Narendra Kotwal

Clival Pituitary Adenoma with Acromegaly: Case Report and Review of Literature

The pituitary develops as a result of complex, intricate, and precise neuro-embryological events in the sixth to eighth weeks of gestation. Some ectopic cell rests can become adenomatous. Rarely, these cell rests in the clivus can be the site of formation of adenoma. Our patient, a 35-year-old parous woman, was being treated for acromegaly, and imaging studies revealed a clival mass lesion. Trans-sphenoidal excision was done and immunohistochemistry revealed the tumor to be a growth hormone-secreting tumor.

Endocrine hypertension – Cushing's syndrome

Hypertension is a major and frequent comorbid finding of Cushings syndrome. This review discusses the etiology and pathophysiology of hypertension in Cushings syndrome, while suggesting methods of management of this condition. It also provides an overview of diagnosis and management strategies in this disease.

Variability of capillary blood glucose monitoring measured on home glucose monitoring devices

Self monitoring of blood glucose helps achieve glycemic goals. Glucometers must be accurate. Many variables affect blood glucose levels. Factors are analytical variables (intrinsic to glucometer and glucose strips) and pre analytical related to patients. Analytical variables depend on factors like shelf life, amount of blood and enzymatic reactions. Preanalytical variables include pH of blood, hypoxia, hypotension, hematocrit etc. CGMS has the potential to revolutionise diabetes care but accuracy needs to be proven beyond doubt before replacing current glucometer devices.

Ogilvie's syndrome in a case of myxedema coma.

Ogilvies syndrome [acute colonic pseudo-obstruction (ACPO)] presents as massive colonic dilatation without a mechanical cause, usually in critically ill patients due to imbalanced sympathetic and parasympathetic activity. The initial therapy remains conservative with supportive measures (correction of metabolic, infectious or pharmacologic factors) followed by neostigmine and decompressive colonoscopy. Surgery is reserved for patients with clinical deterioration or with evidence of colonic ischemia or perforation. A 60-year-old lady presented with fever, altered sensorium, obstipation, bradycardia and abdominal distension. Investigation revealed hyponatremia and acute colonic pseudo-obstruction. Supportive measures and decompressive colonoscopy were not of great benefit. Thyroid profile was suggestive of primary hypothyroidism. Colonic motility was restored only on starting thyroxin. The case is illustrative of the need to consider hypothyroidism, a common endocrine disorder, in the differential diagnosis of Ogilvies.

Central precocious puberty due to hypothalamic hamartoma in a six-month-old infant girl

Precocious puberty defined as an onset of puberty below eight years in girls and nine years in boys, has an incidence of approximately 1 / 5,000 – 1 / 10,000 subjects with a female / male ratio of 20: 1. It is etiologically classified broadly as central and peripheral. We present to you a case of isosexual (central), precocious puberty in a 16-month-old girl, who was symptomatic since the age of six months, and was later, diagnosed to have hypothalamic hamartoma. It is one of the earliest case records ever in the medical literature of menarche, at an extremely early age (six-month-old child) secondary to a central cause.

Statins: Cholesterol guidelines and Indian perspective.

Statins have become an important drug in preventing the occurrence of atherosclerotic cardiovascular disease (ASCVD). The effectiveness of statins in reducing ASCVD has been established in large-scale clinical trials. The lipid management guidelines have been periodically modified due to accumulating evidence about the proportionate benefit achieved with a progressive reduction in cholesterol levels with higher doses of statins and even in those at low risk of development of ASCVD. The current American College of Cardiology/American Heart Association guidelines have based its recommendations from data gathered exclusively from randomized controlled trials. It has simplified the use of statins, but also raised questions regarding the validity of its cardiovascular event risk prediction tool. Epidemiology of cardiovascular disease in India differs from the western population; there is an increased the prevalence of metabolic syndrome and atherogenic dyslipidemia phenotype a group not addressed in the current guidelines. The guidelines are based on trials, which do not have a representative South Asian population. This article reviews the relevant literature, and examines the issues involved in adopting the guidelines to the Indian population.

Efficacy of teriparatide in patients with hypoparathyroidism: A prospective, open-label study

Context: Conventional treatment of hypoparathyroidism with calcium, Vitamin D analogs, and thiazide diuretics is often suboptimal, and these patients have poor quality of life. Teriparatide (parathyroid hormone 1–34 [PTH (1–34)]), an amide of PTH, is widely available for the use in osteoporosis; however, its use in hypoparathyroidism is limited. Aims: The aim of this study is to evaluate the efficacy of PTH (1–34) in the treatment of patients with hypoparathyroidism. Settings and Design: This was a prospective, open-label interventional study in a tertiary care hospital of Indian Armed Forces. Subjects and Methods: All patients with hypoparathyroidism presented to the endocrinology outpatient department were included and were exhibited injection PTH (1–34) 20 μg twice daily that was gradually reduced to 10 μg twice daily along with calcium, active Vitamin D (alfacalcidol), and hydrochlorothiazide. Oral calcium and alfacalcidol doses were also reduced to maintain serum calcium within normal range. The quality of life (QOL) score was calculated using RAND 36 QOL questionnaire at baseline and termination of the study. Statistical Analysis Used: Paired t-test was used to calculate pre- and post-treatment variables. Results: Eight patients (two males) were included in this study having mean age of 35.8 years. PTH (1–34) treatment led to the improvement in serum calcium (6.81–8.84 mg/dl), phosphorous (5.8–4.2 mg/dl), and 24 h urinary calcium excretion (416–203.6 mg). Parameters of QOL showed the improvement in overall QOL, physical performance, energy, and fatigue scores. No major adverse events were noted. Conclusions: Treatment of hypoparathyroidism with PTH (1–34) leads to improvement in calcium profile, reduction in hypercalciuria, and improvement in QOL, whereas it is safe and well tolerated.

Etiopathological differentiation of diabetes mellitus in lean, young adults

OBJECTIVE Classification of diabetes mellitus (DM) into type 1 or type 2 is difficult in lean, young individuals. We studied the β-cell function, insulin resistance (IR) and autoimmunity in young patients with recent onset DM. METHODS In this cross-sectional study, we included patients (age below 35 years) with recent onset DM (<6 months) and normal body weight for evaluation. The detailed clinical examination was done to identify markers of IR. Autoimmune DM was diagnosed using glutamic acid decarboxylase 65 (GAD65), insulin autoantibody (IAA) and islet cell antibody (ICA). Homeostasis model assessment (HOMA) models of HOMA-B and HOMA- IR were used for estimation of β-cell function and IR respectively. The patients were divided into four groups based on, the autoimmunity (A) and ketosis (K) as group 1 (A+K), group 2 (A-K+), group 3 (A+K-) and group 4 (A-K-). Appropriate statistical tests +)were used to analyze the results. RESULTS The study population (n=75, all males) had a mean age of 28.9±4.3years, body mass index 20.6±1.9kg/m2, fasting plasma glucose 177.1±31.4mg/dl and HbA1c of 9.9±2.1% at presentation. The number of patients in groups 1 to 4 are 8, 5, 10 and 52 respectively (p<0.0001). HOMA-IR was higher in groups 2 and 4 (4.1±1.3, 3.6±1.1 respectively), whereas HOMA-B was higher in group 4 (3.6±1.5) alone (p=0.0005). CONCLUSION Type 2 DM is the most common etiology even in young, lean adults in India. Further studies with large numbers are required to confirm our findings.

Core needle biopsy: An additional diagnostic armamentarium

Fine needle aspiration cytology (FNAC) is considered to be most effective and accurate diagnostic test to differentiate benign from malignant thyroid nodules and most guidelines recommend FNAC as the initial test. However, significant percentage of FNAC results are inconclusive owing to nodule characteristic, operator limitations, or limitations of the procedure itself. Core needle biopsy (CNB) in the evaluation of thyroid nodules have been performed since many decades; however, due to large bore needle, complication rates, and previous reports of inaccuracies, presently CNB has not been included by most guidelines in the diagnostic algorithm of thyroid nodules. Multiple recent studies have shown much higher rates of sensitivity, specificity, and accuracy using CNB in differentiating benign from malignant lesions, particularly when initial FNA is indeterminate, nondiagnostic or if there are discordant results between radiologic and cytologic tests or in nodules with macrocalcifications or fibrosis.

Changes in bone mineral density and bone turnover markers in patients undergoing hematopoietic stem cell transplant

Introduction: Hematopoietic stem cell transplant (HSCT) is frequently complicated by endocrine abnormalities and loss of bone mass. This prospective study was conducted to evaluate the bone loss post-HSCT. Materials and Methods: A total of 50 patients was evaluated pretransplantation, and 25 had HSCT (17 males, 8 females; 19 allogenic, 6 autologous). Bone mineral density (BMD) and bone markers were measured at baseline, 3–6 months and 12 months. Results: The mean age and body mass index were 25.1 ± 16.3 years and 19.4 ± 4.5 kg/m2, respectively. There were 15 adults (60%), and 10 adolescents (40%). There was a significant decline in BMD from the baseline at total femur (−8.7%; P < 0.0001), femoral neck (−5.0%; P = 0.003), femoral trochanter (−6.0%; P = 0.001), and Wards triangle (−9.9%; P < 0.0001) at 6 months posttransplantation. From the 6 months to 12 months, there was a significant improvement in BMD at above sites except at Wards triangle. The decline in BMD was nonsignificant at the whole body (−0.3%, P = 0.748) and the lumbar spine (−2.7%, P = 0.130) at 6 months posttransplant. Younger patients with allogenic graft and steroid use are more likely to have significant loss of BMD at hip posttransplant. Serum osteocalcin decreased, and N-telopeptide increased at 3–6 months, which return to baseline at 1-year posttransplant. Conclusions: A significant bone loss is observed at 6 months in patients with post-HSCT. The bone loss occurs predominantly at cortical bone. There is recovery of bone mass at 12 months posttransplant except at Wards triangle. Bone loss after HSCT is multifactorial.