Karthik Balachandran

Assessment of insulin injection techniques among diabetes patients in a tertiary care centre.

AIMS The efficacy of insulin therapy in diabetes depends on proper storage and injection technique. The purpose of this study was to assess the practice of insulin administration among diabetes patients in a tertiary care center. MATERIALS AND METHODS This observational study was done in Endocrinology department of a tertiary care center during April-June 2015. The consecutive patients using insulin for at least three months by either syringe or pen were recruited. All of them underwent a survey by the questionnaire which focused on key insulin injection parameters. RESULTS One hundred and sixty eight (74.67%) patients were storing insulin vials properly. The thigh was the most common site of insulin injection and 209(92.89%) study participants were rotating at the injection sites. Only 48.57% (34/70) subjects were mixing insulin properly before injection. The practice of hand washing and the cleaning of the injection site was practiced by 158(70%) & 171(76.44%) subjects respectively. One hundred and fifty six (69%) patients were injecting with the proper skin fold and 123(55%) subjects were injecting insulin at 90° angle. The majority of patients (91%) were throwing the needle and syringes directly into the garbage and public drainage system. CONCLUSIONS There was a significant gap between the insulin administration guidelines and current insulin injection practice. The diabetic education and counseling about proper insulin injection techniques should be provided to all diabetic subjects.

Tumor(s) induced osteomalacia--a curious case of double trouble.

CONTEXT We report a case of tumor-induced osteomalacia with evidence of synchronous multifocal fibroblast growth factor 23 (FGF23) production. OBJECTIVE The aim is to present a case of tumor-induced osteomalacia and to highlight the fact that incomplete removal of multifocal FGF23-producing tumors, which are not entirely picked up by functional imaging, could be the cause of treatment failure. SETTING The patient was treated in the Department of Endocrinology of a tertiary care center in India. PATIENT We report the case of a 42-year-old male with tumor-induced osteomalacia. INTERVENTION We treated the tumor-induced osteomalacia with staged surgery of the two tumors. The 18F-fluorodeoxyglucose (FDG)-avid lesion (considered the sole culprit lesion after functional imaging) was resected first, followed by the non-FDG-avid lesion. The sequential removal of both tumors resulted in complete cure. RESULTS The patient had hypophosphatemia and hyperphosphaturia. C-Terminal FGF23 level was elevated. Positron emission tomography-computed tomography showed two lesions-an FDG-avid lesion in the right leg, and a non-avid lesion in the left thigh. After removal of the FDG-avid lesion, the hypophosphatemia persisted, and the FGF23 level showed only modest reduction. The patient had complete clinical and biochemical resolution only after removal of the second non-FDG-avid tumor. CONCLUSIONS We present the case of a tumor-induced osteomalacia whose biochemical parameters did not improve after removal of the FDG-avid tumor initially. The possibility of multifocal FGF23 production was considered, and the second, non-FDG-avid lesion was resected, which resulted in complete cure. Thorough clinical examination and meticulous follow-up with documentation of the biochemical resolution are necessary for management of all patients with this rare disorder.

Myoedema: A clinical pointer to hypothyroid myopathy.

Sir, I want to bring to your notice the significance of eliciting the forgotten sign of myoedema in reaffirming the clinical diagnosis of hypothyroid myopathy in daily practice. A 42‐year‐old man was referred to department of endocrinology with the suspicion of hypothyroidism. He had insidious onset history of significant weight gain associated with severe muscle pain, fatigability, and proximal myopathy. His skin was dry, and his mental and motor responses were slow. The ankle jerk was, however, equivocal. A classical myoedema was elicited in him, which increased his likelihood of having hypothyroid myopathy. His biochemical investigations confirmed overt primary hypothyroidism (TSH >150 mIU/l), and his serum creatine phosphokinase (CPK) was elevated at 886 IU/L (Normal range 20‐170). Treatment with thyroxine replacement was initiated, and myoedema disappeared within a week of starting the same. Following 2 months of thyroxine replacement, his serum CPK showed a remarkable reduction.

Congenital hypothyroidism - An usual suspect at an unusual age: A case series.

Menorrhagia is the most common menstrual irregularity in hypothyroid women. However, it is an uncommon presentation of congenital hypothyroidism (CH). In the era of newborn screening across the world, when CH is extremely rare, we came across four cases of CH due to delayed diagnosis, presenting in adulthood with severe menorrhagia. Aims: To signify the atypical presentation of CH in late adulthood due to delayed diagnosis and its sequelae; and to increase the awareness about this treatable condition. Settings and Design: This is a cross-sectional analysis of consecutive patients with CH presenting after 18 years between 2010 and 2012 from the CH registry of Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India. Subjects and Methods: Four patients of CH presenting late (>18 years) with atypical presentations out of total 16 cases of CH within a period of 3 years were analyzed for clinical, hormonal, and imaging findings. Results: Between the years 2010 and 2012, 16 cases of CH were registered at our center out of which four cases presented in late adolescence and adulthood with menorrhagia. Age range of these patients was 18-30 years. All four patients were females presenting with anemia secondary to menorrhagia and upon evaluation were found to have CH. All of them showed improvement after starting treatment and are currently doing well with regular menstrual cycles. Conclusions: Our study demonstrates the importance of thyroid evaluation in a patient presenting with menorrhagia along with short stature. There is need for awareness among clinicians regarding the clinical features of CH and nationwide screening for CH in our country.

Zebra lines in osteogenesis imperfecta on bisphosphonate therapy

A 7-year-old girl presented with a history of recurrent fractures since the age of 1 month. She was born out of a non-consanguineous marriage and had short stature with macrocephaly and triangular facies. Her sclera and teeth were normal. She did not have any hearing defect or a family history of frequent fractures. Her biochemical metabolic profile was normal except for vitamin D deficiency which was corrected. She was provisionally …

Acute lymphocytic leukaemia presenting as a metabolic bone disease

A 7-year-old boy presented with the acute onset of low backache of 2 months duration. An x-ray of thoracolumbar spine revealed multiple vertebral fractures, and biochemical evaluation showed hypercalcaemia with a suppressed parathyroid hormone which raised the possibilities of malignancy, granulomatous conditions or vitamin D toxicity. Despite the absence of blast cells in his blood, the bone marrow biopsy was unequivocally diagnostic of acute lymphoblastic leukaemia.

Differential response of idiopathic sporadic tumoral calcinosis to bisphosphonates

Context: Tumoral calcinosis is a disorder of phosphate metabolism characterized by ectopic calcification around major joints. Surgery is the current treatment of choice, but a suboptimal choice in recurrent and multicentric lesions. Aims: To evaluate the efficacy of bisphosphonates for the management of tumoral calcinosis on optimized medical treatment. Settings and Design: The study was done in the endocrine department of a tertiary care hospital in South India. We prospectively studied two patients with recurrent tumoral calcinosis who had failed therapy with phosphate lowering measures. Materials and Methods: After informed consent, we treated both patients with standard age adjusted doses of bisphosphonates for 18 months. The response was assessed by X ray and whole body 99mTc-methylene diphosphonate bone scan at the beginning of therapy and at the end of 1 year. We also estimated serum phosphate levels and urinary phosphate to document serial changes. Results: Two patients (aged 19 and 5 years) with recurrent idiopathic hyperphosphatemic tumoral calcinosis, following surgery were studied. Both patients had failed therapy with conventional medical management − low phosphate diet and phosphate binders. They had restriction of joint mobility. Both were given standard doses of oral alendronate and parenteral pamidronate respectively for more than a year, along with phosphate lowering measures. At the end of 1 year, one of the patients had more than 95% and 90% reduction in the size of the lesions in right and left shoulder joints respectively with total improvement in range of motion. In contrast, the other patient (5-year-old) had shown no improvement, despite continuing to maintain normophosphatemia following treatment. Conclusions: Bisphosphonate therapy in tumoral calcinosis is associated with lesion resolution and may be used as a viable alternative to surgery, especially in cases with multicentric recurrence or treatment failure to other drugs.

Multiple endocrine neoplasia 2B: delayed presentation, rapid diagnosis.

Multiple endocrine neoplasia (MEN) refers to the synchronous or metachronous development of tumours in two or more endocrine organs. MEN 2B is associated with medullary thyroid carcinoma and phaeochromocytoma along with classic morphological features such as marfanoid habitus and mucosal neuromas. Dominantly inherited germline mutations involving the REarranged during Transfection (RET) proto-oncogene are responsible. Affected patients usually present in childhood with thyroid mass or gastrointestinal symptoms. We describe the case of a 28-year-old man who presented to us with metastatic medullary thyroid carcinoma. He lacked the classic marfanoid habitus, but had mucosal neuromas and thickened corneal nerves. Whole-body metaiodobenzyl guanidine scan (MIBG) showed tracer uptake in adrenal and thyroid-confirming phaeochromocytoma and medullary thyroid carcinoma. This case exemplifies the late presentation of multiple endocrine neoplasia 2B and emphasises the need to screen all cases of medullary thyroid carcinoma for phaeochromocytoma.

The effect of hypothyroidism on serum irisin level in patients with nondiabetic chronic kidney disease: A pilot study with a cross-sectional design

Both chronic kidney disease (CKD) and hypothyroidism are associated with decreased serum irisin level. The presence of hypothyroidism may influence serum irisin level in CKD patients. The objective of this study was to evaluate the effect of hypothyroidism on serum irisin level in patients with nondiabetic CKD. Two hundred nondiabetic CKD patients aged between 18 and 65 years with glomerular filtration rate <60 mL/min/1.73 m2 were included in this study. Forty-three (21.5%) patients had hypothyroidism (overt and subclinical both). Forty hypothyroid and forty euthyroid CKD patients matched for age and Body Mass Index underwent body composition, biochemical [fasting plasma glucose (FPG) and C-reactive protein], and hormonal (fasting irisin and insulin) evaluation. Body composition analysis including visceral adipose tissue was done by dual-energy X-ray absorptiometry. Homeostatic model assessment 2 insulin resistance was calculated from FPG and insulin levels. The median serum irisin levels were not significantly different between hypothyroid and euthyroid CKD patients [95 (47.74-261.52) vs. 66 (28.25-224.50) ng/mL, P = 0.30]. There was also no difference in renal function, body composition and other metabolic parameters between the two groups. To conclude, the presence of hypothyroidism does not alter serum irisin level in patients with nondiabetic CKD.

Flummoxed by diamox

Sir, A 39-year-old female, case of idiopathic intracranial hypertension, presented to the emergency medicine department with breathlessness and diplopia. She had a history of hyperreactive airway disease and had similar symptoms, 3 months back which was relieved by over-the-counter medications. The diplopia was present even on primary gaze. Ten days before the present episode, she had developed worsening diplopia, for which she was started on acetazolamide (Diamox) 500 mg twice daily by a neurologist. On admission, the patient had wheeze and the breathlessness was attributed to the bronchoconstriction.