Piero Baglioni

Acute Charcot foot

#### Key points A 38 year old man was referred by his general practitioner to our diabetes foot clinic with a swollen red foot (fig 1⇓). He had had type 1 diabetes for 25 years, complicated with retinopathy, peripheral neuropathy, and nephropathy, and was being worked up for dialysis following a failed pancreas-kidney transplant. The absence of pain together with preserved pulses and intact skin raised a suspicion of acute Charcot foot. A plain radiograph of the foot showed fractures through the necks of the first three metatarsals (fig 2⇓). We offloaded the foot in a total contact cast and advised the patient to limit weight bearing. Magnetic resonance imaging (MRI) subsequently confirmed neuroarthropathic changes of acute Charcot (fig 3⇓). Fig 1 Acute Charcot foot Fig 2 Plain radiograph of the foot showing fractures through the necks of the first three metatarsals Fig 3 Axial T1 weighted MRI showing pathological fractures through the necks of the first three metatarsals (arrows) with oedema in metatarsal shafts and lateral cuneiform bones (arrow heads). These features, in a patient with diabetes and no history of trauma, suggest acute Charcot foot Charcot’s neuroarthropathy is a destructive process of bone and joint, typically seen in a foot that …

Value of Baseline Serum Thyrotropin as a Predictor of Hypothyroidism in Patients with Diabetes Mellitus

OBJECTIVE To determine whether serum thyrotropin measurement performed at diagnosis of diabetes mellitus or at initial patient contact predicts subsequent development of hypothyroidism. METHODS We retrospectively reviewed the computerized records of patients attending annual visits between January 2008 and December 2008 at a hospital diabetes mellitus clinic. Serum free thyroxine and thyrotropin at current and baseline annual visits were documented. A Cox regression model was used to analyze the relationship between development of thyroid dysfunction and patient characteristics including age, sex, type of diabetes, and baseline serum thyrotropin concentration. Kaplan-Meier survival curves were generated for predictors of hypothyroidism. RESULTS Clinical records of 1101 patients were reviewed (595 men [54%] and 506 women [46%]). Mean age was 60.0 ± 17 years. Two hundred twenty-three patients (20.3%) had type 1 DM and 878 (79.7%) had type 2 diabetes. Thyroid dysfunction was present in 136 patients (12.4%) at baseline and developed in 71 patients (6.4%) at follow-up (median duration, 37 months). Overt and subclinical hypothyroidism developed in 28 (2.5%) and 38 (3.5%) patients, respectively. Incident hypothyroidism was associated with baseline thyrotropin concentration greater than 2.2 mIU/L (relative risk, 10.4; confidence interval, 5.6-19.6; P<.001) and female sex (relative risk, 1.8; confidence interval, 1.1-2.9; P = .007). The predictive influence of sex was abolished in patients with a thyrotropin value greater than 2.2 mIU/L. This TSH threshold yielded an optimal sensitivity and specificity of 83% and 72%, respectively, for predicting hypothyroidism. CONCLUSIONS Baseline serum thyrotropin predicted hypothyroidism in patients with diabetes mellitus even at thyrotropin concentrations within the reference range. Selective annual thyroid screening in diabetic patients with baseline thyrotropin concentrations greater than 2.2 mIU/L may be more cost-effective than universal screening.

Primary HIV infection

Primary HIV infection encompasses the biological and clinical manifestations of the period between initial contact with the virus and the appearance of specific antibodies.1 #### Case scenario A previously healthy 19 year old man was admitted to our medical ward with a history of fever, sore throat, and a maculopapular rash on his trunk. An upper respiratory tract infection had been diagnosed in the community a few days before. A monospot test (for infectious mononucleosis caused by Epstein-Barr virus) was negative, and he initially denied risky sexual behaviour and declined an offer of HIV testing. His symptoms improved, but before discharge he mentioned to the ward sister that he had had a casual sexual encounter with a man a few weeks earlier. He then consented to an HIV test, which was positive for the p24 antigen. #### How common is primary HIV infection?2 Primary HIV infection is symptomatic in most individuals but is easy to miss.3 4 In a …

Giant prolactinoma in an elderly man.

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: J.S. was responsible for conception of the letter and wrote the first draft. J.S., S.T., and J. TV. contributed to design, subsequent drafts of the letter, critical revisions, and final approval of the version submitted for publication. Sponsor’s Role: This letter was not sponsored by any agent or company.

What about the cost

As practising clinicians, we believe that Mehanna and colleagues’ review on investigating thyroid nodules should have been accompanied by a formal cost-benefit analysis because of its potential public health implications.1 As the authors acknowledge, ultrasonography detects thyroid nodules …

Resistant hypertension with adrenal nodule: are we removing the right gland?

Summary Resistant hypertension is often difficult to treat and may be associated with underlying primary aldosteronism (PA). We describe the case of an elderly gentleman who presented with severe and resistant hypertension and was found to have a left adrenal incidentaloma during evaluation but had aldosterone excess secondary to unilateral adrenal hyperplasia (UAH) of the contralateral gland, which needed surgical intervention. A 65-year-old gentleman was evaluated for uncontrolled high blood pressure (BP) in spite of taking four antihypertensive medications. The high BP was confirmed on a 24-h ambulatory reading, and further biochemical evaluation showed an elevated serum aldosterone renin ratio (ARR) (1577 pmol/l per ng per ml per h). Radiological evaluation showed an adrenal nodule (15 mm) in the left adrenal gland but an adrenal vein sampling demonstrated a lateralization towards the opposite site favouring the right adrenal to be the source of excess aldosterone. A laparoscopic right adrenalectomy was performed and the histology of the gland confirmed nodular hyperplasia. Following surgery, the patients BP improved remarkably although he remained on antihypertensives and under regular endocrine follow-up. PA remains the most common form of secondary and difficult-to-treat hypertension. Investigations may reveal incidental adrenal lesions, which may not be the actual source of excess aldosterone, but UAH may be a contributor and may coexist and amenable to surgical treatment. An adrenal vein sampling should be undertaken for correct lateralization of the source, otherwise a correctable diagnosis may be missed and the incorrect adrenal gland may be removed. Learning points Severe and resistant hypertension can often be associated with underlying PA. ARR is an excellent screening tool in patients with suspected PA. Lateralization with adrenal venous sampling is essential to isolate the source and differentiate between unilateral and bilateral causes of hyperaldosteronism. Adrenal incidentalomas and UAH may coexist and the latter may often be the sole cause of excess aldosterone secretion. Decisions about adrenalectomy should be made only after integrating and interpreting radiological and biochemical test findings properly.

Adrenal incidentaloma's: are lessons still to be learned?

Sir, The widespread use of imaging procedures has led to an increased discovery of incidental masses in the adrenal glands. The probability of finding an adrenal adenoma on abdominal computed tomography (CT) increases with age and is ∼0.2 % in 20–29 years age group as compared to 7% in the elderly people.1,2 Although the majority of these incidentaloma’s are non-functioning benign adenoma’s but their increased prevalence poses a diagnostic and therapeutic challenge. The natural history of adrenal incidentaloma’s is yet to be clearly defined as they may present at a later date as cortisol secreting adenomas, pheochromocytoma, adrenal cortical carcinoma and metastatic carcinoma. This possibility of conversion from a non-secreting state to an autonomous hypersecretory tumor is low but careful assessment and vigilance is needed with timely follow-up for early diagnosis. We present one such patient who had a benign adenoma at presentation but went on to develop an adrenal cortical carcinoma with metastases leading to severe challenges in management. A 50-year-old female patient was presented to the gynaecologist in February 2007 with complaints of menorrhagia. An ultrasound of abdomen not only confirmed a fibroid of the uterus but also showed a doubtful shadow in the left adrenal gland. This was followed with a CT scan that showed an adrenal adenoma of 3.5 × 3 cm with no adjoining lymphadenopathy or ascites. The patient was normotensive and her serum potassium was normal. She was referred to us for evaluation and we proceeded to do further investigations. Her overnight dexamethasone suppression tests showed a serum cortisol of 71 nmol/l but a 24 h urine-free cortisol and urine catecholamines was normal on three occasions, which was performed over a period of 1 month. An aldosterone renin ratio was estimated after appropriate measures and this confirmed a normal value as …