Juan Francisco Merino-Torres

A case of lipoatrophy with insulin detemir

Lipoatrophy is a rare cutaneous side-effect that can develop at the site of insulin injection. Since the introduction of human recombinant insulin the number of cases has decreased although cases have been reported in association with the use of rapid acting insulin analogues and continuous subcutaneous insulin infusion (CSII), recently one case has been reported with the use of insulin glargine. Insulin-induced lipoatrophy is a subcutaneous fat atrophy at the sites of injection which is relevant not only because of the cosmetic problem, but also because of the variability of absorption it causes in the site of injection. This report describes a patient with a type 1 diabetes mellitus who develops a lipoatrophy induced by insulin detemir. To our understanding this is one of the first reported cases of lipoatrophy induced by insulin detemir.

Differentiated thyroid carcinoma in a girl with resistance to thyroid hormone management with triiodothyroacetic acid.

Abstract Thyroid hormone resistance syndrome is characterized by a reduced target tissue response to the action of thyroid hormone, which leads to high levels of free thyroxine and free triiodothyronine with non-suppressed levels of thyrotropin (TSH). Recently, three cases of papillary thyroid carcinoma associated with thyroid hormone resistance syndrome were published. The main challenge in this situation is the difficulty of maintaining the suppression of TSH levels without producing symptoms of hyperthyroidism. We present another case of an association of thyroid hormone resistance syndrome and papillary thyroid carcinoma, and we share our experience with 3,5,3′-triiodothyroacetic acid, which made possible an easier management of the carcinoma after surgery, maintaining the TSH levels suppressed despite the resistance to thyroid hormones.

Documento de posicionamiento: evaluación y manejo de la hipoglucemia en el paciente concon diabetes mellitus. Grupo de Trabajo de Diabetes Mellitus de la Sociedad Española de Endocrinología y Nutrición

OBJECTIVE To provide practical recommendations for evaluation and management of hypoglycemia in patients with diabetes mellitus. PARTICIPANTS Members of the Diabetes Mellitus Working Group of the Spanish Society of Endocrinology and Nutrition. METHODS Recommendations were formulated according to the Grading of Recommendations, Assessment, Development, and Evaluation system to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (PubMed). Papers in English and Spanish with publication date before 15 February 2013 were included. For recommendations about drugs only those approved by the European Medicines Agency were included. After formulation of recommendations, they were discussed by the Working Group. CONCLUSIONS The document provides evidence-based practical recommendations for evaluation and management of hypoglycemia in patients with diabetes mellitus.

Alterations in carbohydrate metabolism in cirrhotic patients before and after liver transplant

AIM The main objective of this study is to demonstrate whether carbohydrate metabolism alterations identified in patients with advanced cirrhosis show any improvement after liver transplant. METHODS The study included 86 patients who underwent liver transplant between March 2010 and February 2011. An oral glucose tolerance test was performed before the liver transplant, and 6 and 12 months after. Beta cell function and insulin resistance were also calculated, applying formulae that use basal plasma glycaemia and insulin, and plasma glycaemia and insulin during an oral glucose tolerance test. Risk factors for pre- and post-transplant diabetes were also studied. The diagnosis of diabetes was based on an OGTT. RESULTS The proportion of patients with diabetes before transplant, and at month 6 and 12 after transplant were 70.9%, 48.8% and 39.2%, respectively. Compared to baseline, at month 6 the odds ratio of having diabetes was 0.39 (IC 95% [0.21, 0.73]) and at month 12 it was 0.26 (IC 95% [0.14, 0.50]). The composite insulin sensitivity index values at 6 and 12 months were 1.72 units higher (IC 95% [0.84, 2.58]) and 1.58 units higher (IC 95% [0.68, 2.44)] than baseline. A statistically significant association was found between high MELD values and high body mass index, and risk of pre-transplant diabetes (p=0.001 and p=0.033, respectively). Cirrhosis aetiology did not influence the risk of diabetes. CONCLUSIONS In this study, we were able to ascertain that alterations in carbohydrate metabolism typical of advanced cirrhosis improve after liver transplant. This improvement is mainly due to an improvement in insulin resistance.

Detection of glucose abnormalities in patients with acute coronary heart disease: Study of reliable tools in clinical practice

Aim: To investigate the prevalence of glucose abnormalities in patients with acute coronary syndrome and to assess the reliability of certain clinical or analytical variables to predict a pathologic result of oral glucose tolerance test (OGTT) at 3 months from discharge. Subjects and methods: Prospective study of 102 patients admitted to the coronary care units. Patients were classified according to the American Diabetes Association criteria. Three months after discharge, an OGTT was performed to non-diabetic patients. Results: Forty-six (45.1 %) patients were identified as diabetic (5 previously undiagnosed) and 56 (54.9%) as non-diabetic. OGTT identified 22% of diabetes, 33% of impaired glucose tolerance, and 45% of normal glucose tolerance. Fasting glucose (r=0.55, p<0.001), glycated hemoglobin (HbA1c) (r=0.46, p<0.001), low HDL cholesterol (HDL-c) levels (r=−0.34, p<0.02), waist-hip ratio (r=0.45, p<0.01), high systolic blood pressure (r=0.5, p<0.01), and presence of acute myocardial infarction (r=0.46, p<0.001) at admission resulted significant to predict a pathologic result of OGTT. Conclusions: Glucose abnormalities are frequent in acute coronary syndrome patients. Certain clinical and analytical markers at admission such as fasting glucose, HbA1c, HDL-c<40 mg/dl, waist-hip ratio, and systolic blood pressure, are useful to recognize patients with a higher predisposition to present a pathologic result in OGTT at 3 months from discharge.

Metabolic acidosis as a complication of intravenous dextrose administration in a patient with insulinoma.

There are few cases published in literature in which the use of intravenous dextrose as treatment for an insulinoma resulted in a metabolic acidosis. This is due perhaps to the usual method of administration, which is usually at low concentrations, for limited periods or low volumes. We present the case of a woman with suspected insulinoma by laboratory findings in which an endogenous hyperinsulinism was observed. During hospitalization, the patient required a progressive increase of the glucose infusion to prevent severe hypoglycemia. Two days before surgery, the patient presented symptoms of malaise and muscle weakness and a metabolic acidosis with hypokalemia became apparent in the blood analysis. This metabolic imbalance was attributed to a long period of treatment with high volume of intravenous dextrose infusion. If large doses of dextrose are required in a patient with an insulinoma, then the possibility of a metabolic imbalance must be considered during the follow-up. When the suspicion of an insulinoma is high, and all the attempts of pre-operative localization fail, patients should be derived early to specialized centers with modern imaging techniques, so that surgery is not delayed, and this rare and threatening complication could be avoided.

Desnutrición caloricoproteínica grave tras bypass gástrico

La cirugia bariatrica da lugar a una perdida de peso que perdura y mejora las comorbilidades de la obesidad morbida. Pueden darse complicaciones tras ella, la mayoria nutricionales y de caracter leve, pero en algunos casos pueden ser graves y comprometer la vida del paciente. Se presenta el caso de una mujer de 50 anos en quien se desarrollo desnutricion caloricoproteinica grave tras cirugia bariatrica y que preciso que se revirtiera la intervencion. Se discuten los factores que dieron lugar a la desnutricion y las opciones de tratamiento.: Bariatric surgery achieves lasting weight loss and improves the comorbidities associated with morbid obesity. After surgery, patients can develop complications, mainly mild nutritional alterations. However, in some patients, complications can be serious and lifethreatening. We present the case of a 50-year-old woman who developed severe protein-calorie malnutrition after bariatric surgery, which required surgical reversion. The factors leading to malnutrition in this patient and the treatment options are discussed.

Outcomes in patients with diabetes 10 years after liver transplantation

There are discrepancies between studies regarding the effect of diabetes mellitus on morbidity and mortality in patients undergoing liver transplantation. The aim of the present study was to compare mortality, risk of liver graft rejection, and cardiovascular events in patients with and without diabetes undergoing liver transplantation over a 10‐year follow‐up period.

Brain abscess as the initial presentation of a macroprolactinoma: Case report

Macroprolactinomas may behave invasively and infiltrate the skull base, causing a subsequent thinning that can also lead to a bone defect and a direct route of entry for pathogens. We describe the case of a 34-year-old male admitted to hospital with fever (38°C), headache, stiffness in the neck, diplopia and neurological impairment. Brain magnetic resonance imaging showed two bilateral abscesses in the fronto-parietal areas with intracranial venous sinus thrombosis and a pituitary adenoma that extended from the suprasellar region, eroding the sellar floor into the sphenoid sinus. Laboratory hormone measurements showed increased levels of prolactin and low levels of FSH, LH and testosterone. The patient received antibiotic treatment and surgery was performed. The patient developed central deafness as a neurological deficit. It is advisable to include pituitary adenoma in the differential diagnosis of meningitis even though its onset as intracranial abscess and rectus sinus thrombosis is extremely rare.

Insuficiencia suprarrenal inducida por acetato de megestrol: a propósito de 2 casos

Megestrol acetate (MA) is a synthetic progestogen widely used in patients with cancer cachexia, in elderly subjects at risk of malnutrition, and in patients with human immunodeficiency virus infection because of its effect to promote appetite and weight increase. It is however not free from side effects, among which potential development of adrenal insufficiency (AI) or Cushing’s syndrome due to an antagonist or a weak agonist action for the glucocorticoid receptor, respectively, has been reported. Two clinical cases seen at our hospital where biochemical AI occurred in the setting of treatment with MA are reported below. The first patient was a 67-year-old male admitted to psychiatry for behavioral changes. The patient had type 2 diabetes mellitus treated with gliclazide and mantle cell lymphoma diagnosed 5 years before, treated with chemotherapy and hematopoietic stem cell transplantation and on complete remission at the time. He had been treated with MA 160 mg/day for the past 2 years. Magnetic resonance imaging of the brain showed frontotemporal atrophy, while laboratory test results were as follows: cortisol, 2.19 g/dL (normal range [NR], 8--25 g/dL); ACTH, <5 pg/mL (NR, 9--40 pg/mL); testosterone, 1.92 ng/mL (NR, 3--10 ng/mL); FSH, 9.4 mU/mL (NR: 2.0--10.0 mU/mL); and LH, 2.7 mU/mL (NR, 1.5--9.3 mU/mL). Serum electrolyte levels were normal. The patient had no symptoms or signs suggesting AI. Prior corticosteroid treatment was ruled out. An ACTH performed to confirm diagnosis showed cortisol levels of 2.8, 14.0, and 18.0 g/dL at 0, 30, and 60 min, respectively. Because of the borderline response, treatment was started with hydrocortisone 10 mg/day, and MA was discontinued. One month later, the patient had a basal cortisol level of 20.7 g/dL and an ACTH level of 33.2 pg/dL, and hydrocortisone was therefore discontinued; testosterone was also normalized. The second patient was a 70-year-old male with history of hypertension, dyslipidemia, and an esophageal tumor diagnosed in 2011. After surgery, moderated mixed malnutrition was diagnosed, and treatment was therefore started with MA 160 mg/day. Laboratory tests results included: basal cortisol, 7.36 g/dL with ACTH 17.6 pg/mL; testosterone, 1.03 ng/mL; LH, 5.5 mU/mL, and FSH, 13.7 mU/mL. Levels of all other pituitary and adrenal hormones and electrolytes were normal. An ACTH stimulation test revealed cortisol levels of 1.36, 8.8, and 10.2 g/day at 0, 30, and 60 min, respectively. Treatment was started with hydrocortisone 20 mg/day in three divided doses, and MA was discontinued. After 2 months, values of ACTH (12.5 ng/mL), cortisol