Sema Yarman

Sunlight exposure and vitamin D deficiency in Turkish women.

Vitamin D is an essential steroid involved in bone metabolism, cell growth, differentiation, and regulation of the minerals in the body. The main sources of this vital vitamin are adequate diet and photosynthesis in the skin. The aim of this study was to investigate the efficiency of vitamin D synthesis in 48 premenopausal women (14–44 years) in relation to three different types of dressing in summer. Women in the first group (Group I) dressed in a style which exposed the usual areas of the skin to sunlight; women in the second group (Group II wore traditional clothing with the skin of the hands and face uncovered, while the third group (Group III) dressed in traditional Islamic style, covering the whole body including hands and face. Serum 25OHD levels of Group I, Group II, and Group III were 56±41.3 nmol/l, 31.9±24.4 nmol/l, 9±5.7 nmol/l, respectively (Group I vs Group Ill, p<0.001; Group II vs Group III, p<0,03; Group I vs Group II, p>0.05). Vitamin D levels were low in 44 percent of the Group I and 60% of the Group II, which suggested that sun exposure of skin areas of hands and face may partially provide vitamin D synthesis, but may not be enough to eliminate vitamin D deficiency. All the patients in group III had vitamin D levels below normal. This study emphasizes the necessity of vitamin D fortification of food even in a sunny country where some people may not be exposed to sunlight because of inappropriate clothing or an indoor-life.

Lymphocytic panhypophysitis in a young man with involvement of the cavernous sinus and clivus

Lymphocytic hypophysitis is an unusual inflammatory lesion that is caused by autoimmune destruction of the pituitary gland. We report a case of 42-year-old man who presented with a 6-month history of severe headache, blurred vision in the right eye, hearing loss, polyuria, polydipsia, and impotence. Medical history showed that he and his mother had osteopetrosis. The results of the physical examination and laboratory tests showed that secondary hypothyroidism, hypogonadism, and hypocortisolism had developed. Central diabetes insipidus was diagnosed by water deprivation test. MRI of the sella showed pituitary enlargement with symmetrical suprasellar expansion, compression of the chiasma, thickened infundibulum, and involvement of both bilateral cavernous sinuses and clivus. Hormonal substitution with hydrocortisone, levothyroxine, and DDAVP resulted in rapid improvement of all symptoms and signs. Transsphenoidal biopsy was diagnostic of lymphocytic hypophysitis. In spite of extensive literature reviewing, we have not been aware of any case of lymphocytic hypophysitis with clivus involvement. The present case represents a variant of lymphocytic hypophysitis which has progressed to involve bilateral cavernous sinuses and the clivus.

Concomitant Association of Thyroid Sarcoidosis and Graves’ Disease

Objective: Graves’ disease (GD) with sarcoid involvement of the thyroid gland has rarely been reported. Method: We report a case of GD with thyroid sarcoidosis in a 28-year-old woman. Thyroid function was assessed by triiodothyronine (T3), thyroxine (T4), thyroid-stimulating hormone (TSH) and TSH receptor antibodies (TSH-R Ab). Thyroid scintigraphy, ultrasound and fine-needle aspiration biopsy were performed. The patient underwent surgery. Result: The patient had a nodular goiter. Serum T3, T4 and TSH-R Ab levels were elevated with suppressed TSH level. Scintigraphy showed diffuse activity as seen in GD, and ultrasound revealed that parenchyma was heterogenous. Sarcoidosis was discovered on routine chest X-ray. Although no sarcoid involvement was found on specimen, the thyroid gland showed non-caseating granulomas on histology. Conclusion: Since sarcoid involvement of the thyroid gland can cause hypofunction, we report the uncommon infiltration of sarcoidosis with hyperthyroidism.

Co-Secretion of Aldosterone and Cortisol by an Adrenocortical Carcinoma

We report a rare case of adrenocortical carcinoma. A 26-year-old woman presented with hypokalemia and hypertension due to hyperaldosteronism. She had no signs of Cushing’s syndrome. Endocrinological data showed excess of aldosterone production and nonsupressible cortisol production on 2 mg of dexamethasone. Magnetic resonance imaging showed left adrenal tumor. Transabdominal left adrenalectomy was performed and histopathological diagnosis was adrenocortical carcinoma. Her blood pressure and hypokalemia returned to normal after adrenalectomy. There is no recurrence after 36 months. We want to emphasis the importance of adrenal tests before the operation even if there are no signs of excess cortisol production.

Interleukin-6-producing pheochromocytoma presenting with fever of unknown origin

Pheochromocytoma usually presents with typical signsand symptoms, such as headache, sweating, and palpita-tions due to excessive catecholamine release. Few publica-tions have reported that these tumors are capable ofsecreting a variety of bioactive neuropeptides and hormonesother than catecholamines, resulting in unusual clinicalmanifestations.

Acute renal failure associated with nonfulminant hepatitis A virus infection.

Hepatitis A is usually a mild self-limiting infection of the liver. Nonfulminant acute renal failure very rarely complicates type A viral hepatitis. An unusual case, a 32-year-old female with serologically proven acute hepatitis A infection, was complicated by acute renal failure and the patient in this study is the first case associated with Cushings disease. She recovered, and the laboratory tests returned normal one month after initial hospitalization. Although the mechanism responsible for renal failure in acute hepatitis A virus infection is still uncertain, possible causes are discussed with the review of literature.

Hypoglycemia due to Ectopic Release of Insulin from a Paraganglioma

Insulin-secreting pancreatic tumors and insulin-like growth hormone-secreting non-islet cell tumors can cause hypoglycemia. However, insulin-releasing paraganglioma or pheochromocytoma has almost never been reported. A 67-year-old female patient was admitted to our hospital because of headache, palpitation, perspiration, faintness, frequent sense of hunger and absent-mindedness. These intermittent symptoms had begun approximately a year before admission. On physical examination, she had high blood pressure of 150/90 mm Hg. Hormonal studies demonstrated increased urinary norepinephrine levels, and hyperinsulinemic hypoglycemia was confirmed while the patient was symptomatic. Abdominal MRI revealed a retroperitoneal mass measuring 4.5 cm in the pancreatic region. She was treated with an alpha-blocking agent to control blood pressure preceding the removal of the mass. Histopathological diagnosis was paraganglioma, and immunohistochemically insulin staining in the neoplastic cells was demonstrated. Her blood pressure normalized and hypoglycemia relieved after the operation. The patient did not have recurrence of hypoglycemia after a year of follow-up. Paraganglioma is a rare tumor of the neural crest, and co-secretion of insulin and catecholamines has been reported only by a single case report in the literature. The present patient is another case with this co-secretion.

The evaluation of lipid peroxidation and acute effect of octreotide on lipid peroxidation in patients with active acromegaly

BACKGROUND Although lipid peroxidation has been suggested to play a role in the etiology of many diseases, there is no report about its role in acromegaly in the literature. In the present study, we analyzed the basal levels of lipid peroxides (LPO) in newly diagnosed acromegalic patients, and to evaluate whether octreotide (OCT) has any effect on lipid peroxidation in these patients. METHODS Plasma lipid peroxide levels before and after acute OCT administration were measured in 12 newly diagnosed acromegalic patients. Blood samples were drawn at basal and 4, 8, and 24 h after octreotide injection (100 microg s.c.). Plasma concentrations of lipid peroxides were estimated from measurement of thiobarbituric acid reactive substance (TBARS), using 1,1,3,3-tetra-ethoxypropane as a standard. RESULTS This study shows that acromegalic patients have significantly higher basal plasma lipid peroxides levels compared to hours after OCT injection (p<0.001). Although a significant decrease was observed after 8 and 24 h in comparison to basal level (p<0.001), the lipid peroxide levels tended to increase at 24 h though still low when compared to basal level. CONCLUSION Acromegalic patients have high basal lipid peroxide levels, which was significantly decreased after OCT administration.

Hyponatremia as the presenting manifestation of Sheehan's syndrome in elderly patients

Background and aims: Hyponatremia is not a disease in itself, but a manifestation of a variety of disorders and side-effects of diuretics; alternatively, it may be the only manifestation of hypopituitarism or hypothyroidism. In our experience, diagnosis of hypopituitarism in hyponatremic patients is often overlooked, especially in the elderly. Methods: We report here data from five elderly multiparous women (mean age 69 yr; range 62–78 yr) with a past history of complicated delivery, in whom initial symptoms were due to hyponatremia (serum sodium less than 128 mEq/L) who went undiagnosed and untreated for a long time (up to 4:2 years) after the initial event. Results: Initial hormonal levels indicated hypopituitarism, and magnetic resonance imaging led to diagnosis of empty sella in all patients, so that they were diagnosed as suffering from Sheehan ’s syndrome (SS). The occurrence of sodium and water disorders associated with SS depends on the degree of pituitary damage, time of onset since the initial pituitary insult, and concurrent medical conditions which also play a role in sodium and water balance. In these patients, clinical condition and hyponatremia improved rapidly after glucocorticoid substitution. L-thyroxine was appropriately substituted subsequently. Conclusions: We suggest that, especially in elderly patients, much more attention should be paid to patients’ past history. Early recognition of severe hyponatremia due to hypopituitarism with adrenal insufficiency is critical, and treatment with hydrocortisone results in safe and improved quality of life.

Severe osteomalacia in a patient with idiopathic chronic pancreatitis

We report a 30-year-old woman who was confined to a wheelchair because of severe myopathy. She was first seen by a neurologist because of a convulsive syndrome of unknown etiology when she was nine. She was started on anticonvulsive drugs but the drug was stopped when her serum calcium level was found to be very low. She had a history from childhood of steatorrhea and abdominal pain after a fatty meal and became vegetarian at age five years. She worked in a hospital as a nurse and at home her living room received no direct sunlight. As a result of these conditions osteomalacia progressed. We believe an awareness of chronic pancreatitis (CP) during childhood could have prevented the consequences of the disease in this case.