Sandra Belo

Pregnancy after bariatric surgery: Maternal and fetal outcomes of 39 pregnancies and a literature review

We aimed to evaluate the impact of bariatric surgery (BS) on maternal and fetal outcomes.

IL-4 and IL-6 levels and adipose tissue distribution in HIV-1 patients under antiretroviral therapy

PurposeCombined antiretroviral therapy (cART) for the treatment of HIV-1 infection has been associated with complications, including lipodystrophy. Several interleukins have been implicated in the pathology and physiology of lipodystrophy. The present study aimed to compare the levels of IL-4 and IL-6 in HIV-1 patients under cART with and without, clinically and fat mass ratio defined, lipodystrophy and in four different groups of fat distribution: (1) no lipodystrophy; (2) isolated central fat accumulation; (3) isolated lipoatrophy and (4) mixed forms of lipodystrophy.MethodsIn the present cross-sectional study we evaluated IL-4 and IL-6 levels, insulin resistance and insulin sensitivity indexes in 86 HIV-infected adults under cART.ResultsNo significant differences in IL-4 and IL-6 levels between the four groups of body composition were observed. Patients with HOMA-IR >4 presented higher levels of IL-6 and lower levels of IL-4, although without statistical significance. No correlation between IL-6, or IL-4, HOMA-IR and quantitative body fat mass distribution was found.ConclusionAlthough there was a tendency for patients with isolated lipoatrophy and isolated fat accumulation to present higher IL-6 levels, these differences were not statistically significant. No differences were found relating IL-4 levels.

Pregnancy and Tumor Outcomes in Women with Prolactinoma

Context Management of prolactinomas during pregnancy has always been a challenge. There is a concern about the risk of tumor growth, as well as the effects of the treatment on the developing fetus. Another issue that has been less studied is the outcome of women with prolactinoma after pregnancy and lactation. Objectives To evaluate remission of hyperprolactinaemia after pregnancy and lactation in women with prolactinoma. To describe the safety of dopamine agonists for the fetus and pregnancy outcomes. Methods A retrospective study of 32 pregnancies in women with prolactinoma was conducted in a single-centre. Other causes of hyperprolactinemia were excluded. Prolactin level was recorded at the time of diagnosis, during treatment, and during follow-up. Results The pregnancies resulted in one spontaneous abortion (3.1%) and 31 live births (96.9%). No stillbirths, multiple or ectopic pregnancies or trophoblastic disease were recorded. There was only one malformation (club foot) recorded (3.1%) and normalisation of prolactin after pregnancy without medical treatment occurred in 12% of patients. Conclusions Fetal exposure to bromocriptine or cabergoline during pregnancy is not associated with an increased risk of adverse neonatal or pregnancy disclosures. There is considerable diversity among endocrinologists in the management of prolactinomas during pregnancy and after birth, which indicates that there is a need for better consensus and for carefully drawn-up guidelines to follow.

Prolactin-Producing Pituitary Carcinoma, Hypopituitarism, and Graves’ Disease—Report of a Challenging Case and Literature Review

Introduction The diagnosis of pituitary carcinoma is very rare, requires the evidence of metastatic disease, and has a poor overall survival. Malignant prolactinoma frequently requires dopamine agonist therapy, pituitary surgery, radiotherapy, and even chemotherapy. Case description A 19-year-old female presented with galactorrhea, primary amenorrhea, and left hemianopsia. Complementary study detected hyperprolactinemia and a pituitary macroadenoma with cavernous sinus invasion and suprasellar growth. She was treated with cabergoline and bromocriptine without clinical or analytical improvement. Resection of the pituitary lesion was programmed and a non-contiguous lesion of the nasal mucosa was detected during the approach. This metastasis led to the diagnosis of prolactin-producing pituitary carcinoma. After partial resection, the patient was submitted to radiotherapy for residual disease with persistent symptoms. She developed growth hormone deficiency, central hypothyroidism, hypogonadism, and permanent diabetes insipidus. Six years later she was admitted for the suspicion of secondary adrenal insufficiency and thyrotoxicosis. Physical findings, laboratory data, thyroid ultrasound, and scintigraphy achieved the diagnosis of Graves’ disease and hypocortisolism. She was treated with hydrocortisone and methimazole, but central hypothyroidism recurred after antithyroid drug withdrawal. Nine years after the diagnosis of a pituitary carcinoma, she maintains treatment with bromocriptine, has a locally stable disease, with no metastases. Conclusion This report highlights an unusual presentation of a prolactin-producing pituitary carcinoma in a young female. The patient had multiple hormone deficiencies due to a pituitary lesion and treatments. The posterior development of hyperthyroidism and adrenal insufficiency brought an additional difficulty to the approach.

Insulin resistance and sex hormone-binding globulin are independently correlated with low free testosterone levels in obese males

Male obesity is associated with decreased testosterone levels but the pathophysiological mechanisms behind this association are not completely understood. This study aimed to investigate the impact of hyperglycaemia/insulin resistance and sex hormone‐binding globulin (SHBG) levels on testosterone levels in a population of obese men. We investigated the impact of several clinical, anthropometric and analytic measures on testosterone levels in 150 obese males. Testosterone deficiency was present in 52.0% of the enrolled patients. This percentage dropped to 17.6% when only calculated free testosterone (FT) was accounted, as SHBG levels were correlated negatively with body mass index (r = −.20; p < .05). Older age (p < .05) and higher homoeostasis model assessment of insulin resistance (HOMA‐IR) (p < .01) and lower SHBG levels (p < .05) were independently correlated with lower FT. Weight and fasting plasma glucose lost their statistical significance after multivariate adjustment. Patients with type 2 diabetes mellitus and pre‐diabetes had lower FT than those with normal glucose tolerance (p < .05 and p < .01 respectively). Insulin resistance, and not hyperglycaemia and weight per se, seems to be the main determinant of low testosterone levels in obese males. Low SHBG levels are correlated with low FT even after HOMA‐IR adjustment. This suggests that SHBG can be associated with testosterone deficiency beyond the influence of insulin resistance unlike previously reported.

A rare case of spontaneous Cushing disease remission induced by pituitary apoplexy

One week after the diagnosis, the patient presented to the Emergency Department (ER) with severe headaches, nausea, vomits and psychomotor impairment. On physical examination, the patient was hemodynamically stable without any focal neurologic deficits. Blood tests showed severe hyponatremia of 114 mEq/L (135–145). Despite the ER head CT scan that revealed no significant alterations, blood was collected for cortisol and the remaining pituitary hormonal profile and the patient was given 100 mg of hydrocortisone. She was then admitted because of a pituitary apoplexy and ensuing secondary adrenal insufficiency was suspected. The results of the laboratorial study were available on the next day and revealed panhypopituitarism: serum cortisol 1.2 μg/dL; ACTH 41.3 ng/L; TSH 0.04 μUI/L (0.35–4.94); free T4 0,96 ng/dL (0.70–1.48); free T3 1.56 pg/mL (1.71–3.71); FSH 2.14mU/mL (25.8–134.8); LH 0.23mUI/mL (7.7–58.5); oestrogen <5.0 pg/mL (<5–54.7); IGF-1 19 ng/mL (72–167); hGH 0.07 ng/ mL (<8). Glucocorticoid therapy led to symptomatic improvement and to normalization of the sodium levels to 139 mEq/L. Pituitary MRI demonstrated a pituitary macroadenoma with features of tumoral haemorrhage in its interior (Fig. 1), confirming the apoplexy hypothesis. Beyond hypertension, no other precipitating factor such as surgery or trauma was identified. She was evaluated by a neurosurgeon that considered that urgent surgery was not needed as the patient presented good clinical evolution and no neurological deficits. The patient was discharged and medicated with 20 mg of hydrocortisone and 50 μg of levothyroxine. Six months after the apoplectic event, the blood analysis revealed hypocortisolism persistency (morning cortisol 7.4 μg/dL; ACTH 3.8 ng/L) that was corroborated 1 year later. The MRI showed signs of past pituitary apoplexy without residual tumour. Facing the resolution of the Dear Editor-in-Chief,

Malignant melanoma with synchronous thyroid metastases: case report and literature review

Thyroid metastases are rare in clinical practice. We describe the case of an 85-year-old woman who was referred to our department due to a multinodular goiter with compressive symptoms and subclinical hyperthyroidism. The patient was also undergoing evaluation for a polyp in her left nasal cavity, which was then diagnosed as a malignant melanoma of the nasal mucosa. A thoracoabdominal magnetic resonance imaging obtained for cancer staging revealed a > 50% tracheal obstruction caused by the goiter. The patient underwent simultaneous total thyroidectomy and melanoma excision. Histological analysis of the thyroid showed the presence of multiple metastatic foci from the melanoma. Due to the patients age, a decision was made to maintain her under surveillance and administer palliative treatment if necessary. Although metastases to the thyroid are rare, they should be considered in the differential diagnosis of thyroid lesions in patients with a known primary tumor. The thyroidectomy, performed in this patients case, allowed the diagnosis of the metastases and relief of compressive symptoms caused by the goiter.

COMUNICAÇÕES ORAISXIV Congresso Português de Endocrinologia/64a Reunião Anual da SPEDMPorto, 24 a 27 de Janeiro de 2013CO095. CARACTERÍSTICAS CLÍNICAS, ANALÍTICAS, IMAGIOLÓGICAS, TRATAMENTO E OUTCOME NUMA POPULAÇÃO DE DOENTES ACROMEGÁLICOS

variaveis. Apresentam-se resultados dos doentes tratados no nosso servico nos ultimos 16 anos. Metodos: Avaliacao retrospectiva dos 21 doentes (20 mulheres) com DC observados de 1996 a 2011, submetidos a CH. O diagnostico foi confirmado com base nos doseamentos de ACTH, cortisol urinario, provas de supressao com dexametasona (dose fraca e forte) e prova de CRH. A imagiologia hipofisaria por RM foi efectuada em todos os doentes e o cateterismo dos seios petrosos apenas nos casos de dificuldade no diagnostico diferencial. Resultados: A RM hipofisaria revelou macroadenoma (n = 3), microadenoma (n = 13) e ausencia de imagem (n = 5). Seis doentes efectuaram cateterismo dos seios petrosos. Com excepcao de 1 caso (macroadenoma invasivo), a abordagem cirurgica foi trans-esfenoidal, verificando-se cura em 13 doentes (62%). Destes, apos um follow up medio de 4,6 anos, apenas 2 recidivaram. Dos 8 doentes com persistencia da doenca apos CH, 5 foram reoperados, obtendo-se cura em 3, que persiste em 2 casos decorridos mais de 5 anos. Das 3 recidivas apos 1 ou 2 CH, duas ocorreram mais de 10 anos depois. Verificou-se 1 obito no pos-operatorio imediato de um destes casos. Foi efectuada suprarrenalectomia bilateral em 4 doentes e 3 estao sob terapeutica medica. Conclusao: O racio mulheres/homens na nossa serie e muito superior ao descrito na literatura. A taxa de cura apos primeira ou segunda CH (76%) e semelhante a descrita em outros centros. Duas recidivas ocorreram muito para alem dos 2 anos habitualmente referidos, dado verificado pela duracao do follow-up que e maior que o de outras series. A radioterapia nao foi opcao no tratamento dos nossos doentes.

CO020. ÍNDICE DE MASSA CORPORAL ANTES DA GRAVIDEZ E AUMENTO PONDERAL DURANTE A GESTAÇÃO – FACTORES DE RISCO PARA COMPLICAÇÕES MATERNAS E FETAIS EM MULHERES COM DIABETES GESTACIONAL

Introducao: Indice de massa corporal (IMC) pre-gravidez e aumento ponderal durante a gestacao elevados sao fatores de risco bem conhecidos para a saude materna e fetal. Objetivo: Avaliar os efeitos do IMC pre-gravidez e do aumento de peso durante a gestacao no risco de complicacoes maternas e fetais em mulheres com diabetes gestacional (DG). Metodos: Foi estudada uma cohort de 4.323 mulheres com DG. Foram avaliados dados relativos a peso, estatura e IMC maternos antes da gravidez e aumento ponderal durante a gestacao assim como informacao relativa a outcomes maternos (tipo de parto, hipertensao induzida pela gravidez, pre-eclâmpsia, hemorragia pre-parto) e fetais (hidrâmnio, peso ao nascimento, malformacoes congenitas, morte fetal, ictericia neonatal, infeccao e dificuldade respiratoria). O diagnostico de DG foi efetuado segundo os criterios da OMS. Na analise estatistica foram utilizados os testes t para amostras independentes e qui-quadrado. Resultados: A idade media ao diagnostico de DG foi de 33 ± 5 anos e o IMC pregravidez foi de 26,7 ± 5,6 Kg/m2. O aumento ponderal medio durante a gestacao foi de 10,9 ± 5,6 Kg. Mulheres com excesso de peso, ou obesidade, antes da gravidez apresentaram maior frequencia de hipertensao induzida pela gravidez (1,1% vs 0,8%; p < 0,001) e hidrâmnio (1,0% vs 0,7%; p < 0,001), e recem-nascidos com maior peso (3.138 ± 482 vs 3.336 ± 596 g; p < 0 ,001) comparativamente a mulheres com IMC normal. Os recem-nascidos de mulheres com maior aumento ponderal apresentaram maior frequencia de infecoes neonatais (1,5% vs 0,1%; p = 0,003) e dificuldade respiratoria (0,8% vs 0,1%; p = 0,006), quando comparados com recem-nascidos de mulheres com IMC estavel durante a gravidez. Conclusao: Alem da necessidade de um controlo glicemico rigoroso na DG, tem vindo a ser atribuida uma importância crescente ao controlo do peso antes e durante a gestacao uma vez que estes tem sido considerados fatores de risco independentes para complicacoes maternas e fetais.