediate metabolic states between normal and diabetic glucose homeostasis. The preva lence of prediabetes ranges from 20 to 40%. It is becoming increasingly recognised that both macrovascular and microvas cular complications can occur in patients with prediabetes. Indeed 8–12% of patients with prediabetes have retinopathy. We report a case with retinopathy to illustrate the need for screening all patients with prediabetes, as we do in patients with type 2 diabetes. Healthcare resources are already stretched, looking after the epidemic of type 2 diabetes and this additional burden of screening would have major resource implications.

Diabetic Foot Ulcer: Amputation on Request?

In 2000, a Scottish surgeon received significant publicity for amputating lower limbs from healthy patients who were thought to have a Body Integrity Identity Disorder (1). We present a type 1 diabetic patient with a recurrent foot ulcer who requested a lower-limb amputation. Although very different, this situation also created difficult ethical issues that we have attempted to address. Peter C. Brown (aged 54 years) was diagnosed as having type 1 diabetes at age 21 years. Between early 2006 and November 2008, he had several admissions with a diabetic foot ulcer that partly resolved but never fully healed (2). By early November 2008 and after discussions with his family, he decided that he …

An unusual case of profound hyponatraemia and bilateral adrenal calcifications

We report a case of a 65-year-old lady who presented with acute confusion and profound hyponatraemia (plasma sodium of 97 mmol/L). Five years earlier she had developed sepsis and was found to have hyponatraemia, thought to be due to syndrome of inappropriate antidiuretic hormone secretion. The patient was lost to follow-up. The patient was covered with steroids and investigations confirmed primary adrenal failure with flat response of cortisol to adrenocorticotropic hormone (ACTH) stimulation and very high level of ACTH. Adrenal auto-antibodies were negative and a computed tomography of the adrenals showed bilateral adrenal calcifications, suggestive of previous haemorrhage or infarction. Bilateral adrenal calcification due to haemorrhage/infarction usually does not present with severe hyponatraemia; however, adrenal insufficiency should be excluded in all cases of severe hyponatraemia. In suspected cases, patients should be treated with steroids, even when symptoms or signs are absent, while results of investigations are awaited.