Nisha Bhavani

Transient congenital hypothyroidism

Transient thyroid function abnormalities in the new born which revert back to normal after varying periods of time are mostly identified in the neonatal screening tests for thyroid and are becoming more common because of the survival of many more premature infants. It can be due to factors primarily affecting the thyroid-like iodine deficiency or excess, maternal thyroid-stimulating hormone receptor (TSHR) antibodies, maternal use of antithyroid drugs, DUOX 2 (dual oxidase 2) mutations, and prematurity or those that affect the pituitary-like untreated maternal hyperthyroidism, prematurity, and drugs. Most of these require only observation, whereas some, such as those due to maternal TSHR antibodies may last for upto three-to-six months and may necessitate treatment. Isolated hyperthyrotropinemia (normal Tetraiodothyronine (T4) and high Thyroid Stimulating hormone (TSH)) may persist as subclinical hypothyroidism in childhood. Transient hypothyroxinemia (low T4 and normal TSH) is very common in premature babies. The recognition of these conditions will obviate the risks associated with unnecessary thyroxine supplementation in childhood and parental concerns of a life long illness in their offspring.

Utility of Gallium-68 DOTANOC PET/CT in the localization of Tumour-induced osteomalacia.

Tumour‐induced osteomalacia (TIO) is a rare disorder characterized by hypophosphataemic osteomalacia caused by small mesenchymal tumours secreting fibroblast growth factor 23 (FGF 23). The most difficult part in the management of these patients is the localization of tumours causing TIO.

Technetium uptake predicts remission and relapse in Grave's disease patients on antithyroid drugs for at least 1 year in South Indian subjects.

Context: Most of the information on remission related factors in Graves disease are derived from Western literature. It is likely that there may be additional prognostic factors and differences in the postdrug treatment course of Graves disease in India. Aim: To study factors which predict remission/relapse in Graves disease patients from South India. Also to establish if technetium (Tc) uptake has a role in predicting remission. Subjects and Methods: Records of 174 patients with clinical, biochemical, and scintigraphic criteria consistent with Graves disease, seen in our Institution between January 2006 and 2014 were analyzed. Patient factors, drug-related factors, Tc-99m uptake and other clinical factors were compared between the remission and nonremission groups. Statistical Analysis Used: Mann–Whitney U-test and Chi-square tests were used when appropriate to compare the groups. Results: Fifty-seven (32.7%) patients attained remission after at least 1 year of thionamide therapy. Of these, 11 (19.2%) patients relapsed within 1 year. Age, gender, goiter, and presence of extrathyroidal manifestations were not associated with remission. Higher values of Tc uptake were positively associated with remission (P- 0.02). Time to achievement of normal thyroid function and composite dose: Time scores were significantly associated with remission (P - 0.05 and P - 0.01, respectively). Patients with lower FT4 at presentation had a higher chance of remission (P - 0.01). The relapse rates were lower than previously reported in the literature. A higher Tc uptake was found to be significantly associated with relapse also (P - 0.009). Conclusion: The prognostic factors associated with remission in Gravess disease in this South Indian study are not the same as that reported in Western literature. Tc scintigraphy may have an additional role in identifying people who are likely to undergo remission and thus predict the outcome of Graves disease.

A comparative study of zoledronic acid and once weekly Alendronate in the management of acute Charcot arthropathy of foot in patients with diabetes mellitus

Aim: The aim of this study was to assess and compare the response to two forms of treatment-immobilization with zoledronic acid injection and immobilization with oral weekly Alendronate, in patients with diabetes mellitus and acute Charcot arthropathy (CA) of foot in terms of clinical and radiological parameters. Material and Methods: Patients attending the endocrinology and podiatry clinic with history of diabetes mellitus and Acute CA were taken for study. The patients were randomized into two treatment groups. Group Z-zoledronic acid injection along with total contact cast (TCC). Group A-Tab. Alendronate 70 mg. once a week till the complete clinical resolution of acute CA along with TCC. Forty-five patients were randomized and 40 of them completed the study. The primary end point was complete clinical resolution of acute CA-defined as temperature difference between normal and affected foot <1°F. Results: Among the 40 patients, 30 (75%) had complete clinical resolution. The mean number of days taken for complete clinical resolution since the initiation of treatment (either Zoledronic acid or Alendronate) was approximately 122 days. There was no significant difference in a number of days required for complete clinical resolution, between the two forms of therapy. There was more than 50% reduction in the visual score between the baseline and the final scan. The target to non-target ratio in the skeletal phase also showed an average of 40% reduction from the baseline to the final skeletal scintigraphy. Conclusion: Both Intravenous Zoledronic acid and oral alendronate had comparable efficacy with respect to the time taken for attaining complete clinical resolution of acute CA of foot. However, Alendronate therapy was cost effective among the two. 99mTc MDP bone scan can be used as an adjuvant to the clinical parameters in assessing the response to therapy.

Treatment outcomes in pediatric differentiated thyroid carcinoma.

Abstract Background Until the American Thyroid Association (ATA) guidelines on management of pediatric differentiated thyroid carcinoma (DTC) became available in 2015, all children with DTC were treated like adults. This study aims to investigate the outcome of pediatric DTC and factors predicting the response to therapy in pediatric DTC managed according to adult guidelines. Methods Clinical records of 41 children less than 18 years of age diagnosed with DTC followed from 2007 in a single center were reviewed. According to the new ATA classification for pediatric DTC, five had low-risk, 28 had intermediate-risk and eight had high-risk disease at presentation. Results There was no mortality or recurrence in this cohort of pediatric DTC patients and the cure rate was 46% during a mean follow-up of 44 months when they were managed according to adult guidelines. Neither the new ATA risk classification nor any clinicopathological character was identified which could predict the response to therapy. The new ATA guidelines would have avoided 27% of the radioiodine therapies given. Conclusions This study showed that DTC in children managed according to adult guidelines had a good cure rate. The new ATA guidelines on pediatric DTC might have drastically reduced the number of radioiodine therapies in the affected children. Long term prospective studies are needed to validate the benefits and risks of both these approaches.

Prevalence of thyroid disorders is not different in type 2 diabetes mellitus compared to nondiabetics in South India

Studies on thyroid disorders in type 2 diabetes mellitus (DM) are fewer than those in type 1 diabetes, but data from different parts of the world have shown conflicting results. To look at the prevalence of thyroid disorders in type 2 DM and nondiabetic controls separately in a community cohort and a hospital cohort from the same locality in South India. Thyroid function tests and thyroid autoantibodies were done in 986 people in the community (258 diabetics and 634 nondiabetics). In the hospital cohort of 194 people (147 diabetics and 47 nondiabetics), an ultrasonography of the neck was done in addition. Thyroid dysfunction was more common in the community compared to the hospital cohort 15.9 vs 9.6% but there was no difference in the proportion of people with thyroid dysfunction in diabetics and nondiabetics in both the community and the hospital cohorts. (15.6 vs 16.2% in the community and 9.6 vs 6.3% in the hospital in diabetics and nondiabetics respectively). Clinical goiter and sonographically detected goiter were also similar in diabetics and nondiabetics in the community and the hospital cohorts respectively. Females had more prevalence of goiter irrespective of the presence of diabetes. Commonest thyroid dysfunction was hypothyroidism and subclinical hypothyroidism in both cohorts. This unique study conducted in a community and hospital cohort from the same locality showed that the prevalence of thyroid disorders is similar in type 2 diabetic and nondiabetic subjects in our population.

Radiofrequency Ablation Followed by Percutaneous Ethanol Ablation Leading to Long-Term Remission of Hyperparathyroidism

A 30-year-old male with cerebral palsy and motor impairment presented with right femur fracture. He had gradually worsening mobility and contractures of all extremities for the preceding 5 years. Evaluation showed multiple vertebral and femoral fractures, severe osteoporosis, a large parathyroid adenoma, and parathormone (PTH) exceeding 2500 pg/mL. Because of poor general health and high anesthetic risk, parathyroidectomy was deemed impractical. Ultrasound-guided radiofrequency ablation (RFA) helped achieve 50% size reduction and PTH levels with better control of hypercalcemia. Later, as calcium and PTH remained elevated, percutaneous ethanol ablation was performed with resultant normalization of PTH and substantial symptomatic improvement. Two years later, he still remains normocalcaemic with normal PTH levels. We propose that RFA and percutaneous ethanol ablation be considered as effective short-term options for surgically difficult cases, which could even help achieve long-term remission. Although not previously reported, our case illustrates that both RFA and percutaneous ethanol ablation could be safely performed successively achieving long-term remission.

Plexiform Neurofibroma of Clitoris

The most frequent genital presentation of neurofibromatosis in females is clitoromegaly. We report a case of a 5-year-old girl with neurofibromatosis type 1 with clitoral plexiform neurofibromatosis. Clitoroplasty was done, and the histopathology confirmed the diagnosis. Though rare, plexiform neurofibroma of clitoris should always be considered as a differential diagnosis in children with clitoromegaly before embarking on detailed investigations.

Glycemic control is difficult to attain in type 2 diabetes mellitus despite insulin therapy

The standard way of treating a type 2 diabetic patient is to start them on monotherapy with oral hypoglycemic agents (OHAs), then proceed to combination therapy, and when OHAs are no longer found to control blood glucose adequately, start them on insulin with or without stopping the OHAs in the hope that addition of insulin will achieve euglycemia [1]. But in practice, we often find that glycemic control is not optimal in majority of type 2 diabetic patients more so when patients are on insulin than when they are on OHAs [2]. There was not enough scientific data to support this view. Hence, a study aiming to assess the level of glycemic control in type 2 diabetic patients and to compare the glycemic control in type 2 diabetic patients taking insulin with or without OHAvs those on OHA alone was planned. Adult type 2 diabetic patients who were on treatment for their diabetes started by a general practitioner at their local place for atleast 2 years were included in the study. All these patients were coming to a tertiary referral university teaching hospital for the first time in 2010. One hundred patients taking insulin with or without OHAs and 100 on OHA alone were included in the study. The former was taken as group 1 and the latter as group 2. Details of duration of diabetes, HbA1c, FPG, PPPG, presence of diabetic retinopathy, nephropathy and neuropathy were analyzed. The details of treatment are given in Table 1. The results comparing the different parameters between groups 1 and 2 are given in the Table 2. The study revealed an overall poor control of type 2 diabetes mellitus in our community in a general practice set up, especially when they are in an advanced stage of their disease inspite of insulin therapy. Only 16 % of the total population ( 9% on insulin and 24 % on OHAs) had the target HbA1c of < 7 %. Those on insulin had longer duration of disease, higher HbA1c, higher FPG and PPPG, and higher incidence of microvascular complications. The reasons for a poor glycemic control in those on insulin with or without OHA compared to OHA alone may be manifold.

Autoantibodies to Insulin and Dysglycemia in People With and Without Diabetes: An Underdiagnosed Association

The potential effects of inhibitory immunoglobulins to insulin were first described in insulin-treated patients many decades ago (1). This antibody response is thought to occur in at least 40% of patients on insulin therapy (2). Subsequent case reports documented glycemic excursions in the form of markedly increased insulin requirements and unpredictable hypoglycemic episodes, both of which were attributable to insulin autoantibodies (3). Autoantibodies to insulin also can occur occasionally in patients who have not been previously exposed to insulin. Autoimmune hypoglycemia resulting from high titers of insulin autoantibodies have been reported, mostly from Japan, as a rare cause of hyperinsulinemic hypoglycemia (4). There has only been one confirmed case of autoimmune hypoglycemia reported from India (5). The estimation of insulin autoantibodies is an integral part of the diagnosis in such cases. Apart from insulin, other inciting agents implicated include sulfahydryl group–containing drugs and alpha-lipoic acid (ALA). Autoimmune hypoglycemia also has been reported to be associated with autoimmune disorders and plasma cell dyscrasias (6). Spontaneous resolution has been reported in a few cases of autoimmune hypoglycemia, and a dramatic response to steroids was seen in some other cases that manifested both hypoglycemia and hyperglycemia. In this article, we describe our experience with patients who presented with glycemic excursions resulting from insulin autoantibodies from a single university referral teaching center in South India. ### Case Presentation At the Department of Endocrinology of Amrita Institute of Medical Sciences in Kochi, Kerala, India, a large tertiary care center, between 2008 and 2014, we diagnosed eight cases in which insulin autoantibodies could be implicated as the etiological factor responsible for spontaneous hyperinsulinemic hypoglycemia. One patient presented exclusively with postprandial hypoglycemia–related symptoms, whereas the others presented with a combination of fasting and postprandial symptoms. During the same time period, there were only seven cases of histopathologically proven insulinomas …