Rana Bhattacharjee

Inter-patient Variability in Clinical Efficacy of Metformin in Type 2 Diabetes Mellitus Patients in West Bengal, India

Background and objective: Metformin is often used as a first-line therapy for Type 2 diabetes mellitus (T2DM), but the glycemic response to metformin is variable in patients. Here, we aimed to assess the inter-patient variability in terms of glycemic response to metformin in the state of West Bengal, India. Material and methods: We enrolled newly diagnosed treatment naive 113 patients with T2DM. Patients were subjected to assay of glycated hemoglobin (HbA1c), fasting blood glucose (FBG), postprandial blood glucose (PP) and measurement of body mass index (BMI), waist circumstances (WC) before and after the end of 3 months of immediate release metformin (2000mg/day) therapy. Results: Out of 113 patients, 111 (58 male and 53 female; average age 43.13 years) were provided with 3 months of metformin therapy. 102 individuals responded to metformin, but HbA1c levels of 9 patients did not improve after 3 months of drug therapy. Conclusions: In the present study, metformin lead to improvements in glycemic control in 92% of newly diagnosed T2DM patients but in 8% does not which is much less in this part of India.

Mitochondrial myopathy associated with myasthenia gravis in a young man

An 18-year-old man presented with progressive weakness of proximal muscles with prominent diurnal variation for 3 months. He had bilateral ptosis since his childhood without diurnal variation or double vision. Neurological examination showed involvement of levator palpebrae superioris and lateral rectus muscles bilaterally. The plasma glucose after 75 gm glucose load was 302 mg/dL. The electrophysiological study revealed myopathic pattern and a decremental response in repetitive nerve stimulation. The plasma lactate was elevated and the muscle biopsy showed numerous ragged-red fibers. Serum acetylcholine receptor antibody assay was positive. We diagnosed myasthenia gravis with mitochondrial myopathy.

Effects of thyroid status on glycated hemoglobin

Introduction: Glycated hemoglobin (HbA1c) can be altered in different conditions. We hypothesize that HbA1c levels may change due to altered thyroid status, possibly due to changes in red blood cell (RBC) turnover. Objectives: The objective of this study was to determine the effects of altered thyroid status on HbA1c levels in individuals without diabetes, with overt hyper- and hypo-thyroidism, and if present, whether such changes in HbA1c are reversed after achieving euthyroid state. Methods: Euglycemic individuals with overt hypo- or hyper-thyroidism were selected. Age- and sex-matched controls were recruited. Baseline HbA1c and reticulocyte counts (for estimation of RBC turnover) were estimated in all the patients and compared. Thereafter, stable euthyroidism was achieved in a randomly selected subgroup and HbA1c and reticulocyte count was reassessed. HbA1c values and reticulocyte counts were compared with baseline in both the groups. Results: Hb A1c in patients initially selected was found to be significantly higher in hypothyroid group. HbA1c values in hyperthyroid patients were not significantly different from controls. HbA1c reduction and rise in reticulocyte count were significant in hypothyroid group following treatment without significant change in glucose level. Hb A1c did not change significantly following treatment in hyperthyroid group. The reticulocyte count, however, decreased significantly. Conclusion: Baseline HbA1c levels were found to be significantly higher in hypothyroid patients, which reduced significantly after achievement of euthyroidism without any change in glucose levels. Significant baseline or posttreatment change was not observed in hyperthyroid patients. Our study suggests that we should be cautious while interpreting HbA1c data in patients with hypothyroidism.

Bilateral adrenal myelolipoma in Cushing's disease: a relook into the role of corticotropin in adrenal tumourigenesis

Adrenal myelolipomas are infrequently encountered benign tumours of unknown aetiology. In the majority of cases they are unilateral, and clinically and hormonally silent, only requiring periodic follow-up. However, bilateral adrenal myelolipomas are sometimes associated with endocrine disorders and warrant appropriate evaluation. Though the understanding of the pathophysiology of adrenal myelolipomas has long been elusive, adrenocorticotropic hormone (ACTH) has been proposed as the main tropic factor in a number of studies. Cushings disease is rarely associated with bilateral and sometimes giant myelolipomas. In this article, the association of bilateral adrenal myelolipomas with Cushings disease has been discussed and the role of ACTH in the tumourigenesis has been reviewed.

Precocious puberty: A blessing in disguise!

Germ cell tumors may lead to incomplete isosexual male precocity and are commonly located in the pineal gland. Germinomas of the basal ganglia are almost always unilateral and precocious puberty is a rare manifestation in them. We report a 9.5-year-old boy who presented with incomplete isosexual precocity due to bilateral basal ganglia germinoma.

Evolving adrenal insufficiency

Introduction: Tuberculosis is the most common cause of Addisons disease in India. The exact status of adrenal reserve in tuberculosis is still an enigma and recovery of adrenal function is unpredictable. Objective: We report a case with a pre-Addisonian state and unchanged adrenal size after 1 year treatment. Materials and Methods: A 31-year patient with adrenal tuberculosis was diagnosed and treated with anti tubercular drugs (ATDs) and steroid. Results: A 31-year male, presented with fever and weight loss for 3½ months with anorexia, nausea, hyperpigmentation of skin, and buccal mucosa and weakness with past h/o adequately treated pulmonary tuberculosis at 3 years of age. On examination, the patient was anemic. A non-tender, firm right (Rt.) submandibular lymphnode was palpable. Investigations revealed: High erythrocyte sedimentation rate (ESR), negative HIV, and sputum for acid fast bacilli (AFB). Initial cortisol was high but subsequently became low with negative short synacthin test (SST). Computed tomography showed bilateral (B/L) enlarged hypodense adrenal mass with inconclusive fine needle aspiration cytology (FNAC) and negative AFB culture. Rt. submandibular lymph node FNAC showed caseating granuloma. ATDs and steroids were started, the lymphadenopathy regressed and symptoms subsided. However, after 1 year of treatment steroid withdrawal failed and adrenal size remained the same. Conclusion: The adrenal has considerable capacity to regenerate during active infection and ultimately become normal or smaller in size. However, in the case reported here, they failed to regress. Reversal of adrenal function following ATD is a controversial issue. Some studies have shown normalization following therapy, while others have contradicted it similar to the finding in our case.

A comparative study between total contact cast and pressure-relieving ankle foot orthosis in diabetic neuropathic foot ulcers.

Background: Off-loading of the ulcer area is extremely important for the healing of plantar ulcers. Off-loading with total contact cast (TCC) may be superior to other off-loading strategies studied so far, but practical limitations can dissuade clinicians from using this modality. This study was conducted to evaluate the efficacy of TCC compared with that of a pressure-relieving ankle foot orthosis (PRAFO) in healing of diabetic neuropathic foot ulcers and their effect on gait parameters. Methods: Thirty adult diabetic patients attending the foot clinic with neuropathic plantar ulcers irrespective of sex, age, duration and type of diabetes were randomly assigned to 1 of 2 off-loading modalities (TCC and PRAFO). Main outcome measures were ulcer healing after 4 weeks of randomization and effect of each of the modalities on various gait parameters. Results: The percentage reduction of the ulcer surface area at 4 weeks from baseline was 75.75 ± 9.25 with TCC and 34.72 ± 13.07 with PRAFO, which was significantly different (P < .001). The results of this study however, showed that most of the gait parameters were better with PRAFO than with TCC. Conclusions: This study comprehensively evaluated the well known advantages and disadvantages of a removable (PRAFO) and a nonremovable device (TCC) in the treatment of diabetic neuropathic foot ulcer. Further studies are needed involving larger subjects and using 3D gait analysis to collect more accurate data on gait parameters and wound healing with different off-loading devices.

Diabetes and primary infertility in young males: do not forget cystic fibrosis.

Cystic fibrosis (CF) is an autosomal recessive disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator ( CFTR ) gene. Defects in the CFTR gene cause abnormal chloride transport along the apical membrane of epithelial cells, resulting in progressive lung disease, pancreatic dysfunction, elevated sweat chloride, and male infertility. Atypical forms of CF are increasingly being recognized in older children and adults, posing a diagnostic challenge to clinicians. It is a diverse disorder affecting different organ systems of the body to varying degrees and combinations. Instead of having the classic symptoms, individuals with atypical CF might have involvement of only one organ system, and symptoms might not develop until adolescence or adulthood. We describe here two young men with diabetes who presented with primary infertility. Medical work up for evaluation of infertility led to a diagnosis of CF in both. A 32-year-old married man, diagnosed with diabetes 3 years ago, consulted us for primary infertility. There was no history suggestive of erectile dysfunction, and he had preserved libido. He had been diagnosed with diabetes during an evaluation for leg cramps. He denied abdominal pain or steatorrhea and had no past acute metabolic decompensation. There was no family history of diabetes in any first- or second-degree relatives. On physical examination, there was no acanthosis. His height was 158 cm, and his weight was 56 kg (BMI 22.4 kg/m²). He had normal testicular volume (25 mL) bilaterally, with normal consistency. The patient was initially diagnosed with fasting and postprandial hyperglycemia, as evidenced from his initial blood glucose reports (fasting plasma glucose [FPG] 168 mg/dL, posprandial glucose [PPG] 240 mg/dL).Baseline biochemical parameters were within normal limits, including normal morning testosterone, luteinizing horman (LH), and follicle-stimulating hormone (FSH) levels. An abdominal ultrasound showed apparently normal liver, pancreas, and kidneys. He had been taking glipizide …

Case Studies in Insulin Therapy: The Last Arrow in the Treatment Quiver

B ecause type 2 diabetes is a progressive disease, its natural course requires initiation of insulin in a significant proportion of patients, especially when oral agents fail to achieve glycemic targets. Most practicing physicians and endocrinologists acknowledge that neither the transition to nor the journey with insulin treatment is often as smooth as one would hope. Most have occasionally met with patients who plead for help in controlling their blood glucose levels with oral drugs alone. Often, doctors struggle to persuade such patients to start insulin. In this article, we share some of our experiences—some common throughout the world and others unique to our country—in caring for patients who are prescribed insulin. It is important to learn from these experiences with insulin because it represents, more often than not, the last arrow in our treatment quiver. The patient was a 45-year-old man who has had type 2 diabetes for the past 6 years and had been taking insulin for the past 2 years. His body weight was 50 kg (BMI 24 kg/m2). He presented with uncontrolled and recently increased blood glucose levels and a dramatic increase in insulin dose during the past 5 months without any apparent cause. He had no history of fever, infections, or steroid use. He had had multiple hospital visits during the past few months. Figure 1. Discoloration with hypertrophy on medial aspects of both thighs on the site where the patient described in Case Study 1 was injecting insulin. The patient appeared to be well educated and concerned about this situation. To our surprise, however, we found he was injecting insulin on the medial aspect of his thighs. Examination showed lipohypertrophy with swelling in that region (Figure 1). The crowded clinic with its lack of trained diabetes educators and nurses was the perfect setting for this …

Pituitary gigantism: a case report.

Objective: To present a rare case of gigantism. Case Report: A 25-year-old lady presented with increased statural growth and enlarged body parts noticed since the age of 14 years, primary amenorrhea, and frontal headache for the last 2 years. She has also been suffering from non-inflammatory low back pain with progressive kyphosis and pain in the knees, ankles, and elbows for the last 5 years. There was no history of visual disturbance, vomiting, galactorrhoea, cold intolerance. She had no siblings. Family history was non-contributory. Blood pressure was normal. Height 221 cm, weight 138 kg, body mass index (BMI)28. There was coarsening of facial features along with frontal bossing and prognathism, large hands and feet, and small goitre. Patient had severe kyphosis and osteoarthritis of knees. Confrontation perimetry suggested bitemporal hemianopia. Breast and pubic hair were of Tanner stage 1. Serum insulin like growth factor-1 (IGF1) was 703 ng/ml with all glucose suppressedgrowth hormone (GH)values of >40 ng/ml. Prolactin was 174 ng/ml. Basal serum Lutenising Hormone (LH), follicle stimulating Hormone (FSH) was low. Oral glucose tolerance test (OGTT), liver and renal function tests, basal cortisol and thyroid profile, Calcium, phosphorus and Intact Parathyroid hormone (iPTH) were normal. Computed tomographyscan of brain showed large pituitary macroadenoma. Automated perimetry confirmed bitemporal hemianopia. A diagnosis of gigantism due to GH secreting pituitary macroadenoma with hypogonadotrophichypogonadism was made. Debulking pituitary surgery followed by somatostatin analogue therapy with gonadal steroid replacement had been planned, but the patient refused further treatment.